Cardio Flashcards
1
Q
What is atherosclerosis?
A
A combination of fatty deposits in artery wall (athero) and hardening/stiffening of blood vessels (sclerosis)
2
Q
What are the effects of atherosclerotic plaques?
A
-Stiffening
-Stenosis (narrowing of arteries)
Plaque rupture
3
Q
What does stenosis cause?
A
Reduced blood flow
4
Q
What does stiffening of the artery wall do?
A
Causes hypertension + strain on heart as trying to pump against more resistance
5
Q
What does plaque rupture do?
A
Creates a thrombus that can block distal vessels e.g. acute coronary syndrome where a coronary artery becomes blocked
6
Q
List 3 non-modifiable risk factors for CVD
A
-Older age
-Family history
-Male
7
Q
List 8 modifiable risk factors for CVD
A
-Hyperlipidaemia
-Smoking
-Alcohol consumption
-Poor diet
-Lack of exercise
-Obesity
-Poor sleep
-Stress
8
Q
Name 5 medical comorbidities that increase the risk of CVD
A
-Diabetes
-Hypertension
-Chronic kidney disease
-Inflammatory conditions e.g. rheumatoid arthritis
-Atypical antipsychotic meds
9
Q
Name 6 conditions atherosclerosis can cause
A
-Angina
-MI
-TIA
-Strokes
-Peripheral arterial disease
-Chronic mesenteric ischaemia
10
Q
What does an atherosclerotic plaque consist of?
A
-Lipid
-Necrotic core
-Connective tissue
-Fibrous cap
11
Q
How does high LDL lead to inflammation + atherosclerosis?
A
LDL can pass in + out of arterial wall + in XS accumulates in wall, then undergoes oxidation + glycation-damages endothelial cells
12
Q
What are chemoattractants?
A
Chemicals that attract leukocytes, they are released from endothelium at the site of injury + produce a concentration gradient
13
Q
What is the fibrous cap of fibrous plaques made of?
A
-Collagen
-Elastin
14
Q
What 4 cells are contained within fibrous plaques?
A
-Smooth muscle cells
-Macrophages
-Foam cells
-T lymphocytes
15
Q
What is a TCFA?
A
Thin capped fibroatheroma (what occurs before plaque rupture when cap thins)
16
Q
What causes plaque rupture?
A
Increase in inflammatory conditions e.g. more enzyme activity, cap is weakened + ruptures
17
Q
Name 5 differences between ruptured plaques + eroded plaques
A
-Rup=large lipid core, eroded=small lipid core
-Rup=lots of inflammatory cells
-Eroded=more fibrous tissue
-Eroded=larger lumen
-Ruptured=red thrombus (RBCs + fibrin) vs eroded=white thrombus (platelets + fibrinogen)
18
Q
What does aspirin do?
A
Irreversibly inhibits platelet cyclo-oxygenase
19
Q
How do PCSK9 inhibitors help reduce risk of atherosclerosis?
A
They are monoclonal antibodies that inhibit the PCSK9 protein in the liver-improved clearance of cholesterol from blood
20
Q
What do statins do?
A
Reduce cholesterol synthesis in liver by inhibiting HMG CoA reductase
21
Q
Name 4 lifestyle changes that reduce the risk of developing atherosclerosis
A
-Stop smoking
-Reduce alcohol consumption
-Improve diet-fat less than 30% of calories, more wholegrains, less sugar, 5 a day fruit, 2 a week fish etc
-Increase exercise
22
Q
How much exercise does NICE recommend weekly?
A
-150mins+ of moderate intensity exercise or 75mins vigorous activity
-Strength training 2+ days a week
23
Q
What is a QRISK score?
A
Estimates % risk that a patient will have a stroke/MI in the next 10 years
24
Q
In relation to the QRISK score, when should patients be offered statins?
A
Results above 10%
25
What medication (including dose) should patients with a QRISK score >10% be offered?
Statin-initially atorvastatin 20mg at night
26
Patients with which conditions are offered atorvastatin as primary prevention?
-Chronic kidney disease
-Type 1 diabetes
27
What are the 4 A's of CVD secondary prevention?
-Antiplatelet meds e.g. aspiring, clopidogrel
-Atorvastatin
-Atenolol (or other beta-blockers)
-ACE inhibitor (often ramipril)
28
What is the inheritance pattern for familial hypercholesterolaemia?
Autosomal dominant
29
What are the 3 types of acute coronary syndrome?
-Unstable angina
-ST elevation MI (STEMI)
-Non-ST elevation MI (NSTEMI)
30
What is thrombosis?
