Cardiac Pathology Flashcards

Question

What is Dressler’s syndrome?

Answer 1

Recurrent pericarditis pleural effusions fever anaemia and ESR increase 1–3 wks post-MI

Answer 2

Blood vessels outside of your heart and brain to narrow, block, or spasm.

Answer 3

**_Fontaine_** 1 Asymptomatic 2 Intermittent claudication 3 Ischaemic rest pain 4 Ulceration/gangrene (critical ischaemia)

Answer 4

Cramping pain in calves, thighs and buttocks relieved by rest Also known as claudication

Answer 5

Absent pulses Punched out ulcers Postural colour change (Buerger’s Test)

Answer 6

**_ABPI_** Normal is 1-1.2; PAD is 0.5-0.9 gangene\<0.5 **_Colour Duplex USS_** Quick and non-invasive, can show vessels and blood flow within them **_MR/CT angiography_** Identify stenosesand quality of vessels. **_Blood tests_** Raised CK-MM, shows muscle damage

Answer 7

**_Risk factor modification_** Quit smoking, treat HTN, lower cholesterol, improve DM control, lower fat diet. **_Medications_** Anti-platelet, clopidogrel is recommended as 1st line. **_Exercise programmes_** Reduce claudication by improving blood flow. **_PTA or surgery if severely stenosed_**

Answer 8

May be due to a thrombosis (in ‘vasculopaths’), emboli, graft occlusion or trauma

Answer 9

Pain Pallor Pulselessness Paresthesis Paralysis Perishing cold

Answer 10

If not revascularized then lose limb

Answer 11

Circulatory failure resulting in inadequate organ perfusion

Answer 12

Low BP Evidence of tissue hypoperfusion.

Answer 13

Skin is pale, cold, sweaty and vasoconstricted Pulse is weak and rapid Pulse pressure reduced, MAP may be maintained Urine output reduced Confusion, weakness, collapse, coma

Answer 14

Prolonged hypotension can lead to life threatening organ failure

Answer 15

Hypovolaemic shock Cardiogenic shock **_Distributive shock_** Septic shock Analphylactic shock Neurogenic shock

Answer 16

Low circulating blood volume

Answer 17

**_Loss of blood_** Acute GI bleeding Trauma Ruptured AA **_Loss of fluid_** Dehydration Burns

Answer 18

Identify and treat underlying cause. Raise the legs. Give fluids

Answer 19

Cardiogenic shock is a state of inadequate tissue perfusion primarily due to cardiac dysfunction. May occur suddenly or after progressively worsening heart failure

Answer 20

MI Arrhythmias PE Tension pneumothorax Cardiac tamponade Myocarditis Endocarditis Aortic dissection

Answer 21

Low BP High HR High RR Confusion Pallor Clammy Pale peripheries Reduced urine output

Answer 22

**_ECG_** Tachycardic **_Blood pressure_** Low **_JVP pressure_** RAISED U&E, troponins/cardiac enzymes, ABG CXR Echocardiogram

Answer 23

Treat the cause Oxygen Diamorphine IV for pain and anxiety Correct arrhythmias, U&E abnormalities or acid–base disturbance Monitor CVP, BP, ABG, ECG, urine

Answer 24

Sepsis exists when a systemic inflammatory response is associated with an infection

Answer 25

Septic shock exists when sepsis is complicated by persistent hypotension unresponsive to fluid resuscitation

Answer 26

Age Diabetes mellituis (DM) Immunocompromised Alcoholics Burns IVDU Pregnancy Catheter

Answer 27

Low BP High HR Low sats (O2) High resp rate (RR) Lactate \>2 Unresponsive

Answer 28

Cultures (2 peripheral blood, plus urine/sputum/CSF) LACTATE ABG and BP

Answer 29

OXYGEN FLUIDS (check BP and ABG) IV ANTIBIOTICS (Tacozin and gentamicin, and vancomycin)

Answer 30

Intense allergic reaction. Massive release of histamine and other vasoactive mediators causing haemodynamic collapse.

Answer 31

Type-I IgE-mediated hypersensitivity reaction.

