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YEAR 6: PACES > Medicine 1 > Flashcards

Medicine 1 Flashcards

1
Q

List the cardiac causes of clubbing.

A

Infective endocarditis
Congenital cyanotic heart disease
Atrial myxoma

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2
Q

What causes the four heart sounds?

A

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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3
Q

What murmur is caused by aortic stenosis?

A

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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4
Q

How does aortic sclerosis differ from aortic stenosis on examination?

A

No radiation to the carotids
Normal pulse character

NOTE: HOCM is another differential for an ejection systolic murmur

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5
Q

List some causes of aortic stenosis.

A

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

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6
Q

What are the main symptoms of severe aortic stenosis?

A

Syncope
Angina
Dyspnoea (this carries worst prognosis)

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7
Q

List the echocardiogram features of severe aortic stenosis.

A

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

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8
Q

Outline the management of aortic stenosis.

A

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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9
Q

What are the benefits of TAVI compared to open repair?

A

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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10
Q

What murmur is caused by mitral regurgitation?

A

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

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11
Q

What are some clinical signs of mitral regurgitation?

A 
Displaced apex 
Apical thrill 
Quiet S1
Pansystolic murmur radiating to the axilla 
S3 (rapid ventricular filling) 
Look for valvulotomy scar
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12
Q

List some causes of mitral regurgitation.

A

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

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13
Q

What are some echocardiogram features of severe mitral regurgitation?

A

Regurgitant volume > 60 mL

Systolic pulmonary flow reversal

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14
Q

Outline the management of mitral regurgitation.

A

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

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15
Q

What murmur is caused by aortic regurgitation?

A

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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16
Q

List some causes of aortic regurgitation.

A 
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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17
Q

Outline the management of aortic regurgitation.

A 
General: MDT, risk factor modification
Reduce afterload (ACEi, BB, diuretics) 
Surgical valve replacement (if symptomatic or LV dysfunction)
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18
Q

What murmur does mitral stenosis cause?

A 
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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19
Q

What are some signs of mitral stenosis?

A

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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20
Q

List some causes of mitral stenosis.

A

Rheumatic heart disease (MOST COMMON)
Senile degeneration
Endocarditis
Congenital

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21
Q

Outline the management of mitral stenosis.

A

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

22
Q

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

A 
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

23
Q

Outline the management of rheumatic fever.

A 
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
24
Q

Outline the secondary prevention of rheumatic fever.

A

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

25
Q

What is the difference between acute and subacute endocarditis?

A

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

26
Q

List some clinical features of infective endocarditis.

A 
Petechiae (common)
Splenomegaly (common)
Clubbing 
Splinter haemorrhages 
Janeway lesions 
Osler's nodes 
Fever 
Roth spots 
Haematuria
27
Q

Which murmurs are most commonly associated with infective endocarditis?

A

Mitral regurgitation

Aortic regurgitation

28
Q

Outline the Duke criteria for infective endocarditis.

A

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

29
Q

Outline the management of infective endocarditis.

A

Acute Severe: flucloxacillin/vancomycin + gentamicin IV

Subacute: benzylpenicillin + gentamicin IV

30
Q

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

A 
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
31
Q

Name three different types of prosthetic valve.

A

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

32
Q

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

A

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

33
Q

What might a lateral thoracotomy scar be due to?

A

Mitral valve replacement
Mitral valvotomy
Coarctation repair
Blalock-Taussig shunt

34
Q

What might leave a subclavicular scar in cardiology?

A

Pacemaker

ICD

35
Q

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

A

Angoigraphy

36
Q

Which cardiothoracic procedures may be done through a midline sternotomy?

A

CABG
Aortic valve replacement
Mitral valve replacement

37
Q

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

A

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

38
Q

List some complications of valve replacement.

A

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)

39
Q

How can any murmur be made louder in a patient?

A

Make them exercise

40
Q

List some causes of atrial fibrillation.

A 
Ischaemic heart disease 
Valvular pathology (mainly mitral)
Rheumatic heart disease 
Thyrotoxicosis 
Pneumonia
PE 
Post-op
Electrolytes (e.g. hypokalaemia) 
Alcohol
41
Q

Which investigations are useful for identifying a cause of AF?

A 
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

42
Q

How can ventricular ectopics be clinically distinguished from AF?

A

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

43
Q

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

A

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

44
Q

What CHADS-Vasc score requires warfarinisation?

A

1 or more

45
Q

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

A

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

46
Q

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

A

Prevention: bisoprolol or sotalol

Pill in the pocket: flecainide or amiodarone

47
Q

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

A

3 weeks of warfarin (and rate control) before cardioversion

Can be done earlier if a TOE excludes a mural thrombus

48
Q

List some contraindications of warfarin.

A 
Bleeding tendency 
Compliance issues (dosing/monitoring) 
Risk of falls 
Peptic ulcer disease
Pregnancy
49
Q

List some complications of warfarin.

A

Bleeding

Osteoporosis

50
Q

List some indications for permanent pacing.

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

YEAR 6: PACES (22 decks)

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