Medicine 1 Flashcards by Akash Srinivasan

List the cardiac causes of clubbing.

Infective endocarditis
Congenital cyanotic heart disease
Atrial myxoma

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What causes the four heart sounds?

S1: mitral valve closure
S2: aortic valve closure
S3: rapid ventricular filling of dilated left ventricle
S4: atrial contraction against stiff ventricle

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What murmur is caused by aortic stenosis?

Ejection systolic murmur loudest in the right 2nd ICS heart best when sitting forward and in end expiration
Radiates to the carotids
Soft S2 and presence of S4 indicates severity

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How does aortic sclerosis differ from aortic stenosis on examination?

No radiation to the carotids
Normal pulse character

NOTE: HOCM is another differential for an ejection systolic murmur

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List some causes of aortic stenosis.

Senile calcification
Bicuspid aortic valve (2% of population)
Rheumatic heart disease

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What are the main symptoms of severe aortic stenosis?

Syncope
Angina
Dyspnoea (this carries worst prognosis)

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List the echocardiogram features of severe aortic stenosis.

Pressure gradient > 40 mm Hg
Valve area < 1 cm^2
Jet velocity > 4 m/s

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Outline the management of aortic stenosis.

General: MDT, optimise cardiovascular risk, monitor with regular follow-up/echos, treat angina (BB) and heart failure (ACEi + BB)
Surgical valve replacement
TAVI (effective in older/frail patients who are not fit for open repair)
Balloon valvuloplasty is an alternative to TAVI (NOTE: effect reduces after 1 year)

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What are the benefits of TAVI compared to open repair?

Heart does not need to be stopped and heart-lung bypass is not necessary
Avoids large thoracotomy scar
Less strain on body (so better for frail patients)

NOTE: it is associated with a higher risk of stroke

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What murmur is caused by mitral regurgitation?

Pansystolic murmur heard loudest at the apex in the left lateral position at end-expiration
Radiates to the axilla

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What are some clinical signs of mitral regurgitation?

Displaced apex 
Apical thrill 
Quiet S1
Pansystolic murmur radiating to the axilla 
S3 (rapid ventricular filling) 
Look for valvulotomy scar

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List some causes of mitral regurgitation.

LV dilatation (e.g. hypertension, connective tissue disorders)
Annular calcification
Rheumatic heart disease
Mitral valve prolapse

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What are some echocardiogram features of severe mitral regurgitation?

Regurgitant volume > 60 mL

Systolic pulmonary flow reversal

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Outline the management of mitral regurgitation.

General: MDT, risk factor modification
AF - rate control and anticoagulation
Reduce afterload (ACEi, BB, diuretics)
Valve replacement (if symptomatic)

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What murmur is caused by aortic regurgitation?

High-pitched early diastolic murmur loudest at the lower left sternal edge when sitting forward in end-expiration

NOTE: can cause Austin-Flint murmur (rumbling mid-diastolic murmur due to regurgitant blood hitting the mitral valve)

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List some causes of aortic regurgitation.

Bicuspid aortic valve 
Rheumatic heart disease 
Ankylosing spondylitis 
Rheumatoid arthritis 
Connective tissue disease (Marfan's, Ehlers-Danlos) 
Infective endocarditis 
Type A aortic dissection

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Outline the management of aortic regurgitation.

General: MDT, risk factor modification
Reduce afterload (ACEi, BB, diuretics) 
Surgical valve replacement (if symptomatic or LV dysfunction)

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What murmur does mitral stenosis cause?

Loud S1 (opening snap) and rumbling mid-diastolic murmur heard loudest at the apex in the left lateral position in end-expiration with the bell
Radiates to the axilla

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What are some signs of mitral stenosis?

Malar flush (severe)
AF
Tapping apex beat (palpable first heart sound)
NON-displaced apex beat
Right ventricular heave
Blowing mid-diastolic murmur with presystolic accentuation (if not in AF)

NOTE: tends to be middle-aged women who had rheumatic fever in childhood

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List some causes of mitral stenosis.

Rheumatic heart disease (MOST COMMON)
Senile degeneration
Endocarditis
Congenital

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Outline the management of mitral stenosis.

Consider rheumatic fever prophylaxis (pen V)
AF rate control and anticoagulation
Surgical: percutaneous balloon valvuloplasty (FIRST LINE provided valve mobile and not calcified)
Alternative: valvotomy or replacement

NOTE a TOE to check for a left atrial mural thrombus should be performed before intervention

What is the Duckett-Jones criteria for rheumatic heart disease?

MAJOR 
- joints (arthritis)
- carditis 
- nodules subcutaneous 
- erythema marginatum 
- Sydenham's chorea 
MINOR
- Fever 
- High ESR or CRP 
- Arthalgia
- Prolonged PR interval 
- Previous rheumatic fever

Rheumatic heart disease if 2 major or 1 major + 2 minor

Outline the management of rheumatic fever.

Bed rest 
Ben pen 1.2 mg IM for 10 days 
Analgesia for carditis/arthritis: aspirin/NSAIDs 
Consider oral prednisolone if CCF 
Consider diazepam for chorea

Outline the secondary prevention of rheumatic fever.

900 mg Benzathine benzylpenicillin every 3-4 weeks IM for 10 years

What is the difference between acute and subacute endocarditis?

