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what are the signs on ECG of a posterior MI?
ST depression and tall R waves in V1 and V2
how is corrected QT calculated?
QT interval / square root of RR interval
what are low voltage QRS complexes caused by?
- increased haematocrit
what is the carotid pulse like in AS?
describe the apex beat of AS?
heaving but undisplaced
where is AS best heard and where does it radiate to? which phase of breathing is it best heard in?
- left sternal edge
- best heard in expiration
- radiates to carotids
name 4 causes of AS? (remember pneumonic)
- congenital bicuspid valve calcification
- rheumatic heart disease
- senile calcification of normal tricuspid valve
how does AS present?
- sudden death
what type of murmur is AS?
which 4 drugs are patients with heart failure on?
- loop diuretic - frusemide
- beta blocker eg metoprolol (selective B1)
how does constrictive pericarditis present?
- like RIGHT sided heart failure: ankle oedema, raised JVP, hepatomegaly, ascites
- because heart is in a rigid fibrotic pericardial sac preventing DIASTOLIC FILLING
what is kussmaul's sign?? and which disease is it assoc. with?
- JVP rises paradoxically with inspiration
- in constrictive pericarditis and cardiac tamponade
how is constrictive pericarditis diagnosed?
CT or MRI: pericardial thickening and CALCIFICATION (as its chronic disorder)
what are the causes of constrictive pericarditis?
- 1. idiopathic
- 2. after heart surgery - haemopericardium
- 3. TB
- 4. connective tissue disease e.g. RA, SLE
- 5. CRF
- 6. malignancy and radiotherapy
what are the signs of cardiac tamponade?
- high JVP with paradoxically rises with inspiration (Kussmaul's sign)
- pulsus paradoxus: fall in BP > 10mmHg on inspiration
- due to effusion cannot hear the HS on auscultation
if a pt with CLD has an apex beat in 6th ic space mid AXILLARY line, whats cause?
- alcoholism causes dilated CM so get LV dilation
- and also mitral regurgitation: pan-systolic murmur
what are the most common causes of AR?
- rheumatic fever
- indective endocarditis
what are the causes of chronic AR?
- chronic rheumatic heart disease
- Ank spond
what happens to the pulse in AR?
- collapsing pulse
- wide pulse pressure
what happens to the apex beat in AR?
- displaced laterally
- thrusting quality
what type of murmur is in AR? where heard? how accentuated (2)?
- early diastolic murmur
- left sternal edge (aortic area)
- patient sits forward, breath held in EXPIRATION
what is Eisenmenger syndrome?
- initially L to R shunt (eg VSD/ASD/patent ductus arteriosus)
- so increased flow through pulm vessels and so pulm HTN
- pulmonary hypertension causing shunt reversal
- as high pressure in R side of heart so get R to L shunt
what is the ductus arteriosus?
- connection between pulmonary artery and aortic arch
- need in fetes to bypass the lungs which are fluid filled
Why do you get pulmonary oedema with mitral stenosis?
high left atrial pressure
who should mitral stenosis be suspected in?
- older pt
- recurrent pulm oedema
- little evidence of LV disease
other than a murmur, what other features suggest mitral stenosis?
- hx of rheumatic fever
- tapping apex beat
- loud 1st HS
what is a common cause of pulmonary oedema in YOUNG people?
- myocarditis: fever, gradual onset (unlike MI)
- signs of R heart failure initially
what are the causes of myocarditis?
- coxsackie virus
- Group A strep (rheumatic fever)
what is the Rx of myocarditis?
- may need INOTROPIC DRUGS or ventricular assist device
- or transplant
when is a machinery like murmur heard?
what kind of heart sound abnormality/murmur do you get with mitral valve prolapse?
- late systolic murmur
- midsystolic click
when do you get a pansystolic murmur?
- mitral regurgitation
- tricuspid regurgitation
when do you get early diastolic murmurs?
- aortic regurgitation
- pulmonary regurgitation (rarely)
what is a Graham Steel murmur?
- when pulmonary regurgitation is due to pulm HTN caused by MS
- then the early diastolic murmur of PR is called GSM
when do you get a mid diastolic murmur?
- mitral stenosis
- aortic regurgitation (austin flint murmur) due to fluttering of the anterior mitral valve cusp caused by the regurgitant stream
what is an austin flint murmur?
AR due to fluttering of
how does the breathing phase affect sound of murmurs?
- expiration increases blood flow to the left side of the heart so accentuates left sided murmurs e.g. aortic or mitral valve ones
- inspiration increases blood flow to R, so pulmonary and tricuspid
if a malar flush is seen, which valve disease is this associated with?
name 3 situations when a paradoxical pulse is seen
- cardiac tamponade
- constrictive pericarditis
- severe asthma
when is pulsus alternans seen and what is it?
- alternating beats which are weak then strong
- severe heart failure
which arteritis do you get absent pulses in?
what are the causes of long QT syndrome?
