Cardio Flashcards
1
Q
What is acute pericarditis?
A
Inflammation of the pericardium
2
Q
Causes Acute Pericarditis
A
Idiopathic
OR
Secondary to :
(Common)
> VIRUSES - Coxsackie, flu, EBV, mumps, varicella, HMV
> BACTERIA - pneumoniae, rheum fever, TB, staphs, strep
(Rarer)
> FUNGI
> Myocardial infarction - Dressler’s
> Drugs - hydraline, penicillin
Also : Uraemia, Rheum Arthritis, SLE, traume, surgery, malignancy
3
Q
Signs / Symptoms Acute Pericarditis
A
Central pain
Worse upon inspiration / when supine
Relief when sitting up
Pain is severe, sharp
Radiates to arm - trapezius ridge
Pericardial friction rub
Hiccups (phrenic involvement)
Sometimes fever
NOT crushing pain
4
Q
Ix Acute Pericarditis
A
ECG - saddle shaped ST segment elevation - GS!!!!!!
PR depression
PeRicardiTiS
(can be normal though)
Bloods - FBC, ESR, U&E, cardiac enzymes (troponin may be ↑), Viral serology, blood cultures
CXR - will show cardiomegaly if pleural effusion
5
Q
Tx Acute Pericarditis
A
Treat cause!
NSAIDs w/ gastric protection (PPI)
(Corticosteroids if resistant to NSAIDs)
Colchicine
Limited by nausea & diarrhoea
Reduces recurrence
Consider colchicine before steroids/immunosuppressants if relapse/continuation doesn’t occur
(bc steroids cause reoccurrence)
Rest until symptoms resolve
(Pericardiocentesis IF effusion/tamponade)
6
Q
DDx Acute Pericarditis
A
Pneumonia
Pleurisy
Pulmonary embolus
MI
Aortic dissection
GORD
7
Q
What is the mechanism of colchicine when used to treat acute pericarditis?
A
Inhibits migrations of neutrophils to site of inflammation to reduce risk of occurrence
8
Q
Complications of acute pericarditis
A
Pericardial effusion
Cardiac tamponade
Chronic constrictive pericarditis
9
Q
What is Pericardial Effusion?
A
Fluid in pericardium
10
Q
Cause Pericardial Effusion
A
Causes of Acute pericarditis
(happens after)
11
Q
Signs / Symptoms Pericardial Effusion
A
Effusion obscures apex beat ∴ heart sounds are soft
Dyspnoea
↑ JVP
12
Q
Tx Pericardial effusion
A
Treat cause!
Most resolve spontaneously
If effusion recurs, excision of pericardial segment allows fluid to be absorbed through pleural and mediastinal lymphatics
13
Q
What is constrictive pericarditis?
A
Heart is in a rigid pericardium
14
Q
Signs / Symptoms Constrictive Pericarditis
A
RHF Sx -
o Jugular venous distension
o Oedema
o Hepatomegaly
o Ascites
↑ JVP - paradoxically w/ inspiration = Kussmaul’s sign
Diffuse apex beat
Quiet heart sounds
Diastolic pericardial knock
S3
Pulsus paradoxus
AF
15
Q
Causes Constrictive Pericarditis
A
Often unknown
TB
After ANY type of pericarditis
Can happen after intracardial haemorrhage (during surgery)
MUST be distinguished from restrictive cardiomyopathy
16
Q
Ix Constrictive Pericarditis
A
CXR - small/normal heart +/- pericardial calcification
CT/MRI - diagnostic !!!! shows pericardial thickening and calcification
Rules out myopathies
Echo - cardiac catheterisation
17
Q
Tx Constrictive Pericarditis
A
Surgery - excision of pericardium
18
Q
What is Beck’s Triad?
A
- ↑ JVP
- ↓ BP
- Small, quiet heart
19
Q
What is Cardiac Tamponade?
A
MEDICAL EMERGENCY!
When pericardial fluid raises intra-cardiac pressure
∴ ↓ ventricular filling
& ↓ Cardiac filling
20
Q
Causes Cardiac Tamponade
A
ANY pericarditis
Aortic dissection
Haemodialysis
Warfarin
Transseptal Puncture (cardiac catherisation)
21
Q
Signs / Symptoms Cardiac Tamponade
A
↑Pulse
↓ BP
PULSUS PARADOXUS
Beck’s triad
Kussmaul’s sign
Muffled S1&2
22
Q
Ix Cardiac Tamponade
A
CXR - big globular heart
ECG - low voltage QRS
ECHO - GS!!!!
Echo-free zone around heart (>2cm or >1cm if acute)
+/- diastolic collapse of RA + RV
23
Q
Tx Cardiac Tamponade
A
URGENT drainage! - pericardiocentesis
Send fluid for culture
24
Q
When should CCBs be avoided?
A
HEART FAILURE !!!!!!!!!!!! (except amlodopine)
25
What is the WHO classification of Hypertension?
140/90 mmHg on at least 2 separate classifications
26
Risk factors of HTN
Obesity
Lack of exercise
Family history
Smoking
Old age
Low birthweight
Male
Afro-Caribbean
Poor diet - high cholesterol
27
Causes of HTN
**1° - Essential HTN** (95%)
**2° causes** - (5%)
> Renal (MC 2°) - CKD, Glomeronephritis, PAN, polycystic kidneys, systemic sclerosis etc
> Endocrine - Phaechromocytoma, Conn's, Cushing's
> ALSO : Pregnancy, Coarctation of aorta, Pre-eclampsia @ 3rd trimester, Drugs (the Pill, NSAIDs, vasopressin)
28
Signs / Symptoms HTN
Asymptomatic
Sometimes headaches but not much more than general population
29
Ix HTN
If 140/90 mmHg, confirm w/ :
> 24hr ambulatory BP monitor (ABPM)
> Multiple home BP measurements (HBPM)
--
ALSO : test for end-organ damage w/ :
> Urinalysis (kidneys) - protein, creatinine:albumin ratio, haematuria
> ECG/Echo (LV hypertrophy)
> Fundoscopy (HTN retinopathy)
> Bloods - serum creatinine, eGFR, BG (DM)
> Clinical history (MI, stroke)
--
ALSO : exclude 2° causes w/ :
> U&E (e.g. ↓K+ in Conn's, ↑ Ca2+ in Hyperparathyroidism)
--
Measure sitting AND standing BP if :
Type 2 Diabetes
> 80 years
Symptoms of postural hypotension
30
How does ABPM compare to clinical BP?
ABPM is always lower
Should always "add" 12/7 to "convert" to clinical if need to make decisions for Tx
31
When do you/do you not treat HTN?
If ≥ 160/100 mmHg, always treat
If end-organ damage, always treat
If ≥ 140/90, treat IF high risk of cardiac disease (Qrisk2 score)
--
Bear in mind, most adults over 50 will always benefit with HTN treatment no matter their BP
but idk that's what the book says but i think its bc of money, we obvs can't give everyone stuff
? idk
32
BP Goal for HTN treatment
< 140/90 (clinical)
< 135/80 (ABPM/HBPM)
< 130/80 in diabetes !!
--
Reduce slowly! Rapid reduction can be fatal !!
33
Tx HTN
**Lifestyle changes** -
Stop smoking, low fat diet & high consumption of fruit and veg, ↓Alcohol, ↓ Salt intake, ↑ Exercise, If obese - lose weight
**Drugs** -
Most drugs take 4-8 weeks to work properly, so be patient
Also, take multiple BP measurements before adding more
DIAGRAM !!!!!! LEARN!!!!!!!!
34
What is Malignant HTN?
Rapid rise in BP, causes vascular damage
Urgent care required!
Systolic > 200
Diastolic > 130
35
Risk factors Malignant HTN
More common in young & black people
36
Signs / Symptoms Malignant HTN
Headaches
Visual disturbances
Bilateral renal haemorrhages ∴ Papilloedema
Pathological hallmark = fibrinoid necrosis
37
Complications Malignant HTN
Hypertensive Emergencies e.g. :
AKI
HF
Encephalopathy
38
Tx Malignant HTN
Sodium nitroprusside
39
Why is is important not to rapidly reduce BP with Hypertension?