Answer 32

Drugs, eg penicillin, and contrast media in radiology Latex Stings, eggs, fish, peanuts, strawberries, semen (rare)

Answer 33

Itching, sweating, diarrhoea and vomiting, erythema, urticaria, oedema Wheeze, laryngeal obstruction, cyanosis Tachycardia, hypotension

Answer 34

Oxygen Remove the cause Adrenaline IM IV fluids Chlorphenamine (antihistamine) and hydrocortisone (steroid) If wheeze, treat for asthma

Answer 35

Distributive Disruption of the autonomic pathways within the spinal cord

Answer 36

Spinal cord injury Epidural Spinal anaesthesia

Answer 37

Cold and clammy suggests cardiogenic shock or fluid loss. Warm and well perfused, with bounding pulse points to septic shock. Any features suggestive of anaphylaxis—history, urticaria, angio-oedema, wheeze? CVS: usually tachycardic and hypotensive. JVP or central venous pressure: If raised, cardiogenic shock likely. Check abdomen: Any signs of trauma, or aneurysm? Any evidence of GI bleed?

Answer 38

Dopamine and vasopressin (ADH). Atropine is administered for slowed heart rate.

Answer 39

Kidneys - Acute tubular necrosis Lung – Acute Respiratory Distress Syndrome (ARDS) (or “shock lung”) Heart – myocardial ischaemia and infarction Brain – confusion, irritability, coma

Answer 40

**_Acute Respiratory Distress Syndrome_** Impaired oxygenation Bilateral pulmonary infiltrates No cardiac failure / normal PAOP

Answer 41

**_Alveolar capillary membrane injury_** Non-cardiogenic pulmonary oedema Neutrophil influx **_Exudative phase_** **_Proliferative phase_** Reorganisation of exudates, fibroblast proliferation **_Fibrotic phase_** Scarring

Answer 42

Extrapulmonary Causes Pulmonary Causes

Answer 43

**_Extrapulmonary Causes_** Shock of any cause Head injury Drug reaction Sepsis

Answer 44

**_Pulmonary Causes_** Pneumonia Chemical pneumonitis Smoke inhalation Near drowning

Answer 45

Primary heart muscle disease – often genetic. Three types.

Answer 46

Heart muscle becomes thick, heavy and hypercontactile.

Answer 47

Sarcomeric protein gene mutations. Autosomal dominant inheritance.

Answer 48

Leading cause of death in the young

Answer 49

Asymmetric septal hypertrophy Intervenricular septum more than free wall Take up more room so less filling More stiff and less compliant Stroke volume goes down Heart failure LV outflow tract (LVOT) obstruction

Answer 50

Diastolic heart failure

Answer 51

Pulling of the mitral valve towards the atrioventricular septum Venturi effect

Answer 52

Crescendo-decrescendo murmur Aortic valve stenosis

Answer 53

**_Sudden death._** Fast arrythmias Palpitations Dyspnoea Dizzy spells or syncope

Answer 54

Jerky pulse Double apex beat Systolic thrill at lower left sternal edge Harsh ejection systolic murmur

Answer 55

**_Echo_** Asymmetrical septal hypertrophy; small LV cavity with hypercontractile posterior wall; midsystolic closure of aortic valve **_ECG_** LVH; progressive T wave inversion; deep Q waves, AF

Answer 56

Beta-blockers or verapamil for symptoms. Amiodarone for arrhythmias (AF, VT). Anticoagulate for paroxysmal AF or systemic emboli.

Answer 57

Digoxin Increase contraction force, increase obstruction

Answer 58

Causes all four chambers of the heart to enlarge

Answer 59

Alcohol Increased BP Haemochromatosis Viral infection Autoimmune

Answer 60

Large space, thin walls Weak contraction Less blood pumped out in each beat Biventicular congestive heart failure Systolic heart failure

Answer 61

Holosystolic murmur S3 sounds also present, blood slamming into wall in diastole

Answer 62

Fatigue Dyspnoea Pulmonary oedema Right ventricular failure Emboli Atrial fibrillation Ventricular tachycardia

Answer 63

Increased pulse Decreased blood pressure Increased JVP Pleural effusion Oedema Jaundice, hepatomegaly, ascites Displaced diffuse apex beat, S3 gallop Mitral or tricuspid regurgitation

Answer 64

**_Blood_**: Plasma BNP is sensitive and specific in diagnosing heart failure. **_CXR_**: Cardiomegaly, pulmonary oedema. **_ECG_**: Tachycardia, non-specific T wave changes, poor R wave progression. **_Echo_**: Globally dilated hypokinetic heart and low ejection fraction. Look for MR, TR, LV mural thrombus.

