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Phase 4 > Cardio > Flashcards

Cardio Flashcards

1
Q

What is an abdominal aortic aneurysm?

A

a permanent pathological dilation of the aorta >3cm or >1.5x the expected diameter

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2
Q

what is the mortality of ruptured AAA?

A

80%

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3
Q

what is the pathophysiology of AAA?

A

lipid deposits in abdo aorta and atheroma formation causes inflammation.
Inflammation causes damage to internal and external elastic laminae of aortic wall.
Loss of elastic laminae reduces ability of vessel to cope with variation in BP causing aorta to dilate over Time
Ongoing dilation causes fibrosis and thinning of aorta wall

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4
Q

Are heart conditions generally more common in men or women?

A

men

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5
Q

where are AAAs most common?

A

90% below the renal arteries

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6
Q

when is screening done for AAA?

A

Men from 65 years
Women >70 with risk factors

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7
Q

What happens in AAA screening if a small aneurysm is found?

A

Small = 3-4.4cm

Surveillance and repeat scan in 1 year

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8
Q

what happens in AAA screening if a medium aneurysm is found?

A

medium = 4.5-5.4cm

Repeat scan in 3 months

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9
Q

what happens in AAA screening if a large aneurysm is found?

A

Large = >5.5cm

Refer to vascular surgery

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10
Q

What are 6 risk factors for Aortic aneurysm?

A

Male
smoking + COPD
increased age
genetics/FHx
connective tissue disorders- mafans
Hypertension and CVD

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11
Q

what are 4 presentations of AAA?

A

Usually asymptomatic until rupture/near rupture

Pain in back/loin, abode pain radiating through to back

Palpable pulsate abdominal mass

Cardiovascular failure and shock - tachycardia + hypotension

Distal ischaemia - due to emboli causing distal arterial occlusion

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12
Q

What is the 1st line investigation of AAA?

A

abdominal ultrasound

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13
Q

when is elective repair recommended in AAA?

A

Symptomatic aneurysm
Diameter growing >1cm a year
Diameter >5cm

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14
Q

what is the management for AAA?

A

Open surgical repair
Endovascular aneurysm repair (EVAR)

EVAR preferred in haemodynamically stable patients

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15
Q

what are 4 complications of AAA?

A

MI/bowel ischamia/limb ischaemia
Blood transfusion reactions
Abdominal compartment syndrome
Graft infection

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16
Q

what are 2 complications of open AAA repair?

A

Abdominal wound dehiscence
incisional hernias

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17
Q

what are 2 complications of EVAR AAA repair?

A

Haematomas/pseudo aneurysms in goin acess site
leakage of blood around stent graft - CT angio surveillance for the rest of patients life

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18
Q

what are 2 considerations for driving with AAA?

A

inform DVLA of aneurysm >6cm
stop driving if aneurysm >6.5cm

Stricter rules for HGVs

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19
Q

What is acute coronary syndrome?

A

a spectrum of conditions that includes unstable angina (UA), non-ST-elevation myocardial infarction (non-STEMI), and ST-elevation myocardial infarction (STEMI)

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20
Q

what is the number one cause of death globally?

A

cardiovascular disease

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21
Q

what is the underlying cause of most acute coronary syndromes?

A

coronary artery disease

rare - coronary artery spasm

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22
Q

what are the 3 pathophysiological origins of ischaemic heart disease?

A

increased myocardial O2 demand (exercise, infection)

reduced coronary blood flow (atherosclerosis)

Reduced myocardial oxygen delivery (anaemia, hypoxaemia)

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23
Q

what is angina pectoris?

A

Chest pain on exertion due to myocardial ischaemia

alleviated on rest

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24
Q

What are 3 differentials for angina?

A

GORD
Panic Disorder
Pericarditis

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25
Q

what medication is used for the symptomatic relief for angina?

A

Sublingual glyceryl trinitrate (GTN) spray

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26
Q

what are 4 complications of stable angina?

A

MI
Heart failure
Arrhythmia due to ischaemic heart disease
Sudden cardiac death

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27
Q

what are 5 risk factors for aortic dissection?

A

HTN, other CVD risk factors
Conditions affecting the aorta - Bicuspid aorta, coarctation of aorta, aortic valve replacement, CABG
Connective tissue disorders - EDS, Marfan’s

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28
Q

What is the pathophysiology for aortic dissection?

A

There is a tear in the intimal lining of the aorta => blood to enters the aortic wall under pressure forming a haematoma which separates intima from adventitia and creates a false lumen

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29
Q

what is the stanford classification of aortic dissection?

A

Type A - Affects ascending aorta before brachiocephalic artery

Type B - Affects descending aorta after L subclavian artery

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30
Q

what is the DeBakey system for classifying aortic dissection?

A

1 - begins in ascending aorta involving at least arch if not whole aorta
2 - isolated to ascending aorta
3a - begins in descending till above diaphragm
3b - begins in descending and extends below diaphragm

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31
Q

What are 6 manifestations of aortic dissection?

A

Tearing pain in chest from front to back or inter scapular pain

radio radial delay

difference in BP >20mmHg between both arms

Diastolic murmur

focal neurological deficit

Tachycardia, hypotension, collapse and cardiogenic shock

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32
Q

What are 3 investigations that can be done for aortic dissection?

A

ECG
CXR - widened mediastinum

Contrast enhanced CT angiogram chest, abdo, pelvis

MRI angio

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33
Q

what is the management of Stanford type A aortic dissection?

A

Beta blockers (IV labetalol) + analgesia

midline sternotomy to remove section of aorta and replace with synthetic graft, aortic valve may need to be replaced

BP 100-120 systolic

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34
Q

what is the management of Stanford type B aortic dissection?

A

IV labetalol + analgesia

May be able to manage medically - monitoring, analgesia, BP control

Thoracic endovascular aortic repair (TEVAR)

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35
Q

where is aortic dissection most common?

A

ascending aorta

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36
Q

what investigation can be used in unstable patients for aortic dissection?

A

Transoesophageal echocardiograph

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37
Q

what are 6 complications of aortic dissection?

A

cardiac tamponade
aortic regurgitation
MI
Stroke
paraplegia
death

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38
Q

what is S1 caused by?

A

Closing of the AV valves at the start of systole

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39
Q

what is S2 caused by?

A

Closing of the semilunar (pulmonary and aortic) valves at the end of systole

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40
Q

what is S3 heart sound?

A

3rd heart sound heard just after S2 - Lub du-dub

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41
Q

what is one cause of S3 heart sounds?

A

Heart failure

Due to rapid ventricular filling causing chordae tendineae to twang

Can also be normal in younger patients due to very good heart function

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42
Q

what is S4 heart sound?

A

Le-Lub Dub

Always abnormal - due to stiff, hypertrophic ventricles causing turbulent flow from atria - ventricular hypertrophy

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43
Q

what is the murmur in aortic regurgitation?

A

Early diastolic soft decrescendo murmur

Can also cause Austin flint murmur - apex diastolic rumbling

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44
Q

when does aortic regurgitation usually become symptomatic?

A

when the ejection fraction <50%

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45
Q

what are 6 causes of aortic regurgitation?

A

bicuspid aortic valves
rheumatic fever
endocarditis
connective tissue disorders - Marfans, EDS
Aortic dissection/anyeurysm
Idiopathic/age related

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46
Q

what is the pathophysiology of aortic regurgitation?