Bc cerebral auto-regulation is poor
∴ ↑ Risk of stroke
40
What is Atrial fibrillation?
Describe its pathophysiology
"Irregularly irregular"
Chaotic atrial rhythm
300-600 BPM
AV node responds intermittently, not all impulses are conducted to ventricles (bc AVN refractory period)
∴ Cardiac output ↓
41
Causes AF
Any condition that ↑Atrial pressure, e.g. :
HF
HTN
Coronary artery disease
Rheumatic heart disease
Valvular heart disease
Thyrotoxicosis
MI
PE
Pneumonia
Caffeine
Alcohol
ETC
42
RF AF
Elderly people
(& then obvs causes)
43
Full form - CHA2DS2VASC score
What does it measure?
When should you give medications?
**C**ongestive heart failure, 1
**H**TN, 1
**A**ge ≥ 75, **2**
**D**iabetes, 1
**S**troke, TIA, thromboembolism history, **2**
**V**ascular disease, 1
**A**ge 65-74, 1
**S**ex **C**ategory - FEMALE, 1
STROKE RISK
If 1, consider oral coags or aspirin
If 2+, give oral coag !! (DOACs, warfarin)
44
Full form - ORBIT score
What does it measure?
1 **O**lder age (≥ 75 years),
2 **R**educed haemoglobin/anaemia
2 **B**leeding history - GI/intracranial bleeding, haemorrhagic stroke
1 **I**nsufficient kidney function - eGFR < 60 mL/min/1.73 m2
1 **T**reatment w/ antiplatelets
BLEEDING RISK
45
Ix AF
**ECG** !!!
Irregularly irregular
Absent P waves
Rapid, irregular QRS somplexes
F waves
46
If someone has an irregular pulse, what Ix should you do?
ECG!! ON EVERYONE W/ IRREGULAR PULSE
47
Signs / Symptoms AF
USUALLY ASYMPTOMATIC
Palpitations
Fatigue, anxiety
Dyspnoea +/- chest pain
HF
Apical pulse > radical pulse
S1 variable intensity
48
Tx AF
ACUTE
If any associated illness (pneumonia), obvs treat
--
If **<** 48 hours, DC cardioversion.
If haemodynamically unstable, very urgent!
Give anticoag before - must be on anticoag to have DC cardioversion!
If DC cardioversion doesn't work, give flecaride/amiodarone
49
Tx AF
CHRONIC (most patients)
If any associated illness (pneumonia), obvs treat
--
Assess stroke/bleeding risk with CHA2DS2VASc/ORBIT to decide what to do
--
**Rate Control**
1. B-blockers (bisoprolol) OR CCB (verapamil)
2. If doesn't work, then give Digoxin and then consider Amiodarone
**Rhythm control**
> DC cardioversion
If DCC is chosen, first pre-treat with amiodarone OR sotalol (sotalol only if no other heart disease!!!) for AT LEAST 4 WEEKS
> If not DC C, then flecainide (if NO structural defect) /amiodarone (if structural defect, IV) instead
FOLLOWED BY :
**Anti-coagulation** - DOAC ! e.g. apixaban
Can do warfarin depending on patient but needs way more monitoring and both are equally affective
--
Need to decide how to balance bleeding risk and stroke risk, depends on lots of things e.g. age (falling risk) ∴Talk to them and figure a plan out
50
When treating AF, when should you not give B-blockers?
Don't give with Diltiazem or verapamil without expert advice
BC risk of bradycardia
51
Main goals of Tx AF
Rate control
Anti-coagulation
52
Mechanism of amiodarone
Inhibits Na+/K+ activated myocardial adenosine
↑ Duration of ventricular + atrial muscle action
∴ Nerve impulses take longer
53
Anti-Coagulation = PREVENTION of TIA/Stroke
Rate control/Rhythm control = TREATMENT of AF
54
DDx AF
Atrial flutter
55
Complications AF
STROKE!!!!!!
56
What are the types of angina?
Stable - induced by effort and relieved by rest
Unstable (crescendo) - increases in severity, occurs at rest or recent onset (less than a month)
Variant (Pinzmetal's) - caused by coronary artery spasm, angina w no provocation, usually at rest
Decubitus - precipitated by lying down
Nocturnal - at night, may wake patient from sleep
57
Risk factors Stable Angina
(Modifiable & non-modifiable)
**Non-Mod :**
Gender
FHx
Personal history
Age
--
**Mod :**
Smoking
Diabetes
Hypertension
Hypercholesterolaemia
Sedentary lifestyle
Stress
58
Precipitants of Angina
**Reduces blood supply :**
Anaemia
Hypoxaemia
Hypothermia
Hypovolaemia
Hypervolaemia
--
**Increases demand :**
Hypertension
Hyperthyroidism
Valvular heart disease
Tachyarrhythmia
Cold weather
59
Signs / Symptoms Angina
**Central, crushing retrosternal chest pain - radiates to arms, jaw, neck**
Chest pain comes on w/ exertion, rapidly resolved by rest and/or GTN
Exacerbated by cold weather, anger, excitement, big munch
Dyspnoea
Palpitations
Syncope
Nausea
Sweatiness
Faintness
60
How do you score angina?
1. Central tight chest pain radiating to jaw, neck, arms
2. Precipitated by exertion
3. Relief by rest and GTN spray
--
1/3 Non-anginal
2/3 Atypical angina
3/3 Typical angina
61
Ix Stable angina
ECG - normal, MAY show ST depression & T wave inversion
CT angiography - shows narrowing of coronary artery. Once seen, can open w balloon or stent
Stress ECG
Bloods - FBC, cardiac enzymes, glucose, lipid profile
CXR - heart size & pulmonary vessels
62
Tx Stable angina
Lifestyle - weight loss, ↑ exercise, quit smoking
Treat underlying conditions - HTN, DM
--
**Drugs**
PRN, FIRST FIRST LINE - Glyceryl trinitrate (GTN)
-
1. Beta blockers e.g. bisoprolol, atenolol, propranolol OR CCBs - aterodilators e.g. amlodopine
2. BB + CCB
3. Another anti-anginal = Ivabradine
OR long-acting nitrates
--
Then consider ACEi or ARBs or statins
--
THEN consider Surgery (PCI or CABG)
63
What is the mechanism of GTN when treating Stable angina?
Dilate coronary arteries which reduces preload
Nitrate is a venodilator
64
Common S/E of GTN
Headaches
65
What is the mechanism of Beta blockers when treating Stable angina?
↓HR and force of contractions
Neg chronotropic and inotropic
66
When is BB contraindicated for Stable Angina?
What alternative medications can you give instead?
ASTHMA !! or in patients with heart block
Use CCB instead (or Ivabradine)
67
WHEN ARE BB CONTRAINDICATED?
ASTHMA
68
Mechanism of CCB when used to treat Angina
Blocks Ca2+ influx into cell
Relaxes coronary arteries
↓ Force of LV contraction
69
Mechanism of Aspirin when used to treat heart failure
Inhibits platelet aggregation by inhibiting COX
70
If Aspirin is CI, what else could you use instead to treat angina?
Clopidogrel
71
Mechanism of statins
HMG-CoA reductase inhibitor
∴ Reduces cholesterol
72
To control BP in Angina, patient can be given ACEi
If condition is very severe, what other drug might you consider?
Angiotensin receptor blocker e.g. candesartan or losartan
73
Mechanism of Ivabradine
Inhibits pacemaker current in SAN
∴ ↓ HR
74
What are the risks of PCI? How could you avoid these?
Risk of restenosis or thrombosis
Drug-eluting stents reduces this risk
75
Advantages & disadvantages of CABG
Good prognosis
Longer recovery
76
Mechanism of PCI
Balloon dilation of stenotic vessels
77
DDx Angina
Pericarditis
PE
Chest infection
GORD
78
What does Acute coronary syndrome include?
