Revision List CVS Flashcards
1
Q
What is infective endocarditis
A
Infection of the heart valves and or other endothelium lined structures
2
Q
Types of IE
A
Left sided native IE
Left sided prosthetic IE
Right sided IE
etc
3
Q
At risk populations for IE?
A
IVDU Poor dental hygiene Prosthetic valves Young with congenital heart disease Elderly Rheumatic heart disease
4
Q
Organisms that cause IE
A
S. viridans
S. aureus/epidermidis
Diptheroids
5
Q
Symptoms of IE
A
Fever
Night sweats
Weight loss
6
Q
Signs of IE
A
Petechiae Osler's nodes Roth spots Splinter haemorrhages Janeway lesions
7
Q
Criteria used to diagnose IE?
A
Modified Duke’s Criteria
8
Q
Major Criteria for IE?
A
- Positive blood culture
2. Echo evidence of IE/new valve leak
9
Q
Minor Criteria for IE?
A
- Predisposing factors: heart condition/IVDU
- Fever>38
- Vascular phenomena esp. emboli
- Immunological phenomena: glomerulonephritis, osler’s nodes
- Equivocal blood culture = +ve but not notable
10
Q
How many of each criteria is diagnostic for IE?
A
2 majors
1 major 3 minor
5 minors
11
Q
Investigations for IE
A
- FBC: raised ESR/CRP, neutrophilia, normochromic normocytic anaemia + Blood CULTURES
- Urinalysis: haematuria
- CXR: cardiomegaly
- ECG: long PR intervals, regular
- Echocardiogram - Transthoracic and transoesophageal
12
Q
Advantages and disadvantages of TTE?
A
Non invasive so less discomfort
Poor sensitivity images
13
Q
Advantages and disadvantages of TOE?
A
Greater sensitivity - can look for mitral lesions and aortic root abscess
But… discomfort due to insertion AND risk of perforation and aspiration
14
Q
Treating IE?
A
Abx for 6 weeks
Staphylococci - rifampicin/vancomycin
Others - penicillin
15
Q
When do you operate in IE?
A
Recurrent infection despite Abx treatment
16
Q
What surgical procedures are possible to help treat IE?
A
Removed infected prosthetic/Devices
Remove large vegetations before emboli
17
Q
What are the 3 types of aortic stenosis? Most common?
A
Supravalvular
Subvalvular
Valvular - most common
18
Q
Example of supravalvular aortic stenosis
A
congenital fibrous diaphragm above the aortic valve
19
Q
Example of subvalvular aortic stenosis
A
Congenital fibrous diaphragm/ ridge below aortic valve
20
Q
Acquired causes of aortic stenosis?
A
Rheumatic HD
Degenerative calcification - MOST common
21
Q
Congenital causes of aortic stenosis?
A
Congenital aortic stenosis
Congenital bicuspid valve
22
Q
Congenital aortic stenosis is commonly associated with?
A
Coarctation, dissection and aneurysm of aorta
23
Q
Pathophysiology of aortic stenosis?
A
Narrowing of aorta - increased pressure gradient to LV - initially compensated by LVH but then exhausted –> function declines –> failure.
24
Q
Clinical presentation of aortic stenosis?
A
Chest pain
Syncope
Dyspnoea
25
What may you found on examining a patient with aortic stenosis?
1. Pulsus Tardus
2. Pulsus Parvus
3. 2nd HS = soft/absent
4. 4th HS = prominent due to LVH
5. Ejection systolic murmur - crescendo/decrescendo
26
What investigations may be used to analyse aortic stenosis?
1. Echo: Left ventricular size/function and doppler derived gradient and valve area measured
2. ECG: LVH, left atrial delay, left ventricular strain
3. CXR: LVH, calcified aortic valve
27
How does LVH present on ECG?
S in V1/V2 >30mm
R in V5/6 >30mm
Left axis deviation
Prolonged QRS
28
Management of aortic stenosis?
1. Maintain good dental hygiene - IE risk
2. Surgical aortic valve replacement
3. Transcatheter aortic valve implantation - crack and insert stent
29
What is contraindicated in aortic stenosis?
vasodilators are contraindicated as it my trigger hypotension and syncope
30
Indications of aortic valve replacement?
1. Symptomatic patient with severe aortic stenosis
2. Decreased ejection fraction
3. Undergoing CABG with moderate AS
31
Mitral regurgitation aetiology?
Abnormalities of valve leaflets:
1. Myxomatous degeneration - most common - weakening of chordae tendinae -> floppy mitral valve
2. Ischaemic mitral valve
3. Rheumatic heart disease
4. IE
5. Dilated cardiomyopathy
32
Pathophysiology of mitral regurgitation?
Backflow of blood --> atrium --> left atrial enlargement and LVH as heart has to increase contractility to increase SV and maintain CO.