A

There is reflux of blood from the aorta to the L ventricle in diastole => increased LV preload => LV hypertrophy and dilation => eventual heart failure

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47
Q

what are 5 signs of aortic regurgitation?

A

Early diastolic decrescendo murmur
Wide pulse pressure
De Musset’s head bobbing with pulse
Quincke’s sign - nail capillaries pulsing
Austin flint murmur

Heart failure

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48
Q

what is the management for aortic regurgitation?

A

Lifestyle modification
ACEi
Beta blockers

Severe - loop diuretics and aortic valve repair/replacement

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49
Q

what are 3 complications of aortic regurgitation?

A

L ventricular dysfunction and heart failure
AF
Sudden cardiac death

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50
Q

what is the most common valvular disease?

A

Aortic stenosis

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51
Q

what is the murmur in aortic stenosis?

A

Harsh ejection systolic crescendo-decrescendo murmur

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52
Q

where does aortic stenosis murmur radiate to?

A

Carotids

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53
Q

when is aortic stenosis murmur enhanced?

A

sitting forward and expiration

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54
Q

what are 6 risk factors for aortic stenosis?

A

Bicuspid aortic valve and other congenital leaflet abnormalities
Age related calcifications
Rheumatic Fever
HTN, smoking, high lipids
Mediastinal radiotherapy
CKD - due to abnormal calcium homeostasis

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55
Q

what are 2 conditions that have higher incidence of bicuspid aorta?

A

Turner’s syndrome
coarctation of aorta

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56
Q

what are 6 manifestations of aortic stenosis?

A

crescendo derescendo ejection systolic murmur
Exertional dyspnea
Chest pain
Exertion syncope
Fatigue
Heart failure features

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57
Q

what are 3 indications for valve replacement in aortic steonsis?

A

Severe and symptomatic
Severe and asymptomatic but either evidence of heart failure or symptoms on exercise testing

LVEF <50%
Aortic valve gradient >40 mmHg

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58
Q

what are 3 management options for aortic stenosis?

A

Observation if patient is asymptomatic

Surgical aortic valve replacement (SAVAR)
transcutaneous aortic valve implantation (TAVI)
Balloon valvuloplasy

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59
Q

what are 3 complications of aortic stenosis?

A

Heart failure
valve replacement complications - infective endocarditis, valve thrombus, haemolysis, aortic regurg

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60
Q

What is atrial fibrillation?

A

a supraventricular tachyarrhythmia with uncoordinated atrial electrical activation and consequently ineffective atrial contraction

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61
Q

what is the most common cardiac arrhythmias?

A

atrial fibrillation

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62
Q

what are 7 causes of atrial fibrillation?

A

PIRATES

Pulmonary - COPD
Rheumatic HD (valvular disease)
Anaemia, alcohol
Thyroid disease
Electrolyte disturbance
Sepsis/Sleep apnoea
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63
Q

What are 6 risk factors for atrial fibrillation?

A 
increasing age
DM 
hyperthyroidism
Hypertension
valvular heart disease 
diet and lifestyle factors (caffeine, alcohol, etc)
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64
Q

What are 5 presentations of atrial fibrillation?

A 
irregularly irregular pulse 
Palpitations
SOB
hypotension/dizziness/fainting - RED FLAG 
chest pain - RED FLAG
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65
Q

what are 3 investigations for atrial fibrillation?

A

ECG - irregularly irregular QRS complexes with absent P waves and chaotic baseline
serum electrolytes
Thyroid function tests

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66
Q

what are 3 differentials for atrial fibrillation?

A

atrial flutter
wolff-pankinson-white syndrome
atrial tachycardia

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67
Q

what are the 1st line rhythm control treatments for atrial fibrillation?

A

beta blocker - bisoprolol
OR
rate limiting CCB - verapamil

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68
Q

what are 3 complications for atrial fibrillation?

A

acute stroke, MI, congestive HF

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69
Q

what are the ECG characteristics of Atrial fibrillation?

A

regularly irregular R-R interval
absence of distinctive repeating P waves
irregular atrial activations

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70
Q

What is cardia tamponade?

A

raised intra-pericardial pressure due to pericardial effusion which restricts cardiac filling and decreasing cardiac output.

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71
Q

what are 5 causes of cardiac tamponade?

A 
iatrogenic (surgery/trauma)
pericarditis 
malignancy
trauma 
aortic dissection
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72
Q

What are 6 manifestations of cardiac tamponade?

A 
dyspnoea and chest pain
elevated jugular venous pressure
pulses paradoxus 
hypotension
tachycardia 
pericardial rub
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73
Q

what are 6 investigations of cardiac tamponade?

A 
ECG - electrical alternans 
Transthoracic ECHO (gold)
CXR
FBC - raised WBCs, low Hb 
ESR - elevated
Troponin - elevated
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74
Q

what are 3 differentials of cardiac tamponade?

A

constrictive pericarditis, pericardiocentesis, fluid for culture and cytology

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75
Q

what are 3 treatments for cardiac tamponade?

A

effusion only - anti-inflammatories - ibuprofen, aspirin, colchicine

acute - urgent pericardiocentesis or surgical drain

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76
Q

what are 2 complications of cardiac tamponade?

A

constrictive pericarditis

cardiac arrest

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77
Q

What is hypertension?

A

Persistent elevation of arterial blood pressure
BP ≥140/90 mmHg

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78
Q

what are 4 causes of hypertension?

A

excess sodium intake
renal sodium retention
RAAS dysfunction
increased peripheral resistance

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79
Q

what are 4 risk factors for hypertension?

A

obesity
sedentary lifestyle
high alcohol intake
DM

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80
Q

BP =

A

CO X TPR

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81
Q

what are 3 presentations of hypertension?

A

dyspnoea
retinopathy
headaches

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82
Q

what are 5 causes of hypertension?

A 
drug induced 
renal artery stenosis/kidney disease
pregnancy
Conn's syndrome 
Cushing's syndrome
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83
Q

what is the management of hypertension?

A

55+/black - CCB - amlodipine
<55 - ACEi or ARB (ramipril or cadesartan)

CCB + ACEI
+ thiazide diuretics

Resistant hypertension not controllable by 3 drugs

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84
Q

what are some side effects of calcium channel blockers?

A 
Constipation
Dizziness
Fast heartbeat (palpitations)
Fatigue
Flushing
Headache
Nausea
Rash
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85
Q

what are some side effects of ACEi?

A

Dry cough.
Increased potassium levels in the blood (hyperkalemia)
Fatigue.
Dizziness from blood pressure going too low.
Headaches.
Loss of taste.

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86
Q

what are 3 complications of hypertension?

A

coronary artery disease
stroke
CKD

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87
Q

what is infective endocarditis?

A

an infection involving the endocardial surface of the heart due to organisms in blood stream (bacteraemia) adhering to endocardial injury leading to platelet and fibrin plug formation and activation of the coagulation cascade causing vegetations

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88
Q

why is IE more common in developing countries?

A

increased prevalence of rheumatic fever and therefore increased mitral stenosis and other valvular disease

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89
Q

what are 7 risk factors for IE?

A

Patient factors
- >60 years, Male
- IVDU/ indwelling lines
- Immunosuppression
- Recent dental surgery/procedure
Cardiac factors
- Hx of endocarditis
- Prosthetic valves
- Structural heart disease - valve, congenital , HOCM etc

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90
Q

what are 5 manifestations for IE?

