Cardio Flashcards

1
Q

What is angina?

A

constricting chest pain caused by reduced blood flow (and hence oxygen supply) to the myocardium due to atherosclerosis narrowing the lumen of coronary arteries

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2
Q

What is stable angina?

A

symptoms only come on with exertion
relieved by rest or glyceryl trinitrate (GTN)

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3
Q

What is unstable angina?

A

symptoms appear randomly whilst at rest
type of acute coronary syndrome (ACS)
requires immediate management

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4
Q

What are the main signs and symptoms of aortic stenosis?

A

chest pain
SoB
syncope
exertional dizziness
ejection systolic murmur radiating to the carotids

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5
Q

What kind of murmur is associated with aortic stenosis?

A

ejection systolic murmur
radiating to the carotids
decreased during Valsalva maneuvre

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6
Q

What features are associated with severe aortic stenosis?

A

narrow pulse pressure
thrill
LV hypertrophy

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7
Q

What are the main causes of aortic stenosis?

A

degenerative calcification - most common cause in >65y.o.
bicuspid aortic valve - most common cause in < 65y.o.
William’s syndrome - supravalvular
post-rheumatic disease
subvalvular - hypertrophic cardiomyopathy

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8
Q

What is the management of aortic stenosis in asymptomatic patients?

A

conservative - observation

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9
Q

What is the management of aortic stenosis in symptomatic patients?

A

valve replacement

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10
Q

When do you consider surgery in asymptomatic patients with aortic stenosis?

A

if the valvular gradient is > 40mmHg and has features of left ventricular systolic dysfunction

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11
Q

What are the options for aortic valve replacement (AVR) in aortic stenosis?

A

surgical AVR
transcatheter AVR

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12
Q

What patients are suitable for surgical AVR?

A

young
low-medium operative risk
may have cardiovascular disease (combined surgery)

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13
Q

When should mechanical vs bioprosthetic valve be used?

A

mechanical
- younger patients (< 65 in aortic, <70 in mitral)
bioprosthetic
- older patients
- tend to last shorter

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14
Q

What patients are suitable for transcatheter AVR?

A

high operative risk

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15
Q

What patients are suitable for aortic balloon valvuloplasty?

A

children with aortic stenosis with no calcification
adults with critical aortic stenosis who are not fit for valve replacement

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16
Q

What is aortic regurgitation?

A

leaking of the aortic valve

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17
Q

What are the main causes of aortic regurgitation?

A

valve disease
aortic root disease

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18
Q

What are some causes of aortic regurgitation due to valve disease with chronic presentation?

A

rheumatic fever - most common cause in the developing world
calcific valve disease
connective tissue disease - SLE, rheumatoid arthritis
bicuspid aortic valve

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19
Q

What is the most common cause of aortic regurgitation in the developing world?

A

rheumatic fever

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20
Q

What are some causes of aortic regurgitation due to aortic root disease with chronic presentation?

A

bicuspid aortic valve
spondyloarthropathies - e.g. ankylosing spondylitis
HTN
syphilis
Marfan’s
EDS

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21
Q

What are some causes of aortic regurgitation due to valve disease with acute presentation?

A

infective endocarditis

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22
Q

What are some causes of aortic regurgitation due to aortic root disease with chronic presentation?

A

aortic dissection

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23
Q

What are some features of aortic regurgitation?

A

early diastolic murmur - loudest at left sternal edge
wide pulse pressure
collapsing pulse
Quincke’s sign - nailbed pulsation
Austin flint murmur - low pitched rumbling mid-diastolic murmur heard best at the apex (in severe AR)

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24
Q

How is aortic regurgitation assessed?