Acute: normal valves --> caused by S. aureus and S. epidermidis --> RF: IVDU, skin wounds, immunosuppression Subacute: abnormal valves --> caused by S. viridans, S. bovis, HACEK --> RF: prosthetic valves, damages valves

List some clinical features of infective endocarditis.

``` Petechiae (common) Splenomegaly (common) Clubbing Splinter haemorrhages Janeway lesions Osler's nodes Fever Roth spots Haematuria ```

Which murmurs are most commonly associated with infective endocarditis?

Mitral regurgitation | Aortic regurgitation

Outline the Duke criteria for infective endocarditis.

MAJOR - +ve blood culture (typical organism in 2 cultures or persistently positive cultures) - endocardial involvement (positive echo (e.g. vegetation), new valvular regurgitation) MINOR - predisposition (cardiac lesion, IVDU) - fever - emboli (e.g. Janeway lesions) - immune phenomena (e.g. Osler's nodes) - +ve blood culture not meeting major criteria For diagnosis: 2 major OR 1 major + 3 minor OR 5 minor

Outline the management of infective endocarditis.

Acute Severe: flucloxacillin/vancomycin + gentamicin IV | Subacute: benzylpenicillin + gentamicin IV

What might you see on general inspection of a patient with a valve replacement?

``` Audible valve click Bruising (anticoagulation) Warfarin alert bracelet Anaemia Midline sternotomy (CABG, open valve replacement) +/- saphenous vein sampling Neck scars from line insertion Femoral/radial scars from angiography ```

Name three different types of prosthetic valve.

Starr-Edwards - 3 artificial sounds Tilting disc (Bjork-Shiley) or bileaflet (St. Jude) - 1 artificial sound Bioprosthetic - normal heart sounds NOTE: bileaflet valves are most commonly used

How might mitral valve replacements sound different from aortic valve replacements?

Aortic: Lub-Click (systolic flow murmur) Mitral: Click-Dub (diastolic flow murmur)

What might a lateral thoracotomy scar be due to?

Mitral valve replacement Mitral valvotomy Coarctation repair Blalock-Taussig shunt

What might leave a subclavicular scar in cardiology?

Pacemaker | ICD

What is a scar in the antecubital fossa of a cardiology patient suggestive of?

Angoigraphy

Which cardiothoracic procedures may be done through a midline sternotomy?

CABG Aortic valve replacement Mitral valve replacement

Outline the factors considered when deciding on a type of valve replacement.

METAL: durable, needs lifelong warfarin, better for young patients or patients who are already on warfarin (e.g. for AF) PORCINE: less durable (10 years), no need for warfarin, better for elderly/at risk of haemorrhage NOTE: porcine also known as Carpentier-Edwards valves

List some complications of valve replacement.

Thromboembolus Bleeding (due to warfarin) Bioprosthetic dysfunction and LVF (usually within 10 years but can be treated percutaneously by valve in valve) Haemolysis Infective endocarditis (S. viridans, S. epidermidis) Atrial fibrillation (particularly mitral valve replacement)

How can any murmur be made louder in a patient?

Make them exercise

List some causes of atrial fibrillation.

``` Ischaemic heart disease Valvular pathology (mainly mitral) Rheumatic heart disease Thyrotoxicosis Pneumonia PE Post-op Electrolytes (e.g. hypokalaemia) Alcohol ```

Which investigations are useful for identifying a cause of AF?

``` FBC (infection) U&E (K+) TFTs (hyperthyroid) Troponin D-dimer CXR (pulmonary oedema, pneumonia, calcified mitral valve) Echo (valve pathology, LV function) ``` NOTE: important differential is multiple ventricular ectopics

How can ventricular ectopics be clinically distinguished from AF?

Exercise the patient AF: pulse remains irregularly irregular VE: as heart rate increases, pulse becomes regular (closes the window for ventricular ectopics)

What is the difference between paroxysmal, persistent and permanent AF?

Paroxysmal: < 7 days and self-terminates Persistent: > 7 days and requires cardioversion Permanent: > 1 year or when no further attempts to rhythm control are made

What CHADS-Vasc score requires warfarinisation?

1 or more

How should a patient with acute AF presenting < 48 hours of onset be managed?

1st line: rhythm control (DC cardioversion or chemical cardioversion (flecainide or amiodarone)) Start LMWH Rate control (BB, CCB, digoxin) NOTE: rhythm control is first line in younger patients, first episode AF and when there is an obvious precipitant to the AF

Which medications should be used in the management of paroxysmal AF?

Prevention: bisoprolol or sotalol | Pill in the pocket: flecainide or amiodarone

How should patients presenting more than 48 hours after the onset of AF be managed?

3 weeks of warfarin (and rate control) before cardioversion | Can be done earlier if a TOE excludes a mural thrombus

List some contraindications of warfarin.

``` Bleeding tendency Compliance issues (dosing/monitoring) Risk of falls Peptic ulcer disease Pregnancy ```

List some complications of warfarin.

Bleeding | Osteoporosis

List some indications for permanent pacing.

``` Complete AV block Mobitz type 2 Symptomatic bradycardia Drug-resistant tachyarrhythmias Biventricular pacing in chronic heart failure ```