A

Fever - chills, anorexia, weight loss

New Heart murmur

Petechiae and splinter haemorrhages

Septic PE

Malaise, arthralgia, night sweats

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91
Q

what are 3 clinical signs for IE?

A

Roth spots - retina

Janeway lesions -
non-tender macules palms and soles

Osler nodes - painful nodules on fingertips

Splenomegally, finger clubbing - in long standing disease

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92
Q

what are 3 investigations for IE?

A

BLOOD CULTURES X3 SETS OVER 30-60 MINS

ECHO - TTE 1st line, TOE more sensitive - vegetations

ECG, CT, CXR - metastatic infections

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93
Q

what are 5 rarer pathogens that can be culture negative in IE?

A

HACEK

Haemophilus
Aggregatibacter
Cardiobacterium
Eikenella
Kingella

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94
Q

what are 2 investigations that can be done in patients with suspected IE and prosthetic valves?

A

18F-FDG PET/CT
SPECT-CT

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95
Q

how should blood cultures for IE be taken?

A

BEFORE antibiotics

3 x at 30min-1 hour intervals

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96
Q

what are 3 differentials for IE?

A

rheumatic fever
atrial myxoma
non-bacterial thrombotic endocarditis

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97
Q

what criteria is used to diagnose IE?

A

Duke’s criteria

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98
Q

what are the major criteria for dukes criteria?

A

2 positive blood cultures of typical organisms
ECHO findings - vegetations, perivalvular abscess, new valvular regurg

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99
Q

what are the 5 minor Duke’s criteria?

A

Predisposing heart condition or IVDU

Fever >38

Immunological phenomena - janeway, osler, roth, glomerulonephritis

Microbiological evidence

Vascular abnormalities - arterial emboli, septic emboli, pulmonary infarct, intracranial haemorrhage

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100
Q

what are 3 complications of IE?

A

Valvular insufficiency and Heart failure
Metastatic emboli - stroke, PE, renal infarction, spleen, psoas abscess
Glomerulonephritis due to secondary immune complex deposition

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101
Q

when is surgery required in IE?

A

valvular regurgitation/dysfunction
heart failure
intracardiac abscess
persistent infection/difficult to treat organism

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102
Q

What is ischaemic heart disease?

A

Ischaemic heart disease, an inability to provide adequate blood supply to the myocardium

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103
Q

what is the primary cause of ischaemic heart disease?

A

atherosclerosis

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104
Q

what are 4 risk factors for ischaemic heart disease?

A

smoking
hypertension
hyperlipidaemia
diabetes

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105
Q

what is the pathophysiology of atherosclerosis?

A

Endothelial cell injury due to change in Virchow’s triad causes sticky endothelial cells => fatty streak => macrophages ingest lipids and become foam cells => collagen, fibrin, smooth muscle, LDLs and WBCs make up plaque => plaque grows and obstructs lumen

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106
Q

what is a manifestations of ischaemic heart disease?

A

chest pressure/squeezing provoked by exercise/emotional stress

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107
Q

what are 3 investigations for IHD?

A

ECG
FBC
lipid profile

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108
Q

what are 3 differentials for IHD?

A

aortic dissection
pericarditis
pulmonary embolism

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109
Q

what is the management of IHD?

A

lifestyle management
antiplatelet therapy (clopidogrel)
statin (atorvastatin)
GTN spray
beta blocker
calcium channel blocker

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110
Q

what are 3 complications of IHD?

A

heart failure
MI
sudden cardiac death

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111
Q

what is the murmur in mitral regurgitation?

A

pan systolic high pitched whistling murmur

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112
Q

where does mitral regurgitation radiate to?

A

L axilla

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113
Q

what are 4 causes of mitral regurgitation?

A

Age related weakening of valves
Ischaemic heart disease
Infective endocarditis
Rheumatic heart disease
Connective tissue disorders - EDS, Marfans

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114
Q

what are 3 risk factors for mitral regurgitation?

A

Hx MI/IE/rheumatic fever
Congenital heart disease
Cardiomyopathy - HCM

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115
Q

what are 5 signs of mitral regurgitation?

A

Pan systolic murmur
Soft S1
S3 - if associated LVSD
Displaced apex beat laterally

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116
Q

what is the management of mitral valve regurgitation?

A

If severe/symptomatic - Emergency surgery (valvuloplasty/replacement)

LVEF <60% = surgery
LVEF >60% = watchful waiting

Heart failure management

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117
Q

what are 3 complications of mitral valve regurgitation?

A

atrial fibrillation
pulmonary hypertension
L heart failure

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118
Q

what is the murmur in mitral stenosis?

A

Mid-diastolic low pitched rumble

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119
Q

what historically is the most common causes of mitral stenosis?

A

rheumatic fever

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120
Q

what are 4 risk factors for mitral stenosis?

A

streptococcal infection + rheumatic fever
Congenital defects
Infective endocarditis
SLE and amyloidosis

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121
Q

What are 6 signs of mitral stenosis o/e?

A

Mid diastolic murmur
Loud S1 - tapping apex beat
Opening Snap
Malar flush - red skin over cheeks and nose due to back pressure in pulmonary system causing CO2 rise
AF
Low volume pulse

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122
Q

what are 3 presenting features of mitral stenosis?

A

SOB - due to increased pulmonary venous pressure
Haemoptysis

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123
Q

what is the management of mitral stenosis?

A

Surgery - PC balloon valvoplasty or valve repaire/replacement

Heart failure optimisation

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124
Q

what are 4 complications of mitral stenosis?

A

AF
Pulmonary hypertension
Thromboembolism
Infective endocarditis

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125
Q

What is pericardial effusion?

A

when the fluid in the pericardial space exceeds its physiological amount (>50 mL).

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126
Q

what are 3 causes of pericardial effusion?

A

malignancy
infection - EBV. CMV, S.aurea
TB

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127
Q

what is the investigation for pericardial effusion?

A

chest imaging

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128
Q

what are 3 differentials for pericardial effusion?

A

malignancy
viral pericarditis
congestive heart failure

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129
Q

how long does acute pericarditis last?

A

<6 weeks

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130
Q

what are the most common causes of pericarditis?

A

90% idiopathic or viral - coxsackie virus, mumps, EBV, CMV, VZV, HV
rare - fungi and drugs

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131
Q

what are 5 risk factors for pericarditis?

A 
male 
20-50 years 
previous MI
neoplasm
infection
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132
Q

what are 4 presentations of pericarditis?

A

sharp, severe retrosternal chest pain, worse with inspiration, relieved leaning forward
low grade fever
pericardial rub
hiccups (phrenic involvement)

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133
Q

what are 4 investigations for pericarditis?

A

ECG - saddle shaped upward ST elevation and PR depression, T wave flattening
TT ECHO
CXR - water bottle heart
ESR and CRP

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134
Q

what are 3 differentials for pericarditis?

A

pulmonary embolism
MI
Pneumonia

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135
Q

what is the 1st line treatment for pericarditis?

A

NSAIDs and colchicine

+ prednisolone (2nd line)

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136
Q

what are 3 complications of pericarditis?

A

pericardial effusion with/without tamponade
chronic constructive pericarditis
myocarditis

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137
Q

what is the most common cause of PAD?

