Medicine - Cardiology Flashcards
Recall 2 observations about a person’s pulse that may be seen if they have aortic stenosis vs aortic regurgitation
Aortic stenosis: NARROW pulse pressure, slow rising pulse
Aortic regurgitation: WIDE pulse pressure, ‘waterhammer’ pulse (Corrigan’s pulse)
Pulse pressure = SBP-DBP (eg if BP = 120/80, PP = 40)
How would you describe the heart sounds that are auscultated in aortic stenosis vs regurgitation?
Aortic stenosis = soft S2 +/- S4
Aortic regurgitation = soft S2 +/- S3
What is the difference in cause between an S3 and S4 heart sound?
S3 heart sound is caused by blood filling against a non-compliant ventricle, whereas S4 is blood filling against a compliant ventricle
How can you hear the difference between an S3 and S4 heart sound?
S3 is early diastolic
S4 is late diastolic
What clinical examination findings can help differentiate aortic stenosis caused by valve sclerosis from aortic stenosis caused by HOCM?
In HOCM, the valsalva manoevre increases the volume of the murmur, whereas squatting decreases it
What might a CXR reveal in aortic stenosis?
Left ventricular hypertrophy
Pulmonary oedema
Valve calcification
What is the most useful investigation for assessing the severity of aortic stenosis?
Echo +/- doppler
Recall some general principles of management of heart valve disease
QRISK3 score to stratify risk
Manage risk with a statin (eg atorvastatin) and an antiplatelet (aspirin/ clopidogrel)
Manage coexistent HTN/ angina etc
Recall some indications for open replacement of the aortic valve (rather than cath lab procedure)
Symptomatic
Non-symptomatic with a low EF
Severe undergoing CABG
What does CABG stand for?
Coronary artery bypass graft
What are the 2 main types of artificial aortic valve?
Ball-in-cage
Bileaflet/ tilting disc
Recall some pros and cons of TAVI
Pros: no bypass required, no large scars
Cons: higher risk of stroke compared to open replacement
What is a balloon aortic valvuloplasty
Procedure which stretches the aortic valve to improve symptoms of aortic stenosis
When is the aortic stenosis murmur heard vs aortic regurgitation?
AS: Ejection systolic
AR: Early diastolic
What is an Austin Flint murmur?
‘Rumbling diastolic murmur’
- Associated with severe aortic regurgitation
- Best auscultated in 5th ICS in MCL
- Caused by blood flowing back through the aortic valve and over the mitral valve
When in the heart cycle is an Austin flint murmur heard, and what causes it?
Mid-diastole
Caused by regurgitant jet that runs over the mitral valve leaflets
Which heart murmurs are best heard on expiration?
Left heart murmurs
Where is the aortic regurgitation murmur best auscultated?
Erb’s point - Left 3rd ICS parasternal
Where is the main site of production of BNP?
Left ventricle (not actually brain, as name may suggest)
What is the advantage of measuring NT-proBNP over BNP?
NT-proBNP has a much longer half life as it is inactive - BNP, being an active hormone, has a much shorter half life
What can an echo and doppler be used to determine in cases of aortic regurgitation?
Severity
LV function
Cause
What is the mainstay of medical management for aortic regurgitation (other than managing cardiac risk with statins etc)?
Reduce afterload - can use:
ACE inhibitors (eg enalopril/ captopril)
Beta blockers (bisoprolol etc)
Diuretics (furosemide etc)
Which 2 antihypertensives are contra-indicated in aortic stenosis?
Beta blockers (don't want to depress LV function) Nitrates (may precipitate life-thretening hypotension)
Which heart murmur is most associated with atrial fibrillation?
Mitral stenosis
Which of the left heart murmurs will NOT produce a displaced apex beat?
Mitral stenosis (causes atrial hypertrophy not ventricular)
By what mechanism can heart valve disease cause a parasternal heave, and which murmurs can cause this?
Right ventricular hypertrophy (RVH) is cause of PSH (right ventricle is most anterior chamber of the heart so can cause heave)
MS and MR can cause RVH - as increased left atrial pressure –> pulmonary HTN –> RVH
Why might the apex beat be displaced in mitral regurgitation?