Answer 65

Digoxin Diuretics ACE-i Anticoagulation Bi-ventricular pacing Cardiac transplantation.

Answer 66

Heart muscle becomes stiff and less compliant

Answer 67

Amyloidosis Familial amyloid cardiomyopathy Afro-americans Senile cardiac amyloidosis Elderly

Answer 68

Amyloidosis Sarcoidosis Collection of immune cells Haemochromatosis Radiation Endocardial fibroelastosis Loffler endomyocarditis Eosinophils in lung tissue and heart tissue

Answer 69

Proteins that have been misfolded and become insoluble Deposit in tissue in organs making them become less compliant **_Familial amyloid cardiomyoopathy_** Mutant transthyretin protein misfolded and prone to deposit in heart tissue Normally transport thyroxine and retionol **_Senile cardiac amyloidosis_** Normal TTR deposits in heart

Answer 70

Heart muscle stays same size When blood comes in heart doesn't stretch Less blood Less pumped out Heart failure

Answer 71

Diastolic heart failure

Answer 72

These are mainly of right heart failure with increase JVP Kussmaul’s sign (JVP rising paradoxically with inspiration) Quiet heart sounds S3 Diastolic pericardial knock, hepatosplenomegaly, ascites, and oedema.

Answer 73

**_ECG_** Low amplitude QRS

Answer 74

Treat underlying cause Heart transplant

Answer 75

An arrhythmic risk.

Answer 76

Ion channel protein gene mutations.

Answer 77

potassium, sodium or calcium channel.

Answer 78

Long QT, short QT, Brugada and CPVT.

Answer 79

Recurrent syncope and have a structurally normal heart.

Answer 80

An inherited condition. Cardiomyopathy or ion channelpathy.

Answer 81

Normal heart/arrhythmia.

Answer 82

Aortic aneurysm or dissection.

Answer 83

Abnormal buldge in vessel

Answer 84

Male Over 60 Hypertension Smoking

Answer 85

Atheroma Trauma Infection Connective tissue disorders Inflammations

Answer 86

Weakness in vessel wall Ballooning outwards of vessel wall due to pressure Laplace's law causes positive feedback loop Gives bigger aneurysm

Answer 87

When the diameter exceeds 1.5 times the normal size

Answer 88

Common sites Aorta (infrarenal most common), iliac, femoral and popliteal arteries. Complications Rupture; thrombosis; embolism; fistulae; pressure on other structures.

Answer 89

**_True aneurysms_** Abnormal dilatations that involve all layers of the arterial wall. THEN EITHER Fusiform OR saccular (Berry aneurysms) **_False aneurysms (pseudoaneurysms_**) Blood in the outer layer only (adventitia) which communicates with the lumen (eg after trauma).

Answer 90

Blood spurts out of the hole Less blood goes downstream Ischaemia of downstream cells

Answer 91

Severe left flank pain Abdomen Chest Lower back Groin Pulsating mass with heartbeat Hypotension

Answer 92

Often incidental finding Ultrasound CT MRI

Answer 93

Elective surgery. Stenting.

Answer 94

Tear in tunica intima, causes blood to pool between intima and media

Answer 95

**_Chronic hypetension_** Stress increase blood volume Coarctation **_Weakened aortic wall_** Marfan's Ehlers-Danlos syndrome Decrease blood flow to vasa vasorums **_Aneurysms_**

Answer 96

Within the first 10cm of aorta

Answer 97

**_Blood back up into pericardial space causing_** Pericardial temponade **_Blood goes out intima and comes back into blood vessel through and hole_** **_Blood flows does the aorta inbetween the layers and puts compression on other arteries_** Renal artery Subclavian artery

Answer 98

Type A (70%) dissections involve the ascending aorta, irrespective of site of the tear, Whilst if the ascending aorta is not involved it is called type B (30%)

Answer 99

Sharp chest pain radiating to back Weak pulse in downstream artery Difference in BP between left and right arms Hypotension Shock

Answer 100

**_CXR_** Widend aorta **_Transoesophageal echo_** True lumen and flase aorta **_Angiogram_**

Answer 101

**_Surgery_** Removal of dissected aorta Blocks entry of blood into wall of aorta Wall reconstructed with synthetic graft Stent **_Blood pressure meds_** Beta Blockers

Answer 102

Marfan, Loeys-Dietz, vascular Ehler Danlos (EDS).