A

atherosclerosis - most common

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138
Q

what are 6 risk factors for PAD?

A

Older age, male
Fhx
Smoking, alcohol, diet
Sedentary lifestyle + obesity
poor sleeep
stress

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139
Q

what are 5 conditions that increase risk of vascular disease?

A

Diabetes
HTN
CKD
Inflammatory conditions
Atypical antipsychotics

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140
Q

what are 7 presentations of PAD?

A

most asymptomatic

Intermittent claudication
Paleness/cold legs
Gangrene
Dependent rubor - deep red limb when lower than rest of body
Muscle atrophy
Hair loss
Erectile dysfunction
Non-healing wound

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141
Q

What are the 6 signs of acute limb ischamia?

A

6Ps

Pulseless
Pain
Pallor
Perishingly cold
Paralysis
Paraesthesia

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142
Q

what is Leriche syndrome?

A

TRIAD
- thigh/buttock claudication
- Absent femorals
- Male impotence

due to occlusion in distal aorta or proximal common illiac artery

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143
Q

what are 3 investigations for PAD?

A

Ankle-brachial pressure index
Duplex ultrasound
CT/MRI angiography

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144
Q

what are 3 differentials for intermittent claudication?

A

DVT
Lumbar spinal stenosis
Chronic venous insuficiency

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145
Q

what is the management of intermittent claudication?

A

1 - Lifestyle modification
1 - Exercise training

Medical
- Atorvostatin 80mg
- Clopidogrel 75mg (aspirin 75mg is clopi not tolerated)
- Naftidrofuryl oxalate (5-HT2 receptor agonist causing peripheral vasodilation)

Surgical
- endovascular angioplasty and stenting
- endarterectomy
- bypass

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146
Q

what are 3 clinical features of critical limb ischaemia?

A

pain at rest
non-healing wounds
gangrene

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147
Q

what is the management of critical limb ischaemia?

A

Endovascular angioplasty + stenting
Endarterectomy
Bypass surgery
Amputation - if not able to restore blood flow

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148
Q

what is acute limb threatening ischaemia?

A

severe manifestation of peripheral artery disease usually due to a thrombus

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149
Q

what is the management of acute limb threatening ischaemia?

A

endovascular thrombolysis
endovascular thrombectomy
Surgical thrombectomy
endarterectomy
bypass
amputation

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150
Q

what is the secondary prevention of acute limb ischaemia?

A

lifelong aspirin or clopidogrel 75mg

Atorvostatin 80mg

151
Q

what are 3 complications of PAD?

A

critical limb ischaemia
gangrene and ulceration
amputation

152
Q

what is normal ankle brachial pressure index?

A

0.9-1.3

153
Q

what does ABPI 0.6-0.9 indicate?

A

mild PAD

154
Q

what does ABPI 0.3-0.6 indicate?

A

moderate to severe PAD

155
Q

what does ABPI <0.3 indicate?

A

severe PAD or critical limb ischaemia

156
Q

what is buerger’s test?

A

for peripheral artery disease in legs

Raise legs to 45 degrees with patient supine for 1-2 mins - observe for pallor

sit patient with legs over side of bed in PAD legs go blue initially, due to ischaemic tissue deoxygenating blood, then dark red due to vasodilation in response to anaerobic waste products

157
Q

what is the 1st step of atherogenesis?

A

endothelial dysfunction

158
Q

what is the 2nd step of atherogenesis?

A

formation of lipid layer of fatty streak within intima

159
Q

what is the 3rd step of atherogenesis?

A

migration of leukocyte and smooth muscle cells into the vessel wall

160
Q

what is the 4th step of atherogenesis?

A

foam cell formation

161
Q

what is the 5th step of atherogenesis?

A

degradation of the extracellular matrix

162
Q

what are the 1st, 2nd and 3rd line anti-anginal medications?

A

1 - B blocker - Bisoprolol
OR
Calcium Channel Blocker - verapamil, Diltizem (rate limiting)

2 - Increase to Max dose of BB or CCB

3 - BB AND CCB (Change to Modified release Nifedipine)

163
Q

what is the preventative treatment for angina?

A

Lifestyle changes
aspirin
statin
ACEI

164
Q

what are the primary investigations for angina?

A

ECG - 1st line
functional imaging - stress echo
transcatheter angiography

165
Q

what is stage 1 hypertension?

A

clinical - >140/90

ambulatory - >135/85

166
Q

what is stage 2 hypertension?

A

clinical - >160/100

ambulatory - >150/95

167
Q

what is stage 3 hypertension?

A

> 180/120

168
Q

what are the 2 shockable pulseless arrythmias?

A

ventricular tachycardia
ventricular fibrillation

169
Q

what are 2 non-shockable rhythms?

A

pulseless electrical activity
asystole

170
Q

what is the 1st line treatment for AF with HF?

A

digoxin

171
Q

what is the treatment for haemodynamically unstable AF?

A

DC cardioversion

172
Q

what does CHA2DS2-VASc calculate?

A

stroke risk for AF when considering anticoagulation

173
Q

what does HAS-BLED calculate?

A

the risk of major bleeding for patients on anticoagulants

174
Q

what does CHA2DS2-VASc stand for?

A

Congestive HF
Hypertension
Age >75 = 2 points
Diabetes
Stroke/TIA/thromboembolism
Vascular disease
Age <65 = 1 point
Sc - Sex category (+2 women)

175
Q

what does HAS-BLED stand for?

A 
Hypertension 
Abnormal liver/renal function
Stroke 
Bleeding 
Labile INRs 
Elderly >65 
Drugs + Alcohol
176
Q

what are 3 causes of atrial flutter?

A

idiopathic - 30%
CHD
obesity

177
Q

what is bradycardia?

A

HR < 50 BPM

178
Q

what is 1st degree heart block?

A

delay in AV conduction but every atrial impulse leads to a ventricular contraction

179
Q

what is Mobitz type 1 2nd degree heart block?

A

AV conductions get longer (PR interval) until there is no ventricular contraction then are a normal length again in a cycle

180
Q

what is Mobitz type II 2nd degree heart block?

A

intermittent failure of AV conduction resulting in a ratio of missing to normal QRS complexes

181
Q

what is 3rd degree heart block?

A

complete heart block - no relationship between P waves and QRS complexes

182
Q

what are cannon A waves seen in?

A

JVP in complete heart block

183
Q

what is the 1st line management of unstable heart block?

A

IV atropine

184
Q

what are 3 causes of RBBB?

A

pulmonary embolism
cor Pulmonale
ischaemic heart disease

185
Q

what are 3 causes of LBBB?

A

ischaemic heart disease
hypertension
cardiomyopathy

186
Q

what sound is there in RBBB?

A

wide splitting of second heart sound

187
Q

what sound is there is LBBB?

A

reverse splitting of second heart sound

188
Q

what does the ECG look like in RBBB?

A

MaRRoW

V1 - R wave looks like an M
V6 - Slurred S wave looks like a W

189
Q

what does the ECG look like in LBBB?

A

WiLLiaM

V1 - slurred S wave looks like a W
V6 - R wave looks like an M

190
Q

what sex if AF more common in?

A

women

191
Q

What is Wolff Parkinson White syndrome?

A

extra connections between the atria and ventricles causing tachycardia

192
Q

what does the ECG look like in Wolff parkinson white?