Left ventricle is pumping the stroke volume AND the regurgitant volume
Differentiate the timing of mitral stenosis and mitral regurgitation
Mitral stenosis is a MID DIAstolic murmur
Mitral regurgitation is a pan SYStolic murmur
Which of the heart murmurs might radiate to the axilla?
Mitral regurgitation
Recall some clinical signs of pulmonary hypertension
Malar flush
Raised JVP
Right ventricular (parasternal) heave
Loud S2
What might be seen on an ECG in mitral valve disease
Atrial fibrillation P mitrale (bifid 'm-shaped' p waves in lead II as well as V1-V6)
What is the mainstay of medical management for mitral stenosis, other than heart disease risk modification eg statins?
RhF prophylaxis with benzylpenicillin
AF (rate control + DOAC)
Diuretics for symptomatic relief
What is the first line surgical treatment for mitral stenosis?
Balloon valvuloplasty
What is the mainstay of medical management for mitral regurgitation (other than managing cardiac risk with statins etc)?
Like AR, reduce afterload - can use:
ACE inhibitors (eg enalopril/ captopril)
Beta blockers (bisoprolol etc)
Diuretics (furosemide etc)
Describe briefly the NYHA classifications
1 - no limitation on activity
2 - comfortable at rest but dyspnoea on ordinary activity
3 - marked limitation on ordinary activity
4 - dyspnoea at rest
Recall the broad approach to medically managing heart failure
BASHeD up by the heart:
(Beta blocker or
ACE inhibitor)
Spironolactone
Hydralazine (+ nitrate)
Digoxin
Which extra immunisations should be offered in patients with heart failure?
Annual influenza
Pneumococcal
What must be monitored whilst patients are on spironolactone?
Potassium (as is a potassium-sparing diuretic)
Recall some drugs that are contra-indicated in heart failure
Thiozolidinediones (type 2 diabetes)
Verapamil (as is negative inotrope)
NSAIDs (can cause fluid retention)
Glucocorticoids (can cause fluid retention)
Flecainide (negative inotrope, arrhythmogenic)
How quickly should GTN spray relieve angina pain?
Within 5 minutes
What is the first line investigation for angina in stable patients, and what score is this investigation used to calculate?
CT coronary angiography
Calcium score
What are some pharmacological options for preventing angina (NOT symptomatic relief)?
Aspirin (75mg, OD)
Atorvastatin (80mg, ON)
ACE inhibitor (especially if co-existent DM)
Antihypertensives
What calcium score would be classified as low risk, and what score would be high risk?
Low risk < 100
High risk > 400
What care needs to be taken when prescribing CCBs and BBs together?
If you prescribe a non-dihydropyrimidine CCB (eg verapamil) with a BB it can cause complete heart block
What are some medical options for managing angina symptoms?
1st line: GTN (spray or sublingual) + beta blocker or CCB (if CCB used as monotherapy, use a rate limiting one like verapamil or dilitiazem)
2nd line: GTN + BB AND CCB
3rd line options:
- Long-acting nitrates eg Isosorbide mononitrate
- Ivabradine
What are the 3 types of AF?
Acute (<48 hours)
Paroxysmal (self-limiting, <7 days, recurs)
Persistent (>7 days, may recur even after cardioversion)
How does anti-clotting drug choice differ following a stroke, depending on whether or not they have AF?
If they have AF –> anti-coagulant (DOAC or warfarin if DOAC is CI)
If they do NOT have AF –> anti-platelet
Why are anti-platelets not used in AF?
Anti-platelets are specifically for artherogenic causes of clots eg atheroma
Within what window of AF beginning can it be treated differently to longer-standing AF? What is this different treatment? Why is it so difficult to treat within the initial window of time?
AF <48 hours duration and HAEMODYNAMICALLY UNSTABLE can be cardioverted electrically
Difficult to establish onset of AF as patient may not have palpitations, or may be unsure as to when they started
For how long before and after cardioversion for arrhythmia should a patient be anti-coagulated?