A

echocardiography

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25
How is aortic regurgitation managed?
medical management of heart failure (if associated) surgery if - symptomatic with severe AR - asymptomatic with severe AR and LV systolic dysfunction
26
What is mitral stenosis?
obstruction of blood flow across the mitral valve from LA to LV leads to increases in pressure within the left atrium, pulmonary vasculature and right side of the heart
27
What is the most common cause of mitral stenosis?
rheumatic fever
28
What are the features of mitral stenosis?
SoB - due to pulmonary hypertension haemoptysis - due to pulmonary hypertension mid-late diastolic murmur - best heard in expiration over the apex loud S1 malar flush AF opening snap - indicates mobility of mitral valve leaflets
29
What features can be seen in CXR in mitral stenosis?
LA enlargement
30
How is mitral stenosis managed?
if associated AF - anticoagulation if asymptomatic - monitoring (conservative), regular echo if symptomatic - percutaneous mitral balloon valvotomy OR mitral valve surgery
31
What are the two most common valve diseases?
aortic stenosis mitral regurgitation
32
What are the risk factors for mitral regurgitation?
female lower BMI age renal dysfunction prior MI prior mitral stenosis/prolapse collagen disorders - Marfan's, EDS
33
What murmur is associated with mitral regurgitation?
pansystolic murmur loudest over mitral area radiating to axilla
34
What are the causes of mitral regurgitation?
post MI / coronary artery disease - due to damage to papillary muscles mitral valve prolapse infective endocarditis - vegetations prevent closure of valve leaflets rheumatic fever congenital
35
What are the features of mitral regurgitation?
mostly asymptomatic symptoms usually from LV failure - fatigue, SoB, oedema
36
What investigations are useful in suspected mitral regurgitation? What will they show?
ECG - broad P waves - atrial enlargement CXR - cardiomegaly (enlarged LA and LV) echocardiography
37
How is mitral regurgitation managed?
medical - in acute cases - nitrates, diuretics, intra-aortic balloon pump if heart failure - ACE inhibitors, beta blockers, spironolactone surgery - in acute and severe MR surgical repair over replacement preferred in degenerative causes
38
What murmur does tricuspid regurgitation cause?
pansystolic
39
What are some features of tricuspid regurgitation?
thrill in tricuspid area raised JVP with big C-V waves pulsatile liver (regurgitation into the venous system) peripheral oedema ascites
40
What are the possible causes of tricuspid regurgitation?
"functional" - due to L-sided heart failure or pulmonary hypertension infective endocarditis carcinoid syndrome Ebstein's anomaly connective tissue disorders (e.g. Marfan's)
41
What murmur does pulmonary stenosis cause?
ejection systolic murmur loudest in pulmonary area in deep inspiration
42
What are some features of pulmonary stenosis?
thrill on palpation raised JVP with big A waves (RA contracting against hypertrophic RV) peripheral oedema ascites
43
What are the most common causes of pulmonary stenosis?
congenital -> Noonan syndrome -> tetralogy of Fallot
44
What is tetralogy of Fallot?
congenital pathology; four coexisting pathologies: - ventricular septal defect - overriding aorta - pulmonary valve stenosis - RV hypertrophy
45
What is infective endocarditis?
infection of the inner surface of the heart (endothelium) mostly affects the valves
46
What are the risk factors for infective endocarditis?
IVDU structural heart pathology CKD (esp. dialysis) immunocompromised Hx of infective endocarditis
47
What structural heart pathologies can increase the risk of infective endocarditis?
valvular disease congenital heart disease hypertrophic cardiomyopathy prosthetic valves implanted cardiac devices
48
What organisms can cause infective endocarditis? And what is the most common one?
Staphylococcus aureus - most common streptococcus enterococcus
49
How does infective endocarditis present?
non-specific infective symptoms (fever, night sweats, fatigue) new / changing murmur splinter haemorrhages Osler's nodes / Janeway lesions Roth spots splenomegaly finger clubbing (if chronic)
50
How is infective endocarditis investigated?
blood cultures - before ATB echocardiography (transoesophageal is more sensitive - can see vegetations) if prosthetic valves - special imaging: - SPECT CT - 18F-FDG CT/PET
51
What is the name of the tool used to diagnose infective endocarditis?
Duke Criteria
52
What score (from the Duke Criteria) is required to diagnose infective endocarditis?
1 major + 3 minor criteria OR 5 minor criteria
53
What are the major criteria in Duke Criteria?
persistently positive blood cultures specific imaging findings (e.g. vegetations on echo)
54
What are the minor criteria in Duke Criteria?
predisposition (e.g. valve pathology, IVDU) fever above 38 vascular phenomena (e.g. intracranial haemorrhage, Janeway lesions, splenic infarction) immunological phenomena (e.g. Osler's nodes, Roth spots, glomerulonephritis) microbiological phenomena (e.g. positive cultures not qualifying as major criteria)
55
How is infective endocarditis managed?
hospital admission IV broad-spectrum ATB (e.g. amoxicillin) for 4 weeks (6 weeks if prosthetic valve) surgery - if HF related to valve pathology / large vegetations / not responding to ATB
56
What are the key complications of infective endocarditis?
high mortality rate heart valve damage -> regurgitation HF infective and non-infective emboli (-> stroke, splenic infarction) glomerulonephritis -> renal impairment
57
What is pericarditis?
inflammation of pericardium - membrane surrounding the heart
58
What are the most common causes of pericarditis?
idiopathic viral other causes: autoimmune uraemia medications - e.g. methotrexate
59
How does pericarditis present?
