Cardio Flashcards
What is an abdominal aortic aneurysm?
a permanent pathological dilation of the aorta >3cm or >1.5x the expected diameter
what is the mortality of ruptured AAA?
80%
what is the pathophysiology of AAA?
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
Are heart conditions generally more common in men or women?
men
where are AAAs most common?
90% below the renal arteries
when is screening done for AAA?
Men from 65 years
Women >70 with risk factors
What happens in AAA screening if a small aneurysm is found?
Small = 3-4.4cm
Surveillance and repeat scan in 1 year
what happens in AAA screening if a medium aneurysm is found?
medium = 4.5-5.4cm
Repeat scan in 3 months
what happens in AAA screening if a large aneurysm is found?
Large = >5.5cm
Refer to vascular surgery
What are 6 risk factors for Aortic aneurysm?
Male
smoking + COPD
increased age
genetics/FHx
connective tissue disorders- mafans
Hypertension and CVD
what are 4 presentations of AAA?
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
What is the 1st line investigation of AAA?
abdominal ultrasound
when is elective repair recommended in AAA?
Symptomatic aneurysm
Diameter growing >1cm a year
Diameter >5cm
what is the management for AAA?
Open surgical repair
Endovascular aneurysm repair (EVAR)
EVAR preferred in haemodynamically stable patients
what are 4 complications of AAA?
MI/bowel ischamia/limb ischaemia
Blood transfusion reactions
Abdominal compartment syndrome
Graft infection
what are 2 complications of open AAA repair?
Abdominal wound dehiscence
incisional hernias
what are 2 complications of EVAR AAA repair?
Haematomas/pseudo aneurysms in goin acess site
leakage of blood around stent graft - CT angio surveillance for the rest of patients life
what are 2 considerations for driving with AAA?
inform DVLA of aneurysm >6cm
stop driving if aneurysm >6.5cm
Stricter rules for HGVs
what is the number one cause of death globally?
cardiovascular disease
what is the underlying cause of most acute coronary syndromes?
coronary artery disease
rare - coronary artery spasm
what are the 3 pathophysiological origins of ischaemic heart disease?
increased myocardial O2 demand (exercise, infection)
reduced coronary blood flow (atherosclerosis)
Reduced myocardial oxygen delivery (anaemia, hypoxaemia)
what is angina pectoris?
Chest pain on exertion due to myocardial ischaemia
alleviated on rest
what are the 3 typical features of angina pain?
constricting discomfort in front of chest, neck, shoulders, jaw or armpit
precipitated by physical exertion
relieved by rest or GTN in 5 mins
what are 3 investigations for angina?
1 - CT coronary angiogram
2 - non-invasive functional imaging - stress echo, perfusion MRI, myocardial perfusion scintigraphhy with SPECT
3 - Invasive coronary angiogram
what is the management of angina pectoris?
RAMOS
Refer to cardiology
Advise about diagnosis, management and when to call ambulance
Medical treatment - 4As, 1 - b blocker/C channel blocker
Procedural/surgical intevention
Secondary prevention
what is the medical management of acute angina atack?
sublingual glyceryl trinitrate (GTN)
taken when symptoms start
2nd dose after 5 mins
3rd dose after another 5 mins
Call ambulance at 15 mins
what are 2 side effects of GTN?
Headaches
Dizziness
what is the long term management of angina?
1 - Beta blocker OR rate limiting C channel blocker (diltiazem/verapamil)
2 - ADD non-rate limiting calcium channel blocker to B blocker
3 - Long acting nitrates - isosorbide mononitrate
How should long acting nitrates be dosed?
asymmetrical dosing to avoid tolerance and maintain a daily nitrate free period of 10-14 hours
what are 4 medications for the secondary prevention of angina?
4As
Aspirin 75mg OD
Atorvostatin 80mg OD
ACEi - if HTN, DM, CKD, HF
Already on B blocker/CCB
what are 4 complications of stable angina?
MI
Heart failure
Arrhythmia due to ischaemic heart disease
Sudden cardiac death
what are 5 risk factors for aortic dissection?
HTN, other CVD risk factors
Conditions affecting the aorta - Bicuspid aorta, coarctation of aorta, aortic valve replacement, CABG
Connective tissue disorders - EDS, Marfan’s
What is the pathophysiology for aortic dissection?
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
what is the stanford classification of aortic dissection?
Type A - Affects ascending aorta before brachiocephalic artery
Type B - Affects descending aorta after L subclavian artery
what is the DeBakey system for classifying aortic dissection?
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
What are 6 manifestations of aortic dissection?
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
What are 3 investigations that can be done for aortic dissection?
ECG
CXR - widened mediastinum
Contrast enhanced CT angiogram chest, abdo, pelvis
MRI angio
what is the management of Stanford type A aortic dissection?
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
what is the management of Stanford type B aortic dissection?
IV labetalol + analgesia
May be able to manage medically - monitoring, analgesia, BP control
Thoracic endovascular aortic repair (TEVAR)
where is aortic dissection most common?
ascending aorta
what investigation can be used in unstable patients for aortic dissection?
Transoesophageal echocardiograph
what are 6 complications of aortic dissection?
cardiac tamponade
aortic regurgitation
MI
Stroke
paraplegia
death
what is S1 caused by?
Closing of the AV valves at the start of systole
what is S2 caused by?
Closing of the semilunar (pulmonary and aortic) valves at the end of systole
what is S3 heart sound?
3rd heart sound heard just after S2 - Lub du-dub
what is one cause of S3 heart sounds?
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
what is S4 heart sound?