Blood coagulation inside a vessel
31
rName the 5 most common causes of aterial thrombosis
-Atherosclerosis *
-Inflammatory
-Infective
-Trauma
-Tumour
32
What are the most common presentation of an arterial thrombosis?
-MI
-Stroke
-Peripheral vascular disease
33
Name 4 Tx's for a cardiac arterial thrombosis
-Aspirin/other antiplatelets
-Low molecular weight heparin (LMWH)/Fondaparinux
-Thrombolytic therapy
Reperfusion-catheter directed Tx + stents
34
Name 4 Tx's for a cerebral arterial thrombosis
-Aspirin
Thrombolysis
-Reperfusion
35
How would you diagnose a venous thrombosis?
-Signs + symptoms
-Blood test e.g. D-dimer
-Imaging
36
What are the 3 parts of Virchows triad?
-Endothelial damage
-Stasis/lack of blood flow
-Blood constituents
37
How could you treat a venous thrombosis?
-Heparin/LMWH
-Warfarin
-DOAC (direct oral anticoagulants)
38
Name 3 ways you can prevent venous thrombosis
-Mechanical/chemical thromboprophylaxis
-Early mobilisation
-Good hydration
39
Why is LMWH now given more than heparin?
Longer half-life, once-daily, less variation in dose + renally excreted
40
What are the drawbacks with warfarin?
-Hard to use
-Individual variation in dose
-Need to monitor
41
How does aspirin work?
Inhibits thromboxane formation + therefore platelet aggregation
42
What does heparin do?
Binds to antithrombin + increases activity
43
How does warfarin work?
-Stops synthesis of factors II, VII, IX + X
-Is a vit K antagonist
-Prolongs prothrombin time
44
What are NOAC/DOAC used for?
Extended thromboprophylasis and treatment of AF and DVT/PE
45
Name 3 antiplatelets
-Clopidogrel
-Aspirin
-Ticagrelor
46
What are the signs + symptoms for DVT?
-Leg pain
-Swelling
-Tenderness
-Warmth
-Discolouration
47
Name a complication of DVT
Phlegmasia (extreme DVT)
48
What is the most common cause of angina?
Ischaemic heart disease
49
What is angina?
Chest pain caused by reduced blood flow to the heart
50
What are the predisposing factors for IHD?
-Age
-Smoking
-FH
-DM
-Hyperlipidemia
-Hypertension
-CKD
-Obesity
-Physical inactivity
-Stress
51
Name 3 environmental factors for CVD
-Cold weather
-Heavy meals
-Emotional stress
52
When does myocardial ischemia occur?
When there is an imbalance between the heart's O2 demand + supply from an increase in demand/limit in supply
53
Name 3 ways in which the heart's O2 supply can be limited
-Impairment of blood flow by arterial stenosis
-Increased resistance e.g. ventricular hypertrophy
-Reduced O2 carrying capacity of blood e.g. anaemia
54
Name 4 types of angina other than stable
-Prinzmetal's angina (coronary spasm)
-Microvascular angina
-Crescendo angina
-Unstable angina
55
What is the pneumonic for investigating pain?
OPQRRRSTT
56
What does OPQRRRSTT stand for in relation to pain?
-Onset
-Position
-Quality (nature/character)
-Relationship (with exertion, posture, meals, breathing etc)
-Radiation
-Relieving/aggregating factors
-Severity
-Timing
-Treatment
57
Name 6 differential diagnoses for chest pain
-MI
-Pericarditis/myocarditis
-PE
-Chest infection
-Aortic dissection
-GORD
58
What investigations could you do for chest pain?
-Bloods
-Lipids
-ECG
-CT coronary angiogram
-Exercise testing
-Stress echo
-Perfusion MRI
59
Name 4 treatments for angina, prescribed in GP
-Aspirin
-GTN
-Beta blocker
-Statin
60
What effect do beta blockers have on the heart?
-Decrease HR, LV contractility, CO + therefore O2 demand
61
Name 4 side effects of beta blockers
-Tiredness
-Bradycardia
-Erectile dysfunction
-Cold hands + feet
62
What is the main contra-indication for beta blockers?
-Severe asthma
63
What do nitrates do?
Venodilation
64
How does aspirin work?
-Cyclo-oxygenase inhibitor
-Decreases prostaglandin synthesis, including thromboxane, decreases platelet aggregation
65
What is the main side effect of aspirin?
Gastric ulceration
66
Name an ACE inhibitor
Ramipril
67
Name 4 Tx's for angina prescribed in hospital
-ACE inhibitor
-Long acting nitrate
-Calcium channel blocker
-Potassium channel opener
68
Name 2 surgeries for more serious/uncontrolled angina/CHD
-Coronary angioplasty/stenting/PCI
-CABG
69
What are the pros of PCI?