Pulmonary HTN --> RV dysfunction
Progressive HF ReF a.k.a systolic HF.
33
Symptoms of mitral regurgitation
Fatigue
Dyspnoea
Lightheaded??
34
Signs of Mitral regurgitation?
1. Pansystolic murmur at apex --> radiate to axilla S3 HS
35
Investigations in MR?
1. ECG: LVH, LA enlargement
2. CXR: LA enlargement, central pulmonary artery enlargement
3. ECHO: estimation of LA/LV size and function `
36
Management of MR?
1. Medication:
a. Vasodilation - ACEi/hydralazine
b. Betablockers/Digoxin/CCB - rate control for AF
c. Diuretics for fluid overload
2. IE prophylaxis
3. Surgery if criteria fulfilled
37
When to Surgery in MR?
1. EF<60 or LVESD> 45mm
2. Symptoms at rest/exercise
3. New onset AF/increase PaP
38
What is aortic regurgitation?
Leakage of blood back into LV during diastole valve due to ineffective capitation of aortic cusps.
39
Aetiology of aortic regurgitation?
1. Bicuspid aortic valve congential
2. Rheumatic heart disease
3. IE - acute
40
Effects of aortic regurgitation?
Increase LV size, dilation and hypertrophy
Progressive dilation --> HF
Regurgitation --> diastolic blood pressure --> cardiac ischaemia
41
Physical exams findings of AR?
1. Wide pulse pressure
2. hyper dynamic and displaced apical impulse
3. Diastolic blowing murmur at left sternal border
4. Austin flint murmur (apex)
5. Systolic ejection murmur -> increased aortic valve
42
Clinical presentation of AR?
Progressive dyspnoea - exertional, orthostatic, paroxysmal nocturnal dyspnoea
Palpitations --> increase force of contractions
43
Investigation of AR?
Echo
CXR
ECG: LVH - tall R waves, deeply inverted T waves
44
Treating AR?
1. IE prophylaxis
2. Vasodilators
3. Serial echocardiogram to monitor progress
4. Surgical Tx: valve replacement.
45
Indications for AR surgery?
Any symptoms at rest or exercise
| EF <50% / LV dilated
46
Aetiology of MS?
Rheumatic HD
IE
Mitral annular calcification
47
Pathophysiology of MS?
To maintain CO --> LA dilation/hypertrophy --> pulmonary congestion --> progressive dyspnoea
Increased transmural pressures --> LA enlargement/fibrillation
Pulmonary venous hypertension --> right heart failure symptoms
Haemoptysis --> due to elevated pulmonary pressure --> rupture of bronchial vessels
48
Signs of MS?
1. 'A' wave in jugular venous pulsations due to pulmonary HTN and RVH
2. RHF signs
3. Mitral facies --> bilateral, cyanotic or dusty pink/purple colouration on cheek patches
4. Diastolic murmur - low pitched, patient lean to left
5. Loud opening S1 snap : apex due to abrupt halt in leaflet movement in early diastole
49
Management of MS?
Serial echocardiography
2. Medical: beta blockers, CCB, Digoxin = improve diastolic filling, diuretics for fluid overload
3. Mitral valve replacement/percutaneous mitral valve balloon valvotomy
50
Define acute pericarditis
Acute inflammation of the pericardium with or without pericardial effusion.
51
What can causes of the pericarditis be divided into?
1. Infectious
| 2. Non-infectious
52
What are infectious causes of pericarditis?
1. Viral - most common:
- Enterovirus, Herpes virus, adenovirus
2. Bacterial: M. tuberculosis
3. Fungal: histoplasma species - more likely in immunocompromised patients
53
What are non-infectious causes of pericarditis?
1. Autoimmune - RA, Sjorgren's, scleroderma
2. Neoplastic: secondary and metastatic tumours
3. Metabolic: uraemia, myxoedema
4. Traumatic/iatrogenic
54
Describe early onset iatrogenic cause of pericarditis?
1. Direct injury, penetrating thoracic injury/oesophageal
| 2. Indirect injury - non penetrating thoracic injury
55
Describe delayed onset iatrogenic cause of pericarditis?
1. Pericardial injury syndromes, iatrogenic trauma e.g. coronary percutaneous intervention
56
Describe other iatrogenic cause of pericarditis?
1. Amyloidosis
2. Aortic dissection
3. Pulmonary arterial hypertension
4. Chronic heart failure
57
5 symptoms of pericarditis?
1. Severe pleuritic chest pain
2. Dyspnoea
3. Cough
4. Systemic: antecedent fever, skin rash, joint pain, weight loss
58
Differential diagnosis of pericarditis?
1. Pneumonia
2. MI/ischaemia
3. GORD
4. PE/pneumothorax
59
Signs of pericarditis?
