Cardiology

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mewinstanley@googlemail.com
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258804
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Cardiology
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2014-02-09 09:11:49
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Cardiology
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Cardiology objectives for finals
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  1. Revise Anatomy + Physiology of heart [not question, just learn]
    Coronoary Circulation → arises from coronary sinus [aortic root]


    • LCA → Left Main
    • -LAD [ant septum, ant lat + apircal walls LV]
    • -Circumflex system [lat post + inf LV]


    • RCA → SA + AV node
    • -Right Main → RA, RV + Inferopost LV
    • -Post descending → inf septum
  2. Revise the conducting system of the heart
    SA Node → junction of SVC + RA; depol at autonomic rate + circulating catecholamines

    AV → slower conduction than SA slows HR

    • His-Purkinje system → bundle of His + bundle branches
    • -1 BB on R
    • -2 on L → ant + post fascicles
  3. Define;
    -End diastolic Volume
    -Preload
    -Afterload
    -EDV; vol of blood in V at end diastole [fullest the V gets] effect → filling time + venous return

    -Preload; stretching of ventricle during diastole, proportional to EDV

    • -Afterload; force V must generate to overcome SVR + open SL to eject blood. Effect → any ^^SVR
    • as afterload ^^, SV decreases
  4. CO = ?
    CO = SV x HR
  5. Mummy, how are atheromatous plaques made?
    Know from years

    • Endothelial damage
    • oxidised FFA
    • Foam cells
    • accumulation of thrombus
    • decrease of lumen
  6. Compare Stable Vs Unstable angina
    i.e. features, features of high risk?
    Stable

    • Fixed stenosis, demand led ischaemia
    • predictable, w symptoms develop over chronic
    • risk → minimal exertion, bad exercise test [^duration, ^^changes, ABN BP]

    Unstable [ruptured plaque]

    • Dynamic stenosis, supply led ischaemia
    • acute symptoms, unpredictable
    • risk → frequent/nocturnal, ECG change w symptoms, ^^troponin
  7. Define ACS
    • Acute coronoary syndrome
    • chest pain at rest/ minimal exertion, spectrum form unstable angina → evolving MI

    [MI, unstable angina, coronary spasm (Cocaine)]
  8. Define MI?
    "evidence of myocardial necrosis in clinical setting consistent w myocardial ischaemia"

    • Rise of cardiac biomarker [Troponin] +1 of;
    • -CF of MI
    • - ECG changes [new ST^/Twave changes/LBBB]
    • -Patho Q waves
    • -Imaging suggesting wall motion abn
  9. What are the symptoms + signs of ACS?
    • Symp;
    • cardiac CP [central, crushing, neck + L arm]
    • angor animi
    • n+v, SOB, LoC

    • Signs;
    • ^^symp tone [pallor, clammy, tachy]
    • impaired Myocardial function → hypotensive, cool, oliguria, narrow PP, ^^JVP, S3, lung creps
    • Complications → MVR, Pericarditis
  10. Ix in ACS/MI?
    • 12 lead ECG + repeats
    • -ST elevation [full thickness occlusion]
    • -hyperacute T waves [tall]
    • -T wave inversion [Later]
    • -Q waves [not time specific, acute = transmural]

    Bloods → Troponin [base + 12hour]

    CXR → pulmonary oedema
  11. How does MI cause ST elevation?
    • ST = ventricular systolic depol + subsequent repol
    • damaged muscle has changed physiological + electrical properties
    • ST elevates due to early repolarisation/ premature end systole
  12. What is the Initial Mx of ACS/MI?
    ABCDE

    • MONICA
    • Morphine, Oxygen, Nitrates, Interventional Cardiology [4hours STEMI], Aspirin 300mg

    NSTEMI → Thrombolyse, admit, PCI later
  13. Outline secondary prevention of MI
    Risk stratify;

    • -ASSIGN [no prev CVD] GRACE [new ACS/MI]
    • -ETT as per bruce protocol

    Lifestyle & risk modification → change modifiable factors [smoking, hyperlipidaemia, med diet, normotension]