STEMI
NSTEMI
Unstable angina
79
Describe unstable angina
New onset of angina or deterioration of previously stable angina
Chest pain occurs at rest, not relieved by GTN
Crescendo chest pain
More frequent, lasts longer
80
State the differences between a STEMI, NSTEMI & Unstable angina
ECGs & cardiac markers
81
Difference in STEMI and NSTEMI pathology
| like artery shit
**STEMI** - *complete occlusion of major coronary artery*
Full thickness cardiac muscle damage
**NSTEMI** - *partial occlusion of major or complete occlusion of minor artery*
Partial thickness cardiac muscle damage
Infarction distally + ischaemia proximally
Usually diagnosed retrospectively w troponin and ECG results
--
-> Artery previously affected by atherosclerosis
82
Pathology of ACS
Rupture/erosion of fibrous cap of coronary artery atheromatous plaque
∴ formation of platelet-rich cloth, inflammation & vasoconstriction !
-> from platelet release of serotonin and thromboxane A2
83
ECG changes in ACS
**Unstable angina** - Normal/T wave depression
**NSTEMI** - ST depression and/or T wave inversion
--
**STEMI** - ST elevation, tall T waves OR sometimes new LBBB (in larger MIs)
After hours/days - Q waves
84
In which leads would you see ST elevation in an **anterior MI**?
Which Coronary artery is occluded?
V1-V6
LAD
85
In which leads would you see ST elevation in an **Septal MI**?
Which Coronary artery is occluded?
V1-V4
No septum Q in V5+6 (???)
LAD-septal branches
86
In which leads would you see ST elevation in an **Lateral MI**?
Which Coronary artery is occluded?
I, avL, V5, V6
Circumflex branch of left coronary artery or MO
87
In which leads would you see ST elevation in an **Inferior MI**?
Which Coronary artery is occluded?
II, III, avF
RCA or RCX
88
In which leads would you see ST elevation in an **Posterior MI**?
Which Coronary artery is occluded?
ST DEPRESSION in V1-V4 (bc view of heart is inverted on ECG)
ST elevation in V7-V9
89
In which leads would you see ST elevation in an **Right ventricle MI**?
Which Coronary artery is occluded?
V1, V4
RCA
90
In which leads would you see ST elevation in an **Atrial MI**?
Which Coronary artery is occluded?
PTa in I, V5, V6
RCA
91
What is the PTa segment?
Segment between P and Q wave
92
Causes of ACS
**Rupture/Erosion of atherosclerotic plaque (arterial thrombosis)**
--
Less common:
Coronary vasospasm (without plaque rupture)
Drug abuse (cocaine etc)
Dissection of coronary artery
Thoracic aortic dissection
93
Ix ACS
**ECG** !!
--
**Bloods** - FBC, U&E, Glucose, Lipids
--
**Cardiac enzymes :**
> **Troponin T & I** - vvv sensitive and specific but not diagnostic
Rise within 3-12 hours
Peak at 24-48 hours
<14ng/L = normal, >30ng/L = definite MI (in between is possible but not definite)
> **Creatinine Kinase** - CK-MB! vvv specific and sensitive
Will peak earlier if reperfusion occurs
Rise within 3-12 hours of pain
Can be used to determine reinfarction -> levels drop to normal after 36-72 hours
> Myoglobin
1-4 hours after pain
↑ sensitive but not specific
--
**CT angiography**
94
Types of Creatinine Kinase
CK-MM, skeletal muscle
CK-BB, brain
CK-MB, heart!
95
State some cardiac causes of increased troponin
CHF
ACS or Chronic coronary artery disease
Myocarditis, Endocarditis, Pericarditis
Tachy/Bradyarrhythmia's
Heart block
96
State some non-cardiac causes of increased troponin
PE
Gram neg sepsis
Severe pulmonary HTN
Renal failure
COPD
Diabetes
Drugs
Acute neurological events
97
Why is it very important to treat unstable angina?
Bc 50% of Px will get an infarction within 30 days if left untreated
98
If a patient presents with unstable angina but their QRISK2 score is low, what could you do?
Elective stress test
99
Tx Unstable Angina
> **RF modification !!!** i.e. stop smoking, lose weight, healthy diet, exercise
--
**PCI & CABG** - if risk assessment score is medium/high
--
**Antiplatelet therapy**
> ASPIRIN - 300mg initially, then 75mg daily !!
Dual therapy with P2Y12 receptor inhibitors e.g. Clopidogrel
> Platelet glycoprotein IIb/IIIa receptor inhibitors - high risk Pxs
--
**Anti-Coagulants**
> LMWH
> Fondaparinux
--
Nitrates - GTN spray, IV
Beta blockers - bisoprolol
Statins - simvastatin
ACEi - ramipril
CCBs - amlodopine (If BB CI)
100
Describe the prescription - dual therapy of Aspirin with P2Y12 receptor inhibitors
Clopidogrel - 300mg initially, then 75mg for 12 months
OR
Ticagrelor - 180mg initially then 90mg bd
OR
Prasugrel
101
Mechanism of dual therapy
(Aspirin w/ P2Y12 receptor inhibitors)
Inhibits ADP-dependent activation of IIb/IIIa glycoproteins
∴ prevents amplification of platelet aggregation
102
Aspirin mechanism
Irreversibly inhibits COX-1
∴ ↓ production of thromboxane A2
∴ less platelet aggregation
103
Give an example of a Platelet glycoprotein IIb/IIIa receptor inhibitors
Abciximab
104
Common Signs / Symptoms MI
**Crushing central chest pain - "Elephant sitting on chest'**
Levine's sign
Pain may radiate to left arm, neck or jaw
Sweating
SOB/Dyspnoea
Fatigue
Nausea
Pallor
Palpitations
4th heart sound
> 20 mins
Not relieved by GTN spray
Pulse/BP may ↑ or ↓
Pansystolic murmur
THERE ARE ALSO ATYPICAL PRESENTATIONS
105
When does a silent infarction occur?
In elderly patients, diabetics or those with HTN
106
How does a silent infarction present?
Hypotension
Arrhythmias
Pulmonary oedema
107
Initial management of MI
HOSPITAL &
**MONAC :**
**M**orphine
**O**xygen (sats <94%)
**N**itrates
**A**spirin - 300mg chewed!
**C**lopidogrel
--
Beta blocker IV
Refer for PCI, thrombolysis (IV alteplase) or CABG **ASAP**
108
When is IV betablockers CI when treating MI?
Hypotension
HF
Bradycardia
Asthma
109
Secondary management MI
(prevention)
RISK FACTORS ! (diabetes, smoking, HTN, hypercholesterolaemia, exercise, diet - oily fish, fruit+veg, low saturated fats)
--
**ACAAB**
**A**spirin - 75mg od
**C**lopidogrel/Tricagralor
**A**tovorstatin - or any statin
**A**CE-i - to maintain BP
**B**Bs - ↓HR to prevent shearing of arteries
110
Ix MI
**ECG**
STEMI - ST elevation, tall T waves
_Might_ present as a new LBBB
Pathological Q waves
NSTEMI - ST depression and/or T wave inversion
--
Cardiac enzymes - troponin T, creatinine kinase, myoglobin
CT angiography
CXR
FBC
U&E
Blood glucose and lipids
110
Comps MI
**DARTH VADER**
**D**eath
**A**rrhythmia
**R**upture
**T**amponade
**H**eart failure
**V**alve disease
**A**neurysm
**D**ressler syndrome
**E**mbolism
**R**ecurrence regurg
111
What advice do you give to a patient who's just had an MI?
Return to work after 2 months - NOT ALL e.g. not airline pilots, divers, air traffic controllers
No air travel for 2 months
No sex for 1 month
112
Quick!
Breathlessness, fluid retention, fatigue - What is the disease?
