Cardiology for Finals
FY1s Poornima Mohan & Ghazal
Acute coronary syndromes
Valvular heart disease
Midline sternotomy scar
What is this scar?
Which 3 procedures would cause this scar?
What else would you look for?
What could this be?
What are the indications?
Where else should you look?
“We have this patient with chest
66 year old with a background of DM type 2,
hypertension and a 40 pack yr smoking hx. Day 1
post inguinal hernia repair.
Has been having central crushing chest pain for last
15 minutes. No relief from GTN. Hot & sweaty,
Obs: BP- 120/60 P-75 RR- 24 Sats 98% on RA
What ECG features suggest an STEMI??
ST elevation in 2mm in 2 or more contigous limb leads
ST elevation in 2 or more contigous chest leads
New onset LBBB
What features suggest an to NSTEMI ???
ST depression and /or T wave inversion in 2 or more
leads. Risk is assessed using the TIMI score.
What does this ECG show?
What would you do as an F1?
1) Assess haemodynamic stability
3) Initiate ACS protocol
STEMI - Primary PCI
NSTEMI – Risk assessment and PCI
Unstable angina – Functional Testing +/- Angiogram
Universal Secondary Prevention and Cardiac Rehabilitation
1) EXERCISE TOLLERANCE TEST
2) CT CALCIUM SCORING
4) STRESS ECHO
3) MYOCARDIAL PERFUSION
Valvular heart disease
Common exam question
Can find lots of patients with valve replacement
Things to know are
- Which valve
- What the cause could have been
- Clinical signs
- Basic principles of management
Questions about complications of surgery
“ A 72 year gentleman man presents with a history of
collapse as he was rushing up a hill to catch a bus.
There was no LOC. He reports no associated
weakness/numbness/tingling in the limbs, visual
disturbance, slurred speech, headache, chest pain, or
palpitaions. This had never occurred before.
He has noticed that he is increasingly SOB of late whilst
gardening/ doing house-work etc.
He has no previous cardiac history. He suffers from
hypertension and gout.”
1) Senile calcification
2) Biscuspid Aortic valve
3) strep associated – Rheumatic
Exertional : Dysponea, syncope angina
Features of AS on examination ????
Features on Examination
narrow pulse pressure
slow rising pulse
Forcefull apex beat
ESM radiating to the carotid- heard all over the precordium
Features of left ventricular dysfunction
Severe Stenosis → 1) Narrow PP 2) Quite or loss of S2
DDX for an ESM → 1) HOCM 2) VSD 3) Aortic sclerosis.
Management : TAVI vs Open AVR +/- CABG?
Exam tip : Which heart sound is metallic in an AVR??
“ A 72 year old lady presents with a history of increasing SOB, orthoponea
and palpitations over a few months. She has a history of Angina,
Hypertension. She is found to be in Atrial fibrillation”
Function – Chronic
ischemia (post MI)
CCF (LV dilatation)
small volume pulse
displace apex beat
loud PSM radiating to the axilla
• MGX: mitral valve clip vs Open MVR
+/- CABG. Discuss indication. Decision
is often based on a TOE.
Consider patients pre-morbid state
Medical : Diuresis
ACE inhibitors and B-blockers.
Surgical : Assessment with an TTE / TOE and angiogram.
Mitral clip or an open Valve Replacement
Rheumatic Heart disease
Tapping apex beat – palpable 1st HS
Left parasternal heave / Enlarged LA
Loud 1st heart sound
CXR- Enlarged left atrium,
calcified valves and pulmonary
ECG – p-mitrale and AF
Medical : Rate control (digoxin)
Surgical : Valve replacement
Valveotomy (open / closed)
Causes : Acute (inf. Endocarditis)
Chronic: Connective tissue disorders
(RA), Rheumatic heart disease, syphilitic heart
disease . Aortitis: Marfans / Anklysing
collapsing pulse – hyperdynmaic apex beat
Early diastolic murmur
Other causes of a collapsing pulse?
Anything that causes a high circulating volume:
Valve replacement vs conservative management
Rumbling mid- Pansystolic
Complications of Valve replacements
• INFECTION : early vs late.
• FAILURE OF VALVE: early vs late
• THROMBUS FORMATION vs HAEMMOHRAGE
What would you do as an F1?
Conservative: if AF, rate control. Diuretics
• Surgical: Valve repair/ replacement
“ A 54 year old lady initially presents with an abscess.
She vascular infarcts on CT and is admitted to the acute
stroke unit. She has no major risk factors for a CVA.
On doing base line bloods she has CRP 300
Urine dip show blood +++
She’s on the stroke ward, she has some left sided
weakness. Obs stable, and apyrexial so far “
What is the diagnosis???
What would you look for ???
What would you look for?
• Signs of sepsis
• New murmur or
change in existing
• Embolic features e.g.
What would you do as an FY1?
Urine dip & MCS
1. Risk factors?
Lifestyle factors (IVDU), cardiac lesions, aortic or mitral valve
disease, PDA, VSD, coarctation, prosthetic valve
• Strep viridans (35-50%), HACEK (Haemophilus, actinobacillus,
• SLE – Libman-Sachs endocarditis
3. Criteria for Diagnosis?
Duke criteria for diagnosis
2 major OR 1 major and 3 minor OR all 5 minor criteria
• +ve blood culture
typical organism in 2 separate cultures or persistently +ve blood
• Endocardium involved
• Positive echo or new valvular regurgitation
• Fever >38C
• Vascular/immunological signs
• +ve blood cultures that do not meet major criteria
• +ve echo that does not meet major criteria
• MDT decision
• Conservative management: Long-term
antibiotics and serial echos
• Surgical management: Valve replacement
A congenital defect where the heart is situated on the
right side of the body
Isolated dextrocardia – heart placed further to the right
in thorax, associated with other cardiac abnormalities
Dextrocardia situs inversus – heart placed to the right
side as a mirror image