-
what are the signs on ECG of a posterior MI?
ST depression and tall R waves in V1 and V2
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how is corrected QT calculated?
QT interval / square root of RR interval
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what are low voltage QRS complexes caused by?
- hypothyroidism
- COPD
- increased haematocrit
-
what is the carotid pulse like in AS?
slow rising
-
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)
- CRAS
- congenital bicuspid valve calcification
- rheumatic heart disease
- atheroma
- senile calcification of normal tricuspid valve
-
how does AS present?
- dyspnoea
- syncope
- palpitations
- sudden death
- angina
-
what type of murmur is AS?
ejection systolic
-
which 4 drugs are patients with heart failure on?
- loop diuretic - frusemide
- ACEi
- beta blocker eg metoprolol (selective B1)
- spironolacotne
-
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?
- hypotension
- tachycardia
- 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
- Reiter's
- Ank spond
- RA
- syphilis
- Marfans
-
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
- diphtheria
- HIV
- toxoplasma
- Group A strep (rheumatic fever)
-
what is the Rx of myocarditis?
- supportive
- may need INOTROPIC DRUGS or ventricular assist device
- or transplant
-
when is a machinery like murmur heard?
patent DA
-
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?
mitral stenosis
-
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?
takayasu's arteritis
-
what are the causes of long QT syndrome?
- congenital: Romano Ward syndrome, Jervell-Lange Nielson syndrome (assoc with deafness)
- acquired:
- 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?
- RVH
- PE causing right ventricular strain
- anterolateral MI
- left posterior hemiblock
- RBBB
-
describe the JVP in constrictive pericarditis
abrupt x and y descents
-
What are the causes of atrial fibrillation?
- IHD
- hypertensive heart disease
- rheumatic MITRAl valve disease
- mitral prolapse
- mitral stenosis
- thyrotoxicosis
- hypertrophic CM
-
which 2 heart conditions is thyrotoxicosis related to?
- atrial fibrillation
- dilated CM
-
which heart condition is Down's syndrome linked with?
- VSD
- patent ductus arteriosus
-
which heart condition is marfan's associated with?
- atrial regurgitation
- VSD
- ASD
-
which heart condition is turner's syndrome linked with?
coarctation of the aorta
-
which heart condition is myxoedema related to?
cardiomyopathy
-
Which murmur is left atrial myxoma related to?
mitral regurgitation
-
what are the causes of mitral regurgitation?
- rheumatic fever
- ASD
- marfans
- 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?
LAD
-
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?
DC shock
-
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
- VSD
- 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
- kentucky
-
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
- fungi
- MI,
- Dressler's: autoimmune pericarditis stimulated by myocardial necrosis, 4-6wks after MI
- Uraemic pericarditis
- RA
- SLE
-
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?
- ibuprofen
- colchicine
- 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?
CONSTRICTIVE pericarditis
-
what is the main cause of mitral stenosis?
chronic rheumatic heart disease
-
what are the main symptoms of mitral stenosis?
- dyspnoea
- palpitations
- chest pain
- haemoptysis
-
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?
AF
-
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
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