For IPE Flashcards
When are ventricular ectopic felt most and why?
Feels like a missed beat when sitting or lying down
They are terminated when the SAN fires more quickly than normal
What are the cardiac red flags for syncope episodes?
Abnormal ECG HF New/unexplained murmur or SOB >65 years with TLOC without prodrome structural heart problems FH of sudden cardiac death <40y/o TLOC during exercise
What are the modifiable risk factors for cardiovascular disease?
Smoking
Diabetes
Hypertension
Hyperlipidaemia
Explain the two normal heart sounds
S1- lub - closure of the mitral and tricuspid valves
S2- dub- closure of the aortic and pulmonary valves
What is the 3rd heart sound and when is it heard?
Blood rushing into the ventricles during rapid filling phase of early diastole
Normal in children and adults <30 y/o
Causes - HF, MI, hypertension and cardiomyopathy
What is the 4th heart sound and when is it heard?
Atrial contraction into a non compliant ventricle
Causes - HF, MI, hypertension and cardiomyopathy
What types of echos are there to visualize the heart? Which is preferred?
Transthoracic and transoesophageal
Transoesophgeal gives better pictures
What can a ECHO of the heart be used for?
Global LV function, estimating right heart haemodynamic, valve disease, congenital heart disease, pericarditis, pericardial effusion and HCOM
What test is indicated in all those with stable chest pain?
Ct angiogram of the coronary arteries
Explain the NYHA of cardiac failure
1 - no limitation of physical activity- ordinary activity doesn’t cause undue fatigue
2- Slight limitation of physical acitivty- ordinary activity results in fatigue, SOB or palpitations
3- marked limitations of physical acitivity - comfortable at rest and less than ordinary activity causes fatigue, SOB and palpitations
4 - symptoms of heart failure at rest
Explain the CHADVASC score
Probability of thromboembolic events in patients with AF
- CCF
- Hypertension (even if treated)
- Age
> 65-74 = 1
> Greater than 75 =2 - DM
- Stroke or TIA = 2
- PVD
- Female
Anticoagulate males with 1 and females with 2
What score is used against CHADVASC?
HAS BLED - used to assess the risk of a major bleed in someone with AF that is anticoagulated
What classification is used for CCF?
Framingham classification
What are the major components to the framingham classification?
PND Raised JVP Hepatojugular reflex Crackles at lung bases Cardiomegaly on CXR Acute pulmonary oedema Gallop rhythm Increased CVP Weight loss of greater than 4.5kg in 5 days due to diuretics
What are the minor components of the framingham classification?
Bilateral ankle oedema Nocturnal cough Dyspnoea on normal exertion hepatosplenomegaly pleural effusion decreased vital capacity tachycardia
What criteria needs to be met with the framingham classification to diagnose CCF?
2 Major or
1 major and 2 minor
What is the difference between hypertensive urgency and hypertensive emergency?
Urgency - severely elevated BP with no end organ damage
Emergency - severely elevated BP with end organ damage
What should be done first if a patient has high blood pressure in consultation?
ABPM
What is the first line treatment for hypertension?
<55 or DM - ACEi
>55y/o or afrocarribean - CCB
What are some secondary causes for hypertension?
Renal causes - GN, RAS, pyleonephritis and polycystic kidneys
Endocrine causes - phaechromocytoma, cushing disease, liddle disease, acromegaly and conns syndrome
Drug causes - steriods, COCP, NSAIDs and leflunomide
Other causes - pregnancy and coarctation of the aorta
What testing should be under taken if a secondary cause is suspected?
MRA to look at the kidneys and adrenal glands
Renin aldosterone ratio to look for Conns
Urine metanephrines or serum catecholamines
What organs are most severely affected by hypertension?
Eyes Kidneys Heart Brain Lungs ( malignant hypertension can present with flash pulmonary oedema)
What are the stages of hypertensive retinopathy?
Tortous A with copper wiring
Av nipping
Flame haemorhages with cotton wool spots
Papilloedema
What anti hypertensive drug is used in pregnancy?