Heart failure
(Anything with ↓CO)
113
Describe the NYHA classes
**I** No limitation of physical activity, so so calm
**II** Comfy at rest but slight breathless, palpitations etc during ordinary exercise
**III** Still comfy at rest, marked limitation of physical activity, symptoms at less than ordinary exercise
**IV** Symptoms even at rest! Getting dressed in the morning etc is uncomfortable.
114
RF heart failure
Age (65+)
Obesity
Male
If previous history of MI
African
115
Two types of Heart Failure
Systolic
Diastolic
116
Ejection fraction of systolic heart failure
Ejection fraction < 40% (Stroke vol/End diastolic vol)
117
Ejection fraction of diastolic heart failure
Ejection fraction > 50% (Stroke vol/End diastolic vol)
118
Why is there reduced preload in diastolic heart failure?
Bc abnormal filling of LV
119
Systolic heart failure Causes
Ischaemic heart disease!!
MI
HTN
Cardiomyopathy
120
Diastolic heart failure causes
Constrictive pericarditis
Cardiac tamponade
HTN
121
Name some compensatory changes for Heart Failure
Sympathetic stimulation
RAAS
Cardiac changes (ventricular dilation, myocyte hypertrophy)
122
Describe how sympathetic stimulation makes compensatory changes against heart failure
When SNS is activated - it improves ventricular function (by ↑HR and myocardial contractibility)
Also,
123
Describe how RAAS makes compensatory changes against heart failure
↓CO and ↑Sympathetic tone means ↓Renal perfusin
∴ RAAS IS ACTIVATED
∴ ↑Na+ and H2O retention
Further increases venous pressure and maintains stroke vol (Starling mechanism)
& then, as salt and water retention increases, periph and pulmonary congestions cause OEDEMA
∴ dyspnoea
ALSO : Angiotensin II also causes arteriolar constriction which increases afterload
124
Describe what cardiac changes are made to compensate against heart failure
125
If changes are made to compensate for heart failure, why do patients become symptomatic?
Bc compensatory changes become overwhelmed
∴ becomes pathological
126
3 cardinal symptoms of HF
SOB
Fatigue
Ankle swelling (fluid retention)
127
What is Left-sided heart failure?
When heart is unable to transport blood around the body
USUALLY SYSTOLIC FAILURE
aka unable to pump properly
but can be diastolic (unable to fill properly)
128
Causes LHF
IHD
HTN
Cardiomyopathy
Aortic stenosis - aortic valve narrows
129
Signs / Symptoms LHF
Cardiomegaly - displaced apex beat
Pulmonary oedema
S3 + S4
Pleural effusion
Crepitations in lung bases
Tachycardia
↓BP
Cool peripheries
Heart murmur
Exertional dyspnoea
Weight loss
Paroxysmal nocturnal dyspnoea
Nocturnal cough - pink, frothy sputum
Orthopnoea
130
Explain the pathophysiology of HTN as a cause for left-sided heart failure
↑Arterial pressure
∴ harder for LV to pump blood out
∴ LV hypertrophy
∴ greater demand for oxygen
Coronaries are squeezed by the extra muscle
∴ ↓Blood delivered to tissues
131
Describe the pathophysiology of Cardiomyopathy as a cause for Left-sided HF
DCM - heart chamber dilates so ventricles can fill w more blood (↑ preload)
∴ muscle wall gets tinner and wear
∴ systolic HF
RCM - heart becomes stiff ∴ less compliant ∴ can't stretch
∴ diastolic HF
132
Causes RHF
Left ventricular failure
HTN
Pulmonary stenosis
Lung disease (COR PULMONALE)
Atrial/Ventricular shunt
133
Signs / Symptoms RHF
Ascites
Nausea
Anorexia
**↑JVP**
Hepatomegaly/Splenomegaly
Pitting oedema
Weight gain (fluid)
134
Ix Heart Failure
**CXR** - **ABDCDE**
**A**lveolar oedema (Bat's wing)
Kerley **B** lines (interstitial oedema(
**C**ardiomegaly
**D**ilated upper lobe vessels of lung
**E**ffusion (pleural)
--
ECG - can show underlying causes (e.g. arrhythmias, IHD, LV hypertrophy etc)
Bloods - **Brain Natriuretic Peptide**
Not spec (can be raised in acute PE)
FBC
LFTs
U&Es
TFTs
Cardiac enzymes - Creatinine kinase, troponin I, troponin T, Myoglobulin
**Echocardiogram (TTE)** **GS!!!!**
Do if ECG and BNP abnormal
135
When might Brain Natriuretic Peptide be raised?
In acute PE
Secreted by ventricles in response to myocardial wall stress
↑HF patients
Levels correlate with ventricular wall stress and severity of HF
136
Acute Tx HF
100% oxygen
Nitrates - GTN spray (dilates vessels to allow adequate perfusion of heart)
IV opiates
IV furosemide - to reduce fluid overload
Consider inotropic drugs to ↑contractibility of dilated vessels
137
Chronic Tx HF
**ABAL**
**A**CE-inhibitors (e.g. ramipril or ARB)
**B**eta-blocker
**A**ldosterone antagonists - spironolactone
**L**oop diuretics (e.g. furosemide)
--
Also : Calcium glycoside (digoxin)
Ventricular assist device
HEART TRANSPLANT
138
When can ACE-i NOT be used to treat HF?
If patient has bilateral renal artery stenosis
139
S/E ACE-i
Cough - accumulation of bradykinin
Hypotension
Hyperkalaemia
Renal dysfunction
140
What can you give instead of ACE-i?
i.e. in HF if cough is too bad
Angiotensin-II-receptor blocker
141
When are BBs CI?
ASTHMA
3RD DEGREE HEART BLOCK
142
What must you remember when giving BB for a HF patient?
(idk if it's in general or just for HF patients)
Must give a low dose
Slow up titration
143
What lifestyle advice would you give a HF patient?
Education
Obesity control
Diet
Stop smoking
Cardiac rehab
144
How do ACE-i work?
Dilate blood vessels
145
How does calcium glycoside (Digoxin) help to treat HF?
Inhibits Na/K pump
∴ slows HR
146
What is an Acute Medical failure?
**Medical emergency!!!!!!!**
LHF or RHF developing over mins/hours
Ix and causes are similar to chronic HF
147
Clinical features of Acute Heart Failure
Cardiogenic shock - Hypotension, tachycardia, oliguria, cold extremities
Hypertensive HF - ↑BP, preserved LV function, pulmonary oedema on CXR
High output HF – septic shock, warm peripheries, pulmonary congestion, BP may be low
Right HF – low CO, elevated jugular venous pressure, hepatomegaly, hypotension
Acute pulmonary oedema – acutely breathless, tachycardia, profuse sweating (SNS overactivity), wheezes and crackles throughout chest, hypoxia, pulmonary oedema on CXR
148
Comps Acute HF
Arrhythmias
149
Describe the pathophysiology of IHD as a cause for LHF
IHD caused by atherosclerosis
(↓blood to heart ∴ ↓O2 ∴ myocardium damaged)
∴ dead myocytes
∴ scar tissue (which doesn't contract)
∴ ↓ contract force
∴ systolic heart failure
150
Describe in which scenarios LFH can sometimes be diastolic
Chronic HTN **AND** aortic stenosis
Both cause LV hypertrophy
∴ ↑contract force
∴ **concentric hypertrophy**
∴ ↓ LV col
∴ ↓ Room for filling
∴ diastolic heart failure
HCM - causes LV hypertrophy
∴ ↓ room for filling
∴ diastolic HF
RCM (described already)
151
Describe why HF presents with pulmonary oedema
↓ Blood pumping into body
∴ Blood backs up into lungs
∴ ↑ pressure and ∴ ↑ fluid moving from blood vessels into interstitial sace
∴ Pulmonary Oedema
152
Describe why HF presents with dyspnoea
Extra fluid in pulmonary veins/capillary beds = bad
bc ↓ O2 <--> CO2 exchange
BC more fluid in alveoli ∴ more time for gases to diffuse through
∴ Dyspnoea
153
MI Treatment Guidlines
idk i need to learn this
154
What does S1 describe?