-Less invasive
-Convenient
-Repeatable
70
What are the pros of CABG?
-Prognosis
-Deals with complex disease
71
What does PCI stand for?
Percutaneous coronary intervention
72
What does CABG stand for?
Coronary artery bypass graft
73
What are the cons of PCI?
-Risk stent thrombosis
-Not for complex disease
-Dial antiplatelet therapy
74
What are the cons of CABG?
-Invasive
-Risk of stroke/bleeding
-Can't do if frail/comorbidities
-Length of stay + recovery
75
Name 4 psychosocial factors that play a role in onset + management of CHD
-Coronary prone behaviour pattern
-Depression + anxiety
-Psychosocial work characteristics
-Social support
76
What investigations would you do for a DVT?
-D-dimer
-US
-CT
-MR venogram
77
How would you treat a DVT?
-LMWH for min 5 days
-Oral warfarin for 3-6mths
-Compression stockings
-Treat any underlying causes
78
How can you prevent a DVT?
-Hydration
-Early mobilisation
-Compression stockings
-Foot pumps
-LWMH
79
What are the signs + symptoms of a PE?
-Breathlessness
-Pleuritic chest pain
-Tachycardia
-Tachypnoea
-Pleural rub
80
Name 6 differential diagnoses of a PE
-MSK pain
-Infection
-Malignancy
-Pneumothorax
-Cardiac causes
-GI causes
81
Describe the layers of the pericardium
-Fibrous parietal layer
-Pericardial cavity
-Visceral single layer stuck to epicardium
82
What is acute pericaditis?
Inflammatory pericardial syndrome with/without effusion
83
What is pericardial effusion?
Build-up of extra fluid in the space around the heart
84
What are the 4 requirements for diagnosing pericarditis?
Need 2/4 of:
-Chest pain
-Friction rub
-ECG changes
-Pericardial effusion
85
What are the most common causes of pericarditis?
-*Viral e.g. enteroviruses
-Bacterial e.g. myobacterium TB
-Autoimmune e.g. Sjorgen syndrome, rheumatoid arthritis
-Neoplastic
-Metabolic e.g. uraemia, myxoedema
-Trauma
-Iatrogenic injury
-Aortic dissection
-Amyloidosis
86
What are the key presenting symptoms for pericarditis?
-Sharp, rapid onset + pleuritic chest pain, it can radiate to arm + is relieved by sitting forward
-Dyspnoea
-Cough
-Hiccups
87
Name 7 differential diagnoses for pericarditis
-MI
-Pneumonia
-PE
-GORD
-Pneumothorax
-Pancreatitis
-Peritonitis
88
What investigations would you do for suspected pericarditis?
-*ECG
-Bloods
-Chest x-ray
-Echocardiogram
-Clinical exam
89
What would you be looking for in a clinical exam for pericarditis?
-Signs of effusion e.g. Kussmauls sign
-Fever
-Sinus tachycardia
-Pericardial rub-crunching snow sound
90
Name 3 ways in which you might manage pericarditis
-Sedentary activity until resolution of symptoms/ECG
-NSAID/aspirin
-Colchicine reduces recurrence
91
What are the major complications + risks of pericarditis?
-Large pericardial effusion
-Cardiac tamponade
92
What are the minor complications + risks of pericarditis?
-Myopericarditis
-Immunosuppression
-Trauma
93
What causes of pericarditis increase the risk of a constriction developing?
-Bacterial causes - particularly with TB + purulent pericarditis
94
What ECG changes indicate pericarditis?
-Diffuse ST elevation
-Concave ST
-No reciprocal ST depression
-Saddle shaped
-PR depression
95
What is a normal adult heart rate?
60-100bpm
96
Define tachycardia
Heart rate >100 bpm
97
Define bradycardia
Heart rate <60bpm
98
How do you calculate heart rate using a regular rhythm ECG?
300/number of large squares between 2 complexes (R-R interval)
99
How do you calculate heart rate with an ECG when the rhythm is irregular?
Count number of complexes per strip, multiply by 6
100
How long does a small square on ECG represent?
0.04s
101
How long does a large square on ECG represent?
0.2s
102
How long do 5 large squares on ECG represent?
1s
103
What is an ECG lead?
Graphical representation of of the heart's electrical activity
104
How many physical electrode are attached in a 12-lead ECG?
10
105
How many chest electrodes are there?
6
106
How many limb leads are there + where are they placed?
4:
-Ulnar process of right arm
-Ulnar process of left arm
-Malleolus of left leg
-Malleolus of right leg
107
What view of the heart do the chest leads give?
