Medicine 1 Flashcards
List the cardiac causes of clubbing.
Infective endocarditis
Congenital cyanotic heart disease
Atrial myxoma
What causes the four heart sounds?
S1: mitral valve closure
S2: aortic valve closure
S3: rapid ventricular filling of dilated left ventricle (Kentucky, Most commonly caused by HFrEF, reduced EF means more blood left i.e. greater end diastolic volume and so after contraction blood from atria rushes into an already full LV)
S4: atrial contraction against stiff ventricle (Tenesse, chronic htn leads to LVH and atria contracting against a stiff hypertrophied LV causes this sound just before S1)
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. (tennesse) S4 is caused by atria contracting against stiff ventricle (due to hypertrophy from contracting against a higher afterload)
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
List some causes of aortic stenosis.
Senile calcification
Bicuspid aortic valve (2% of population)
Rheumatic heart disease
What are the main symptoms of severe aortic stenosis?
Syncope
Angina
Dyspnoea (this carries worst prognosis)
List the echocardiogram features of severe aortic stenosis.
Pressure gradient > 40 mm Hg
Valve area < 1 cm^2
Jet velocity > 4 m/s (speed of blood flow across valve)
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)
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
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
What are some clinical signs of mitral regurgitation?
Displaced apex (due to LVH) Apical thrill Quiet S1 Pansystolic murmur radiating to the axilla S3 (rapid ventricular filling) Look for valvulotomy scar
List some causes of mitral regurgitation.
Mitral valve prolapse (most common)
LV dilatation (e.g. hypertension, connective tissue disorders)
Annular calcification
Rheumatic heart disease
What are some echocardiogram features of severe mitral regurgitation?
Regurgitant volume > 60 mL
Systolic pulmonary flow reversal
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)
What murmur is caused by aortic regurgitation?
High-pitched early diastolic murmur loudest at the lower left sternal edge (erb’s point) when sitting forward in end-expiration
NOTE: can cause Austin-Flint murmur (rumbling mid-diastolic murmur due to regurgitant blood hitting the mitral valve)
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
Outline the management of aortic regurgitation.
General: MDT, risk factor modification Reduce afterload (ACEi, BB, diuretics) Surgical valve replacement (if symptomatic or LV dysfunction)
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
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
List some causes of mitral stenosis.
Rheumatic heart disease (MOST COMMON)
Senile degeneration
Endocarditis
Congenital
Outline the management of mitral stenosis.
Consider rheumatic fever prophylaxis (pen V)
AF rate control and anticoagulation
Surgical: percutaneous balloon valvotomy (FIRST LINE provided valve mobile and not calcified)
Alternative: 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
Diagnostic criteria:
1.evidence of recent strep infection (antibodies, throat swab or positive rapid GAS test) AND
2. 2 major or 1 major + 2 minor
Outline the management of rheumatic fever.
Bed rest
Penicillin V
Analgesia for carditis/arthritis: NSAIDs are first line
Outline the secondary prevention of rheumatic fever.
penicillin V often used after acute infection to prevent recurrence. Given for years and years..
What is the difference between acute and subacute endocarditis?
Acute: previously normal valves –> rapid deterioration caused by S. aureus and S. epidermidis –> RF: IVDU, skin wounds, immunosuppression
Subacute, more insidious onset: affects damaged valves –> caused by less virulent organisms e.g. 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
- blood cultures: 2x cultures on separate occasions positive for typical IE organisms eg staph aureus, strep viridans)
- echo evidence: vegitation or new murmur
MINOR
- predisposition (cardiac lesion, IVDU)
- fever
- Vascular phenomena - septic emboli, Janeway lesions, splinter haemorrhages, roth spots
- immune phenomena: osler
- +ve blood culture not meeting major criteria e.g. contains organisms that are not typical for IE
For diagnosis: 2 major OR 1 major + 3 minor OR 5 minor
Outline the management of infective endocarditis of the native valve
initial blind therapy: IV amoxicillin
but if confirmed staph - fluclox
if confirmed strep viridans - benzyl pencillin
if penicillin allergic for all 3 above scenarios = vancomycin
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 can be terminated with pharmacological or electrical cardioversion
Permanent: > 1 year i.e. AF that is continuous and cannot be converted back to normal sinus rhythm, or the decision is made to not attempt to restore sinus rhythm. e.g. long term AF who are rate controlled only but not rhythm controlled
What CHADS-Vasc score requires warfarinisation?
2 or more (consider if scores 1)
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 DOAC (warfarin if DOAC contraindicated) and rate control before elective 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.
Anything from Mobitz Type 2 and above needs pacing (i.e. mobitz 2 and complete AV block. This is because mobitz 2 can progress to complete block) Symptomatic bradycardia Drug-resistant tachyarrhythmias Biventricular pacing in chronic heart failure (HFrEF patients have ventricular dyssynchrony and dont beat efficiently, this improves efficiency of beating and make them coordinate together)