A 
short PR interval 
slurred upstroke (DELTA WAVES)
wide QRS
193
Q

what are 2 complications of Wolff Parkinson White?

A

prone to AF

sudden death

194
Q

what are 2 eponymous signs for AAA rupture?

A

Grey-Turner’s sign - flank bruising secondary to rupture

Cullen’s sign - peri-umbilical bruising

195
Q

what is the overall most common causative organism for IE?

A

S. Aureus

196
Q

what demographics are staph epidermis IE infections associated with?

A

indwelling lines and prosthetic valves

197
Q

what is the second most common causative pathogen in IE?

A

Viridans (group B) strep

198
Q

what is the most common pathogen in IE after dental work?

A

veridans (group B) strep

199
Q

what kind of strep is veridans group strep?

A

Alpha haemolytic on blood agar, optochin resistant => group B

200
Q

what is the treatment for veridans group IE?

A

IV Benzylpenicillin +/- gentamicin (veridans group)

4-6 weeks

201
Q

what kind of bacteria is gentamicin useful against?

A

gram negs

202
Q

what does S. Aureus look like on blood agar?

A

coagulase +ve, gram +ve cocci in clusters growing golden colonies on blood agar

203
Q

Is S. Aureus coagulase +ve or -ve?

A

+ve

204
Q

is S. epidermis coagulase +ve or -ve?

A

-ve

205
Q

what pathogens can cause IE in immunosuppressed people?

A

FUNGAL IE

206
Q

what is the treatment for enterococci IE?

A

IV amoxicillin + gentamicin
4-6 weeks

6 weeks in non-native valves

207
Q

what is the treatment for S. aureus/epidermis IE?

A

flucloxacillin + gentamicin
(or vancomycin if MRSA)
4-6 weeks

6 weeks in non-native valves

208
Q

what are 2 risk factors for atrial septal defects?

A

foetal alcohol syndrome
Down syndrome

209
Q

what is the most common congenital heart defect?

A

ventral septal defect

210
Q

what is patent ductus arteriosus?

A

when the ductus arteriosus (the shunt to avoid the lungs in foetal circulation) fails to close upon birth

211
Q

what is the most common form of congenital cyanotic heart disease?

A

tetralogy of Fallot

212
Q

what are 3 risk factors for tetralogy of Fallot?

A

FHx
Rubella infection
increased maternal age

213
Q

what are the 4 malformations in tetralogy of Fallot?

A

PROVe

Pulmonary stenosis
RV hypertrophy
Overriding aorta
Ventricular septal defect

214
Q

what are 6 signs of tetralogy of fallot?

A

ejection systolic murmur
reduced SpO2
respiratory distress
cyanosis
clubbing
failure to thrive

215
Q

what is the most common cause of sudden cardiac death in young people?

A

hypertrophic obstructive cardiomyopathy (HOCM)

216
Q

what is the inheritance pattern for hypertrophic obstructive cardiomyopathy (HOCM)?

A

autosomal dominant

due to defect in sarcomere proteins occurring in 1 in 500 people

217
Q

what is a cardiomyopathy?

A

disorder of the heart muscle

218
Q

what 3 things are seen on echo in hypertrophic obstructive cardiomyopathy?

A

MR SAM ASH

Mitral Regurgitation
Systolic Anterior Motion - of anterior mitral valve leaflet
Asymmetric Hypertrophy

219
Q

what are 6 presentations of hypertrophic obstructive cardiomyopathy?

A

On exertion:
SOB
Fatigue
Dizziness
Syncope
Chest pain
Palpitations

220
Q

what 4 finding may be seen on examination with hypertrophic obstructive cardiomyopathy?

A

Murmurs - harsh systolic ejection murmur at L lower sternal border due to LVOT obstruction
S4 gallop
Bifid carotid pulse
Signs of heart failure

221
Q

what is the pathophysiology of hypertrophic obstructive cardiomyopathy?

A

Due to mutations in genes coding for Beta-myosin heavy chain proteins used to make sarcomere proteins

L ventricular hypertrophy -> decreased compliance -> decreased cardiac output

222
Q

what may be seen on ECG in hypertrophic obstructive cardiomyopathy?

A

L eft ventricular hypertrophy
T wave inversion in chest leads
Arrythmias - AF or ventricular tachycardia

223
Q

what is seen on ECG in L ventricular hypertrophy?

A

Limb leads
- R wave - >25mm I
- S wave >25 III
- R wave >11mm aVL
- R wave >20mm aVF
- S wave >14mm aVR

Chest
- R wave >26mm V4,5,6
- R wave V5/6 + S wave V1 >35mm
- Largest R wave + Largest S wave in chest leads >45mm

Increased R wave peak time >50ms in V5/6
St segment depression and T wave inversion in L side leads

224
Q

what are 3 other investigations that can be used for hypertrophic obstructive cardiomyopathy?

A

Cardiac MRI
Exercise stress testing
Genetic testing

225
Q

what are 6 complications of hypertrophic obstructive cardiomyopathy?

A

Heart failure
AF
Sudden cardiac death
Mitral regurg
Infective endocarditis
Syncope and presyncope

Cerebral embolism due to AF and pulmonary HTN are rarer complications

226
Q

what are 5 medical therapies for hypertrophic obstructive cardiomyopathy?

A

1 - Beta blockers

2 - Ca Channel blockers - Verapamil - alternative to BB

3- Disopyramide - antiarrythmic - in combo with BB

Diuretics - if needed
Anticoag - if AF

227
Q

what are 2 management options for refractory hypertrophic obstructive cardiomyopathy with severe LVOT obstruction?

A

Septal myectomy
Alcohol septal ablation

228
Q

who is seen as high risk in hypertrophic obstructive cardiomyopathy?

A

Hx of cardiac arrest or sustained ventricular arrythmias
FHx of sudden cardiac death
Unexplained syncope
Severe LVH or marked LVOT obstruction

229
Q

what is the management of high risk hypertrophic obstructive cardiomyopathy patients?

A

Implantable cardioverter defibrillator

Heart transplant

230
Q

what are 2 medications that are avoided in hypertrophic obstructive cardiomyopathy as they can worsen left ventricular outflow tract obstruction?

A

ACEi
Nitrates

231
Q

what is rheumatic fever?

A

autoimmune condition triggered by streptococcus bacteria

232
Q

what bacteria is in rheumatic fever?

A

group A beta-haemolytic strep - Strep pyogenes

usually follows strep throat

233
Q

what criteria is used to diagnose rheumatic fever?

A

Jones criteria

234
Q

what does jones criteria stand for?

A 
Joint arthritis
Organ inflammation
Nodules
Erythema marginatum rash
Sydenham chorea
235
Q

what are 5 X-ray indications of heart failure?

A

ABCDE

Alveolar Oedema 
Kerley B lines 
cardiomegaly 
Dilation of upper lobe vessels 
pleural effusion
236
Q

what are the 5 types of shock?

A 
anaphylactic 
septic
cariogenic 
haemoragic 
neurogenic
237
Q

where is BNP released from?

A

the ventricles of the brain

238
Q

what are delta waves on an ECG?

A

slurred upstroke in the QRS complex

seen in Wolff Parkinson white syndrome => due to accessory conduction pathways

239
Q

what is the 1st line investigation in stable angina?

A

CT coronary angiography

240
Q

what is an embolism?