Answer 103

Dominantly with a 50% risk.

Answer 104

Two. Visceral single cell layer adherent to epicardium Fibrous parietal layer 2mm thick Acellular collagen and elastin fibres 50ml of serous fluid.

Answer 105

Great vessels lie within the pericardium Two layers are continuous Left atrium is mainly outside the pericardium Parietal layer has fibrous attachments to fix the heart in the thorax.

Answer 106

Restrains the filling volume of the heart. If the volume is exceeded the pressure is translated to the cardiac chambers.

Answer 107

Fluid builds up in the pericardium and results in compression of the heart.

Answer 108

Any pericarditis Aortic dissection MI Trauma Trans-septal puncture at cardiac catheterization Cancer

Answer 109

Pulse increase BP decerease Pulsus paradoxus JVP increase Kussmaul’s sign Muffled S1 and S2.

Answer 110

Falling BP Rising JVP Muffled heart sounds.

Answer 111

**_Beck’s triad_** Falling BP; rising JVP; muffled heart sounds. **_CXR_** Big globular heart (if \>250mL fluid). **_ECG_** Low voltage QRS ± electrical alternans. **_Echo is diagnostic_** Echo-free zone around the heart ± diastolic collapse of right atrium and right ventricle.

Answer 112

The pericardial effusion needs urgent drainage

Answer 113

Pericardium slowly adapts to the increasing fluid and therefore reduces the effect on diastolic filling of the chambers.

Answer 114

Accumulation of fluid in the pericardial sac.

Answer 115

Any cause of pericarditis.

Answer 116

Dyspnoea Raised JVP Bronchial breathing at left base Look for signs of cardiac tamponade

Answer 117

**_CXR_** Enlarged, globular heart. **_ECG_** Low-voltage QRS complexes and alternating QRS morphologies (electrical alternans). **_Echo_** Shows an echo-free zone surrounding the heart.

Answer 118

Treat the cause. Pericardiocentesis may be diagnostic (suspected bacterial pericarditis) or therapeutic (cardiac tamponade).

Answer 119

Inflammatory pericardial syndrome with or without effusion.

Answer 120

Idiopathic.

Answer 121

**_Enteroviruses_** Coxsackie B viruse Herpesviruses (EBV, CMV, HHV-6),

Answer 122

Dresseler's syndrome Happens after heart attack When an MI happens lots of necrosis This also affects the pericardium

Answer 123

Blood levels of urea and nitrogen get high Due to kidney problems Iritate serous pericardium Secrete thick pericardial fluid Full of fibrin strands and white blood cells Wall of pericarditis gets a buttered bread apperance

Answer 124

Rheumatoid arthritis Scleraderma SLE

Answer 125

Fluid and immune cells move from tiny blood cells into the fibrous pericardium

Answer 126

Hard for the heart to expand and relax Stroke volume goes down Heart rate goes up

Answer 127

**_Fever_** **_Chest pain_** Worse with heavy breathing Better with sitting up and leaning forward

Answer 128

2 of 4 of: Chest pain. Friction rub. ECG changes. Pericardial effusion.

Answer 129

Pneumonia Pleurisy Pulmonary embolus Chostocondritis Gastro-oesophageal reflux Myocardial ischaemia/infarction. Aortic dissection

Answer 130

**_Clinical examination_** Pericardial rub Sinus tachycardia Fever Signs of effusion (pulsus paradoxus, Kussmauls sign) **_ECG_** Bloods **_CXR_** Silouette **_Echocardiogram_**

Answer 131

**_First few weeks_** Diffuse ST segment elevation Decrease PR **_After that_** T waves flattened **_After that_** ECG returns back to normal

Answer 132

**_FBC_** Modest increase in WCC, mild lympocytosis **_ESR & CRP_** High ESR may suggest aetiology ANA in young females - SLE **_Troponin_** Elevations suggest myopericarditis

Answer 133

**_Sedentary activity_** **_NSAID_** Ibuprofen PO or Aspirin PO **_Treat cause_** **_Colchicine_** PO limited by nausea and diarrhoea, reduces recurrence.