V1-septal
V2-septal
V3-anterior
V4-anterior
V5-lateral
V6-lateral
108
What are the three main types of cardiomyopathy?
-Hypertrophic
-Dilated
-Arrhythmogenic
109
What causes hypertrophic cardiac myopathy (HCM)?
Sarcomeric protein gene mutations
110
What can HCM cause?
-Angina,
-Dyspnoea
-Palpitations
-Syncope
-Left ventricular outflow obstruction
111
How does dilated cardiomyopathy (DCM) present?
Heart failure symptoms
112
What is the main presenting feature of arrhythmogenic cardiomyopathy (ACM)?
Arrhythmia
113
What are cardiac channelopathies?
Defect in microscopic channels in the walls of heart cells through which electrolytes e.g. Na, K, Ca pass.
114
What do cardiac channelopathies cause?
Heart rhythm disturbances
115
Name 4 cardiac channelopathies
-Long QT
-Short QT
-Brugada
-CPVT
116
What causes arrhythmic CD?
Desmosome gene mutations
117
What is the main target for blood pressure control?
Peripheral resistance - interplay between RAAS + sympathetic nervous system
118
What do ACE inhibitors do?
Stop/reduce conversion angiotensin I -> angiotensin II, therefore decreasing blood pressure
119
Name 3 main conditions that ACE inhibitors are used for
-Hypertension
-Heart failure
-Diabetic nephropathy
120
Name a key ACE inhibitor
Ramipril (ACE inhibitors = 'il's)
121
What are the main adverse effects of ACE inhibitors?
-Hypotension
-Acute renal failure
-Hyperkalaemia
-Foetal abnormalities
-Cough
-Rash
-Anaphylactoid reaction
122
Why can ACE inhibitors cause rashes, cough, anaphylactoid reactions?
ACE also helps break down bradykinins, if it is inhibited, kinins build up
123
What are the most common uses of angiotensin II receptor blockers (ARB)?
-Hypertension
-Diabetic nephropathy
-Heart failure (when ACE-I contraindicated)
124
Name 3 angiotensin II receptor blockers
-Candesartan
-Valsartan
-Losartan
(ARB's = 'sartan's)
125
What are the main adverse effects of ARBs?
-Hypotension
-Hyperkalaemia
-Renal dysfunction
-Rash
-Angio-oedema
-Foetal abnormalities
126
What are the main conditions that calcium channel blockers are used in?
-Hypertension
-Ischaemic heart disease-angina
-Arrhythmia
127
Name 4 calcium channel blockers
-Amlodipine
-Nifedipine
-Verapamil
-Diltiazem
CCB's often end in 'dipine'
128
What are the main differences between amlodipine, verapamil + diltiazem?
-All calcium channel blockers BUT
-Amlodipine targets peripheral vessels
-Verapamil targets heart
-Diltiazem targets both
129
What are the main adverse effects of CCBs?
Due to peripheral vasodilation:
-Flushing
-Headache
-Oedema
-Palpitations
Others:
-Verapamil: Bradycardia. AV block, constipation
-Diltiazem: Bradycardia + AV block
130
What are the main uses of beta-adrenoceptor blockers?
-Ischaemic heart disease
-Heart failure
-Arrhythmia
-Hypertension
131
Name 3 beta-adrenoceptor blockers (BB)
-Bisoprolol
-Atenolol
-Propranolol
BB = 'olol'
132
What are the main adverse effects of BB?
-Fatigue
-Headache
-Sleep disturbance
-Bradycardia
-Hypotension
-Cold peripheries
-Erectile dysfunction
-Worsening of: asthma, COPD, PVD, heart failure
133
What are the main uses of diuretics?
Hypertension
-Heart failure
134
What are the 4 classes of diuretics?
-Thiazides
-Loop diuretics
-Potassium-sparing diuretics
-Aldosterone antagonists
135
Give an example of a thiazide
Bendroflumethiazide
136
Give an example of a loop diuretic
Furosemide
137
Give an example of a potassium-sparing diuretic
Spironolactone
138
What are the main adverse effects of diuretics?
-Hypovolaemia
-Hypotension
-Low electrolytes e.g. hypokalaemia
-Raised uric acid (gout)
-Impaired glucose tolerance
-Erectile dysfunction (thiazides)
139
Name a drug that can be used for hypertension in pregnancy
Methyldopa
140
What medication would you prescribe for hypertension for a diabetic/under 55yrs?