    Cardiac rehab → early mobilise, aim to work by 4-6/52

    • Drugs;
    • -Aspirin + clopidogrel [antiplatelet therapy]
    • -ACEi [Enalapril/ramipril] → counteract remodelling + prevent HF onset
    • -BB → if tolerated
  14. Give 5 complications of MI/ACS?
    MI as complication for ACS ≠ acceptable
    Arrythmia → VF, VT, AF [atrial overstretch], Sinus brady [Inf MI]

    Acute circulatory failure

    pericarditis [only MI] → day 2/3, Tx opiates, NSAIDS ^^aneurism nb Dressler Syndrome [fever, pericardiits, pleurisy → autoimmune → colchicine/steroids]

    • Mechanical Complications;
    • -Papillary Muscle rupture [Mitral] → shock, acute PulmOedema, emergency MVR
    • -Septal Rupture → LR shunt through VSD [haemodynamic unstable, loud pansystolic murmur]
    • -Ventricular rupture → transmural MI → tamponade

    Embolism

    • Impaired ventricular function
    • -thinning wall + stretch impaired area
    • -^^wall stress → dilation + hypertrophy
    • -ACEi help prevent
  15. Draw outline of arrythmias
  16. Define AF and give 6 causes?
    Irregularly irregular tachycardia

    • Atrial arrythmia 350-600bpm, w ventricular escape of <200bpm
    • ^^risk of embolism → stagnant flow

    • causes;
    • -Heart failure, MI, HTN, PTE, MV disease, Infection, hyperthyroid, Post op
  17. What are the CF and Ix of AF?
    CF;

    • - Palpitations, SOB, LoC [syncope]
    • -Irregularly irregular pulse

    • Ix
    • -ECG → absent P waves, irregular QRS
    • -U+E, TnI, TFT
    • -Echo → LVSD
  18. Outline the Mx of AF?
    RACE → if haemodynamically stable
    RACE = Rate/Rhythmn control, Anticoagulate, Cardiovert, Etiology

    • Rate → BB → >65, CAD, Antuarrythmic contraindicated, AF >1year
    • Rhythmn → Amiodarone/Flicanide → young, symptomatic/CCF, 1st lone AF

    Anticoagulate → asses stroke risk [CHADS2VASC], heparin if low risk, warfarin/Aspirin if high

    • Cardioversion;
    • - <48hours no anticoagulation
    • - >48hours anticoagulate 3/52 prior, 4/52 after

    Etiology → treat cause
  19. How do you treat;
    -Paroxysmal AF
    -AF in Heart Failure
    -Paroxysmal AF

    Flicanide PRN + anticoagulation

    -AF in HF

    Digoxin + Amiodarone
  20. What is sinus tachycardia, what cuases it and how is it Mx?
    Sinus tachy= HR >100bpm

    Due to ^^ symp tone; fever, hypotension, anaemia, thyrotoxicosis etc...

    Mx → Tx cause, consider BB if symptomatic
  21. What is SVT?
    Narrow complex tachycardia

    Dx of exclusion → paroxysmal aborrhant tachy from atria/ AV junction
  22. What is Atrial Flutter, its ECG pattern and Mx?
    Atrial Flutter = rapid, regular atrial depol ~300bpm w AV block [2:1/ 3:1]

    Causes → CAD, thyrotox, PTE

    • ECG → sawtooth in inf leads [II, III, aVF]
    • -bring out P-waves [slow AV conduction → carotid sinus massage, valsalva, Adenosine]

    • Mx
    • -Unstable → DC cardioversion
    • -Stable → RACE
  23. What is VT?
    >3 ectopic ventricular complexes, rate >100bpm, sustained if >30s duration

    • ECG → wide QRS [>140msec]
    • - monomorphic → intraventricular re-entry circuit → acute MI, cocaine, scarring
    • -Polymorphic → constant changing → acute MI, silent ischaemia