3w before and 4w after OR lifelong (if CHA2DS2VASc high or if paroxysmal AF)
How can chadsvasc score be used to determine the need for longterm anticoagulation?
Score:
0 = no need for longterm anticoagulation
1 = anticoagulate if male, do not anticoagulate if female
2 or more: anticoagulate
What is the main contraindication to be aware of for all CCBs?
Peripheral oedema (increased capillary hydrostatic pressure that results from greater dilation of pre-capillary than post-capillary vessels)
What are the 1st, 2nd and 3rd line options for rate control in AF?
1st line: beta blocker or CCB (verapamil is better than dilitiazem)
2nd line: digoxin
3rd line: amiodarone
With what waveform on the ECG should DC cardioversion be synchronised?
R wave
If synchronised with T wave it can cause VT
Recall 2 options for chemical cardioversion, and any important indications/ contra-indications for each
Flecainide - if young and no structural heart disease
Amiodarone - in structural heart disease (eg HF)
Recall 2 surgical options for managing AF
- Radiofrequency ablation of AV node
- Maze procedure
Recall the components of the CHA2DS2VASc score
CHF
HTN
Age >75
DM
Stroke
Vascular disease
Age 65-74
Sex Category (female)
In HTN, what BP is defined as ‘severe’?
>180/110
What is the first line treatment for HTN for diabetics?
ACE inhibitor
What is the first line treatment for HTN for black Africans?
CCB
What is the first line treatment for HTN for under vs over 55s who are not diabetic or Black African?
Under 55: ACE inhibitor or ARB
Over 55: CCB
Recall some side effects of ACE inhibitors
Angioedema (for around 4 weeks), cough, hyperkalaemia
Recall the name of one thiazide-like diuretic
Indapamide
nb bendoflumethiazide is thiazide, not thiazide-like
Why do CCBs cause oedema?
Cause dilation of arterioles but not venules
What is the atorvastatin dose for primary vs secondary prevention?
Primary prevention: 20mg OD
Secondary prevention: 80mg OD
What is the most commonly affected heart valve in infective endocarditis when the patient is an IVDU?
Tricuspid
What is the most common pathogen to cause an acute presentation of infective endocarditis?
Strep epidermidis
How does strep viridans infective endocarditis most commonly present?
Subacute presentation, most commonly in the developing world
What is Libman-Sacks endocarditis?
Non-infective endocarditis caused by SLE
Differentiate the empirical antibiotics used in native vs prosthetic valves affected by infective endocarditis
Native valve: amoxicillin +/- gentamicin
Prosthetic valve: vancomycin + rifampicin + gentamicin
How far apart should blood cultures be taken to investigate infective endocarditis?
12 hours
What is the most likely pathogen to cause rheumatic fever?
GAS (strep pyogenes)
What is the broad pathophysiology of rheumatic fever?
AB cross reactivity with myosin, muscle glycogen and VSMC
What is the latent period between pharyngeal infection and onset of rheumatic fever?
2-6 weeks
Recall some of the key symptoms of rheumatic fever
Pericarditis
Polyarthritis
Erythema marginatum
What are sydenham’s chorea?
Unwanted jerky movements that appear 2-6 months following rheumatic fever
Recall the Duckett-Jones diagnostic criteria
For diagnosing rheumatic fever:
CASES (major) FRAPP (minor)
Carditis
Arthritis
Sydenham’s chorea
Erythema marginatum
Subcutaneous nodules
What is the antibiotic treatment recommended in rheumatic fever?
Phenoxymethylpenicillin QDS 10/7
What drugs can be used to treat sydenham’s chorea?
Haloperidol
Diazepam
How long does penicillin treatment need to continue following an episode of rheumatic fever to prevent rheumatic heart disease?
If carditis and residual heart disease: 10 years or until age 40 (whichever is longer), possibly lifetime
If carditis but NO residual heart disease: 10 years or until age 21 (whichever is longer)
If NO carditis: 5 years or until age 21 (whichever is longer)
What is ‘fibrinous’ pericarditis?
Pericarditis caused by uraemia