Closing of mitral and tricuspid valve
155
What does S2 describe?
Closing of aortic and pulmonary valve
156
What does S3 describe?
When blood strikes a compliant LV during passive LV filling
157
What does S4 describe?
When blood strikes the LV during atrial contraction if LV is non-compliant
158
When do symptoms occur in aortic stenosis?
When valve area = 1/4 of normal
Normal = 3-4 cm2
159
What are the types of aortic stenosis?
Supravalvular - above valve
Valvular - MC
Subvalvular - below valve
160
Causes Aortic Stenosis
Calcification of congenital bicuspid aortic valve (BAV) - MC, presents in middle age
Degen and calcification of a normal valve - elderly
Rheum heart disease
161
How does GTN spray help relieve Angina symptoms?
GTN spray = nitrates
Nitrates cause release of nitric oxide in smooth muscles
∴ activates guanylate cyclase
Guanlycate cyclase then converts GTP to cGMP
∴ smooth muscle relaxation
∴ vasodilation
162
RF Aortic Stenosis
Congenital BAV
163
Quick!
Elderly person is **SAD**
Exertional **S**yncope, **A**ngina, **D**yspnoea
What is the disease?
Aortic stenosis
164
Signs / Symptoms Aortic Stenosis
CLASSIC TRIAD : Exertional syncope, Angina, Dyspnoea
Heart failure
Slow rising carotid pulse (pulsus tardus)
Weak carotid pulse (pulsus parvus)
Heart sounds - Soft/absent S2
Prominent S4 - bc LV hypertrophy
**EJECTION SYSTOLIC MURMUR**
Crescendo-decrescendo character
165
Pathophysiology Aortic Stenosis
Narrowing of aortic valve
∴ ↓LV emptying
∴ pressure gradient develops between LV and aorta
∴ LV HYPERTROPHY
∴ ↑ Myocardial O2 demand
∴ supply does not meet demand
∴ ischaemia of some myocardium
∴ eventually LV failure
166
Ix Aortic Syncope
**GS!!!** Echocardiography
CXR - normal heart size, LV hypertrophy
Ascending aorta prominent, post-stenotic dilation
Maybe valvular calcification
ECG - ST depression and T inversion in aVL, V5 and V6
LV hypertrophy if severe
To exclude coronary artery disease, cardiac catherisation
167
Tx Aortic Stenosis
SURGERY
Aortic valve replacement - in Sx patients
If not medically fit for surgery, then Transcatheter Aortic Valve Implantation (TAVI) w/ balloon stent
ALSO :
Dental hygiene is important!! Risk of IE
168
Describe the mortality of someone who has symptomatic aortic stenosis
75% mortality at 3 years once symptomatic
169
Causes Mitral Stenosis
**Rheumatic heart disease !**
Infective endocarditis
Mitral annular calcification
Congenital
170
RF Mitral Stenosis
History of rheumatic fever
Untreated strep infections
171
Pathophysiology Mitral Stenosis
Thickening of valve = obstruction from LA to LV
∴ ↑ LV pressure + R heart dysfunction + pulmonary HTN
AF is common bc ↑ LA pressure
ALSO, thrombus risk↑ bc of dilated L atrium - can become systemic emboli! stroke risk!!
If LA pressure is chronically increased, then ↑pulmonary pressure
∴ pulmonary oedema
172
Signs / Symptoms Mitral Stenosis
Progressive exertional dyspnoea
Cough w/ blood-tinged sputum
Haemoptysis (bc rupture of bronchial vessels bc ↑pulmonary pressure)
RHF Sx !
Palpitations
Chest pain
Malar flush !
Low vol pulse
Tapping, non-displaced apex beat
AF signs (not necessarily)
Loud S1 at apex
Since LA might get larger bc LVH, can compress n therefore lead to DYSPHAGIA
Diastolic murmur - best heard when patient is lying on left side w expiration
173
What does loudness signify when listening to a murmur?
NOTHING
DOES NOT INDICATE ANYTHING ABOUT SEVERITY
174
Ix Mitral Stenosis
Echo !!!! (**GS**)
CXR - LA enlargement, pulmonary HTN, sometimes calcified mitral valve, double heart border?? (passmed said)
ECG - AF, LA enlargement
175
Tx Mitral Stenosis
Rate control - if AF, prevent clots and embolisation e.g. digoxin, betablockers
Anti-coags - AF Pxs, prevents clots and embolisation e.g. warfarin
Diuretics - HF e.g. furosemide
Percutaneous mitral balloon valvotomy!
176
Causes Mitral Regurg
Myxomatous degeneration - mitral valve prolapse
Rheum heart disease
IE
Ischaemic mitral valve
DCM
177
RF Mitral Regurg
F
↓BMI
Age
Renal dysfunction
Previous MI
178
Pathophysiology Mitral Regurg
Leakage from LV into LA
∴ LA dilation
**Includes compensatory mechanisms :**
↑LA enlargement
↑LVH - bc LV same effort for less blood
↑Contractility
Progressive LA dilation and RV dysfunction
Progressive LV vol overload
∴ progressive HF !
179
Signs / Symptoms Mitral Regurg
Exertional dyspnoea
Fatigue/Lethargy
Palpitations
R HF -> can lead to congestive HF
Hyperdynamic, displaced apex beat
Soft S1
Pansystolic murmur at apex (radiates to axilla)
Diastolic blowing murmur at L sternal border
Systolic ejection murmur
Austin flint mumur at apex
180
What is a Austin flint murmur caused by?
FLuttering of mitral valve cusps bc of regurg
181
What is a pansystolic murmur?
Uniform intensity
May be accompanied by soft S1
Merges w S2
182
When is a diastolic blowing murmur heard?
When blood flows retrograde into LV
Heard best at Left lower sternal border
183
Ix Mitral Regurg
CXR - shows enlarged LA and LV
The more dilated, the more severe
Echo - (TOE) estimation of LA, LV, size & function
ECG - NOT diagnostic
184
Tx Mitral Regurg
IE prophylaxis !
Vasodilators - ACEi and hydralazine
Rate control for AF - BBs, CCBs, digoxin
Anti-coag for AF and flutter
Diuretics e.g. furosemide
Valve replacement IF patient has any Sx at rest
OR if new onset AF OR if ejection fraction < 60%
185
What is Aortic Regurg?
Blood leaks into LV during diastole
bc aortic cusps are leakyyy
186
Causes Aortic Regurg
Congenital bicuspid aortic valve
Rheumatic heart disease
Infective endocarditis
187
Signs / Symptoms Aortic Regurg
Collapsing waterhammer pulse
Wide pressure pulse
Quincke's sign
De Musset's sign
Muller's sign
Heart sounds - displaced hyperdynamic apex beat
Early diastolic murmur at left sternal edge at 4th IC space (accentuated if Px sits forward w breath held in exp!)
Systolic ejection murmur
188
Ix Aortic Regurg
Echo
ECG - shows evidence of LVH
CXR - cardiomegaly, sometimes also dilation of ascending aorta
189
Tx Aortic Regurg
IE prophylaxis
Vasodilators - ACEi
ONLY if Sx or HTN
SURGERY - replace valve asap before LV dysfunction
190
What can decrease the intensity of an ejection-systolic murmur with Aortic Stenosis?
Valsava manouvre
191
What can increase the intensity of an ejection-systolic murmur with Aortic Stenosis?
Amyl Nitrate
Raising legs
Squatting
Expiration
Bc increases blood flow through valve
192
Pathophysiology Pulmonary Stenosis
Narrowing of outflow of right ventricle
193
Signs / Symptoms Pulmonary Stenosis
**MILD/MOD :**
Well tolerated
RVH
**SEVERE : **
RV failure as a neonate
Collapse
Poor pulmonary blood flow
RVH
Tricuspid regurg
194
Tx Pulmonary Stenosis
Balloon valvuloplasty
Open valvotomy
Open trans-annular patch
Shunt (to bypass blockage)
195
What is Infective Endocarditis?