    • Mx → >30s = emergency
    • -compromised → DC cardioversion
    • - stable → Lidocaine, amiodarone, electrical cardioversion, Type 1A antiarrythmic
  24. What is sinus brady?
    P waves, rate <60bpm

    Causes → ^^ vagal tone [vomiting, inf MI, ^^ICP, Drugs]

    Mx → Tx cause, ?atropine
  25. What is sick sinus syndrome?
    SSS → sinus node dysfunction → marked brady, sinus pause/arrest, SA block

    Symptomatic → pacemaker

    Can be assoc w atrial tachy → Tachy/Brady syndrome
  26. What is 1st degree heart block?
    Bradyrrythmia

    PR >200msec

    common, no Tx
  27. What is 2nd degree heart block?
    some P waves no conducted to Ventricles

    2 kinds;

    Type 1 [Wenkebach]

    • gradual prolonged PRi until QRS dropped
    • block = proximal [AV node]
    • triggers = reversible → ^^vagal tone [post-op], RCA mediated ischaemia

    Type 2

    • PRi constant w sudden drop of QRS
    • Block = distal [Bundle of His]
    • ^^risk of 3rd degree → ?Pacing
  28. What is 3rd degree heart block?
    Complete failure of conducting impulses to ventricles → no relat P-QRS

    • Ventricular depol = escape rhythmn
    • wide complex [ventricular escape]
    • Narrow complex [junctional rhythmn]
    • variable PRi

    Mx → Electrical Pacing
  29. Define Heart Failure & give 3 risk factors?
    Failure of heart to pump blood at sufficient rate to meet metabolic requirments of tissues. Associated with abn of cardiac function w characteristic heamodynamic + neurohumeral changes.

    Aetiology;

    • CAD/MI
    • HTN
    • Idiopathic
    • Toxins [booze]
    • Outside UK → Valve disease/ Congenital Malformations
  30. What is the pathophysiology of heart failure?
    Primary insult → pump dysfunction leads to;

    • remodelling [dilation, hypertrophy]
    • neurohumeral activation [oedema, tachy, vasoconstrict]

    leads to further damage

    compensatory response

    • ^End-daistolic pressure → peripheral vasoconstriction → hypertrophy
    • ^EDV → cardiac dilation

    Systemic response to ineffective circulating volume → Activate SNS + RAAS

    • salt + water retention → intravascular expansion
    • ^HR + myocardial contractility
    • Increased afterload
  31. Name 3 types of HF?
    • Systolic dysfunction → impaired ventricular ejection
    • Diastolic dysfunction → impaired filling of Vent
    • High output failure → demand for ^^CO
  32. Outline systolic dysfunction
    • Impaired myocardial contractility
    • decreased ejection fraction & SV
    • decreased CO

    CF → Displaced apex beat [cardiomegaly], S3, LV dilation

    Causes;

    • Ischaemic → extensive CAD, prev MI
    • Non-ischaemic → HTN, DM, Alcohol, Myocarditis, DCM
  33. Outline Diastolic Dysfunction?
    • 30% of HF have normal systolic function
    • poor filling of ventricles → decreased compliance
    • ^Ventricular filling pressure → ^venous congestion [pulmonary + systmic venous congestion]

    CF → HTN, S4, LVH, apex beat = N

    Causes;

    • Transient → ischaemia [cardiac relaxation requires ATP]
    • Permanent → severe hypertrophy [HTN, AS, HCM], Restrictive cardiomyopathy, MI
  34. Outline high output failure?
    • demand for ^^CO
    • exacerbates existing HF/ decompensate Pt w other cardiac pathology

    DDx;

    • anaemia, thiamine deficit, hyperthyroid, AV fistula
    • Pagets/Renal/Hepatic disease
  35. What are the causes of acute heart failure?
    i.e. precipitants of exacerbations?
    [HEART FAILED]
    • Hypertension
    • Endocarditis/ Environment [heatewave]
    • Anaemic
    • Rheumatic heart disease [other valves etc]
    • Thyrotoxicosis

