CVS Flashcards
Hypotension Muffled heart sound raised JVP tachycardia dyspnoea
Cardiac tamponade
ECG = electrical alternans
cardiac tamponade
Management of Cardiac tamponade
Urgent pericardiocentesis
splinter haemorrhages roth spots janeway lesions new murmur (regurg) osler's nodes fever
Infective endocarditis
RFs for infective endocarditis
valvular disease
prosthetic valve
IV drug use
diagnostic investigations for infective endocarditis:
multiple +ve blood cultures (staph aureus) and ECHO (check valves)
management for infective endocarditis:
penicillin amocillin and gentamicin
penicillin allergy/severe case = + vancomycin
HF signs - urgent valve replacement/surgery
severe tearing chest pain - sometime radiation of pain to back pulse deficit/wide pulse pressure aortic regurg dyspnoea hypotension
widened mediastinum, false lumen on CT CAP/TOE
Aortic dissection
ascending/type A = radiate to thoracic region
descending type B = radiates to back
type A aortic dissection mx
surgical repair and IV labetalol (aim for SBP - 100-120mmHg)
Type B aortic dissection mx
IV labetalol
bed rest
analgesia
ejection systolic (crescendo-decrescendo) murmur radiating to carotids
aortic stenosis
early diastolic (decrescendo) murmur de mussets = head bobbing de quincke's = nailbed pulsation
aortic regurgitation
dizziness, less exercise tolerance/dyspnoea, palpitations,
irregularly irregular pulse
absent p waves
Atrial fibrillation
management of Atrial fibrillation
<48hr = heparin and cardiovert >48hr = anticoagulate (DOAC) for 3wks and cardiovert
CHA2DS2VASC = 2+ = anticoagulate ORBIT score 0-2 - low risk 3 - medium risk 4-7 - high risk
rate control of initiated if presentation>48hrs = beta blocker/diltiazem/verapamil
anticoagulation with DOACs
warfarin second line
palpitations, dyspnoea, fatigue, syncope, SOB
ventricular rate above 300/min/very tachycardic
sawtooth appearance on ECG
Atrial flutter
management of Atrial flutter
cardiovert
radiofrequency ablation of tricuspid valve
ejection systolic murmur + split S2, louder on inspiration
heard in the left sternal edge
Acyanotic
symptomatic in adulthood
atrial septal defect
what is the management of ASD
surgery
mid-late diastolic murmur, loud S1 and opening snap best on expiration rheumatic fever hx malar flush atrial fibrillation
mitral stenosis
pansystolic ‘blowing’ murmur, best @ apec and radiates to axilla
marfans/ehlers-danhlos hx
mitral regurgitation
erythema marginatum subcuatneous nodules fever polyarthritis carditis/valvulitis = chest pain, SOB, regurg murmur chorea hx or sore throat a couple week back
acute rheumatic fever
diagnose rheumatic fever
+ve throat swabs
raised ESR/CRP
ASO titre
ECHO = HF signs
management of acute rheumatic fever
oral penicillin V + NSAIDs
treat HF
usually asymptomatic
may present with headaches, visual changes or palpitations in severe cases
hypertension
HTN diagnosis and checks
a clinic reading persistently above >= 140/90 mmHg, or:
a 24 hour blood pressure average reading >= 135/85 mmHg
fundoscopy: to check for hypertensive retinopathy
urine dipstick: to check for renal disease, either as a cause or consequence of hypertension
ECG: to check for left ventricular hypertrophy or ischaemic heart disease
breathlessness, oedema, reduced exercise tolerance/fatigue raised JVP displaced apex beat bibasal crackles
acute heart failure
dyspnoea cough (frothy sputum) orthopnoea PND weight loss bibasal crackles ankle oedema raised JVP hepatomegaly
chronic heart failure
heart failure Ix
CXR = cardiomegaly and interstitial oedema BNP = >100mg/L ECHO = pericardial effusion - definitive
management of heart failure
first line = ACEi + Beta blocker
second line = spironolactone
specialist care with hydralazine and ivabradine, nitrates and digoxin
offer annual influenza vaccine
offer pneumococcal vaccine every 5 years
heavy constricting chest pain
relieved by rest or GTN spray
~10-15mins
Stable angina
Management of stable angina
beta-blocker or CCB (verapamil/diltiazem)
long acting nitrate if not controlled with adjunct tx Ivabradine, nicorandil or ranolazine if contraindicated - third drug only added if awaiting pci/cabg
chest pain typically at rest
very short lived
radiated to the back
SOB
transient ST elevation in ECG
prinzmetal angina
management of prinzmetal angina
CCB - reduce no, of spasms
GTN fo symptomatic relief
heavy constricting chest pain
radiation to left arm, jaw, or neck
not releievd by rest/GTN
unstable angina
management of unstable angina
unstable angina - no ECG changes and no trop raise
aspirin + ticagrelor and fondaparinux
central/left-sided chest pain, heavy and constricting radiation to the left jaw, neck and arm dyspnoea sweating palpitations
Acute myocardial infarction