Infection of heart valves/other structures WITHIN the heart
e.g. pacemakers, surgical patches etc
196
RF IE
Elderly
IVDU
Congenital heart disease
Prosthetic heart valves or pacemakers
Poor dental hygiene
Male
197
Causes IE
**Staphylococcus Aureus** MC !!
IVDU, diabetes, surgery
Infects damaged and healthy valves
Can destroy valve
**Streptococcus viridans** - dental problems
Attacks previously damaged valves
Doesn't destroy valve
LOW virulence
Staphylococcus epidermis
Infects prosthetic material
Psuedomonas aeruginosa
198
Signs / Symptoms IE
**FROM JANE**
**F**ever!
**R**oth spots
**O**sler's nodes
**M**urmur (arrhythmias)
**J**aneway lesions
**A**naemia
**N**ail bed splinter haemorrhages
**E**mboli - stroke, MI etc
--
+ Headache, fever, malaise, confusion, night sweats, clubbing
199
What is the diagnostic criteria for IE?
**Duke's Criteria**
**2 Major Criteria***
1. 2 +ve blood cultures
2. Echo TOE shows vegetations on valve
**5 Minor Criteria**
1. Predisposing factors
2. Fever
3. Vascular phenomena
4. Immune phenomena
5. Equivocal blood cultures
--
Diagnostic IF :
2 majors
or 1 major + 3 minors
or 5 minors
Possible IE IF :
1 major
or 1 major + 3 minors
or 5 minors
200
Ix IE
Transoesophageal Echo (TOE) - **GS!!!**
Transthoracic Echo (TTE)
Cardiac Muscle Biopsy - will give definite diagnosis but v risky. Only use if will change treatment plan
ECG
CXR - cardiomegaly
Blood cultures - 3 sets from DIFFERENT sites over 24 hours !!
MUST be taken before ABx
But don't delay meds if patient v unwell (e.g. sepsis)
201
Tx IE
Antimicrobials - IV for 6 weeks
Depends on culture
If staph - use vancomycin and rifampicin
If not - use penicillin (benzylpenicillin, gentamycin)
Treat Comps - arrhythmias, HF, heart block, stroke etc
Surgery
202
What is a Cardiomyopathy?
Disease of myocardium that affects mechanical or electrical function of heart
203
Types of Cardiomyopathys
Hypertrophic Cardiomyopathy
Dilated Cardiomyopathy
Restrictive Cardiomyopathy
204
What is the most common cause of sudden death in young and adults?
HCM
205
Causes HCM
Autosomal dominant mutation
206
Signs / Symptoms HCM
Can be asymptomatic
Angina
Dyspnoea
Palpitations
Dizzy spells
Syncope
Crescendo-decrescendo murmur (Aortic stenosis) !!
S4
207
Ix HCM
ECG - usually always abnormal
Deep T wave inversion
Echocardiogram
Microscopically - Myocyte disarray
On a ultrastructural level - myofibrils are in disarray
When stained = blue
Fibrosis
Hypertrophy in coronary arteries
208
Tx HCM
Amiodarone - anti arrhythmic
CCB e.g. amlodopine, diltiazem
BB - atenolol
Surgery
DIGOXIN IS CONTRAINDICATED
209
Pathophysiology HCM
Diastole is main problem, NOT systole bc hearts are stiff and don't relax properly
LV becomes hypertrophied and hypertrophy is asymmetrical
∴ LV outflow tract is blocked during systole
210
Which is the most common cardiomyopathy?
Dilated cardiomyopathy
211
Pathophysiology DCM
Walls either normal or thin
∴ weak contraction
∴ less pumped out
∴ biventricular congestive HF
212
Causes DCM
Idiopathic !! - MC
Infection - coxsackie B
Ischaemia
Alcohol
Thyroid
Genetic
213
Signs / Symptoms DCM
HF Sx usually
SOB
Arrhythmias
↑JVP
214
Ix DCM
CXR - large heart
ECG - non-spec T wave changes
Echo
215
Tx DCM
HF and AF treated like usual
L ventricular assist device
Heart transplant
216
Pathophysiology RCM
Poor dilation of heart = ↓ability to take on blood and pass to rest of body
aka
Ventricles stiffer
∴ Less compliant
∴ ↓cardiac output
∴ HF
217
Causes RCM
Amyloidosis
Sarcoidosis
Idiopathic
Endocardial fibroelastosis
Löffler endocarditis - eosinophils in the heart
Haemochromatosis
218
Signs / Symptoms RCM
Similar to constructive pericarditis
Dyspnoea
↑ JVP
Hepatomegaly
Ascites
S3 + S4
219
Ix RCM
CXR
ECG - low amplitude, smaller QRS
Echo
Cardiac catherterisation
220
Tx RCM
Treat underlying cause
Heart transplant
221
Name some congenital heart defects
From MC to LC
Bicuspid aortic valve
Atrial septal defect
Ventricular septal defect
Coarctation of aorta
Pulmonary stenosis
222
Pathophysiology Bicuspid Aortic Valve defect
Normally, aortic valve = 3 cusps
but in BAV = 2
Leads to aortic stenosis +/- aortic regurg
Valve degens quicker than normal
ALSO, predisposes to IE, aortic dilation and aortic dissection
223
Ix BAV
Echo - intense exercise makes comps appear faster
224
Tx BAV
Surgical valve replacement
225
Which side murmurs are emphasised with expiration?
Left sided murmurs
Meanwhile, R sided are louder with inspiration bc ↑ venous return to heart
226
Describe the 4 stages of chronic limb ischaemia
Stage 1 - asymptomatic
Stage 2 - intermittent claudication
Stage 3 - Rest pain/Nocturnal pain
Stage 4 - Necrosis/Gangrene
227
RF Peripheral Vascular Disease
Same as atherosclerosis!
e.g.
Smoking
Diabetes
Dyslipidaemia
HTN
228
Causes PVD
Atherosclerosis
229
PVD : Hip/Buttock pain
Which artery?
Aortic or iliac arteries
230
PVD : Thigh pain
Which artery?
Common femoral artery
231
PVD : Upper 2/3rd calf pain
Which artery?
Superior femoral artery
232
PVD : Lower 2/3rd calf pain
Which artery?
Popliteal artery
233
PVD : Foot pain
Which artery?
Tibial or Peroneal artery
234
Define Intermittent Claudication
Nerve pain caused by release of adenosine in response to muscle ischaemia
235
6 Ps of Limb Ischaemia
**P**ain
**P**allor
**P**ulseless
**P**erishing cold
**P**araesthesia
**P**aralysis
236
Signs / Symptoms
Compare PAD and PVD
PAD : 6 Ps
PVD : Red, swollen, warm
237
Ix
Compare PAD and PVD
PAD : ABPI
PVD : D-dimer and dopper US
238
Tx
Compare PAD and PVD
PAD : Anti-coags
PVD : Anti-coags, DOACs, warfarin, heparin
239
Comps
Compare PAD and PVD
PAD : Acute limb ischaemia, loss of limb
PVD : PE
240
Describe Beurger's test
Patient supine, lift both legs to 45 deg
Hold for 2 mins
Observe feet colour
The poorer the arterial supply, the less angle legs raised to become pale
--
Then Px sits up, hangs legs over bed at 90 deg
Skin will be blue, then red
241
Why does skin first become blue then red in a positive Beurger's test?