Answer 134

A symptomatic condition where breathlessness, fluid retention and fatigue are associated with a cardiac abnormality that reduces cardiac output A state where the heart is unable to pump enough blood to satisfy the needs of metabolising tissues

Answer 135

CO = HR x SV

Answer 136

Myocardial dysfunction. IHD. Hypertension. Alcohol excess. Cardiomyopathy. Valvular. Endocardial. Pericardial causes.

Answer 137

Inability of the ventricle to contract normally, resulting in decreaed cardiac output. Ejection fraction (EF) is \<40%

Answer 138

IHD MI Cardiomyopathy.

Answer 139

Inability of the ventricle to relax and fill normally Causing increased filling pressures. EF is \>50%.

Answer 140

Constrictive pericarditis Tamponade Restrictive cardiomyopathy Hypertension

Answer 141

Left ventricular failure (LVF) and right ventricular failure (RVF) may occur independently, or together as congestive cardiac failure (CCF).

Answer 142

Hypertension

Answer 143

Dyspnoea, Poor exercise tolerance Fatigue Orthopnoea Paroxysmal nocturnal dyspnoea (PND) Nocturnal cough (±pink frothy sputum)

Answer 144

LVF, pulmonary stenosis, lung disease.

Answer 145

Peripheral oedema (up to thighs, sacrum, abdominal wall), Ascites Nausea Anorexia Facial engorgement Pulsation in neck and face (tricuspid regurgitation) Epistaxis.

Answer 146

History and physical examination **_Blood Tests_** BNP LFTS, FBC, U&Es, BNP, TFTs **_Cardiac enzymes_** Creatinine kinase, troponin I, troponin T CXR ECG. Echocardiography

Answer 147

ABCDE Alveolar oedema Kerley B lines Cardiomegaly Dilated prominant upper lobe vessels Pleural Effusion

Answer 148

**_The sympathetic system_** Increases afterload by causing peripheral vasoconstriction **_The renin-angiotensin-aldosterone axis_** Salt and water retention Increases afterload and preload (^ volume and vasoconstriction) **_Cardiac changes_** Ventricular dilatation Myocytehypertrophy

Answer 149

**_Increased adrenergic activation_** Direct toxicity to myocytes Increased HR and contractility causing extra strain on heart Increased vasocontriction, increased afterload, more strain on heart

Answer 150

Increase salt and water retention Increased preload, extra strain on heart

Answer 151

**_Loop diuretics_** Furosemide **_ACEi_** Lisinopril **_Beta blockers_** Bisoprolol **_Aldosterone antagonists_** Spironolactone **_Calcium glycoside_** Digoxin inhibits Na/K

Answer 152

Pulmonary stenosis RV hypertrophy Overriding aorta VSD

Answer 153

The stenosis of the RV outflow leads to the RV being at higher pressure than the left Therefore blue blood passes from the RV to the LV The patients are BLUE Toddlers may squat

Answer 154

Infants may be acyanotic at birth Pulmonary stenosis murmur as the only initial finding. Cyanotic due to decreasing flow of blood to the lungs as well as right-to-left shunt across the VSD. Toddlers may squat Typical of TOF, as it increases peripheral vascular resistance and decreases the degree of right to left shunt. Adult patients are often asymptomatic

Answer 155

**_ECG_** RV hypertrophy with a right bundle-branch block. **_CXR_** Boot-shaped heart **_Echocardiography_** Can show the anatomy as well as the degree of stenosis.

Answer 156

Hole in the connecting venticles

Answer 157

High pressure LV Low pressure RV Blood flows from high pressure chamber to low pressure chamber Therefore NOT blue Increased blood flow through the lungs

Answer 158

Congenital Acquired (post-MI).

Answer 159

**_Large_** Pan-systloic murmur varies in intensity Small breathless skinny baby Increased respiratory rate Tachycardia Big heart on chest X ray **_Small_** Loud systolic murmur Thrill (buzzing sensation) Well grown Normal heart rate Normal heart size.

Answer 160

**_Large_** Require fixing in infancy (PA band, complete repair) **_Small_** Endocarditis risk Need no intervention

Answer 161

May lead to Eisenmengers syndrome.

Answer 162

High pressure pulmonary blood flow Damages to delicate pulmonary vasculature The resistance to blood flow through the lungs increases The RV pressure increases The shunt direction reverses The patient becomes BLUE.