Labetalol
Give some causes of pericarditis
Coksackie Virus TB Autoimmune conditions - RA, SLE Radiotherapy Kidney failure - uraemia Hypothyroidism Post MI - Dressler's syndrome
Explain the pathophysiology behind pericarditis
Pericardium is acutely inflammed and there is an infilitrate of polymorphonuclear leukocytes and pericardial revascularisation
What are the potiental sequele of pericarditis
Constrictive pericarditis - exudate and adhesions encase the heart within non expansile pericardium
Pericardial effusion which may lead to tamponade
What are the symptoms of pericarditis?
Central chest pain- stabbing pain that is worse on inspiration, relieved by sitting up SOB on lying flat Cough Palpitations Fever
What are the signs of pericarditis?
Tachycardia
Increased temperature
If constrictive
- RHF - increased JVP, severe ascites, hepatomegaly, kusssmaul sign, hypotension and pulsus paradox
What are the signs of tamponade?
Increased JVP
Reduced BP
Muffled heart sounds
Forms Becks triad
What are the ECG changes seen in pericarditis?
Stage 1 - ST segement elevation with PR depression
Stage 2 - ST segment back to baseline with W wave flattening
Stage 3 - T wave inversion - may remain in uraemia, Tb or neoplasm
Stage 4- back to normal
Apart from an ECG what investigations and imaging should be done in someone with suspected pericarditis and why?
Troponin- would be raised
U&Es- check kidney function as failure could cause or kidneys could be damaged if low output
CRP and ESR- would see raised inflammatory markers
ECHO - look for signs of effusion
special tests - virology screen and antibodies if suspecting a autoimmune cause.
What is the management of pericarditis?
NSAIDs (+PPI)
Drain any tamponade
Abx for infective causes
Explain the process of draining a tamponade
Pericardiocentesis
- usually under USS guidance - needle is inserted in 5th ICS at left sternal edge at the cardiac notch of the left lung
- while draining the fluid make sure patient is on ECG to look for signs of cardiac breach
Fluid should be sent to the lab for all the usual things and a drain can be left in
What is infective endocarditis and what is the pathophysiology behind it?
Inflammation of the inner walls of the heart including the valves
Pathophysiology- endothelial damage leads to the deposition of platelets and fibrin. When there is a bacteriaemia eg from brushing teeth the bacteria adhere and colonise on the plaque leading to a biofilm . The fibrin forms over this bacteria and the bacteria are protected against host defences and treatment.
What are the risk factors for IE?
patients with valve replacements
patients with congenital heart disease
patients with poor dental hygiene
IVDU and tattoos with non sterile needles
What are the symptoms of IE?
pleuritic chest pain which radiates to the back
fever and night sweats
fatigue and weight loss
embolus
What are the signs of IE?
New murmur or changes in pre existing murmur
splenomegaly
clubbing, splinter haemorhages, oslers nodes and jane way lesions
Roth spots on fundoscopy
Petechiae
What are the common organisms in IE?
Staph aureus is the most common
Others
- Strep Viridans
- Staph epidermis
- Enterococci (consider some sort of bowel pathology)
- pseudomonas aureginosa
What investigations would be done in a patient with suspected IE?
Blood tests - raised inflammatory markers, normocytic anaemia, check LFTs/ U&Es for signs of end organ damage as a result of sepsis
ECG- rule out pericarditis
CXR- rule out any lung pathology
ECHO - diagnostic to look at valves and infective vegetation
Blood cultures- 3 lots from three different places at 3 different times - helps determine treatment
What are the major features of Duke’s criteria?
Positive blood cultures - typical organism in 2 cultures or persistently positive cultures
Evidence that the endocardium is involved - ECHO showing vegetation, abscess or dehisence of the prosthetic valve
new murmur
What are the minor features of Duke’s criteria?
Predisposing features - cardiac lesion or IVDU
Fever >38 degrees
Vascular/ immunological signs
positive blood cultures that doesnt meet the major criteria
positive ECHO that doesnt meet the major criteria
What is needed in the Duke’s criteria to make a diagnosis?