As legs hang over bed at 90 deg (after supine and 45 deg), blood is deoxygenated in passage through ischaemic tissue
Then red, bc reactive hyperaemia from post-hypoxic vasodilation
242
Ix PAD/PVD
To exclude DM, arteritis, anaemia, renal disease
--
APBI - Ankle Brachial Pressure Index
Normal is 1-1.2
PAD = 0.5 - 0.9
Colour Duplex USS
Shows vessels and blood flow within
MT/CRI angiography - identify stenosis and quality of vessels
Bloods - ↑CK-MM, shows muscle damage
Auscultation - bruit
--
Venous US imaging
CT scan
^idk about these 2
243
What does Starling's Law generally state?
That stroke volume in the heart responds to end-diastolic vol (preload)
244
Tx DVT
Lifestyle - RF modifications
To relieve symptoms and ↓MI risk
Medications - anti-coag
Apixaban = 1st line !!!
245
Causes Critical Leg Ischaemia
Thrombosis (vasculopaths)
Emboli
Graft occlusion
Trauma
246
Signs / Symptoms Critical Leg Ischaemia
Pain in thighs, calves, feet, buttocks
Ulcers - more likely on limb w/ poor blood supply (healing takes longer bc ↓perfusion)
**6 Ps**
Foot pain at night, relieved by hanging foot over bed at night
247
Quick!
Deep duskiness of limb + Sudden deterioration = ?
ARTERIAL OCCLUSION
NOT Gout or cellulitis
248
Tx Critical Limb Ischaemia
Surgical embolectomy
Local thrombolysis with tissue type plasminogen activator (t-Pa)
249
Comps of treatment for Critical limb ischaemia
Risk of reperfusion injury and compartment syndrome post-surgery
250
How would you assess the probability of a DVT?
Wells score
251
Other than AF and atrial flutter, where else can sinus tachycardia occur in?
Anaemia
Fever
HF
Thyrotoxicosis
Acute PE
Hypovolaemia
Atropine
252
Causes Atrial Fibrillation
Any conditions that causes ↑atrial pressure - atrial fibrosis, inflammation etc
HF
HTN
Coronary artery disease
Rheumatic heart disease
Valvular heart disease
Thyrotoxicosis
Cardiac surgery
Cardiomyopathy (RARE)
253
Pathophysiology AF
Atria = 300-600/min
Only some of these impulses are conducted to the ventricles - due to the refractory period of AVN
HR = 120-180 BPM
254
Clinical classes of AF
Acute - onset within prev 48 hours
Paroxysmal - stops spontaneously within 7 days
Recurrent - 2 or more episodes
Persistent - continuous for 7 days or more and not self-terminating
Permanent
255
Signs / Symptoms AF
Palpitations
Irregularly irregular pulse
Dyspnoea
Hypotension
Chest pain & discomfort
Fatigue
Anxiety
S1 heart sound variable in intensity
256
Ix AF
**ECG** - irregularly irregular
F waves
No clear P waves
Rapid and irregular QRS complex
257
Tx AF
If unstable (i.e. syncope, shock, chest pain, HF) = DC synchronised cardioversion (**Control Rhythm**) by defib
If stable/long term =
> BBs or CCBs (**Controls Rate**)
> Digoxin - more in sedentary patients
> Amiodarone
Anticoag w warfarin - prevents thromboemboli
258
Give an example of a CCB
Verapamil
259
Describe the CHADS2VASC
**C**ongestive heart failure (1)
**H**TN (1)
**A**ge > 75 (2)
**A**ge 65 - 74 (1)
**D**M (1)
**S**troke or TIA (2)
**Vasc**ular disease (1)
**S**ex = female (1)
260
What does the CHADS2VASC score measure?
Stroke risk in AF
261
What do you do with the results of the CHADS2VASC score?
0 = lowe it
1 = consider oral anticoag or aspirin
2 = oral anticoag (warfarin, rivaroxaban)
262
What is atrial flutter?
Regular heart rhythm but faster than normal
Atrial HR = 300BPM while ventricular rate = 150BPM
263
In atrial flutter, why is the ventricular rate half the atrial rate?
Bc AV node conducts every second "flutter beat"
264
Causes Atrial Flutter
Idiopathic
Coronary artery disease
HTN
Pericarditis
Obesity
265
Signs / Symptoms Atrial flutter
Palpitations
Chest pain
Syncope
Fatigue
266
Ix Atrial flutter
**ECG** - sawtooth flutter waves (F waves)
Often 2:1 block (2 p waves for every QRS)
267
Tx Atrial flutter
If unstable - DC synchronised cardioversion
IV amiodarone - restore rhythm
Beta blocker (or CCB) - rate
Radiofrequency catheter ablation of re-entry circuit
Oral anticoag - prevent thromboemboli
268
What does the HASBLED score assess?
Risk of major bleeds in AF patients on anticoagulation
Should do regularly
269
Comps AF
HF
Ischaemic stroke
Mesenteric ischaemia
270
Compare AF to atrial flutter
(severity, rarity)
AF is more common and more severe
271
What is Wolff-Parkinson-White Syndrome?
It is a type of :
Atrioventricular Re-entrant Tachycardia (**AVRT**)
When there is an extra accessory pathway bypassing AVN
272
Pathophysiology AVRT
Accessory pathway bypassing AVN
∴ Normally AVN causes a delay but the pathway (Bundle of Kent) reaches slightly earlier - PRE-EXCITATION
(∴ narrow QRS + short PR)
Impulses can travel normally along the Bundle of HIS but then meet the Bundle of Kent and RE-ENTER ATRIA !
273
Signs / Symptoms AVRT
Palpitations
Dizziness
Dyspnoea
Central chest pain
Syncope
274
Ix AVRT
1. Short PR interval
2. "Slurred" start to QRS (DELTA waves)
3. Narrowed QRS
Also Px are prone to AF and MAYBE ventricular fibrillation
275
What does AVNRT stand for?
AV node re-entry tachycardia
276
What does AVRT stand for?
Atrioventricular re-entrant tachycardia
277
RF AVNRT
2x as common in women than men!
278
Pathophysiology AVNRT
2 pathways within AV node - one with a shorter refractory period, slow conduction and longer refractory period, fast conduction
Creates a "ring" of conducting pathways
∴ allows re-entry circuit
∴ produces tachycardia in atria
aka impulse can go round the slow path then bam quickly sneak up the fast path back to the atria!
279
Signs / Symptoms AVNRT
Rapid, regular palpitations - abrupt onset and sudden termination!
Neck pulsation - JVP pulsation
Polyuria
Chest pain
SOB
280
Why does AVNRT sometimes present with polyuria?
AVNRT can cause tachycardia
∴ ↑ atrial pressure
∴ ANP release
which causes polyuria
281
Ix AVNRT
**ECG** - P waves not visible, seen immediately before or after QRS complex
QRS - normal shape
282
Tx AVRT & AVNRT
If stable - vagal manouvres
e.g. breath holding, carotid massage, valsalva manoeuvre
If manoeuvres unsuccessful, IV adenosine
Consider surgical radiofrequency ablation of Bundle of Kent
283
How does IV adenosine work to fix AVRT and AVNRT and atrial flutter etc ?
Causes a complete heart block for a fraction of a second
∴ Should warn a patient, will feel like they are dying for a second ! jeeeez
284
Causes Sinus Bradycardia
**INTRINSIC**
Acute ischaemia
SAN infarction
Sick sinus syndrome
**EXTRINSIC**
Drug therapy - BB, digoxin
Hypothyroidism
Hypothermia
↑Intracranial pressure
285
Tx Intrinsic Sinus Bradycardia
Atropine
Permanent pacemaker
Temporary pacing in acute cases
ATROPINE IS CONTRAINDICATED IN MYASTHENIA GRAVIS AND PARALYTIC ILEUS
286
Tx Extrinsic Sinus Bradycardia
Treat underlying cause
287
Describe 1st degree heart block
Delayed AV conduction
Still reaches the ventricles
Prolonged PR interval > 0.22s on ECG
288
Causes 1st degree heart block
LEV's disease
IHD - scar tissue blocks conduction pathway
Myocarditis
Hypokalaemia
289
Tx 1st degree heart block
Asymptomatic
∴ no treatment required
290
What is 2nd degree heart block?