Le-Lub Dub
Always abnormal - due to stiff, hypertrophic ventricles causing turbulent flow from atria - ventricular hypertrophy
what is the murmur in aortic regurgitation?
Early diastolic soft decrescendo murmur
Can also cause Austin flint murmur - apex diastolic rumbling
when does aortic regurgitation usually become symptomatic?
when the ejection fraction <50%
what are 6 causes of aortic regurgitation?
bicuspid aortic valves
rheumatic fever
endocarditis
connective tissue disorders - Marfans, EDS
Aortic dissection/anyeurysm
Idiopathic/age related
what is the pathophysiology of aortic regurgitation?
There is reflux of blood from the aorta to the L ventricle in diastole => increased LV preload => LV hypertrophy and dilation => eventual heart failure
what are 5 signs of aortic regurgitation?
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
what is the management for aortic regurgitation?
Lifestyle modification
ACEi
Beta blockers
Severe - loop diuretics and aortic valve repair/replacement
what are 3 complications of aortic regurgitation?
L ventricular dysfunction and heart failure
AF
Sudden cardiac death
what is the most common valvular disease?
Aortic stenosis
what is the murmur in aortic stenosis?
Harsh ejection systolic crescendo-decrescendo murmur
where does aortic stenosis murmur radiate to?
Carotids
when is aortic stenosis murmur enhanced?
sitting forward and expiration
what are 6 risk factors for aortic stenosis?
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
what are 2 conditions that have higher incidence of bicuspid aorta?
Turner’s syndrome
coarctation of aorta
what are 6 manifestations of aortic stenosis?
crescendo derescendo ejection systolic murmur
Exertional dyspnea
Chest pain
Exertion syncope
Fatigue
Heart failure features
what are 3 indications for valve replacement in aortic steonsis?
Severe and symptomatic
Severe and asymptomatic but either evidence of heart failure or symptoms on exercise testing
LVEF <50%
Aortic valve gradient >40 mmHg
what are 3 management options for aortic stenosis?
Observation if patient is asymptomatic
Surgical aortic valve replacement (SAVAR)
transcutaneous aortic valve implantation (TAVI)
Balloon valvuloplasy
what are 3 complications of aortic stenosis?
Heart failure
valve replacement complications - infective endocarditis, valve thrombus, haemolysis, aortic regurg
What is cardiac tamponade?
raised intra-pericardial pressure due to pericardial effusion which restricts cardiac filling during diastole and decreases cardiac output.
what is the classic triad of cardiac tamponade?
Beck’s triad
Hypotension
raised JVP
muffled heart sounds
what are 7 causes of cardiac tamponade?
Iatrogenic (surgery/trauma)
pericarditis
malignancy
Trauma
aortic dissection (type A)
MI
Pulmonary hypertension
what can be found O/E in cardiac tamponade?
quiet heart sounds
pulsus paradoxus - abnormally large fall in BP during inspiration
Hypotension
Raised JVP
Fever - with pericarditis
Pericardial rub
what is seen on ECG in cardiac tamponade?
Electrical alternans - alternating QRS complex height
what are 3 differentials of cardiac tamponade?
constrictive pericarditis, pericardiocentesis, fluid for culture and cytology
what are 3 treatments for cardiac tamponade?
urgent pericardiocentesis or surgical drainage
Blood pressure =
Cardiac output X Total peripheral resistance
what is infective endocarditis?
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
what valve is most likely to be affected in infective endocarditis?
mitral valve
why is IE more common in developing countries?
increased prevalence of rheumatic fever and therefore increased mitral stenosis and other valvular disease
what are 7 risk factors for IE?
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
what are 5 manifestations for IE?
Fever - chills, anorexia, weight loss
New Heart murmur
Petechiae and splinter haemorrhages
Septic PE
Malaise, arthralgia, night sweats
what are 3 clinical signs for IE?
Roth spots - retina
Janeway lesions -
non-tender macules palms and soles
Osler nodes - painful nodules on fingertips
Splenomegally, finger clubbing - in long standing disease
what are 3 investigations for IE?
BLOOD CULTURES X3 SETS OVER 30-60 MINS
ECHO - TTE 1st line, TOE more sensitive - vegetations
ECG, CT, CXR - metastatic infections
what are 5 rarer pathogens that can be culture negative in IE?
HACEK
Haemophilus
Aggregatibacter
Cardiobacterium
Eikenella
Kingella
what are 2 investigations that can be done in patients with suspected IE and prosthetic valves?
18F-FDG PET/CT
SPECT-CT
how should blood cultures for IE be taken?
BEFORE antibiotics
3 x at 30min-1 hour intervals
what are 3 differentials for IE?
rheumatic fever
atrial myxoma
non-bacterial thrombotic endocarditis
what criteria is used to diagnose IE?
Duke’s criteria
what are the major criteria for dukes criteria?
2 positive blood cultures of typical organisms
ECHO findings - vegetations, perivalvular abscess, new valvular regurg
what are the 5 minor Duke’s criteria?
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
what are 3 complications of IE?
Valvular insufficiency and Heart failure
Metastatic emboli - stroke, PE, renal infarction, spleen, psoas abscess
Glomerulonephritis due to secondary immune complex deposition
when is surgery required in IE?
valvular regurgitation/dysfunction
heart failure
intracardiac abscess
persistent infection/difficult to treat organism
What is ischaemic heart disease?
Ischaemic heart disease, an inability to provide adequate blood supply to the myocardium
what is the primary cause of ischaemic heart disease?
atherosclerosis
what are 4 risk factors for ischaemic heart disease?
smoking
hypertension
hyperlipidaemia
diabetes
what is the pathophysiology of atherosclerosis?