A

a blocked vessel caused by a foreign body

241
Q

what is a thrombosis?

A

the formation of a solid mass of blood constituents within an intact vessel is the living

242
Q

are there B lymphocytes in atherosclerosis/

A

NO ONLY T

243
Q

what is the MRC scale for?

A

Dyspnoea

244
Q

what is the MRC scale?

A

0 - not breathless unless strenuous exercise
1 - SOB hurrying/up slight hill
2 - has to walk slower then normal or stop
3 - stops walking after 100m/few mins
4 - too breathless to leave house/gets breathless doing normal tasks

245
Q

what does the ECG look like in pericarditis?

A

PeRicariTiS

Saddle shaped upward ST elevation
PR depression
T wave flattening
Low QRS amplitude

246
Q

what is the gold standard investigation for unstable angina?

A

angiography

247
Q

what score is used for stroke risk after a TIA?

A

ABCD2

248
Q

what is the ABCD2 score?

A

Age > 60
BP > 140/90
Clinical features - sensory (1), weakness (2)
Diabetes
Duration - <1 hour (1), >1 hour (2)

249
Q

when should beta blockers be stopped in heart failure?

A

If HR <50 bpm

250
Q

what is normal ejection fraction?

A

50-70%

251
Q

what is reduced ejection fraction?

A

<40%

252
Q

what is classed as raised BNP?

A

> 100 mg/L

253
Q

what are 2 medications used to treat angina that CANNOT be used in combination?

A

Beta blocker + VERAPAMIL

CAN CAUSE COMPLETE HEART BLOCK

254
Q

what calcium channel blocker should be used in combo with a beta blocker for angina management?

A

Modified release Nifedipine

255
Q

what is management of angina if combination therapy is not tolerated?

A

long acting nitrate - isosorbide mononitrate/dinitrate
Ivabradine
Nicorandil
Ranolazine

256
Q

what is a complication to nitrate use in angina?

A

patients can develop a nitrate tolerance and experience reduced efficacy

Not seen in modified release isosorbide mononitrate

257
Q

what is Virchow’s triad?

A

Hypercoagulability
Haemodynamic changes - stasis turbulence
Endothelial injury/dysfunction

258
Q

what can be seen on cardiac biopsy in hypertrophic obstructive cardiomyopathy?

A

myofibrillar hypertrophy with chaotic and disorganised fashion myocytes (disarray) and fibrosis

259
Q

what are 3 conditions associated with hypertrophic obstructive cardiomyopathy?

A

Friedrich’s ataxia
Wolf Parkinson white syndrome

260
Q

What are 4 causes of dilated cardiomyopathy?

A

Chronic alcohol use - most common cause

Coxsackie B
Thiamine (B1) deficiency
Doxorubicin (chemo)

261
Q

what are 3 causes of restrictive cardiomyopathy?

A

amyloidosis
post-radiotherapy
loeffler’s endocarditis - infiltration of heart with eosinophils, leading to fibrosis

262
Q

what is peripartum cardiomyopathy?

A

Typically develops between last month of pregnancy and 5 months post partum

RF = Increased age, greater parity, multiple estations

263
Q

what is takotsubo cardiomyopathy?

A

atypical ballooning of myocardium classically triggered by stress

264
Q

what is the prognosis for takotsubo cardiomyopathy?

A

usually resolves with supportive treatment

265
Q

what is the pathophysiology of takotsubo cardiomyopathy?

A

apex of heart does not contract so appears to balloon out but areas closer to top continue to contract creating octopus trap shape

266
Q

what are 4 features of takotsubo cardiomyopathy?

A

chest pain
ST elevation
Features of heart failure
normal coronary angio

267
Q

who is takotsubo cardiomyopathy most common in?

A

post menopausal women

268
Q

what is the inheritance pattern for arrhythmogenic right ventricular cardiomyopathy?

A

autosomal dominant

269
Q

what is the second most common cause of sudden cardiac death in young people?

A

arrhythmogenic right ventricular cardiomyopathy

270
Q

what is the pathophysiology of arrhythmogenic right ventricular cardiomyopathy?

A

R ventricular myocardium replace with fatty and fibrotic tissues

271
Q

what can be seen on ecg in arrhythmogenic right ventricular cardiomyopathy?

A

V1-3 abnormalities typically t wave inversion

Epsilon wave in 50% of people - terminal notch in qrs complex

272
Q

what are 5 complications of arrhythmogenic right ventricular cardiomyopathy?

A

Ventricular arrythmias - VT, V fib
Sudden cardiac death
Heart failure
Atrial arrythmias
Thromboembolic events

273
Q

what is the most common type of cardiomyopathy?

A

dilated

274
Q

what area is most commonly affected in thoracic aortic aneurysm?

A

Ascending aorta

275
Q

what size is both the ascending and descending thoracic aorta usually less than?

A

<4.5 ascending
<3.5 descending

276
Q

what is a false aneurysm?

A

when the inner two layers (intima and media) rupture leading to dilation in the vessel with blood only being contained with in the outer layer (adventitia)

typically occurs after trauma or surgery

277
Q

what are the three layer of arteries?

A

Intima - most internal
Media
Adventitia - most external

278
Q

what are 5 presentations of thoracic aortic aneurysm?

A

Chest/back pain
Trachea or L bronchus compression causing cough, SOB, stridor
Hiccups - Phrenic nerve compression
Dysphagia - oesophageal compression
Hoarse voice - recurrent laryngeal nerve compression

279
Q

what are the 2 surgical options for thoracic aortic aneurysm?

A

Thoracic end-vascular aortic repair (TEVAR)

Midline sternotomy

280
Q

what are features of ruptured thoracic aortic aneurysm?

A

Severe chest /back pain
Haemodynamic instability
Collapse
Sudden death

Haematemesis - due to bleeding into oesophagus
Haemoptysis due to bleeding into lungs
Cardiac tamponade

281
Q

what is vasovagal syncope related to?

A

stimulation of the vagus nerve due to an emotional event, painful sensation or change in temperature causing parasympathetic activation leading to smooth muscle relaxation and blood vessel dilation. Tjis causes BP to drop and cerebral perfusion to decrease leading to LOC

282
Q

what are 7 pre-syncope symptoms?

A

Hot and clammy
sweaty
Heavy
Dizzy/lightheaded
vision going blurry or dark
headache
Tinitus or muffled hearing

283
Q

what are the 3Ps of vasovagal syncope?

A

Posture - after prolonged standing
Provoking factors - fear, pain, phobia, crowded, hot, dehydrated
Progressive prodrome - pallor, sweating, nausea, vom

284
Q

What are 8 secondary causes of syncope?

A

Hypoglycaemia
dehydration
anaemia
infection
anaphylaxis
arrythmias
valvular heart disease
HOCM

285
Q

what are 4 types of reflex syncope?

A

Vasovagal
situational - micturition, defecation coughing
Carotid sinus hypersensitivity
Atypical reflex syncope - not clear trigger or prodrome

286
Q

what are 6 conditions that can cause cardiac syncope?

A

Structural
- Aortic stenosis
-HOCM
-Pulmonary HTN
- Acute MI

Arrythmias
- Bradycardia (heart block, sick sinus)
- Tachycardia - VT, SVT

287
Q

what investigations are used in syncope?