When atrial impulses fail to reach ventricles
291
Describe Mobitz type 1 pathophysiology
AV node block
Progressive PR interval prolongation until P wave fails to conduct
Then, QRS is absent after first P wave
Eventually, ventricle pacemaker cells kick in
∴ PR interval returns to normal
CYCLE REPEATS
DIAGRAM
292
Signs / Symptoms Mobitz Type 1
Light headedness
Dizziness
Syncope
293
Pathophysiology Mobitz Type 2
Block at intra-nodal level
∴ QRS is widened
**QRS complexes are dropped without PR prolongation !!**
Randomly dropped beats
294
Signs / Symptoms Mobitz Type 2
Chest pain
SOB
Syncope
Postural hypotension
295
Tx 2nd degree heart block
If severe, permanent pacemaker insertion
296
Pathophysiology 3rd degree heart block
Complete disassociation between atrial + ventricular activity
P waves + QRS complex occur independently
297
Causes 3rd degree heart block
CHD
Infection
HTN
298
Signs / Symptoms 3rd degree heart block
Syncope
Dyspnoea
Chest pain
Confusion
299
Ix 3rd degree heart block
ECG - P waves and QRS occur independent
300
Tx 3rd degree heart block
IV atropine (acute)
Permanent pacemaker insertion
301
Causes Bundle Branch Block
Acute - Ischaemia, MI, Myocarditis
Chronic - HTN, Cardiomyopathies
302
Which side is more common to have an accessory pathway and ∴ pre-excitation in AVRT ?
Left side
303
Ix Bundle Branch Block
**ECG** - wide QRS complex
0.08 - 0.12 seconds (incomplete BBB)
> 0.12 (complete BBB)
WILLIAM MARROW
--
RBBB - Deep S wave in leads 1 & V6
Tall late R wave in V1
LBBB - Deep S wave in lead V1
Tall late R wave in leads 1 & V6
304
When does RBBB occur?
PE
RVH
Isolated diastolic HTN
Congenital heart disease e.g. atrial/ventricular septal defects, Tetralogy of Fallot
305
When does LBBB occur?
IHD
Aortic stenosis
HTN
Aortic valve stenosis
306
Tx Bundle Branch Block
Cardiac pacemaker
307
Pathophysiology Bundle Branch Block
Bundle branches become blocked (fibrosis etc)
∴ Impulse is blocked on one side of heart
∴ ventricles don't get impulses at the same time
Instead, spread from left to right or vice versa
308
Signs / Symptoms Bundle Branch Block
Usually asymptomatic
309
Describe WiLLiaM MaRRoW
**W** - QRS looks like W in V1 & V2
i
**LL** - LEFT bundle
ia
**M** - QRS looks like M in V4-V6
--
**M** - QRS looks like M in V1
a
**RR** - RIGHT bundle
o
**W** - QRS looks like W in V5 & V6
310
Why does LBBB also produce abnormal Q waves?
Because Left bundle branch conduction is responsible for initial ventricular activation
311
What can be heard on auscultation in LBBB?
Reverse splitting of S2
312
What can be heard on ausculation in RBBB?
Wide physiological S2 splitting
313
Types of Aortic Aneurysm
True - degeneration affecting all 3 layers (intimal, media and adventitia)
False - collection of blood under adventitia only
314
What arteries are commonly involved in a true aortic aneurysm?
Abdominal aortia - MC!
Iliac
Popliteal
Femoral
Thoracic
315
What shapes are formed in a true aortic aneurysm?
Saccular - one side
Fusiform - both sides
316
When can a false aneurysm form?
After trauma
317
RF Abdo Aortic Aneurysm
Smoking
FHx
Age
Male
HTN
Trauma
COPD
Hypercholesterolaemia
318
Signs / Symptoms AAA
If unruptured, asymptomatic
Once ruptured, SUDDEN epigastric pain radiating to flank!
Abdo, loin, groin pain - pressure effects
Pulsatile abdo swelling - if diameter > 5.5cm, suggests it's unruptured
Expansile aorta - suggests rupture
Presents w: Epigastric pain radiating to back
Hypovolaemic shock
Hypotension
Collapse
319
Ix AAA
**Abdo US** - cheap, easy, sens, spec
CT +/- MRI angiography
320
Tx AAA
Small aneurysm monitoring
Manage RF (↓smoking etc)
Treat underlying cause
Surgery - EVAR (Endovascular repair)
Stent inserted through femoral/iliac artery
OR open surgery - fewer comps but more invasive
--
IF RUPTURED - EMERGENCY!
ABCDE, fluids, surgery!
AAA graft surgery = replace weakened walls w graft
321
Causes Thoracic aortic aneurysm
Cystic medial necrosis
Atherosclerosis
Connective tissue disorders - Marfan's, Ehlers-Danlos
322
Signs / Symptoms Thoracic Aortic aneurysm
Asymptomatic mostly
Pressure effects - Back/neck/chest pain, dysphagia, cough
Aortic regurg - if aortic root involved
Collapse
Cardiac tamponade
Haemoptysis
323
DDx AAA
Acute pancreatitis - but this is non-pulsatile and more assoc with Cullen's & Grey-Turner's sign
GI bleed
Perforated GI ulver
Appendicits
Pyelonephritis
324
DDx Thoracic aortic aneurysm
MI
Thoracic back pain
325
Ix Thoracic aortic aneurysm
Screen men between 65 - 74 with aortic US
CT angiography
MRI
326
Tx Thoracic Aortic Aneurysm
Surgical replacemet
BP control - BB
327
What is AAA?
Abdo aortic aneurysm
Permanent aortic dilation exceeding 50%
Diameter > 3cm
328
In whom is Inflammatory AAA found?
Found in younger patients who smoke + atherosclerotic arteryies
Some Px present with pyrexia
329
A patient can be perfectly healthy with a BBB. Which side?
RBBB
330
What is aortic dissection?
Surgical emergency!!
Tear in aortic intima, causing blood to dissect through the media - separating the layers
331
Common patient for Aortic Dissection
Man 50 - 70 years old
332
RF Aortic Dissection
**HTN** - can be caused by stress, pregnancy, coarctation
Connective tissue - Marfan's, ED
FHx
AAA
Trauma
Smoking
333
Types of Aortic Dissection
Type A - involves ascending aorta MC!!!
Type B - not involving ascending aorta
334
MC locations Aortic dissection
1. Sinotubular junction - where aortic root becomes "tubular", within 2-3cm of aortic valve **MC!**
2. Just distal to L subclavian artery (in descending thoracic aorta)
335
Signs / Symptoms Aortic Dissection
**Sudden onset of severe, central _tearing_ chest pain - radiates to back and down arms !**
Similar to MI but MI pain gets more intense with time but aortic dissection, the pain is worst at the beginning
Absent peripheral pulses
Unequal BP in arms
Neuro Sx / Shock
Hypotension
Aortic regurg (new murmur)
Cardiac tamponade
Compression of other arteries (renal, subclavian) - ∴ AKI, limb ischaemia
336
Ix Aortic dissection
**CT/MRI angiogram OR TOE** - GS!
CT/MRI CI if renal disease
CXR - widened mediastinum
> 8cm - sus!
337
DDx Aortic dissection
MI !!!
338
Causes Aortic dissection
Chronic HTN - pregnancy!
Connective tissue disorder - M/ED
Aneurysms
Infection
Atherosclerosis
Trauma
339
Tx Aortic dissection
**SURGERY**
Type A - open repair
Type B - EVAR (endovascular aneurysm repair)
Prevention/Additionally -
1. BB - esmolol or labetolol
2. Vasodilator sodium nitroprusside
If hypotensive, also consider : IV fluids, blood transfusions, adrenaline
340
Comps Aortic dissection
Cardiac tamponade
Aortic insufficiency (regurg)
Pre-renal AKI
Stroke - ischaemic
341