Endothelial cell injury causes change in Virchow’s triad leading to sticky endothelial cells => fatty streak by LDL => macrophages ingest lipids and become foam cells => collagen, fibrin, smooth muscle, LDLs and WBCs make up plaque => plaque grows and obstructs lumen
what is the murmur in mitral regurgitation?
pan systolic high pitched whistling murmur
where does mitral regurgitation radiate to?
L axilla
what are 4 causes of mitral regurgitation?
Age related weakening of valves
Ischaemic heart disease
Infective endocarditis
Rheumatic heart disease
Connective tissue disorders - EDS, Marfans
what are 3 risk factors for mitral regurgitation?
Hx MI/IE/rheumatic fever
Congenital heart disease
Cardiomyopathy - HCM
what are 5 signs of mitral regurgitation?
Pan systolic murmur
Soft S1
S3 - if associated LVSD
Displaced apex beat laterally
what is the management of mitral valve regurgitation?
If severe/symptomatic - Emergency surgery (valvuloplasty/replacement)
LVEF <60% = surgery
LVEF >60% = watchful waiting
Heart failure management
what are 3 complications of mitral valve regurgitation?
atrial fibrillation
pulmonary hypertension
L heart failure
what is the murmur in mitral stenosis?
Mid-diastolic low pitched rumble
what historically is the most common causes of mitral stenosis?
rheumatic fever
what are 4 risk factors for mitral stenosis?
streptococcal infection + rheumatic fever
Congenital defects
Infective endocarditis
SLE and amyloidosis
What are 6 signs of mitral stenosis o/e?
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
what are 3 presenting features of mitral stenosis?
SOB - due to increased pulmonary venous pressure
Haemoptysis
what is the management of mitral stenosis?
Surgery - PC balloon valvoplasty or valve repaire/replacement
Heart failure optimisation
what are 4 complications of mitral stenosis?
AF
Pulmonary hypertension
Thromboembolism
Infective endocarditis
What is pericardial effusion?
when the fluid in the pericardial space exceeds its physiological amount (>50 mL).
what are 3 causes of pericardial effusion?
malignancy
infection - EBV. CMV, S.aurea
TB
what is the investigation for pericardial effusion?
chest imaging
what are 3 differentials for pericardial effusion?
malignancy
viral pericarditis
congestive heart failure
how long does acute pericarditis last?
<6 weeks
what are 7 causes of pericarditis?
Idiopathic - most common
Infection - TB, HIV, coxsackie, EBV
Autoimmune - SLE, RhA
Injury to pericardium - post MI
Uraemia
Cancer - lung, breast
Medications - methotrexate
what nerve has sensory innervation to pericardium?
Phrenic - C,3,4,5
what are 4 presentations of pericarditis?
sharp, severe retrosternal pleuritic chest pain, worse with inspiration, relieved leaning forward
Pericardial rub
low grade fever and flu like symptoms
hiccups (phrenic involvement)
what are 2 ECG finding in pericarditis?
Saddle shaped ST elevation
PR depression - most specific
Global/widespread picture rather than territories
what can be seen n CXR in pericarditis?
water bottle heart - due to pericardial effusion
what is one investigation that all patients with suspected pericarditis sould have?
Transthoracic echo
what is the 1st line treatment for pericarditis?
NSAIDs AND colchicine
2 - Prednisolone
what are 3 complications of pericarditis?
pericardial effusion with/without tamponade
chronic constructive pericarditis
myocarditis
what is the most common cause of PAD?
atherosclerosis - most common
what are 6 risk factors for PAD?
Older age, male
Fhx
Smoking, alcohol, diet
Sedentary lifestyle + obesity
poor sleeep
stress
what are 5 conditions that increase risk of vascular disease?
Diabetes
HTN
CKD
Inflammatory conditions
Atypical antipsychotics
what are 7 presentations of PAD?
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
What are the 6 signs of acute limb ischamia?
6Ps
Pulseless
Pain
Pallor
Perishingly cold
Paralysis
Paraesthesia
what is Leriche syndrome?
TRIAD
- thigh/buttock claudication
- Absent femorals
- Male impotence
due to occlusion in distal aorta or proximal common illiac artery
what are 3 investigations for PAD?
Ankle-brachial pressure index
Duplex ultrasound
CT/MRI angiography
what are 3 differentials for intermittent claudication?
DVT
Lumbar spinal stenosis
Chronic venous insuficiency
what is the management of intermittent claudication?
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
what are 3 clinical features of critical limb ischaemia?
pain at rest
non-healing wounds
gangrene
what is the management of critical limb ischaemia?
Endovascular angioplasty + stenting
Endarterectomy
Bypass surgery
Amputation - if not able to restore blood flow
what is acute limb threatening ischaemia?
severe manifestation of peripheral artery disease usually due to a thrombus
what is the management of acute limb threatening ischaemia?
endovascular thrombolysis
endovascular thrombectomy
Surgical thrombectomy
endarterectomy
bypass
amputation
what is the secondary prevention of acute limb ischaemia?
lifelong aspirin or clopidogrel 75mg
Atorvostatin 80mg
what are 3 complications of PAD?
critical limb ischaemia
gangrene and ulceration
amputation
what is normal ankle brachial pressure index?
0.9-1.3
what does ABPI 0.6-0.9 indicate?
mild PAD
what does ABPI 0.3-0.6 indicate?
moderate to severe PAD
what does ABPI <0.3 indicate?
severe PAD or critical limb ischaemia
what is buerger’s test?