1. Pericardial rub - pathognomic - crushing snow
2. Sinus tachycardia
3. Fever
4. Pulsus paradoxus, Kussmaul's breathing
5. Beck's triad
60
What is pulsus paradoxus?
Decrease in systolic Bp > 10mmHg during inspiration
Due to: decrease intrathoracic and pericardial pressure, increase venous return to RA and RV - increase RA compliance so decreased LA/LV filling.
-- SIGN of tamponade
61
Kussmaul's breathing
Increase JVP on inspiration
62
Beck's triad?
1. Raised JVP
2. Hypotension
3. Muffled HS
63
How to diagnose pericarditis?
1. ECG - diffuse ST elevation - saddle shape, PR depression
2. Blood tests: FBC --> raised WCC, lymphocytes, ESR, CRP, troponin
3. CXR: often normal, may have pneumonia
64
Management of pericarditis?
1. Sedentary activity with resolution of symptoms/ inflammatory state
2. NSAIDs
3. Colchicine - 3 months reduces recurrence but limited by nausea and diarrhoea
65
What are major complications of pericarditis?
1. Fever >38degrees
2. Subacute onset
3. Large pericardial effusion
4. Cardiac tamponade
5. Lack of response to aspirin/NSAIDs
66
Minor complications of pericarditis?
1. Myopericarditis
2. Immunosuppression
3. Trauma
4. Oral anticoagulant therapy
67
What is pericardial effusion?
1. Collection of fluid within potential space of serous pericardial surface
68
Does pericardial effusion usually result in cardiac tamponade?
1. Chronic accumulation allows adaptation of parietal pericardium - compliance reduces effect on diastolic filling of chambers
69
What is cardiac tamponade?
Rapid fluid accumulation with enough pressure to adversely affect heart function.
Ventricular filling is compromised.
70
Clinical presentation of cardiac tamponade?
1. raised HR, low BP
2. Raised JVP
3. Muffled 1st and 2nd HS
4. Kussmaul's sign = raised JVP and neck vein distension during inspiration
5. Pulsus paradoxus
71
What is constrictive pericarditis?
1. Long term pericardial inflammation --> pericardium thickens, fibrotic, inelastic pericardium restricts cardiac filling and affects heart function.
72
Risk factors for peripheral vascular disease?
1. Smoking
2. Diabetes
3. Hypercholesterolaemia
4. Hypertension
5. Physical inactivity
6. Obesity
73
Clinical presentation of mild ischaemia (critical limb ischaemia)?
1. Stress induced physiological function
- exercise induced angina
- intermittent claudication
74
Clinical presentation of moderate ischaemia (critical limb ischaemia)?
1. Structural and functional breakdown
- ischaemic cardiac failure
- critical limb ischaemia --> rest pain, typically nocturnal, no reserve available for increased demand
- vascular dementia
75
Clinical presentation of severe ischaemia (critical limb ischaemia)?
1. Infarction - gangrenes/infection risk
76
Clinical presentation of intermittent claudication?
1. Muscle cramps on walking - calf, thigh, buttock
77
Clinical presentation of critical leg ischaemia?
1. Rest pain, ulceration, gangrene
78
Acute limb ischaemia clinical presentation?
```
Pale
Pulseless
Paraesthesia
Perishingly cold
Paralysis
Pain
```
79
General symptoms of peripheral vascular disease?
Absent femoral, popliteal or foot pulses
| Cold white legs
80
Diagnosis of peripheral vascular disease?
1. ESR/CRP
2. FBC --> exclude anaemia/polycythaemia
3. ECG to look for cardiac ischaemia
4. Ankle/brachial pressure index --> measure severity of disease
5. Colour duplex ultrasound
6. MR/CT angiography to assess extent and location of stenoses and quality of distal vessels
81
What is ABPI?
Measurement of cuff pressure at which blood flow is detectable by Doppler in the posterior tibial or anterior tibial arteries compared to brachial artery.
82
Treatment of peripheral vascular disease - risk factor modification?
1. Smoking cessation
2. Treat HTN, hyperlipidaemia and diabetes
3. Antiplatelet agent e.g. P2Y12 inhibitor
4. Exercise and weight loss
83
Treatment of peripheral vascular disease - revascularisation for critical ischaemia?
1. Percutaneous transluminal angioplasty
2. Bypass procedure
3. Amputation if severe
84
Treatment of PVD - - acute ischaemia?
1. Surgical emergency requiring revascularisation within 4-6 hours to save limb
2. Intra-arterial thrombolysis
3. Surgical removal of embolus
85
Intermittent claudication key features?
1. Ischaemic leg pain
2. Tissue suffering/not dying
3. Oxygen debt --> build up of lactic acid result in pain
86
Key features of critical ischaemia?
1. Tissue dying and suffering at rest
2. Blood supply is inadequate to allow basal metabolism
3. No reserve for increased demand
4. Nocturnal resting pain
5. Gangrene/ infection risk