ACE inhibitor OR angiotensin II receptor blocker
141
What medication would you prescribe for hypertension for over 55yrs/Afro-Caribbeans
Calcium channel blocker
142
Name the angiotensin II blocker + neprilysin inhibitor used in conjunction in heart failure
Valsartan (AIIB)
Sacubitril (NI)
143
What do neprilysin inhibitors do?
Increase levels of natriuretic peptides
144
What are the main uses of nitrates?
Ischaemic heart disease
-Heart failure
145
What cardiac effects do nitrates have?
-Lower bp
-Arterial + venous dilators
-Reduction of preload + afterload
146
Give 3 examples of nitrates
-GTN spray
-GTN infusion
-Isosorbide mononitrate
147
How are antiarrhythmic drugs classified?
Vaughan Wiliams classification:
I-Na channel blockers
II-beta blockers
III-action potential prolongers
IV-Ca channel blockers
148
How does Digoxin work?
Inhibits Na/K pump-causes Ca lvls to rise
149
What effects does Digoxin have?
-Bradycardia
-Slowing of AV conduction
-Increased force of contraction
150
What is Digoxin used for?
-AF to reduce ventricular rate response
-Severe heart failure
151
What does it mean that Digoxin has a narrow therapeutic range?
Small differences in dose can lead to serious therapeutic failures/ adverse drug reactions
152
What does amiodarone do?
Prolongs QT interval
153
What are the adverse effects of amiodarone?
-Interstitial pneumonia
-Abnormal liver function
-Hyper/hypothyroidism
-Optic neuropathy
-Sun sensitivity
154
What is aortic stenosis?
Narrowing of the aortic valve
155
What are the 3 types of aortic stenosis?
-Valvular-most common
-Supravalvular
-Suvalvular
156
When do symptoms of aortic stenosis start?
When valve area has narrowed to 1/4 of normal area
157
What are the most common causes of aortic stenosis?
-Congenital
-Degenerative calcification-onset in 70s/80s
-Rheumatic heart disease-adhesions + fusion of comissures
158
What is another congenital cause of aortic stenosis (BAD)?
Bicuspid aortic stenosis-born with bicuspid rather than tricuspid valve
159
What effect does A. stenosis have on the left ventricle?
-Pressure gradient develops between l ventricle + aorta
-L ventricle compensates with hypertrophy
-But compensatory mechanisms become exhausted +l ventricle function declines
160
How does a. stenosis present?
-Exertional syncope
-Angina
-Dyspnoea (laboured breathing)
-Sudden death <2%
161
What are the signs of a. stenosis?
-Slow rising carotid pulse
-Soft/absent 2nd heart sound
-Ejection systolic murmur
162
What investigations would you perform for a. stenosis?
-Echocardiogram
163
Name some general management points for a. stenosis
-Fastidious dental hygiene + care
-Consider IE prophylaxis in dental procedures
164
What medications are contraindicated with severe a. stenosis?
Vasodilators
165
How can a. stenosis be surgically treated?
-Aortic valve replacement - TAVI
166
What is a TAVI?
Transcatheter aortic valve implantation
167
When would a patient be considered for an aortic valve replacement?
-Symptomatic with severe AS
-Patient with decreasing ejection fraction
-CABG patients with moderate/severe AS
168
What is mitral regurgitation?
Backflow of blood from left ventricle to left atrium during systole
169
What are the 2 types of mitral regurgitation?
Primary-disease of leaflets
Secondary-disease of ring/architecture around leaflets
170
What are the causes of primary mitral regurgitation?
-MVP
-Rheumatic heart disease
-Infective endocarditis
171
What is the main cause of secondary mitral regurgitation?
Dilated cardiomyopathy
172
What causes mitral regurgitation?
Volume overload
173
How does mitral regurgitation present?
-Pansystolic murmur at apex
-Exertion dyspnoea
-SOB
-Heart failure
174
What investigations would you order for mitral regurgitation?
*Echocardiogram
-ECG
-Chest x-ray
175
How is mitral regurgitation managed?
-Beta-blockers for a-fib
-Anticoagulants for a-fib + flutter
-Nitrates/diuretics in acute
-Serial echocardiography + monitoring
176
What are the indications for surgery in mitral regurgitation?
Symptoms at rest/exercise OR
asymptomatic but ejection fraction <60%
177
What are the surgical treatments for mitral regurgitation?
-TEER-transcatheter edge to edge repair
-Mechanical/tissue mitral valve replacement
178
What is aortic regurgitation?
Leakage of blood into LV during diastole due to ineffective coaptation of the aortic cusps
179
What are the causes of chronic a. regurgitation?
-Bicuspid aortic valve
-Rheumatic
-Infective endocarditis
180
What causes aortic regurgitation?