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
what is the 1st step of atherogenesis?
endothelial dysfunction
what is the 2nd step of atherogenesis?
formation of lipid layer of fatty streak within intima
what is the 3rd step of atherogenesis?
migration of leukocyte and smooth muscle cells into the vessel wall
what is the 4th step of atherogenesis?
foam cell formation
what is the 5th step of atherogenesis?
degradation of the extracellular matrix
what are the 1st, 2nd and 3rd line anti-anginal medications?
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)
what is the preventative treatment for angina?
Lifestyle changes
aspirin
statin
ACEI
what are the primary investigations for angina?
ECG - 1st line
functional imaging - stress echo
transcatheter angiography
what are the 2 shockable pulseless arrythmias?
ventricular tachycardia
ventricular fibrillation
what are 2 non-shockable rhythms?
pulseless electrical activity
asystole
what is the 1st line treatment for AF in someone with heart failure?
digoxin
what is the treatment for haemodynamically unstable AF?
DC cardioversion
what does CHA2DS2-VASc calculate?
stroke risk for AF when considering anticoagulation
what does HAS-BLED/ORBIT calculate?
the risk of major bleeding for patients on anticoagulants
what does CHA2DS2-VASc stand for?
Congestive HF
Hypertension
Age >75 = 2 points
Diabetes
Stroke/TIA/thromboembolism
Vascular disease
Age >65 = 1 point
Sc - Sex category (+2 women)
what is bradycardia?
HR < 50 BPM
what is the 1st line management of unstable heart block?
IV atropine
what are 2 eponymous signs for AAA rupture?
Grey-Turner’s sign - flank bruising secondary to rupture
Cullen’s sign - peri-umbilical bruising
Also seen in acute pancreatitis - signs of retroperitoneal haemorrhage
what is the overall most common causative organism for IE?
S. Aureus
what demographics are staph epidermis IE infections associated with?
indwelling lines and prosthetic valves
what is the second most common causative pathogen in IE?
Viridans (group B) strep
what is the most common pathogen in IE after dental work?
veridans (group B) strep
what kind of strep is veridans group strep?
Alpha haemolytic on blood agar, optochin resistant => group B
what is the treatment for veridans group IE?
IV Benzylpenicillin +/- gentamicin (veridans group)
4-6 weeks
what kind of bacteria is gentamicin useful against?
gram negs
what does S. Aureus look like on blood agar?
coagulase +ve, gram +ve cocci in clusters growing golden colonies on blood agar
Is S. Aureus coagulase +ve or -ve?
+ve
is S. epidermis coagulase +ve or -ve?
-ve
what pathogens can cause IE in immunosuppressed people?
FUNGAL IE
what is the treatment for enterococci IE?
IV amoxicillin + gentamicin
4-6 weeks
6 weeks in non-native valves
what is the treatment for S. aureus/epidermis IE?
flucloxacillin + gentamicin
(or vancomycin if MRSA)
4-6 weeks
6 weeks in non-native valves
what are 2 risk factors for atrial septal defects?
foetal alcohol syndrome
Down syndrome
what is the most common congenital heart defect?
ventral septal defect
what is patent ductus arteriosus?
when the ductus arteriosus (the shunt to avoid the lungs in foetal circulation) fails to close upon birth
what is the most common form of congenital cyanotic heart disease?
tetralogy of Fallot
what are 3 risk factors for tetralogy of Fallot?
FHx
Rubella infection
increased maternal age
what are the 4 malformations in tetralogy of Fallot?
PROVe
Pulmonary stenosis
RV hypertrophy
Overriding aorta
Ventricular septal defect
what are 6 signs of tetralogy of fallot?
ejection systolic murmur
reduced SpO2
respiratory distress
cyanosis
clubbing
failure to thrive
what is the most common cause of sudden cardiac death in young people?
hypertrophic obstructive cardiomyopathy (HOCM)
what is the inheritance pattern for hypertrophic obstructive cardiomyopathy (HOCM)?
autosomal dominant
due to defect in sarcomere proteins occurring in 1 in 500 people
what is a cardiomyopathy?
disorder of the heart muscle
what 3 things are seen on echo in hypertrophic obstructive cardiomyopathy?
MR SAM ASH
Mitral Regurgitation
Systolic Anterior Motion - of anterior mitral valve leaflet
Asymmetric Hypertrophy
what are 6 presentations of hypertrophic obstructive cardiomyopathy?
On exertion:
SOB
Fatigue
Dizziness
Syncope
Chest pain
Palpitations
what 4 finding may be seen on examination with hypertrophic obstructive cardiomyopathy?
Murmurs - harsh systolic ejection murmur at L lower sternal border due to LVOT obstruction
S4 gallop
Bifid carotid pulse
Signs of heart failure
what is the pathophysiology of hypertrophic obstructive cardiomyopathy?
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
what may be seen on ECG in hypertrophic obstructive cardiomyopathy?
L eft ventricular hypertrophy
T wave inversion in chest leads
Arrythmias - AF or ventricular tachycardia
what is seen on ECG in L ventricular hypertrophy?
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
L axis deviation
what are 3 other investigations that can be used for hypertrophic obstructive cardiomyopathy?
Cardiac MRI
Exercise stress testing
Genetic testing
what are 6 complications of hypertrophic obstructive cardiomyopathy?
Heart failure
AF
Sudden cardiac death
Mitral regurg
Infective endocarditis
Syncope and presyncope
Cerebral embolism due to AF and pulmonary HTN are rarer complications
what are 5 medical therapies for hypertrophic obstructive cardiomyopathy?