Initial management of acute MI
- 300mg Aspirin
- Oxygen - if O2 stats are <94%
- Morphine IV for pain
- Nitrates - IV or sublingual
STEMI = need to have PCI done - if not available with 120mins/2hrs then start fibrinolysis
NSTEMI = fondaparinux and GRACE assessment
high risk - PCI within 72hrs (have patient on ticagrelor and heparin)
low risk - ticagrelor
differentiate between first and second degree heart block
First degree = PR interval is >0.20s (usually asymptomatic)
delayed conduction
Second degree
type 1 = progressive prolongation of the PR interval till the missed beat
type 2 = constant PR interval till a missed beat
syncope heart failure regular bradycardia wide pulse pressure variable intensity of S1
ECG = no association of P and Q waves
3 degree heart block
heart failure in infancy / low birth weight
HTN in adults
radio-femoral delay
mid-systolic murmur (more over back)
notching of the border of the ribs in young children
link to Turner’s syndrome
more common in males
coarctation of the aorta
Definitive Ix for coarctation of the aorta
ECHO
ECG &CXR are the other
management of coarctation of the aorta
treat any resulting heart failure, HTN symptoms
Ultimately surgery is required to repair narrowing
classic HF findings systolic murmur (mitral/tricuspid regurg) S3 heart sound systolic dysfunction
Dilated cardiomyopathy
Investigation for dilated cardiomyopathy
CXR = balloon appearance
managment of dilated cardiomyopathy
lifestyle measures
HF medication
Surgery or heart transplant if severe
most common . in young pts
can often be asymptomatic
exertional dyspnoea/syncope
angina
sudden death
syncope often following exercise/exertion
ejection systolic murmur - increased by valsava and decreased by squatting
autosomal dominant - FHx
hypertrophic obstructive cardiomyopathy
Ix for hypertrophic obstrcutive cardiomyopathy
ECHO = mitral regurg, systolic anterior motion & asymmetric hypertrophy
ECG = LVH, deep Q waves, ST segment changes, T wave abnormalities
management of hypertrophic obstructive cardiomyopathy
A = amiodarone B = beta blockers C = cardioverter defibrillator D = dual chamber pacemaker E = endocarditis prophylaxis
SOBOE orthopnea fatigue leg and ankle swelling cough
usually caused by amyloidosis, post radiotherapy or loeffers endocarditis
restrictive cardiomyopathy
Ix of choice for restrictive cardiomyopathy
ECHO - thickened walls
Management for restrictive cardiomyopathy
manage HF amiodarone for arrhythmias anticoagulation implantable cardioverter defibrillator surgery indicated in some cases
sudden onset of palpitations/heart beating faster
tired
weak or lightheaded
nauseous
ECG findings
narrow QRS complexes
rate 140-280
absent p waves
supraventricular tachycardia
management of SVT
acute = vasovagal maneuvers = either valsave or carotid sinus massage
IV adrenaline 6mg, then 12m and then another 12mg (verapamil in asthmatics)
electrical cardioversion if all else fails.
hypotension
collapse
acute HF
ECG = broad QRS complexes HR = >100bpm
ventricular tachycardia
management of ventricular tachycardia
amiodarone, lidocaine and procainamide
if this fails, electrophysiological study & ICD
often occurs following an MI
chaotic, irregular deflections of varying amplitudes
no identifiable P waves ,QRS complexes or T waves
ventricular fibrillation/flutter
management of VF
defibrillation and stop all antiarrhythmics
in the long run - ICD implantation
lead V1 = M shaped QRS
lead V6 = W shaped QRS
split S2
RBBB
Lead V1 = W shaped QRS
Lead V6 = M shaped QRS
LBBB
What is a new onset LBBB a sign of ?
Myocardial Infarction
management of bundle branch blocks
Cardiovert and manage the complications
often asymptomatic
may have complaints of headaches, visual disturbance or in very severe cases seizures
Hypertension
diagnosis of HTN?
a clinic reading persistently above >= 140/90 mmHg,
or:
a 24 hour blood pressure average reading >= 135/85 mmHg
OTHER CHECKS:
fundoscopy: to check for hypertensive retinopathy
urine dipstick: to check for renal disease, either as a cause or consequence of hypertension
ECG: to check for left ventricular hypertrophy or ischaemic heart disease
management of HTN
if under 55/not african-caribbean/diabetic
= start on ACEi/ARB
(Then stepwise addition of CCB or thiazide and then triple therapy)
If above 55/non-diabetic/African-carribbean
= start on CCB
(add on thiazide or ACEi/ARB, and then triple therapy)
if still hypertensive - check K+ level
- if above 4.5mmol/L = alpha/beta blocker
- if below 4.5mmol/L = low dose spironolactone
describe stages of HTN
Stage 1 hypertension — clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent ABPM daytime average or HBPM average blood pressure ranging from 135/85 mmHg to 149/94 mmHg.