Answer 163

Abnormal connection between the two atria (primum, secundum, sinus venosus) Common Often present in adulthood.

Answer 164

Primum: present earlier, may involve AV valves Secundum: may be asymptomatic until adulthood

Answer 165

Slightly higher pressure in the LA than the RA Shunt is left to right Therefore NOT blue Increased flow into right heart and lungs

Answer 166

**_Large_** Significant increased flow through the right heart and lungs in childhood Right heart dilatation SOBOE Increased chest infections If any stretch on the right heart should be closed **_Small_** Small increase in flow No right heart dilatation No symptoms Leave alone NB. The shunt on small to moderate sized defects increases with age

Answer 167

Reversal of left-to-right shunt, ie Eisenmenger’s complex. Paradoxical emboli (vein to artery via ASD; rare).

Answer 168

Pulmonary flow murmur Fixed split second heart sound (delayed closure of PV because more blood has to get out) Big pulmonary arteries on CXR Big heart on chest X ray

Answer 169

In children closure is recommended before age 10yrs. In adults, transcatheter closure is now more common than surgical.

Answer 170

Hole in the centre. Can involve the ventricular septum, the atrial septum, the mitral and tricuspid valves.

Answer 171

Complete defect –Breathless as neonate –Poor weight gain –Poor feeding –Torrential pulmonary blood flow –Needs repair or PA band in infancy –Repair is surgically challenging Partial defect –Can present in late adulthood –Presents like a small VSD / ASD –May be left alone if there is no right heart dilatation

Answer 172

Failure of ductus arterioles to close.

Answer 173

Continuous ‘machinery’ murmur If large, big heart, breathless Eisenmenger’s syndrome –Differential cyanosis (clubbed and blue toes, but pink not clubbed fingers)

Answer 174

Large –Torrential flow from the aorta to the pulmonary arteries in infancy –Breathless, poor feeding, failure to thrive –More common in prem babies –Need to be closed (surgically) •Small –Little flow from the aorta to Pas –Usually asymptomatic –Murmur found incidentally –Endocarditis risk

Answer 175

Surgical or percutaneous. Local anaesthetic. Venous approach.

Answer 176

Narrowing of the aorta at the site of insertion of the ductus arterioles.

Answer 177

**_Severe_** Complete or almost complete obstruction to aortic flow Collapse with heart failure Needs urgent repair **_Mild_** Presents with hypertension Incidental murmur Should be repaired to try to prevent problems in the long term

Answer 178

Right arm hypertension Bruits (buzzes) over the scapulae and back from collateral vessels Murmur

Answer 179

**_Hypertension_** Early coronary artery disease Early strokes Sub arachnoid haemorrhage Re-coarctation requiring repeat intervention Aneurysm formation at the site of repair

Answer 180

Surgery, or balloon dilatation ± stenting.

Answer 181

Normal AV valves has three cusps. This has two

Answer 182

Can be severely stenotic in infancy or childhood Degenerate quicker than normal valves Become regurgitant earlier than normal valves Are associated with coarctation and dilatation of the ascending aorta

Answer 183

Narrowing of the outflow of the right ventricle. Valvar. Sub valvar. Supra valvar. Branch.

Answer 184

Severe –Right ventricular failure as neonate –Collapse –Poor pulmonary blood flow –RV hypertrophy –Tricuspid regurgitation Moderate / mild –Well tolerated for many years –Right ventricular hypertrophy

Answer 185

Treatment –Balloon valvuloplasty –Open valvotomy –Open trans-annular patch –Shunt (to bypass the blockage)

Answer 186

Over 140/90

Answer 187

Essential hypertension (primary, cause unknown). ~95% of cases. Secondary hypertension ~5% of cases.