1 - Beta blockers
2 - Ca Channel blockers - Verapamil - alternative to BB
3- Disopyramide - antiarrythmic - in combo with BB
Diuretics - if needed
Anticoag - if AF
what are 2 management options for refractory hypertrophic obstructive cardiomyopathy with severe LVOT obstruction?
Septal myectomy
Alcohol septal ablation
who is seen as high risk in hypertrophic obstructive cardiomyopathy?
Hx of cardiac arrest or sustained ventricular arrythmias
FHx of sudden cardiac death
Unexplained syncope
Severe LVH or marked LVOT obstruction
what is the management of high risk hypertrophic obstructive cardiomyopathy patients?
Implantable cardioverter defibrillator
Heart transplant
what are 2 medications that are avoided in hypertrophic obstructive cardiomyopathy as they can worsen left ventricular outflow tract obstruction?
ACEi
Nitrates
what are 5 X-ray indications of heart failure?
ABCDE
Alveolar Oedema
Kerley B lines
cardiomegaly
Dilation of upper lobe vessels
pleural effusion
where is BNP released from?
the ventricles of the brain
what are delta waves on an ECG?
slurred upstroke in the QRS complex
seen in Wolff Parkinson white syndrome => due to accessory conduction pathways
what is the 1st line investigation in stable angina?
CT coronary angiography
what is an embolism?
a blocked vessel caused by a foreign body
what is a thrombosis?
the formation of a solid mass of blood constituents within an intact vessel is the living
are there B lymphocytes in atherosclerosis/
NO ONLY T
what does the ECG look like in pericarditis?
PeRicariTiS
Saddle shaped upward ST elevation
PR depression
T wave flattening
Low QRS amplitude
what is the gold standard investigation for unstable angina?
angiography
what score is used for stroke risk after a TIA?
ABCD2
what is the ABCD2 score?
Age > 60
BP > 140/90
Clinical features - sensory (1), weakness (2)
Diabetes
Duration - <1 hour (1), >1 hour (2)
when should beta blockers be stopped in heart failure?
If HR <50 bpm
what is normal ejection fraction?
50-70%
what is reduced ejection fraction?
<40%
what is classed as raised BNP?
> 100 mg/L
what are 2 medications used to treat angina that CANNOT be used in combination?
Beta blocker + VERAPAMIL
CAN CAUSE COMPLETE HEART BLOCK
what calcium channel blocker should be used in combo with a beta blocker for angina management?
Modified release Nifedipine
what is management of angina if combination therapy is not tolerated?
long acting nitrate - isosorbide mononitrate/dinitrate
Ivabradine
Nicorandil
Ranolazine
what is a complication to nitrate use in angina?
patients can develop a nitrate tolerance and experience reduced efficacy
Not seen in modified release isosorbide mononitrate
what is Virchow’s triad?
Hypercoagulability
Haemodynamic changes - stasis turbulence
Endothelial injury/dysfunction
what can be seen on cardiac biopsy in hypertrophic obstructive cardiomyopathy?
myofibrillar hypertrophy with chaotic and disorganised fashion myocytes (disarray) and fibrosis
what are 3 conditions associated with hypertrophic obstructive cardiomyopathy?
Friedrich’s ataxia
Wolf Parkinson white syndrome
What are 4 causes of dilated cardiomyopathy?
Chronic alcohol use - most common cause
Coxsackie B
Thiamine (B1) deficiency
Doxorubicin (chemo)
what are 3 causes of restrictive cardiomyopathy?
amyloidosis
post-radiotherapy
loeffler’s endocarditis - infiltration of heart with eosinophils, leading to fibrosis
what is peripartum cardiomyopathy?
Typically develops between last month of pregnancy and 5 months post partum
RF = Increased age, greater parity, multiple estations
what is takotsubo cardiomyopathy?
atypical ballooning of myocardium classically triggered by stress
what is the prognosis for takotsubo cardiomyopathy?
usually resolves with supportive treatment
what is the pathophysiology of takotsubo cardiomyopathy?
apex of heart does not contract so appears to balloon out but areas closer to top continue to contract creating octopus trap shape
what are 4 features of takotsubo cardiomyopathy?
chest pain
ST elevation
Features of heart failure
normal coronary angio
who is takotsubo cardiomyopathy most common in?
post menopausal women
what is the inheritance pattern for arrhythmogenic right ventricular cardiomyopathy?
autosomal dominant
what is the second most common cause of sudden cardiac death in young people?
arrhythmogenic right ventricular cardiomyopathy
what is the pathophysiology of arrhythmogenic right ventricular cardiomyopathy?
R ventricular myocardium replace with fatty and fibrotic tissues
what can be seen on ecg in arrhythmogenic right ventricular cardiomyopathy?
V1-3 abnormalities typically t wave inversion
Epsilon wave in 50% of people - terminal notch in qrs complex
what are 5 complications of arrhythmogenic right ventricular cardiomyopathy?
Ventricular arrythmias - VT, V fib
Sudden cardiac death
Heart failure
Atrial arrythmias
Thromboembolic events
what is the most common type of cardiomyopathy?
dilated
what area is most commonly affected in thoracic aortic aneurysm?
Ascending aorta
what size is both the ascending and descending thoracic aorta usually less than?
<4.5 ascending
<3.5 descending
what is a false aneurysm?
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
what are the three layer of arteries?
Intima - most internal
Media
Adventitia - most external
what are 5 presentations of thoracic aortic aneurysm?
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
what are the 2 surgical options for thoracic aortic aneurysm?
Thoracic end-vascular aortic repair (TEVAR)
Midline sternotomy
what are features of ruptured thoracic aortic aneurysm?