    • Failure to comply
    • Arrythmia
    • Infection/ Infarction
    • Lung problems
    • Endocrine problems
    • Dietary Indiscretion
  36. In general what are the CF of HF?
    Symptoms

    • Dyspnoea [SoB, ??at rest?]
    • Orthopnoea + PND
    • Cough
    • Ankle swelling
    • Fatigue/TATT

    Signs;

    • Peripheral pitting oedema [ankles/sacrum]
    • ^JVP
    • S3
    • Displaced apex beat [cardiomegaly]
    • Basal crackles [coarse = Pulm Oedema]
    • Pleural Effusion
  37. What are the CXR features of heart failure?
    HERB-B
    • Heart enlargement [Cardiomegaly]
    • Pleural Effusion
    • Redistribution of fluid [alveolar oedema/ upper lobe diversion → batwing]
    • Kerley B-Lines
    • Broncho-alveolar Cuffing
  38. Ix for HF?
    ECG → LVH, Previous MI [Patho Q waves]

    Echo → chamber size, wall motion Abn, sytolic + diastolic function [EF]

    Bloods → FBC, U+E, LFT, Natriuretic peptides [ANP, BNP]

    CXR → exclude pulmonary cause for Pc, HERB-B
  39. What are the featuers of LVH on ECG?
    • ≥ QRS amplitude (voltage criteria; i.e., tall R-waves in LV leads, deep S-waves in RV leads)
    • Delayed intrinsicoid deflection in V6 (i.e., time from QRS onset to peak R is ≥ 0.05 sec)
    • Widened QRS/T angle (i.e., left ventricular strain pattern, or ST-T oriented opposite to QRS direction)
    • Leftward shift in frontal plane QRS axis
  40. How does one classify HF?
    NYHA guidelines

    • stage 1 = no symp/limitations
    • stage 2 = mild symp/limitations
    • stage 3 = marked limitations due to symptoms, comfortable at rest
    • stage 4 = severe limitations, symptoms at rest
  41. What is the acute management of HF?
    [same for acute pulmonary oedema]
    Fuck My NOPP!!!
    • ABCDE
    • Treat Cause

    • Furosemide 40-80mg IV [slow, nb vasodilation]
    • Morphine [decrease PCWP, may not help]
    • Nitrates → GTN, 2 puff if sys >90mmHg
    • O2
    • Positive airway pressure → CPAP/BiPAP NIV
    • Position Patient → sit up, legs over bed
  42. Chronic Mx of CF?
    MDT

    Conservative measures → lifestyle advice

    Symptomatic Tx → O2, night time pillows, Diuretics

    Pharmacological Mx
  43. Outline Pharmacological Mx of HF?
    Principles; Block RAAS + SNS, make comfortable

    Block RAAS

    • ACEi → Cardioprotective → ramipril
    • AIIRB → 2nd line ACEi → Losartan, Candesartan
    • AldosAntag → Block Ald, decrease Na reabsorption → Spironalactone, Epleranone

    Block SNS

    BB → start low and go slow → propanolol, atenolol

    Tx Symptoms

    Diuretics → furosemide, bumetinide
  44. Define HTN?
    Dificult dificult, lemon dificult

    140/90 = abritrary

    200/130 = malignant
  45. What are the causes of HTN? Give5
    Primary → Essential [no one knows why] →95%

    Secondary

    Renal Disease;

    • intrinsic renal disease →75% →GN, PCKD, polyarteritis nedosa
    • Renovascular disease → 24% →renal artery stenosis, RA atheroma, fibromuscular dysplasia [rare]

    Endocrine;

    • Cushings + Conns
    • Phaechromocytoma
    • Acromegaly
    • Hyperparathyroidism

    • Other;
    • Coarctation of Aorta
    • Pregnancy/COCP/HRT
    • MAOI
    • LT Steroids
  46. What are the CF of HTN?
    For HTN retinopathy give the 4 stages.
    • Asymptomatic
    • Occiptal headache on waking
    • End organ damage →LVH, Proteinuria, retinal disease