A

ECG + 24h ECG
Echo
Tilt table testing
Carotid sinus massage
Bloods - FBC, U+E, electrolytes, blood glucose

288
Q

what is dry ganrene?

A

localised tissue necrosis due to chronic ischaemia without infection primarily due to arterial occlusion in PAD, diabetes and vasculitis

Appears dry shrivelled and dark brown/black - usually clear line of demarcation between viable and dead tissue

289
Q

what is wet gangrene?

A

An infectious process along with tissue necrosis. Develops rapidly due to venous or arterial blockage along with bacterial infection

Appears swollen blistered and smelly

290
Q

what are 4 risk factors for wet gangrene?

A

Critical limb ischaemia
Surgical wounds/trauma
Immunosuppression
Severe burns/frostbite

291
Q

what is gas gangrene?

A

Type of wet gangrene caused by gas producing bacteria often from soil or faecal matter

Usually from contaminated wounds or surgical procedures especially those involving the GI tract

292
Q

what bacteria most commonly causes gas gangrene?

A

Clostridium perfringens

293
Q

what is the pathophysiology of gangrene?

A

There is ischaemia and hypoxia leading to cell death

There is accumulation of lactic acid in cells due to anaerobic metabolism

Cells break down leading to tissue necrosis

Bacterial infection

Toxin production

Progression

294
Q

what is the management of gangrene?

A

Surgical debridement of necrotic tissue
Abx - broad spectrum
Hyperbaric oxygen therapy
Tx underlying conditions

295
Q

what are 6 complications of gangrene?

A

gas gangrene
sepsis
necrotising fasciitis
Limb loss
long term pain
fistula formation

296
Q

what are 4 signs of chronic venous insufficiency?

A

Haemosindrin - brown pigmentation on skin
Lipodermatosclerosis - champagne bottle legs
Oedema
Venous eczema

297
Q

what are varicose veins?

A

distended superficial veins measuring more than 3mm in diameter, usually affecting the legs.

298
Q

what are reticular veins?

A

dilated blood vessels in the skin measuring less than 1-3mm in diameter

299
Q

what is Telangiectasia?

A

dilated blood vessels in the skin measuring less than 1mm in diameter. They are also known as spider veins or thread veins.

300
Q

what are 7 risk factors for varicose veins?

A

Increasing age
Fhx
Female
Pregnancy
Obesity
Prolonged standing
DVT - cause damage to valves

301
Q

what are 7 presentations of varicose veins?

A

Heavy/dragging sensation in legs
Aching
Itching
Burning
Oedema
Muscle cramps
Restless legs

Signs of chronic venous insufficiency

302
Q

what are 3 signs of chronic venous insuficiency that can be seen in the lower legs?

A

brown discolouration due to haemosiderin
venous eczema
lipodermatosclerosis

303
Q

what are 5 special tests for varicose veins?

A

Tap test
cough test
Trendelenburghs test
Perthes test
Duplex ultrasound

304
Q

what is the conservative management of varicose veins?

A

Leg elevation
weight loss
regular exercise
Graduated compression stockings

305
Q

what are 3 surgeries for varicose veins?

A

Endothermal ablation
Sclerotherapy – injecting the vein with an irritant foam that causes closure of the vein
Surgical Stripping

306
Q

what are 4 complications of varicose veins?

A

Prolonged and heavy bleeding after trauma
Superficial thrombophlebitis
DVT
Skin changes and ulcers

307
Q

what is the tap test for varicose veins?

A

Apply pressure to saphenofemoral junction and tap the distal varicose vein - feel for thrill at SFJ - suggests incompetent valves between varicose vein and SFJ

308
Q

what is the cough test for varicose veins ?

A

Apply pressure to saphenofemoral junction and ask patient to cough - feel for thrill - suggest dilated vein at SFJ

309
Q

what is trendelenburg’s test for varicose veins ?

A

Pt lies
lift affected leg to drain veins
Apply tourniquet to thigh and stand patient
Tourniquet should prevent varicose veins reappearing if distal to incompetent valve

310
Q

what is Perthes test for varicose veins ?

A

Apply tourniquet to thigh and ask patient to pump calf muscle with heel raises while standing
If superficial veins disappear the deep veins are functioning - increased dilation of superficial veins indicated problem with deep veins (DVT)

311
Q

What is the pathophysiology of varicose veins?

A

leaky valves cause retrograde blood flow => increased pressure into distal veins
Superficial veins are thin walled and unable to withstand great pressure => dilation and tortuosity
One leaky valve puts added pressure on other valves

312
Q

what are the 2 lipids present in the blood?

A

Cholesterol
Triglycerides

313
Q

what are 5 lipoproteins that carry lipids in blood?

A

Chylomicrons
Very-low density lipoproteins (VLDL)
Intermediate density lipoproteins
Low-density lipoproteins
High density lipoproteins

314
Q

what molecule is responsible for 1st steps in atherosclerosis?

A

Low density lipoprotein (bad cholesterol)

315
Q

what molecule is responsible for moving cholesterol from atherosclerotic plaques to liver?

A

High density lipoprotein (good cholesterol)

316
Q

what is the normal level of non-HDL lipids?

A

<4 mmol/L

317
Q

what is the normal level of serum HDL?

A

> 1 mmol/L Men
1.2 mmol/L Women

318
Q

what is a normal total cholesterol:HDL ratio?

A

<6 mmol/L

319
Q

what is normal total cholesterol?

A

< 5 mmol/L

320
Q

what is normal non-fasting triglycerides?

A

<2.3 mmol/L

321
Q

what is normal fasting triglycerides?

A

<1.7 mmol/L

322
Q

what are 5 causes of primary hyperlipidaemia?

A

Hyperchylomicronaemia - causes elevated chylomicrons, evident from childhood
Familial hypercholesterolaemia
Combined hyperlipidaemia
Dysbetalipoproteinanaemia
Hypertriglyceridaemia
Mixed hypertriglyceridaemia

323
Q

what are 8 risk factors for hyperlipidaemia?

A

FHx
Premature CVD
Poor diet
Lack of exercise
Obesity
Diabetes
Hypothyroidism
Nephrotic syndrome
Medications - b blockers, glucocorticoids, amiodarone, diuretics

324
Q

what are 4 signs of hypercholesteraemia?

A

Tendon xanthomata
Xanthelasma - yellow papules on and around eyelids
Corenal arcus
Lipaemia retinalis

325
Q

what is the 1st line management of hypercholesteraemia?

A

Lifestyle modification

1 - Statins - Atorvostatin 10mg OD - can increase up to 80mg

Fenofibrate can be used in raised triglycerides

326
Q

what is the 2nd line medication for hypercholesteraemia?

A

Ezetimibe 10mg OD PO

327
Q

what tool can be used to assess 10 year risk of CVD in >40s?

A

QRisk2/3

328
Q

at what qrisk should a statin be offered?

A

> 10%

329
Q

what are 2 conditions that require lipid lowering therapy?

A

Diabetes - >40 or had for more than 10 years or nephropathy

CKD

Give 20mg Atorvostatin OD

330
Q

what dose of statin is used as secondary prevention 1st line?

A

Atorvostatin 80mg OD

331
Q

what are 3 adverse effects of statins?

A

Myopathy - myalgia, myositis, rhabdo

Liver impairment - check LFTs at 3 and 12 months

Increased risk of intracerebral haemorrhage in prev stroke

332
Q

what is the murmur in tricuspid regurditation?