Pressure + volume overload
181
What are the compensatory mechanisms for aortic regurgitation?
LV dilation-progresses + leads to heart failure
182
What pulse changes + murmurs would occur with aortic regurgitation?
-Wide pulse pressure
-Diastolic blowing murmur
-Austin flint murmur
-Systolic ejection murmur
183
How would you investigate aortic regurgitation?
-Chest x-ray
-Echocardiogram
184
How is aortic regurgitation managed?
-IE prophylaxis
-Vasodilators
-Serial echocardiograms
-SAVR surgery (TAVI much rarer)
185
What is mitral stenosis?
Obstruction of LV inflow that prevents proper filling during diastole
186
What is the main cause of mitral stenosis?
Rheumatic carditis-becoming rarer as incidences of rheumatic heart disease decrease
187
What does mitral stenosis cause?
-Progressive dyspnoea
-Increased transmitral pressure
-Right heart failure
-Hemoptysis
188
What are the signs of mitral stenosis?
-Prominent 'a' wave in jugular venous pulsations
-Signs of r heart failure
-Mitral facies-pink/purple patches on cheeks when mitral stenosis is severe
189
How would you investigate mitral stenosis?
*Echocardiogram-gold standard diagnostic
-ECG
-Chest x-ray
190
How is mitral stenosis managed?
-Serial echocardiography
-Beta-blockers, calcium channel blockers, digoxin for symptoms
-Surgery-percutaneous mitral balloon valvotomy
191
What blood pressure readings count as hypertensive?
Above 140/90 in clinical setting
Above 135/85 with home readings
192
What are the four types of hypertension?
-Primary-develops on its own
-Secondary-underlying causes
-Accelerated/malignant
-White-coat
-Masked-readings higher at home than clinic
193
What is the mnemonic for secondary causes of hypertension?
ROPED
194
Using the mnemonic ROPED, what are the secondary causes of hypertension?
Renal disease
Obesity
Pregnancy
Endocrine
Drugs-alcohol, steroids, NSAIDs, oestrogen, liquorice, anti-anxiety drugs, anti-TNF's
195
What is the most common cause of secondary hypertension?
Renal disease
196
Name 2 endocrine causes of hypertension
-Conn's syndrome
-Pheochromocytoma
197
What complications are associated with hypertension?
-Ischaemic heart disease
-Cerebrovascular accident
-Vascular disease
-Hypertensive retinopathy + nephropathy
-Vascular dementia
-Heart failure
-Left ventricular hypertrophy
198
With one antihypertensive, how much would you expect bp to drop by?
-Systolic vol 8-10mmHg
-Diastolic 4-6mmHg
199
What is the white coat effect on bp?
Effect of bp being taken by doctor/nurse - more than 20/10mmHg difference in bp in clinic vs home readings
200
What should you do with patients with a clinic bp between 140/90 and 180/120 to diagnose hypertension?
24hr ambulatory blood pressure
201
What are the 3 stages of hypertension?
Stage 1-above 140/90
Stage 2-above 160/100
Stage 3-above 180/120
202
What risk assessment should also be performed on those with hypertension?
QRISK score
203
What should happen if a QRISK score is >10%?
Offered statin-atorvastatin 20mg at night
204
What are the symptoms of hypertension?
Very few symptoms-only symptomatic relief with Tx is reduction in headaches
205
What is the bp target for routine + older patients?
Routine-140/90
Older-150/90
206
What groups have a lower target bp? (130/80)
-CKD + diabetes
-Previous stroke
207
What medications are used in the management of hypertension?
-ACE inhibitors
-Beta blockers
-Calcium channel blockers
-Thiazide-like diuretic
-Angiotensin II receptor blocker - ARBs used instead of ACE inhibitors, not together
208
What is accelerated/malignant hypertension?
Extremely high bp - >180/120, with retinol haemorrhages or papilloedema
209
What should you do with a patient with accelerated hypertension?
-Same-day referral
-Fundoscopy (eye) exam
210
What drugs can you give in a hypertensive emergency?
-Sodium nitroprusside
-Labetalol
-Glyceryl trinitrate
-Nicardipine
211
What lifestyle modifications would you advise for a hypertensive patient?
-Increase exercise
-Reduce dietary salt
-Reduce caffeine
-Stop smoking
-Reduce alcohol
212
What is Tetralogy of Fallot?
Most common cyanotic congenital heart disease aka 'blue baby syndrome'
-4 defects
213
What are the 4 defects on Tetralogy of Fallot?
-Ventricular septal defect
-Pulmonary stenosis
-Overriding aorta
-Right ventricular hypertrophy
214
What are some of the causes of Tetralogy of Fallot?