    HTN retinopathy;

    • 1 → tortuous arteries w copper wiring sign
    • 2 → AV nipping
    • 3 → flame haemorrhages + cotton wool spots
    • 4 → papilloedema
  47. How does one investigate HTN?
    BP Measure → Nb white coat

    Basic → U+E, creatinine, eGFR, Cholesterol, glucose, ECG, Urinalysis [protein/blood]

    Exclude 2ndry → Renal USS, retinal angiography, urinary free cortisol, renin + aldosterone, Echo
  48. Mx of HTN?
    Target pressure <140/90 [diabetic 130/80, proteinuria 125/75]

    lifestyle changes → low salt, stop smoking, low fat diet, rduce alcohol, ^^exercise, weight loss

    Pharmacological;

    • Step 1 → <55 = ACEi/AIIRB, >55/Black CCB [amlodipine nb oedema]
    • Step 2 →ACEi/AIIRB + CCB
    • Step 3 →ACEi/AIIRB + CCB + Thiazide like diuretic [bendro]
    • Step 4 → add further diuretic/Alphablocker/BB, consider referral
  49. What is cardiomyoapthy and what are the different types?
    Diseases of heart muscle

    types;

    • Acute myocarditis →inflamm of myocardium [viral/bacterial/toxic]
    • Dilated Cardiomyopahty →big baggy heart, unknown aetiolgy →^^ETOH, consider transplant
    • Hypertrophic cardiomyopathy → LV outflow tract obstruction [assymetrical septal hypertrophy] →sudden death
    • Restrictive CM →features of RVF → causes = amyloid haemochrom, sarcoid
  50. Classify IE? And give likely organisms for each.
    Native valve → acute [staph aureus] sub-acute [strepviridans/enterococci]

    Prosthetic Valve → CoagNeg Staph, Gram negatives

    IVDU → tricuspid, Staph aureus

    Q-fever → coxiella burnetti
  51. What are the clinical features of IE?

    I caught IE, FROM JANE
    • Acute → normal valves → acute heart failure
    • Sub-acute → suspect in Hx damaged valves + fever
    • Fever + Murmur = IE

    • Fever
    • Roth Spots [emboli on retina]
    • Oslers nodes → painful, red raised
    • Murmur

    • Janeway Lesions → small non-tender palms/soles
    • Anaemia
    • Nail haemorrhages [splinter]
    • Embolic events
  52. What are the diagnostic criteria of IE?
    Dukes Criteria

    Major;

    • Blood cultures → typical org in 2 BC or persistently +ve >12h apart
    • Endocardial involvement → +ve echo [veget/abscess], new valve regurge

    Minor;

    • Predisposition [cardiac lesion/IVDU]
    • Fever
    • Vascular/ immunological signs
    • +ve BC [nt meeting maj]
    • +echo [not meeting maj]

    Dx = 2 Maj OR 1 Maj +3Min OR 5Min
  53. Mx of IE?
    • Early recog, liase w Micro + Cardiology
    • Consult local guidelines on empirical antibiotics
    • Consider Surgical Mx if → HF, Valve obstruction, repeated emboli, fungal cause, persistent bacteraemia, abscess
  54. Aortic Stenosis?
    • Mid-systolic murmur [crescendo-decrescendo]
    • Aortic area, radiates down left sternal border + carotids
    • ?S1 ejection click

    Causes; congenital bicuspid aortic valve, calcification, rheumatic heart disease
  55. Mitral stenosis?
    • Low frequency diastolic rumble [bell @ apex]
    • does not radiate

    causes: rheumatic fever, infective endocarditis
  56. Aortic Regurgitation?
    • early diastolic, high pitched + blowing
    • patient sitting up + leaning forward


    causes: Rheumatic heart disease, IE, Marfans, Syphyllis, AnkSpond
  57. mitral regurgitation?
    • Pansystolic harsh murmur, loudest at apex
    • radiates to axilla

    causes: Rheumatic fever, IE, MI, Cardiac Myxoma

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