A

pan systolic
with split second heart sound due to pulmonary valve closing before aortic as R ventricle is emptying faster

333
Q

what are 5 signs o/e of tricuspid regurgitation?

A

Thrill in tricuspid area
raised JVP
Pulsatile liver - due to venous regurg
Peripheral oedema
ascites

334
Q

what are 6 causes of tricuspid regurgitation?

A

Pressure due to left heart failuure or pulmonary hypertension
infective endocarditis
rheumatic heart disease
carcinoid syndrome
ebstein’s anomaly
connective tissue disorders - Marfans, EDS

335
Q

what is the murmur in pulmonary stenosis?

A

ejection systolic murmur loudest in pulmonary area

336
Q

what ecentuates pulmonary stenosis?

A

deep inspiration

337
Q

what is the presentation o/e of pulmonary stenosis?

A

Ejection systolic murmur
widely split S2
thrill in pulmonary area
raised JVP
Peripheral oedema
ascites

338
Q

what are 2 congenital conditions associated with pulmonary stenosis?

A

Noonan syndrome
Tetralogy of Fallot

339
Q

which sided heart failure causes pulmonary oedema?

A

right

340
Q

which sided heart failure causes peripheral oedema?

A

left

341
Q

what is a normal ejection fraction?

A

50%

342
Q

what is ejection fraction?

A

the percentage of blood pumped out of LV with each ventricular contraction

343
Q

equation for ejection fraction?

A

EF = (stroke volume/end diastolic volume) X 100

344
Q

cardiac output equation

A

CO = stroke volume x HR

345
Q

what are 5 causes of heart failure?

A

Ischaemic heart disease
Valvular heart disease - commonly aortic stenosis
Hypertension
Arrythmias - AF commonly
Cardiomyopathy

346
Q

what are 6 key symptoms of heart failure?

A

Breathlessness, worse on exertion
Cough - frothy white/pink sputum
Orthopnoea
Paroxysmal nocturnal dyspnoea
Peripheral oedema
Fatigue

347
Q

what are 9 signs o/e of heart failure?

A

Tachycardia
Tachypnoea
Hypertension
Murmurs
S3 heart sound
Bilateral basal crackles
Raised JVP
peripheral oedema
S3 heart sounds

348
Q

what kind of cough can be characteristic of heart failure?

A

produces white/pink frothy sputum

349
Q

what is paroxysmal nocturnal dyspnoea?

A

suddenly waking in night with severe SOB, cough and wheeze caused by heart failure

350
Q

what classification system can be used for severity of heart failure symptoms?

A

New York heart association classification

351
Q

what is the new york heart association classification of severity of heart failure symptoms?

A

Class I - no limitation on activity
Class II - comfortable at rest, symptomatic with ordinary activity
Class III - comfortable at rest, symptomatic with any activity
Class IV - symptomatic at rest

352
Q

what is the 1st line investigation for heart failure?

A

N-terminal pro-B-type natriuretic peptide = BNP

353
Q

What assessment guides heart failure referral time?

A

BNP
400 - 2000 ng/L - seen + echo in 6 weeks
>2000 ng/L seen + echo in 2 weeks

354
Q

what is the 1st and 2nd line medical management for heart failure?

A

ABAL

ACEI/ARB
Beta blocker - Bisoprolol

Aldosterone antagonist (spiro, eplerenone)

Loop diuretic (furosemide or bumetanide) - symptomatic relief only

355
Q

what is the 3rd line medical management of heart failure?

A

SGLT-2 inhibitors

Ivabradine - if HR sinus >75 and EF <35%

Sacubitril-valsartan - if EF <35% - NOT WITH ACEI/ARB

Digoxin - for symptoms and in AF

Hydralazine + nitrate - may be particularly indicated in Afro-Carribbean patients

356
Q

what in particular needs monitoring in patients with ACEi and aldosterone antagonists (spiro) in heart failure?

A

U+E => potassium levels

both cause hyperkalaemia

357
Q

what surgery may be done in heart failure?

A

Valvuloplasty/replacement
Implantable cardioverter defibrillators - prev VT/ V Fib
Cardiac resynchronisation therapy - biventricular pace makers
Heart transplant

358
Q

what are 5 signs of heart failure of CXR?

A

ABCDE

A - alveolar oedema
B - Kelley B lines
C - cardiomegaly
D - Dilated upper lobe vesels
E - pleural Effusion

359
Q

what is the frank-starling law?

A

Increased end diastolic volume causes increased force of contraction leading to increased stroke volume

360
Q

what is heart failure with reduced ejection fraction and 1 cause?

A

reduced ventricular contractility leading to systolic dysfunction

Caused by damaged myocytes - ischaemic heart disease

361
Q

what is heart failure with preserved ejection factor and causes?

A

Reduced ventricular compliance leading to diastolic dysfunction and reduced filling pressures

Increased ventricular stiffness - due to HTN
Reduced ventricular relaxation - constrictive pericarditis. HOCM

362
Q

what are 6 causes of high output heart failure?

A

Anaemia
AV malformation
pagets disease
pregnancy
thyrotoxicosis
thiamine deficiency - wet beri beri

363
Q

What are 3 compensatory mechanisms in the heart?

A

Neurohormonal activation - sympathetic nervous system and RAAS system activation leading to vasoconstriction, fluid retention, increased HR
Ventricular remodelling
Frank-starling mechanism

364
Q

How do SGLT2 inhibitors work?

A

reversibly inhibit sodium glucose co-transporter 2 in renal proximal convoluted tubule leading to reduced glucose reabsorption and increased urinary excretion

365
Q

what are 7 cardiac causes of acute heart failure?

A

MI
Ventricular rupture
Myocarditis
High output states - sepsis, thyroid storm
Cardiomyopathy - takotsubo/drug induced
Valvular dysfunction - IE, post MI
Arrythmias

366
Q

what are 4 extracardiac causes of acute heart failure?

A

Pericardial effusion and tamponade
Aortic dissection
Pulmonary embolism
Tension pneumothorax

367
Q

what is the medical management of acute heart failure?

A

A-E and stabilise
IV furosemide (40mg)
Fluid restriction
Inotropes or vasopressors
NIV - CPAP
Intubation and ventilation

368
Q

what are 4 causes of myocarditis?

A

Viral - coxsackie B, HIV, HHV6
Bacteria/protazoa - lyme disease (borrelia burgdorferi), toxoplasmosis, diphtheria
Autoimmune
Drugs - doxrubicin, clozapine

369
Q

what is the presentation of myocarditis?

A

Chest pain - improved leaning forward
Systemic upset - fatigue, fever, lethargy
SOB
reduced exercise tolerance
Palpitations
Tachycardia and arrythmias
Collapse
Sudden death

Hx of recent viral illness

370
Q

what are 4 risk factors for myocarditis?

A

Peri-partum and postnatal
Younger age
Exposure to certain drugs/allergens
Autoimmune diseases

371
Q

what can be seen on ECG in myocarditis?

A

sinus tachy
T wave inversion

Pericarditis related - Saddle shaped ST elevation, PR depression

372
Q

what is the gold standard investigation for myocarditis?

A

Endomyocardial biopsy

373
Q

what is the management of myocarditis?

A

Supportive
Immunosuppression
Heart failure therapies
Device therapies - ICD, CRT

Phase 4 (22 decks)

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