Genetic-Down's, DiGeorge, CHARGE, VACTERL
215
What happens at birth in babies with TofF?
Oxygenated + deoxygenated blood mix-meaning deox blood is sent to body-causes cyanosis
216
What is VSD + its symptoms?
Ventricular septal defect - abnormal connection between ventricles
-High pressure LV, low pressure RV
-High pulmonary blood flow
-Breathless, poor feeding, FTT (failure to thrive)
217
What is Eisenmengers syndrome?
-Result of defects, when blood flow between heart + lungs is irregular
-High pressure pulmonary blood flow
-Damage to pulmonary vessels
-RV pressure increases, shunt direction reverses + patient becomes blue
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What is ASD?
Atrial septal defect-common, often present in adulthood
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What does ASD cause?
-Higher LA pressure than RA
-Shunt l->r so not blue
-Increased flow to right heart + lungs
220
What are the clinical signs of ASD?
-Pulmonary flow murmur
-Fixed split second heart sound
-Big pulmonary arteries + heart on chest x-ray
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What parts of the heart do AVSDs (atrio-ventricular septal defects) affect?
Failure to form centre of heart - involves ventricular septum, atrial septum, mitral + tricuspid valves
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What condition is associated with AVSD?
Down's syndrome
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What is PDA?
Patent ductus arteriosus-often treated surgically, even if small as risk of endocarditis
224
Name 4 hole congenital defects
-PDA
-ASD
-VSD
-AVSD
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Name 3 narrowing congenital defects
-Coarctation of aorta
-Bicuspid aortic valve
-Pulmonary stenosis
226
What is coarctation of the aorta?
Narrowing of aorta at site of insertion of ductus arteriosus
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What are the signs of coarc of aorta?
-Right arm hypertension
-Bruits (buzzes) over scapulae
-Murmur
228
How are congenital cardiac defects detected?
Foetal echocardiogram
Newborn baby checks
229
What is a 'tet' spell in an unrepaired TofF?
Sudden episode of profound cyanosis + hypoxia-can be fatal
230
What procedure is performed on patients with univentricular hearts?
Fontan procedure
231
What is infective endocarditis (IE)?
Infection of heart valves/endocardial lined structures within the heart e.g. septal defects, pacemaker leads etc
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What effect does infective endocarditis have?
Sends infectious material around bloodstream + can damage heart valves-lead to heart failure
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How is infective endocarditis treated?
-Antibiotics/antimicrobials
-Cardiac surgery to remove infectious material/repair damage
-Tx of other complications
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What are the types of IE?
-Left-sided
-Right-sided
-Native
-Prosthetic (early or late)
-Device related
-will be combinations of these e.g. left sided early prosthetic
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What are the risk factors for IE + who is most at risk?
-Abnormal valve
-Infectious material introduced into blood
-Previous IE
-Age
-Young IV drug users
-Young with congenital heart disease
-Anyone with prosthetic heart valves
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What is the most common sign of IE?
Fever
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What is the clinical presentation of IE?
-Signs of infection-fever, sweating etc
-Embolisation-stroke, PE, bone infection, kidney dysfunction, MI
-Valve dysfunction-heart failure, arrhythmia
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What is the criteria for diagnosing IE?
Modified Dukes Criteria
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What are the major Dukes criteria for IE?
-Pathogen grown from blood cultures
-Evidence of endocarditis on echo/new valve leak
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What are the minor criteria for iE?
-Predisposing factors
-Fever
-Vascular issues
-Immune issues
-Ambiguous blood cultures
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What investigations would you order for suspected IE?
-Echocardiogram-transthoracic echo preferred, transoesophageal much more uncomfortable but better image
-Blood cultures
-CRP
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Name 5 peripheral signs of IE
-Petechiae
-Splinter haemorrhages
-Osler's nodes
-Janeway lesions
-Roth spots
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When would you operate with IE?
-Infection not cured with antibiotics-recurrence/CRP doesn't fall
-Complications
-To remove infected devices
-To replace valve after infection cured
-To remove large vegetations before they embolise
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What is IE prophylaxis?
Preventative antibiotics for high risk patients with dental procedures
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What conditions cause left axis deviation?
-L ant fascicular block
-L bundle branch block
-L ventricular hypertrophy
246
What conditions cause right axis deviation?
*R heart hypertrophy/strain
-L posterior fascicular block
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What degree of deviation suggests left axis deviation?
QRS complex between -30 to -90
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What degree of deviation suggests right axis deviation?
QRS axis between 90 to 180
249
Where should the normal cardiac axis lie?
-30 to -90
250
With a normal ECG, which leads should be positive?
