Angina pectoris

Features that make angina less likey pain associated with .

.palpitations, dizziness or tingling

Percutaneous coronary intervention Dual antiplatelet therapy

(DAPT; usually aspirin and clopidogel) is
recommended for at least 12 months after stent

Acute coronary syndromes (ACS)

4th heart sound

of deaths occur within 2h of onset of symptoms 50%

Heart filure
Acute heart failure: Often used exclusively to mean new-onset
acute or decompensation of chronic heart failure
characterized by pulmonary and/or peripheral
oedema with or without signs of peripheral hypoperfusion.
:Chronic heart failure
Develops or progresses slowly. Venous congestion is common
but arterial pressure
is well maintained until very late

.
Echocardiography is the key investigation .

BNP distinguishes heart failure from other :

causes of dyspnoea : If BNP >100ng/L, this ‘diagnoses’ heart
failure
Hypertension
the most important risk factor for premature death and CVD;
causing ~50% of all vascular deaths Confirm with 24hr
;ambulatory BP monitoring (ABPM)
or a week of home reading

Malignant’ or accelerated phase hypertension: al hallmark is

fibrinoid necrosis

-blockers are not 1st line for hypertension

recommendation is ACE-i, Ca2+-channel antagonist, and

thiazide. consider: spironolactone 25–50mg/24h or
higher-dose thiazide, but monitor U&E. Alternatively, -
blocker, or selective -blocker

,ACE-i may be 1st choice if co-existing LVF

.or in diabetics (esp. if microalbuminuria, p314) or proteinuria

If a BP reading is >= 140 / 90 mmHg patients should be offered

.ABPM to confirm the diagnosis
Patients with a BP reading of >= 180/110 mmHg should be
considered for immediate treatment

Rheumatic fever (RF)

Diagnosis Use the revised Jones criteria
Major criteria:
Carditis: tachycardia, murmurs (mitral or aortic
regurgitation, Carey Coombs’
murmur
Sydenham’s chorea
Evidence of group A -haemolytic streptococcal
infection:
• Positive throat culture (usually negative by the time RF
symptoms appear).
• Rapid streptococcal antigen test +ve.
• Elevated or rising streptococcal antibody titre (eg anti-
streptolysin O (ASO) or
DNase B titre).
• Recent scarlet fever.
Management
Benzylpenicillin 0.6–1.2g IV
Analgesia for carditis/arthritis: aspirin
moderate-to-severe carditis is present (cardiomegaly,
CCF, or
3rd-degree heart block), add oral prednisolone
diazepam for the chorea.
Secondary prophylaxis
If carditis+persistent valvular disease, continue at least
until age of 40
If carditis but no valvular disease, continue for 10yr
If there is no carditis,
5yrs of prophylaxis

Infective endocarditis (IE)

Fever + new murmur = endocarditis until proven otherwise

Staph aures whith skin infction

Post oprative st albus

Fungel candida in hiv and drug iv

Gram negeti ve bacilli whith prosthec valve

Septic signs: Fever, rigors, night sweats, malaise, weight loss,

anaemia,
spleno megaly, and clubbing

Cardiac lesions: Any new murmur, or a

change in pre-existing murmur, should raise the suspicion of
endocarditis.

Immune complex deposition . Roth spots ; splinter

haemorrhag Osler’s nodes glomerulonephritis

Embolic phenomena Janeway lesions

Diagnosis Use the Modified Duke criteria (BOX ‘Modified Duke
criteria’).62,63 Blood
cultures: Do three sets at different times from different sites
at peak of fever

Prognosis 50% require surgery.

Major criteria:
• Positive blood culture:
• Typical organism in 2 separate cultures or
• Persistently +ve blood cultures, eg 3 >12h apart (or majority
if >3) or
• Single positive blood culture for Coxiella burnet

Infective endocarditis - streptococcal infection carries a good

prognosis

nfective endocarditis - strongest risk factor is previous episode

of infective

Pericardial effusion
, bronchial breathing at left base (Ewart’s
sign:

Constrictive pericarditis
CXR: small heart ± pericardial calcification

Mitral stenosis
Symptoms usually begin when the orifice becomes <2cm2

Pressure of left atrium on local

structures causes hoarseness (recurrent laryngeal nerve),
dysphagia (oesophagus

Malar flush on cheeks

rumbling mid-diastolic murmur

Echo is diagnostic

Mitral regurgitation (MR)

Causes: Functional (LV dilatation)

; pansystolic murmur at apex radiating to

axilla;

Mitral valve prolapse

: Is the most common valvular abnormality
Aortic stenosis (AS)
Causes: Senile calcification is the commonest.

y elderly person with chest pain, exertional dyspnoea, or

syncope

; ejection systolic murmur radiates to the carotids

Post stenotic dilation

Aortic regurgitation (AR)

Collapsing (water-hammer) pulse

Corrigan’s sign: carotid pulsation;

de Musset’s sign: head nodding with each heart beat

Quincke’s sign: capillary pulsations in nail beds

Duroziez’s sign: in the groin,

Traube’s sign: ‘pistol shot’ sound over

femoral arteries;

Austin Flint murmur (p46) denotes severe AR

Echo
is diagnostic

Notes
Hypertrophic obstructive cardiomyopathy An
increased septal wall thickness is also associated with apoor
prognosis

ventricular fibrillation and is the most common

cause of death following a MI.

S1
 closure of mitral and tricuspid valves
 soft if long PR or mitral regurgitation
 loud in mitral stenosis
S2
 closure of aortic and pulmonary valves
 soft in aortic stenosis
 splitting during inspiration is normal
S3 (third heart sound)
 caused by diastolic filling of the ventricle

 considered normal if < 30 years old (may persist in women

up to 50 years old)
 heard in left ventricular failure (e.g. dilated
cardiomyopathy), constrictive pericarditis (called a
pericardial knock)
S4 (fourth heart sound)
 may be heard in aortic stenosis, HOCM,
hypertension
 caused by atrial contraction against a
stiff ventricle
 in HOCM a double apical impulse may be
felt as a result of a palpable S4