Severe chest /back pain
Haemodynamic instability
Collapse
Sudden death
Haematemesis - due to bleeding into oesophagus
Haemoptysis due to bleeding into lungs
Cardiac tamponade
what is vasovagal syncope related to?
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
what are 7 pre-syncope symptoms?
Hot and clammy
sweaty
Heavy
Dizzy/lightheaded
vision going blurry or dark
headache
Tinitus or muffled hearing
what are the 3Ps of vasovagal syncope?
Posture - after prolonged standing
Provoking factors - fear, pain, phobia, crowded, hot, dehydrated
Progressive prodrome - pallor, sweating, nausea, vom
What are 8 secondary causes of syncope?
Hypoglycaemia
dehydration
anaemia
infection
anaphylaxis
arrythmias
valvular heart disease
HOCM
what are 4 types of reflex syncope?
Vasovagal
situational - micturition, defecation coughing
Carotid sinus hypersensitivity
Atypical reflex syncope - not clear trigger or prodrome
what are 6 conditions that can cause cardiac syncope?
Structural
- Aortic stenosis
-HOCM
-Pulmonary HTN
- Acute MI
Arrythmias
- Bradycardia (heart block, sick sinus)
- Tachycardia - VT, SVT
what investigations are used in syncope?
ECG + 24h ECG
Echo
Tilt table testing
Carotid sinus massage
Bloods - FBC, U+E, electrolytes, blood glucose
what is dry ganrene?
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
what is wet gangrene?
An infectious process along with tissue necrosis. Develops rapidly due to venous or arterial blockage along with bacterial infection
Appears swollen blistered and smelly
what are 4 risk factors for wet gangrene?
Critical limb ischaemia
Surgical wounds/trauma
Immunosuppression
Severe burns/frostbite
what is gas gangrene?
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
what bacteria most commonly causes gas gangrene?
Clostridium perfringens
what is the pathophysiology of gangrene?
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
what is the management of gangrene?
Surgical debridement of necrotic tissue
Abx - broad spectrum
Hyperbaric oxygen therapy
Tx underlying conditions
what are 6 complications of gangrene?
gas gangrene
sepsis
necrotising fasciitis
Limb loss
long term pain
fistula formation
what are 4 signs of chronic venous insufficiency?
Haemosindrin - brown pigmentation on skin
Lipodermatosclerosis - champagne bottle legs
Oedema
Venous eczema
what are varicose veins?
distended superficial veins measuring more than 3mm in diameter, usually affecting the legs.
what are reticular veins?
dilated blood vessels in the skin measuring less than 1-3mm in diameter
what is Telangiectasia?
dilated blood vessels in the skin measuring less than 1mm in diameter. They are also known as spider veins or thread veins.
what are 7 risk factors for varicose veins?
Increasing age
Fhx
Female
Pregnancy
Obesity
Prolonged standing
DVT - cause damage to valves
what are 7 presentations of varicose veins?
Heavy/dragging sensation in legs
Aching
Itching
Burning
Oedema
Muscle cramps
Restless legs
Signs of chronic venous insufficiency
what are 3 signs of chronic venous insuficiency that can be seen in the lower legs?
brown discolouration due to haemosiderin
venous eczema
lipodermatosclerosis
what are 5 special tests for varicose veins?
Tap test
cough test
Trendelenburghs test
Perthes test
Duplex ultrasound
what is the conservative management of varicose veins?
Leg elevation
weight loss
regular exercise
Graduated compression stockings
what are 3 surgeries for varicose veins?
Endothermal ablation
Sclerotherapy – injecting the vein with an irritant foam that causes closure of the vein
Surgical Stripping
what are 4 complications of varicose veins?
Prolonged and heavy bleeding after trauma
Superficial thrombophlebitis
DVT
Skin changes and ulcers
what is the tap test for varicose veins?
Apply pressure to saphenofemoral junction and tap the distal varicose vein - feel for thrill at SFJ - suggests incompetent valves between varicose vein and SFJ
what is the cough test for varicose veins ?
Apply pressure to saphenofemoral junction and ask patient to cough - feel for thrill - suggest dilated vein at SFJ
what is trendelenburg’s test for varicose veins ?
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
what is Perthes test for varicose veins ?
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)
What is the pathophysiology of varicose veins?
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
what are the 2 lipids present in the blood?
Cholesterol
Triglycerides
what are 5 lipoproteins that carry lipids in blood?
Chylomicrons
Very-low density lipoproteins (VLDL)
Intermediate density lipoproteins
Low-density lipoproteins
High density lipoproteins
what molecule is responsible for 1st steps in atherosclerosis?
Low density lipoprotein (bad cholesterol)
what molecule is responsible for moving cholesterol from atherosclerotic plaques to liver?
High density lipoprotein (good cholesterol)
what is the normal level of non-HDL lipids?
<4 mmol/L
what is the normal level of serum HDL?
> 1 mmol/L Men
1.2 mmol/L Women
what is a normal total cholesterol:HDL ratio?
<6 mmol/L
what is normal total cholesterol?
< 5 mmol/L
what is normal non-fasting triglycerides?
<2.3 mmol/L
what is normal fasting triglycerides?
<1.7 mmol/L
what are 5 causes of primary hyperlipidaemia?
Hyperchylomicronaemia - causes elevated chylomicrons, evident from childhood
Familial hypercholesterolaemia
Combined hyperlipidaemia
Dysbetalipoproteinanaemia
Hypertriglyceridaemia
Mixed hypertriglyceridaemia
what are 8 risk factors for hyperlipidaemia?
FHx
Premature CVD
Poor diet
Lack of exercise
Obesity
Diabetes
Hypothyroidism
Nephrotic syndrome
Medications - b blockers, glucocorticoids, amiodarone, diuretics
what are 4 signs of hypercholesteraemia?