Answer 188

**_Renal_** CKD **_Endocrine disease_** Conn’s syndrome **_Others_** Coarctation, pregnancy

Answer 189

**_24hr ambulatory BP monitor_** **_Multiple home BP monitoring_** **_Fundoscopy–in severe HTN_** Bilateral retinal haemorrhages Papilloedema **_Overall CVD risk_** Fasting glucose Cholesterol **_End Organ Damage_** 12 lead ECG –past MI, LV hypertrophy Urine analysis –protein, blood

Answer 190

Stop smoking Low-fat diet Reduce alcohol and salt intake Increase exercise Reduce weight if obese

Answer 191

**_Calcium channel blocker_** Amlodipine Nifedipine Verapamil

Answer 192

**_ACE inhibitor_** Ramapril Peridopril OR **_Angiotensin receptor blocker_** Candesartan Valsartan

Answer 193

The other one

Answer 194

**_Thiazide like diuretic_** Chlorothiazide Hydrocholrothiazide

Answer 195

Less blood flow to kidneys Secretes Renin More water and salt retention Higher BP

Answer 196

Tumour on adrenal glands Constantly produce catecholamines Increase heart rate and peripheral vascular resistance Increase BP

Answer 197

Enhances adrenalines effect on blood vessels to constrict them Also can act as a mineralacorticoid (aldosterone) Increase BP

Answer 198

High aldosterone Increased sodium and water retention Increased BP

Answer 199

Hardening of the aorta

Answer 200

When the valve area is 1/4th of normal.

Answer 201

Supravalvular Subvalvular Valvular.

Answer 202

Unicuspid, bicuspid and tricuspid valve.

Answer 203

Congenital bicuspid valve Degenerative calcification Rheumatic Heart disease

Answer 204

Fusion of cusps.

Answer 205

Syncope Angina Dyspnoea Sudden death

Answer 206

Slow rising carotid pulse (pulsus tardus) & decreased pulse amplitude (pulsus parvus) Heart sounds- soft or absent second heart sound, S4 gallop due to LVH. Ejection systolic murmur- crescendo-decrescendo character.

Answer 207

Echocardiography Two measurements obtained are: Left ventricular size and function: LVH, Dilation, and EF Doppler derived gradient and valve area (AVA). ECG CXR –LVH, calcified aortic valve

Answer 208

**_General:_** Fastidious dental hygiene / care Consider IE prophylaxis in dental procedures **_Medical_** - limited role since AS is a mechanical problem. Vasodilators are relatively contraindicated in severe AS **_Surgical Replacement_**: Definitive treatment **_TAVI_** – Transcatheter Aortic Valve Implantation

Answer 209

Definition: Backflow of blood from the LV to the LA during systole Mild (physiological) MR is seen in 80% of normal individuals.

Answer 210

Myxomatous degeneration (MVP) Ischemic MR Rheumatic heart disease Infective Endocarditis.

Answer 211

Pure Volume Overload Compensatory Mechanisms: Left atrial enlargement, LVH and increased contractility Progressive left atrial dilation and right ventricular dysfunction due to pulmonary hypertension. Progressive left ventricular volume overload leads to dilatation

Answer 212

Exertion dyspnoea –exercise intolerance Palpitations Fatigue

Answer 213

Pansystolic murmur at apex radiating to axilla Soft S1 Displaced hyperdynamic apex

Answer 214

ECG: May show, LA enlargement, atrial fibrillation and LV hypertrophy with severe MR CXR: LA enlargement, central pulmonary artery enlargement. ECHO: Estimation of LA, LV size and function. Valve structure assessment TOE v helpful

Answer 215

Vasodilator –ACEi, hydralazine Rate control for AF –BB, CCB, Digoxin Anticoagulant for AF and flutter Diuretics –to control symptoms Surgery for deteriorating symptoms –aim to replace valve

Answer 216

ANY Symptoms at rest or exercise with (repair if feasible) Asymptomatic: If EF \<60%, LVESD \>45mm If new onset atrial fibrillation/raised PAP.

Answer 217

Leakage of blood into LV during diastole due to ineffective coaptation of the aortic cusps.

Answer 218

Bicuspid aortic valve Rheumatic Infective endocarditis.

Answer 219

Combined pressure AND volume overload Compensatory Mechanisms: LV dilation, LVH Progressive dilation leads to heart failure

Answer 220

Exertional dyspnoea Orthopnoea Paroxysmal nocturnal dyspnoea

Answer 221

Collapsing (water hammer) pulse Wide pulse pressure Displaced hyperdynamic apex beat Early diastolic murmur **_Notable eponyms_** Corrigans sign (ear movements) De Musset’s sign (head movements) Duroziez’s sign (Femoral artery murmur) Austin flint murmur (cardiac apex murmur) Traube’s sign (pistol shot over femoral)

Answer 222

**_CXR_** Cardiomegaly **_ECHO_** LV dilation and hypertrophy

Answer 223

**_Vasdilators_** ACEi only if symptomatic or HTN **_Surgical_** Replace valve before LV dysfunction

Answer 224

Obstruction of LV inflow that prevents proper filling during diastole

Answer 225

Rheumatic heart disease Infective endocarditis Mitral annular calcification.