2 major
1 major 3 minor
all 5 minor
What is the management of IE?
Always involve micro
Start on empirical antibodies once all cultures taken and then become specific - need 4 weeks of IV and then oral to take home
educate patient about good oral hygiene and risk of infection from tattoos or drugs
What is angina? Explain the pathophysiology
Chest pain felt due to ischaemia of the heart muscle due to atherosclerosis which restricts the flow of blood in the coronary arteries.
occurs mainly at times of increased heart rate due to increased demand and reduced filling of the coronary arteries due to shortened diastole.
What are the typical criteria for diagnosis of angina?
constricting/ heavy discomfort to the chest/ jaw/shoulder and arms
symptoms brought on by exertion
symptoms are relieved within 5 minutes of rest or GTN
3= typical and 2 = atypical
What are some features that make angina less likely?
continuous pain
pleuritic or worse on swallowing
pain associated with palpitations, dizziness or tingling
What investigations should be cared out in patient with suspected angina?
ECG - may be normal or may see ST depression
Troponin and creatine kinase - normal
FBC - rule out anaemia which could be worsening symptoms
Thyroid function test, lipid and HbA1c
CT angiogram for anyone with stable cardiac pain is gold standard
What is the management of angina?
Counselled about risk factors - stop smoking, reduced alcohol, improved diet, more exercise and better control of DM
Patient given GTN spray- take a maximum of 2 doses 5 minutes apart and if these dont work go to A&E
Statin to control lipids
Aspirin 75mg indicated
B blocker or CCB depending on patients choice
if not controlled with one add the other and if this cannot happen consider long acting nitrate, ivabradine or nicorandil
consider angioplasty or stenting
What is the difference between unstable angina and stable angina?
Unstable angina occurs at rest
unable angina more severe and will have rapid onset
unstable angina is caused by transient formation of platelet clots around atherosclerosis which has already built up
- indicator of impending MI and needs treatment
What is Prinzmental angina?
Caused by spasm of the muscles in the coronary arteries
Comes on at random times including at rest
no signs of blockage or narrowing on angiogram
Treated with CCB and long acting nitrate
Explain the formation of a atherosclerotic plaque
triggered by endothelial injury
lipoproteins are oxidized and taken up by macrophages = foam cells
release of cytokines leads to the accumulation of fat cells and smooth muscle proliferation forming the cap
Explain the pathophysiology behind a STEMI
Complete occlusion of a vessel by the rupture of an atherosclerotic plaque leading to infarct of the tissue that is usually supplied by the this vessel
What are the autonomic nervous system symptoms associated with MI?
Pallor
Sweating
Tachycardia
N&V
How and in who do silent MIs present?
DM and women
May present with syncope, pulmonary oedema, epigastric pain and vomiting
there may be no chest pain
What are the ECG findings in an acute MI?
ST elevation in leads related to coronary vessel affected
Reciprocal changes in other leads
T wave inversion
Pathological Q wave formation
Which leads relate to which vessels/ domains?
Anterior - V1-V4- LAD
Lateral - AvL, V5, V6 - circumflex
Inferior - II, III, AvF - RCA
Posterior - V7-V9
Apart from an ECG what investigations should be considered in those suffering a suspected STEMI?
Portable CXR - look for signs of heart failure
Bloods - FBC- signs of anaemia
Glucose and lipids - RFs
creatinine kinase and troponin I
U&Es- check kidney function before the used of contrast in scans
ECHO - check LV function and for scarring
How is the management of a right sided infarct different to that of a left sided?
In right sided - give fluids to stretch the RV whereas in left sided avoid fluids unless BP low
Explain the process of a stress MRI
Adenosine is given to the patient which allows us to see narrowing in the coronary vessels
outline the immediate management of a STEMI
Morphine and metaclopramide 10mg
Oxygen if not already at targets
Nitrates - GTN 50mg in 50ml 0.9% saline at 2-10ml/hr
Aspirin 300mg chewed and Prasugrel 180mg
What part of a STEMI management is time critical?