Tendon xanthomata
Xanthelasma - yellow papules on and around eyelids
Corneal arcus
Lipaemia retinalis
what is the 1st line management of hypercholesteraemia?
Lifestyle modification
1 - Statins - Atorvostatin 10mg OD - can increase up to 80mg
Fenofibrate can be used in raised triglycerides
what is the 2nd line medication for hypercholesteraemia?
Ezetimibe 10mg OD PO
what tool can be used to assess 10 year risk of CVD in >40s?
QRisk2/3
at what qrisk should a statin be offered?
> 10%
what are 2 conditions that require lipid lowering therapy?
Diabetes - >40 or had for more than 10 years or nephropathy
CKD
Give 20mg Atorvostatin OD
what dose of statin is used as secondary prevention 1st line?
Atorvostatin 80mg OD
what are 3 adverse effects of statins?
Myopathy - myalgia, myositis, rhabdo
Liver impairment - check LFTs at 3 and 12 months
Increased risk of intracerebral haemorrhage in prev stroke
what is the murmur in tricuspid regurditation?
pan systolic
with split second heart sound due to pulmonary valve closing before aortic as R ventricle is emptying faster
what are 5 signs o/e of tricuspid regurgitation?
Thrill in tricuspid area
raised JVP
Pulsatile liver - due to venous regurg
Peripheral oedema
ascites
what are 6 causes of tricuspid regurgitation?
Pressure due to left heart failuure or pulmonary hypertension
infective endocarditis
rheumatic heart disease
carcinoid syndrome
ebstein’s anomaly
connective tissue disorders - Marfans, EDS
what is the murmur in pulmonary stenosis?
ejection systolic murmur loudest in pulmonary area
what ecentuates pulmonary stenosis?
deep inspiration
what is the presentation o/e of pulmonary stenosis?
Ejection systolic murmur
widely split S2
thrill in pulmonary area
raised JVP
Peripheral oedema
ascites
what are 2 congenital conditions associated with pulmonary stenosis?
Noonan syndrome
Tetralogy of Fallot
which sided heart failure causes pulmonary oedema?
left
which sided heart failure causes peripheral oedema?
right
what is ejection fraction?
the percentage of blood pumped out of LV with each ventricular contraction
equation for ejection fraction?
EF = (stroke volume/end diastolic volume) X 100
cardiac output equation
CO = stroke volume x HR
what are 5 causes of heart failure?
Ischaemic heart disease
Valvular heart disease - commonly aortic stenosis
Hypertension
Arrythmias - AF commonly
Cardiomyopathy
what are 6 key symptoms of heart failure?
Breathlessness, worse on exertion
Cough - frothy white/pink sputum
Orthopnoea
Paroxysmal nocturnal dyspnoea
Peripheral oedema
Fatigue
what are 9 signs o/e of heart failure?
Tachycardia
Tachypnoea
Hypertension
Murmurs
S3 heart sound
Bilateral basal crackles
Raised JVP
peripheral oedema
S3 heart sounds
what kind of cough can be characteristic of heart failure?
produces white/pink frothy sputum
what is paroxysmal nocturnal dyspnoea?
suddenly waking in night with severe SOB, cough and wheeze caused by heart failure
what classification system can be used for severity of heart failure symptoms?
New York heart association classification
what is the new york heart association classification of severity of heart failure symptoms?
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
what is the 1st line investigation for heart failure?
N-terminal pro-B-type natriuretic peptide = BNP
What assessment guides heart failure referral time?
BNP
400 - 2000 ng/L - seen + echo in 6 weeks
>2000 ng/L seen + echo in 2 weeks
what is the 1st and 2nd line medical management for heart failure?
ABAL
ACEI/ARB
Beta blocker - Bisoprolol
Aldosterone antagonist (spiro, eplerenone)
Loop diuretic (furosemide or bumetanide) - symptomatic relief only
what is the 3rd line medical management of heart failure?
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
what in particular needs monitoring in patients with ACEi and aldosterone antagonists (spiro) in heart failure?
U+E => potassium levels
both cause hyperkalaemia
what surgery may be done in heart failure?
Valvuloplasty/replacement
Implantable cardioverter defibrillators - prev VT/ V Fib
Cardiac resynchronisation therapy - biventricular pace makers
Heart transplant
what are 5 signs of heart failure of CXR?
ABCDE
A - alveolar oedema
B - Kelley B lines
C - cardiomegaly
D - Dilated upper lobe vesels
E - pleural Effusion
what is the frank-starling law?
Increased end diastolic volume causes increased force of contraction leading to increased stroke volume
what is heart failure with reduced ejection fraction and 1 cause?
reduced ventricular contractility leading to systolic dysfunction
Caused by damaged myocytes - ischaemic heart disease
what is heart failure with preserved ejection factor and causes?
Reduced ventricular compliance leading to diastolic dysfunction and reduced filling pressures
Increased ventricular stiffness - due to HTN
Reduced ventricular relaxation - constrictive pericarditis. HOCM
what are 6 causes of high output heart failure?
Anaemia
AV malformation
pagets disease
pregnancy
thyrotoxicosis
thiamine deficiency - wet beri beri
What are 3 compensatory mechanisms in the heart?
Neurohormonal activation - sympathetic nervous system and RAAS system activation leading to vasoconstriction, fluid retention, increased HR
Ventricular remodelling
Frank-starling mechanism
How do SGLT2 inhibitors work?
reversibly inhibit sodium glucose co-transporter 2 in renal proximal convoluted tubule leading to reduced glucose reabsorption and increased urinary excretion
what are 7 cardiac causes of acute heart failure?