- congenital: Romano Ward syndrome, Jervell-Lange Nielson syndrome (assoc with deafness)
- a) biochemical: hypoK+, hypoMg, hypoCa,
- b) acute myocardial ischaemia, myocarditis, bradycardia (e.g. AV block), head injury
- c) drugs: sotalol, quinidine, antihistamine, macrolides, amiodarone, phenothiazines, TCA
what may excessive QT interval prolongation predispose to?
torsades de pointes
what are the causes of right axis deviation?
- PE causing right ventricular strain
- anterolateral MI
- left posterior hemiblock
describe the JVP in constrictive pericarditis
abrupt x and y descents
What are the causes of atrial fibrillation?
- hypertensive heart disease
- rheumatic MITRAl valve disease
- mitral prolapse
- mitral stenosis
- hypertrophic CM
which 2 heart conditions is thyrotoxicosis related to?
- atrial fibrillation
- dilated CM
which heart condition is Down's syndrome linked with?
- patent ductus arteriosus
which heart condition is marfan's associated with?
- atrial regurgitation
which heart condition is turner's syndrome linked with?
coarctation of the aorta
which heart condition is myxoedema related to?
Which murmur is left atrial myxoma related to?
what are the causes of mitral regurgitation?
- rheumatic fever
- left atrial myxoma
what does the left coronary artery divide into?
- left anterior descending
- circumflex artery
where does LAD run and what does it supply?
- runs in anterior interventricular groove
- supplies: anterior septum and anterior LV wall
if there is an antero-lateral MI which artery is occluded?
what is the main branch of R coronary artery?
posterior interventricular artery (posterior descending)
where does the right coronary artery supple?
what types of heart damage does R coronary artery blockage cause?
- inferior or RV infarctions
- arrhythmia as SAN and AVN not supplied
if there is VT with severe compromise what is the treatment?
if there is VT with moderate compromise what is the treatment?
what are the 4 abnormalities in tetralogy of fallot?
- RV hypertrophy
- right sided outflow obstruction
- over-riding aorta
what is the commonest cause of congenital cyanotic heart disease?
tetralogy of fallout
what is the difference between paroxysmal, permanent and persistent AF?
- paroxysmal: reverts to SR spontaneously (so get intermittent AF and SR). cardioversion is unhelpful
- permanent: remains in AF despite treatment, NOT amenable to cardioversion
- persistent: sustained AF, no SR but IS amenable to cardioversion
what are the causes of a 3rd heart sound?
- 1. dilated LV with rapid ventricular filling eg MR, VSD
- 2. poor LV function e.g. post MI, dilated CM
- 3. constrictive pericarditis or restrictive CM it occurs EARLY and high pitched i.e. PERICARDIAL KNOCK
when do you get a pericardial friction rub, and when pericardial knock?
- rub: acute pericarditis
- knock: constrictive
when do you hear a mid-systolic click?
mitral valve prolapse
when do you hear a gallop rhythm?
- young or athletic people
- LV failure
what is a gallop rhythm
- 3rd HS with a sinus tacky
what is the main cause of pericarditis? and its Rx
- viral pericarditis (Coxsackie, EBV, mumps)
- Rx: bedrest and analgesia
what are the causes of pericarditis?
- virus: coxsackie, EBV, mumps
- bacteria: rheumatic fever, pneumonia, TB
- Dressler's: autoimmune pericarditis stimulated by myocardial necrosis, 4-6wks after MI
- Uraemic pericarditis
when can you get raised troponin?
what does ECG of pericarditis show?
concave (saddle shaped) ST elevation
what may CXR show in pericarditis?
pericardial effusion- large globular heart (then need to do echo)
what is the Rx of pericarditis?
- steroids/immunosuppressants if relapse or continuing symptoms
what does ECG of pericardial effusion show?
- low voltage QRS
- alternating QRS morphologies - electrical alternans
if the JVP has prominent x and y descents, what does this indicate?
what is the main cause of mitral stenosis?
chronic rheumatic heart disease
what are the main symptoms of mitral stenosis?
- chest pain
over time, what can Mitral stenosis cause?
- left atrial hypertrophy
- symptoms of: dysphagia, hoarse voice, collapse of left main bronchus
describe the HS, apex beat and murmur assoc. with mitral stenosis?
- 1. loud first heart sound
- 2. tapping, undisplaced apex beat
- 3. mid diastolic murmur - low rumbling. loudest in apical region
- 4. it get pulmonary hypertension as a complication - get loud 2nd HS and RV heave
what are the rhyhthm disturbances of MS?
together with an inferior MI, what other changes would you expect on ECG and why?
- rhythm disturbances as right coronary artery that supplies inferior heart also supplies SAN and AVN
- get 3rd HB
- ventricular escape rhythm because conduction between A and V is interrupted