Stage 2 hypertension — clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg and subsequent ABPM daytime average or HBPM average blood pressure of 150/95 mmHg or higher.
Stage 3 or severe hypertension — clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher.
Accelerated (or malignant) hypertension is a severe increase in blood pressure to 180/120 mmHg or higher (and often over 220/120 mmHg) with signs of retinal haemorrhage and/or papilloedema (swelling of the optic nerve). q
pain
erythema around the affected area
may be able to feel harder lumps underneath the skin
phlebitis/thrombophlebitis
management of phlebitis/thrombophlebitis
Oral NSAIDs/heparinoids
compression stocking (measure ABPI prior)
LMWH/fondaparinux
US may be done to exclude DVT
aching/burning in muscles following exertion
relieved within minutes of stopping exertion or resting
calves affected > than thigh/buttock
ABPI = 0.6-0.9
intermittent claudication
pale pulseless painful paralysed paresthetic poikilothermic (cold)
arterial occlusion/acute limb ischaemia
management of peripheral arterial disease
intermittent claudication
- supervised exercise programme
- optimise comorbidities 80mg atrovastatin and 75mg clopidogrel 3-6/12
- naftiodrofuryl oxalate
Acute limb ischaemia
- Vasc MDT
- paracetamol/opiods
- endovascular or surgical options
acute limb-threatening ischaemia - ABC and IV opioids - IV UFH emergency assessment by vasc specialist definitive - endovascular therapies or surgical interventions
Ix of choice for peripheral arterial disease
duplex ultrasound
aching, throbbing or itching in the lower limbs
tortuous superficial veins
RFs = female, pregnant, obesity and increasing age
varicose veins
conservative management = leg elevation, weight loss, regular exercise & graduated compression stockings
possible Txs
- endothermal ablation
- foam scleropathy
unilateral localised throbbing pain particularly on walking or weight bearing calf swelling & tenderness oedema, redness and warmth vein distension
DVT
Assessing for DVT
compare the circumference between the legs - >3cm
Wells DVT score - 2 or more is likely
1 or below = unlikely
management of unlikely DVT
offer D-dimer in 4hrs if not offer interim anticoagulation
D-dimer +ve = doppler US
D-dimer -ve = stop anticoagulation
management of likely DVT
proximal leg vein US within 4hrs
if not D-dimer and interim anticoagulation (DOAC - apixaban)
management in provoked and unprovoked DVT
provoked DVT = continue for 3 months
unprovoked DVT = consider undiagnosed cancer and thrombophilia testing
tetralogy of fallot characteristics?
ventricular septal defect
overriding aorta
right pulmonary stenosis
right ventricular hypertrophy
cyanosis and ejection systolic murmur
management of tetralogy of fallot
surgical repair and beta blocker
failure to thrive
HF symptoms - hepatomegaly, tachycardia/pneoa
pallor
pan-systolic murmur
ventricular septal defect
management of VSD
small VSD = usually asymptomatic - requires close monitoring and typically closes spontaneously
moderate-large VSD = nutritional support, diuretics for HF, surgical closure of the defect
large volume, bounding, collapsing pulse wide pulse pressure heaving apex beat left subclavicular thrill continuous 'machinery murmur'
patent ductus arteriosus
patent ductus arteriosus management
indomethacin or ibuprofen (inhibition of prostaglandin synthesis closes the connection)
mid-diastolic murmur (expiration>>) SI opening snap malar flush low volume pulse AF, raised JVP and displaced apex beat
mitral stenosis
typically asymptomatic
some fatigue, SOB and oedema
pan-systolic ‘blowing murmur’, split S2
mitral regurg
management for mitral regurg
medical mx = nitrates/diuretics, digoxin, intra-aortic balloon pump
signs of HF = ACEi, BB and spironolactone
severe = surgery
atypical chest pain/palpitations
mid-systolic click
later systolic murmurs
varies when sitting/standing
common cause = myxomatous degeneration
mitral valve prolapse
management of mitral valve prolapse
dependent on severity
no tx
beta blockers
surgical repair/replacement
systolic murmur louder on inspiration
Pulmonary stenosis
pansystolic murmur louder on inspiration
tricuspid regurg
a drop in BP (usually >20/10 mm Hg) within three minutes of standing
presyncope
syncope
orthostatic hypotension
management of orthostatic hypotension
treatment options include midodrine and fludrocortisone