Primary PCI - must be done within 120 minutes
What is the long term treatment of STEMI ?
Dual antiplatelets - decrease platelet activity
ACEi - reduce BP and therefore afterload of the heart
B- blocker - reduce myocardial demand
> if contraindicated use CCB
Statin - high dose - 80mg atorvostatin
patient should make lifestyle changes and should have a month off work and driving
What are the complications of a STEMI?
Sudden death
Pump failure and pericarditis
- Dressler’s syndrome - treated with NSAIDs and steriods if servere
Rupture of the papillary muscles or septum
- can lead to mitral regurg which can present with pulmonary oedema
- Ventricular septal defect presenting with pan systolic murmur, increased JVP and cardiac failure
Embolism
Aneurysm
- Left ventricular aneurysm - occurs 4-6 weeks later and can present with LVF, recurrent Vt or systemic emboli
> ECG shows persistent ST segment elevation
What are the reversible causes of cardiac arrest?
Hypovolaemia, hypoxia, hydrogen ions, hyper/hypokalaemia or hypothermia
Toxins, tamponade, tension pneumothorax and thrombus
What is the treatment of a cardiac arrest?
CPR
Defibrilate to restart sinus rhythm if a shockable rhythm
1mg of adrenaline - 1;10000- after 3rd shock or at start in non shockable rhythm
Amiodarone 300mg Iv in shockable rhythm after 3rd shock
What is HOCM?
Autosomal dominant inherited condition causing hypertrophy of the myocardium
How does HOCM usually present?
Commonly sudden death at a young age during exercise
S&S- angina, SOB, palpitations, CCF and ejection systolic murmur
What investigations should be done in a patient with suspected HOCM?
ECG -LVH - tall QRS in V5 and V6
ECHO - asymmetrical septal hypertrophy, small left ventricle due to hypertrophy and hypercontractile and dynamic obstruction of LV outflow tract
cardiac catheterisation shows pressure difference between aorta and LV
What is the treatment of HOCM?
B blockers and CCB to treat symptoms Amiodarone if patient has symptoms Anticoagulation must be considered if the patient goes into AF Surgical septal myectomy Consider ICD
What are the causes of HF?
Ischaemic heart disease Non ischaemic heart disease Alcohol Valvular disease Hypertension Congenital heart disease Hyper-dynamic circulation - increased heart rate leading to failure from over load such as thyrotoxicosis, anameia and pagets disease
What are the CXR changes for HF?
Alveolar oedema kerley B lines Cardiomegaly Upper lobe diversion Effusion Fluid in fissures
What are the signs and symptoms of left sided heart failure?
Fatigue SOB Orthopnoea and PND Displaced apex beat Gallop rhythm pink frothy sputum - pulmonary oedema
What are the signs and symptoms of right heart failure?
Fatigue SOB anorexia and nausea increased JVP displaced Apex beat hepatosplenomegaly pitting oedema and ascites
What tests should be carried out on someone with suspected heart failure?
CXR- look for signs of HF
FBC- anaemia may worsen
U&Es- rule out renal cause of symptoms and check for damage
BNP - marker of heart failure
ECHO- degree of ventricular dysfunction and calculate ejection fraction
Outline the management of heart failure
1st line - ACEI and B blocker
> nitrates and hydralazine is an alternative 1st line therapy
2nd line - add spironolactone
Duiretics used to relive symptoms - start with loop and add thiazide if ineffective
consider anticoag as increased risk
Can give drugs that enhance the function of BNP - Sacubatril Valsartan
Treat underlying anaemia
Non pharmacological management - surgcial revascularisation, pacemaker, heart transplant and LVAD or CRT-D
What are the causes of acute heart failure?
MI , HTN , AS, infection or thyrotoxicosis
How does acute left ventricular failure present?
Acute pulmonary oedema - acute dsypnoea, cough, pink frothy sputum, orthopnea, PND, collapse
signs - pallor, sweaty, crepitation
What is the management of acute heart failure?