I, II, II (II = most positive/biggest peak)
251
With a healthy ECG, which lead would be most negative?
aVR
252
Which patients might have a smaller QRS complex?
-Obese
-Have pericardial effusion
-Have infiltrative cardiac disease
253
Name 3 causes of prolonged QT intervals
-Congenital causes
-Drugs
-Electrolyte disturbances
254
What does right axis deviation do to leads I, II, III?
III=most +ve
I= -ve
255
What does left axis deviation do to leads I, II, III?
I=most +ve
II + III= -ve
256
What are the types of AV block?
-1st degree
-2nd degree type 1
-2nd degree type 2-more serious
-3rd degree (complete)-more serious
257
Describe 1st degree AV block
Consistent prolongation of PR interval >0.2s
No dropped QRS complexes
258
Describe 2nd degree AV block type 1
Progressive PR interval prolongation
Some dropped QRS complexes
259
Describe 2nd degree AV block type 2
Consistent PR interval duration
Intermittent dropped QRS complexes
260
Describe 3nd degree AV block
No communication between atria + ventricles
P waves + QRS complexes functioning independently
261
What are the causes of 3rd degree AV heart block?
-Congenital HD
-IHD
-Iatrogenic
-Drugs
-Infection
-Thyroid dysfunction
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What are the causes of 2nd degree type 2 AV heart block?
-MI
-Cardiac surgery
-Autoimmune
-Drugs
-Hyperkalaemia
263
How can you quickly recognise l + right BBB?
WiLLiam (l) MaRRoW (r)
Shape of ECG in leads V1 + V6
264
What causes RBBB?
-Physiological
-Damage to r bundle branch e.g.
COPD, PE, congenital HD, IHD
265
What causes LBBB?
Conduction system degeneration
-IHD
-Cardiomyopathy
-Valvular HD
266
What causes T wave flattening + ST depression?
Ischaemia + infarction
267
Describe an ECG for a patient with hyperkalaemia
-Tall T waves
-Flat P waves
-Broad QRS
268
Describe an ECG for a patient with hypokalaemia
-Flat T wave
-QT prolongation
269
Describe an ECG for a patient with hypercalcaemia
-QT shortening
270
Describe an ECG for a patient with hypocalcaemia
-QT prolongation
271
What is AF?
Cardiac arrhythmia characterised by disorganised electrical activity within the atria resulting in ineffective atrial contraction and irregular ventricular contraction
272
What are the 3 types of AF?
-Paroxysmal
-Persistent
-Permanent
273
What are the main causes of AF?
-Hypertension
-Obesity
-Alcohol
-Heart failure
-Structural pathology
-Acute infection
-Electrolyte imbalance
-PE
-DM
274
Describe the symptoms of AF
-Breathlessness
-Palpitations
-Chest discomfort
-Light-headedness
-Syncope
275
What investigations would you perform for suspected AF?
-Basic obs
-ECG-12 lead + ambulatory
-Echocardiogram
-Chest x-ray
-FBC
-U + E
-LFT
-TFT
-CRP
-Clotting screen
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What are the ECG diagnostic requirements for AF?
-12 lead ECG of >30s showing no repeating P waves +
-Irregular RR intervals
277
What are the 3 principles of AF managament?
-Rate control
-Restore sinus rhythm
-Maintain sinus rhythm
278
What meds are used in the management of AF?
-Rate control: BB, CCB, Digoxin
-Restore sinus rhythm: Electrical/pharmacological cardioversion
-Maintain sinus rhythm: Flecainide, Dronedarone, Sotalol
279
What scoring system is used to asses stroke risk?
CHA2DS2-VASc Risk
280
What should happen if a CHADS-VASC score is >1
Prescribe anticoagulation with warfarin/DOAC
281
What are the categories in the CHA2DS2-VASc score?
Congestive HF
Hypertension
Age 75+ (2)
Diabetes mellitus
Stroke previously/TIA/Thromboembolism (2)
Vascular disease
Age 65-74
Sex category (female)
282
What is heart failure?
Inability of the heart to deliver blood + O2 to match the requirements of tissues, despite normal/increased cardiac filling
283
What are the causes of heart failure?
-IHD
-Hypertension
-Alcohol XS
-Cardiomyopathy
-Valvular disease
284
What are the symptoms of heart failure?
-Breathlessness
-Tiredness
-Cold peripheries
-Leg swelling
-Increased weight
285
What are the signs of HF?
-Tachycardia
-Displaced apex beat
-Added sounds/murmurs
-Hepatomegaly
-Ascites
-Peripheral/sacral oedema
286
What are the 2 main types of heart failure?
Acute + chronic
