04/05/2022

Question 1

Left ventricular hypertrophy on ECG

Answer 1

broad QRS complexes, left axis deviation, Large R waves in left sided leads (v5, v6, I, aVL) and deep S waves in right sided leads (V1, V2)

Question 2

Left sided heart failure signs

Answer 2

• Tachypnoea and tachycardia
• Cool peripheries
• Peripheral or central cyanosis
• Displaced apex beat
• Stony dull percussion: if an effusion is present
• Crackles on auscultation: coarse bi-basal crackles due to pulmonary congestion
• Third heart sound (S3)

Question 3

Left sided heart failure symptoms

Answer 3

• Dyspnoea: particularly exertional
• Orthopnoea (SOB when lying flat)
• paroxysmal nocturnal dyspnoea (SOB at night)
• Fatigue and weakness
• Cough with pink, frothy sputum
• Cardiogenic wheeze

Question 4

Right sided heart failure signs

Answer 4

• Due to backing up of fluid:
  
  • Raised JVP
  • Peripheral pitting oedema
  • Hepatosplenomegaly
  • Ascites

Question 5

Right sided heart failure symptoms

Answer 5

• Fatigue and weakness
• Due to backing up of fluid
  
  • Swelling in the legs
  • Distended abdomen

Question 6

Heart failure first line investigation

Answer 6

N-terminal pro-brain natriuretic peptide: increased in chronic heart failure
ECG:broad QRS complexes; evidence of left ventricular hypertrophy
- CXR:
- A-Alveolar oedema (batwing opacities)
- B- KerleyBlines
- C-Cardiomegaly
- D-Dilated upper lobe vessels
- E- Pleural effusion

Question 7

What classification system is associated with Heart failure

Answer 7

The New York Heart Association Classification System (out of 4)

Question 8

Aortic Stenosis Management

Answer 8

• Percutaneous balloon aortic valvoplasty: dilate narrow valve
• Surgical aortic valvotomy: stenotic valve leaflets are forced apart
• Valve replacement: can be mechanical or bioprosthetic
• Transcutaneous Aortic Valve Implantation (TAVI): inflate balloon across narrow valve and then leave a stent in place

Question 9

Aortic Regurgitation management

Answer 9

• Vasodilator e.g. ACE-inhibitors (ramipril) will improve stroke volume and reduce regurgitation (only if patient is symptomatic or has hypertension)
• Root replacement, if needed
• Replacement of the valve: can be mechanical or bioprosthetic

Question 10

Investigation of Mitral Stenosis

Answer 10

ECHO is gold standard and a doming pattern is seen

Transthoracic ECHO: both the valve area and transmitral gradient can be assessed

Transoesophageal ECHO: performed to look for left atrial thrombosis either after an embolic episode (e.g. stroke) or prior to percutaneous mitral commissurotomy.

Question 11

Mitral Stenosis Management

Answer 11

• Beta-blockers e.g. atenolol and digoxin: control heart rate and prolong diastole for improved diastolic filling
• Valve repair or surgical replacement of the valve. Options include:
  
  • Percutaneous mitral commissurotomy (PMC): balloon enters via right femoral vein. Balloon is inflated to alleviate the stenosis.
  • Open surgery
• Diuretics: for fluid overload
• Anticoagulation/ Vitamin K antagonist: due to risk of thrombus formation

Question 12

Mitral Regurgitation Management

Answer 12

• Vasodilators e.g. ACE-inhibitors (ramipril or hydralazine)
• Diuretics e.g. furosemide or spiranolactone: for fluid overload
• Beta blockers e.g. atenolol/ calcium channel blockers/ digoxin: for heart rate control
• Cardiac resynchronisation therapy (CRT) used when appropriate.
• Anticoagulation in atrial fibrillation and flutter: to prevent thrombus formation
• Valve repair or surgical replacement of the valve.
• Other surgical measures include: ventricular assist devices, cardiac restraint devices and heart transplantation.