MI
Ventricular rupture
Myocarditis
High output states - sepsis, thyroid storm
Cardiomyopathy - takotsubo/drug induced
Valvular dysfunction - IE, post MI
Arrythmias
what are 4 extracardiac causes of acute heart failure?
Pericardial effusion and tamponade
Aortic dissection
Pulmonary embolism
Tension pneumothorax
what is the medical management of acute heart failure?
A-E and stabilise
IV furosemide (40mg)
Fluid restriction
Inotropes or vasopressors
NIV - CPAP
Intubation and ventilation
what are 4 causes of myocarditis?
Viral - coxsackie B, HIV, HHV6
Bacteria/protazoa - lyme disease (borrelia burgdorferi), toxoplasmosis, diphtheria
Autoimmune
Drugs - doxrubicin, clozapine
what is the presentation of myocarditis?
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
what are 4 risk factors for myocarditis?
Peri-partum and postnatal
Younger age
Exposure to certain drugs/allergens
Autoimmune diseases
what can be seen on ECG in myocarditis?
sinus tachy
T wave inversion
Pericarditis related - Saddle shaped ST elevation, PR depression
what is the gold standard investigation for myocarditis?
Endomyocardial biopsy
what is the management of myocarditis?
Supportive
Immunosuppression
Heart failure therapies
Device therapies - ICD, CRT
what is the MOA of statins?
inhibit action of HMG-CoA reductase the rate limiting enzyme in hepatic cholesterol synthesis
what are 3 adverse effects of statins?
myopathy and rhabdomyolysis
Liver impairment - check LFTs at 3 month and 12 months, discontinue if transaminases rise to 3x normal limit
Increase risk of intracerebral haemorrhage in prev stroke
what are 2 contraindications to statins?
Macrolides - erythromycin, clarithromycin
Pregnancy
who should get high dose statins?
people with cardiovascular disease
what T1DM patients should have statins?
if diagnosed >10 years or >40 years or have nephropathy
what QRisk score should people have statins?
> 10%
what is the dose of Atorvastatin for primary prevention?
20mg
what is the dose of atorvastatin for secondary prevention?
80mg
what is brugada syndrome?
Form of inherited CVD that may present with sudden cardiac death
More common in asian populations
what is the inheritance pattern of brugada syndrome?
autosomal dominant
what ECG changes are seen in brugada syndrome?
Convex ST elevation >2mm V1-3 followed by inverted T-wave
Partial RBBB
Changes may be more apparent after flecainide or ajmaline
what is the management of brugada syndrome?
Implantable cardioverter-defibrillator
what is buerger disease?
aka thromboangiitis obliterans
inflammatory condition that causes thrombus formation in small and medium vessels in distal arteria system - hands and feet
strongly associated with smoking
what is the presentation of buerger disease?
painful blue discoloration of fingertips and toes often worse at night
may progress to ulcers, gangrene and amputation
what is seen on angiogram inn buerger’s disease?
corkscrew collaterals - new vessels form to bypass affected arteries
what is the management of buergers disease?
stop smoking
IV iloprost
amputation
what is the normal size of the abdominal aorta?
<1.5cm women
<1.7cm men
> 50 years
when does screening for AAA take place?
males aged 65
what happens to AAAs 3-4.4cm?
small aneurysm - rescan every 12 months
what happens to AAA <3cm?
normal no action needed
what happens to AAAs 4.5-5.4cm?
medium aneurysm - rescan every 3 months
what happens to AAAs >5.5cm?
large aneurysm - refer 2ww to vascular for probable intervention
what puts an AAA at high rupture risk?
symptomatic
diameter >5.5cm
Rapidly enlarging >1cm a year
what is the management of AAA?
elective endovascular repair (EVAR) or open repair
EVAR - stent placed in abdominal aorta via femoral artery to prevent blood collecting in aneurysm
what are 4 presentations of AAA rupture?
Pain in back or loin - abdo pain radiating through to back
Cardiovascular failure - tachy, hypotensive (shock), poorly responsive to fluids
Distal ischaemia - if haematoma in aneurysmal cavity can embolise and cause distal artery occlusion
Death
what investigations should be done for ruptured AAA?
USS - quick diagnostic test to rule out AAA
CT angio - gold standard
Bloods
- FBC
- U+E - due to contrast needed for endovascular procedure
- coag screen
- group, save and cross match for surgery
what are the 2 types of repair for rupture AAA?
open surgical repair - using midline laparotomy for direct visualisation
Endovascular aneurysm repair (EVAR)
what are 7 complications of ruptured AAA?
renal failure
MI
bowel ischaemia
limb ischaemia
graft infection
abdominal compartment syndrome - more common in open surgery
endo leak of blood around aneurysm graft causing enlargement of aneurysm - only with EVAR
what is the usual size for the thoracic aorta?
ascending <4.5cm
descending <3.5cm
what is a false aneurysm?
usually de to trauma such as RTC, when intima and media rupture and there is dilation of vessel with blood only being contained within adventitia whereas true aneurysm has dilation of all layers of vessel
what are 6 presentations of thoracic abdominal aneurysm?
chest/back pain
trachea or L bronchus compression - cough, SOB, stridor
Phrenic nerve compression - hiccups
Oesophageal compression - dysphagea
Recurrent laryngeal nerve compression - hoarse voice
how long does troponin remain raised after MI?
10 days
what biomarker can be used in re-infarction in MI?
Creatine kinase myocardial band (CK-MB) - raised for 2-4 days after MI