O2 if desaturating
Breathing - may need CPAP
Morphine helps to drive the fluid back into the vessels
Furosemide may help but be away of the blood pressure
What is the treatment pathway of a SVT?
A-E Valsalva Carotid sinus massage Adenosine Flecanide
What investigations should be done in a patient experiancing tachycardias?
TFT, anaemia, drugs and U&Es ECG 24 hour tapes Exercise stress tests ECHO- look for valve disease or structural heart abnormalities
What is the definition of a broad and narrow complex?
120 ms of QRS
Explain the dosing of adenosine and how it works
6mg - 12mg - 12mg
Blocks the AVN and wears off after about 20 seconds
contraindicated in asthmatics
What is a major contraindication for flecanide?
Any structural heart disease or previous MI
How do we classify AF?
Paroxsymal
Persistent
Permanent
What are the signs of AF on an ECG??
no P waves
irregularly irregular QRS of different heights
What is meant by rate or rhythm controlled AF?
Rate controlled - use B blocker or CCB (f fails digoxin or amiodarone)
Rhythm controlled - if symptomatic, CCF, younger- use DC cardioversion or flecanide
Which type of drugs is preferred for anticoagulation and when is this contraindicated?
NOACs such as apaxibam
those with metallic valve replacements
What is seen on ECG in atrial flutter?
Saw tooth baseline and variable passage into the ventricles
usually a rate of division by 300
What would indicate the need to cardiovert a patient in a ventrcular arrhthymia?
haemodynamically compromised - <90 SBP, MI or HF including pulmonary oedema
What is the specific management for torsades de point?
Iv magnesium sulphate
What is the definition of bradycardia?
<60bpm
What conditions have an increased risk of asystole and how should this be managed?
Complete heart block with wide QRS
recent asystole
ventricular pause >3 seconds
Mobitz type 2 AV block
should have a pace maker fitted ASAP
What is sick sinus syndrome?
sinus node fibrosis
burst of tachy and then brady
What is the management of sick sinus syndrome?
Permenant pace maker
Anti arrhythymics for tachycardia
assess for anticoag if in AF sometimes
What are the causes of mitral stenosis?
rheumatic fever, old age and calcification
What are the signs and symptoms of mitral stenosis?
AF, malar flush, raised JVP, oedema/ascites, palpitations
mid diastolic murmur that is best heard at the apex with patient lying on left hand side
What are the signs of mitral stenosis on ECG?
bifid p waves
AF
RAD
What are the causes if MR?
rheumatic fever, papillary muscle rupture post MI, cardiomyopathy
What are the S&Ss of MR?
Dyspnoea, fatigue and palpitations
malar flush
palpable thrill
pan systolic murmur radiating to the axilla
What are the causes of AS?
bicuspid valve, age related calcification and rheumatic fever
What are the S&S of AS?
exercise induced syncope
dyspnoea,
angina
slow rising pulse with narrow pulse pressure
ejection systolic murmur radiating to the carotids
What is the treatment for AS and when is it indicated?
Sx- valve replacement in severe disease (in those where surgery is contraindicated can do TVAR)
ASx- observation and no treatment needed unless valvular gradient >40mmHg with features of LVF - consider surgery
Causes of AR?
rheumatic fever, bicuspid valve, IE, marfans and SLE
S&S of AR?
Collapsing pulse with wide pulse pressure
head nodding with each pulse
nail bed capillaries pulsating
pistol shot femorals
early diastolic murmur best heard at L sternal edge in held expiration
What are the features on ECG that suggest VT?
Rapid broad complex tachycardia
Concordance
Fusion and capture beats
AV dissociation
What vessel supplies the electrical system of the heart and what is the consequence of this?
Most commonly the right coronary artery
Inferior MI can lead to heart block and conduction problems.
What is a normal ejection fraction?
50-70%
What is the difference between LV systolic heart failure and diastolic heart failure?
Systolic heart failure is where the heart is failing to pump and the ejection fraction is reduced.
Diastole HF- the heart fails to relax and therefore doesnt fill so although cardiac output is reduced the proportion out of the heart is the same.