Answer 226

LA dilation incerease pulmonary congestion (reduced emptying) Increased Transmitral Pressures Leads to left atrial enlargement and atrial fibrillation. Right heart failure symptoms: due to Pulmonary venous HTN

Answer 227

Dyspnoea Fatigue Palpitations Chest pain…

Answer 228

Malar flush on cheeks Low volume pulse Tapping, non displaced apex beat Rumbling mid-diastolic murmur Loud opening S1

Answer 229

**_ECG_** May show atrial fibrillation and LA enlargement **_CXR_** LA enlargement and pulmonary congestion Occasionally calcified **_MV ECHO_** The GOLD STANDARD for diagnosis Asses mitral valve mobility, gradient and mitral valve area

Answer 230

If in AF, rate control Anticoagulatewith warfarin Diuretics Percutaneous mitral balloon valvotomy

Answer 231

Infection of heart valve/s or other endocardial lined structures within the heart (such as septal defects, pacemaker leads, surgical patches, etc). It’s like a really bad infection, but with the added extras of showering infectious crap all around your bloodstream, and/or eating holes in your heart valves.

Answer 232

Left sided native IE (mitral or aortic) Left sided prosthetic IE Right sided IE (rarely prosthetic as rare to have PV or TV replaced) Device related IE (pacemakers, defibrillators, with or without valve IE Prosthetic; can be Early (within year) or Late (after a year) post op Each type can have different presentations, pathogens and outcomes.

Answer 233

Have an abnormal valve; regurgitant or prosthetic valves are most likely to get infected. Introduce infectious material into the blood stream or directly onto the heart during surgery Have had IE previously

Answer 234

the elderly (in an ageing population) the young i.v. drug abusers the young with congenital heart disease. Anyone with prosthetic heart valves.

Answer 235

Depends on site, organism, etc Signs of systemic infection (fever, sweats, etc) Embolisation; stroke, pulmonary embolus, bone infections, kidney dysfunction, myocardial infarction Valve dysfunction; heart failure, arrythmia

Answer 236

2 Major Criteria Bugs grown from blood cultures evidence of endocarditis on echo, or new valve leak 5 Minor Criteria Predisposing factors Fever Vascular phenomena Immune phenomena Equivocal blood cultures. Definite IE 2 major, 1 major+3 minor, 5 minor Possible IE 1 major, 1 major+3 minor, 5 minor.

Answer 237

ECG (ischemia or infarction, new appearance of heart block) Transthoracic echo (TTE). Safe, non-invasive, no discomfort, often poor images so lower sensitivity. Transoesophageal (TOE/TEE). Excellent pictures as long as you don’t mind having a big tube pushed down your throat. Patients rarely want to have a second TOE. Generally safe but risk of perforation or aspiration. Easiest if ventilated (but never ventilate just for TOE)

Answer 238

Petechiae 10 to 15%, Splinter hemorrhages Osler’s nodes (small, tender, purple, erythematous subcutaneous nodules are usually found on the pulp of the digits) Janeway lesions are erythematous, macular, nontender lesions on the fingers, palm, or sole Roth spots on fundoscopy.

Answer 239

Cultures may remain negative in 2% to 5% of patients with IE. Certain organisms: cell media; special media or microbiological methods, or may require long incubtion 7-21/7. The most common cause for negative blood cultures in patients with IE is prior antimicrobial therapy. WBC is rarely helpful. Raised CRP is almost always present.

Answer 240

Antimicrobials; intravenous for around 6weeks; choice of agent/s based on culture sensitivities Treat complications; arrhythmia, heart failure, heart block, embolisation, stroke rehab, abscess drainage etc Surgery.

Answer 241

the infection cannot be cured with antibiotics (ie recurs after treatment, or CRP doesn’t fall) complications (aortic root abscess, severe valve damage to remove infected devices (always needed) to replace valve after infection cured (may be weeks/months/years later To remove large vegetations before they embolise