low-grade fever chest pain - pleuritic - sharp - central / anterior - worse when lying down, better when sitting forward
60
What examination finding is typical for pericarditis?
pericardial friction rub - rubbing sound occuring alongside heart sounds
61
What is the potential space between the two layers of pericardium called? How is it relevant to pericarditis? What complications can arise from it?
pericardial cavity in pericarditis - can fill up with fluid -> pericardial effusion if pericardial effusion big enough to raise the intra-pericardial pressure -> cardiac tamponade
62
What is the function of the pericardial cavity?
contains small amount of fluid -> provides space to allow heart to beat without friction
63
What is cardiac tamponade? Why is it a problem?
large pericardial effusion that raised intra-pericardial pressure - > affects the heart's ability to function reduced heart filling during diastole -> decreases cardiac output during systole emergency - requires quick drainage
64
How is pericarditis investigated?
blood tests - raised inflammatory markers ECG changes - saddle-shaped (concave) ST elevation - PR depression echocardiogram - to diagnose pericardial effusion
65
How is pericarditis managed? What are the first and second line treatment options?
first line: NSAIDs colchicine - longer-term treatment, prevents recurrence second line: steroids - if recurrent / associated with inflammatory condition pericardiocentesis - removal of pericardial fluid if effusion/tamponade treatment of underlying causes
66
What is the prognosis of pericarditis?
resolves within a month may be recurrent may become chronic
67
What is ejection fraction? What is the normal value?
% of blood in LV squeezed out with each ventricular contraction normal is above 50%
68
What is systolic dysfunction?
problem with ventricle contracting during systole
69
What is diastolic dysfunction?
issue with ventricle relaxing and filling with blood during diastole
70
What are the main types of chronic heart failure? (2 answers correct)
preserved LVEF (LVEF > 50%) reduced LVEF (LVEF < 50%) OR systolic HF (typically reduced LVEF) diastolic HF (typically preserved LVEF)
71
What are some common causes of systolic dysfunction HF?
ischaemic heart disease dilated cardiomyopathy myocarditis arrhythmias
72
What are some common causes of diastolic dysfunction HF?
hypertrophic obstructive cardiomyopathy restrictive cardiomyopathy cardiac tamponade constrictive pericarditis
73
What are the potential causes of left-sided heart failure?
increased LV afterload - e.g. due to arterial HTN, aortic stenosis increased LV preload - e.g. aortic regurgitation
74
What are the potential causes of right-sided heart failure?
increased RV afterload - e.g. pulmonary HTN increased RV preload - e.g. tricuspid regurgitation
75
What does LV failure typically result in?
pulmonary oedema -> leads to signs and symptoms: - dyspnoea - orthopnoea - paroxysmal nocturnal dyspnoea - bibasal fine crackles - wheeze
76
What does RV failure typically result in?
peripheral oedema raised JVP hepatomegaly - due to backflow weight gain - due to fluid retention anorexia - cardiac cachexia
77
What is "high-output heart failure"? What are some examples?
when a normal, healthy heart is unable to pump enough blood to meet the metabolic demands of the body e.g. in - anaemia - arteriovenous malformation - Paget's disease - pregnancy - thyrotoxicosis
78
What are some examination signs in heart failure?
tachycardia tachypnoea HTN murmurs 3rd heart sound bilateral basal crackles raised JVP peripheral oedema
79
What are some symptoms of chronic heart failure?
SoB, worse on exertion cough - can produce white/pink frothy sputum cardiac wheeze (due to pulmonary oedema) orthopnoea paroxysmal nocturnal dyspnoea peripheral oedema fatigue
80
How is heart failure diagnosed?
clinical assessment - Hx, examination NT-proBNP blood test ECG echocardiogram +bloods - to check for anaemia, U&Es, LFTs, TFTs, lipids, diabetes +CXR + lung function tests (spirometry)
81
How is severity of HF symptoms graded? What are the grades?
NYHA - New York Heart Association Classification Class 1: no limitation on activity Class 2: comfortable at rest, symptomatic with ordinary activities Class 3: Comfortable at rest, symptomatic with any activity Class 4: Symptomatic at rest
82
How is chronic heart failure managed? What are the main principles?
RAMPS: R: Refer to cardiology A: Advise about condition M: Medical treatment P: Procedural and surgical management S: Specialist heart failure MDT input
83
How urgently are patients with HF refered to echocardiography?
NT-proBNP between 400-2000 - within 6 weeks NT-proBNP > 2000 - within 2 weeks
84
What is the first-line medical treatment for chronic heart failure?
ABAL A: ACE inhibitor - e.g. ramipril - up to 10mg B: Beta blocker - e.g. bisoprolol - up to 10mg A: Aldosterone antagonist (if symptoms still persist) - e.g. spironolactone, eplerenone L: Loop diuretics - e.g. furosemide, bumetanide
85
Give some examples of ACE inhibitors
ramipril lisinopril ...-pril
86
Briefly explain the mechanism of action of ACE inhibitors
1. low BP - kidneys release renin 2. renin converts angiotensinogen into angiotensin I 3. ACE converts angiotensin I into angiotensin II in the lungs - inhibited by ACE inhibitors 4. angiotensin II constricts blood vessels and stimulates release of aldosterone (to retain salt and water in kidneys) -> both increase BP
87
Give some examples of aldosterone antagonists
eplerenone spironolactone ...-one
88
Briefly explain the mechanism of action of aldosterone antagonists
aldosterone - produced by adrenal glands - regulates salt and water balance - retention of Na (and water) - excretion of potassium aldosterone antagonists block this action: - lower BP - prevent loss of K
89
Briefly explain the mechanism of action of loop diuretics
they block the reabsorption of Na and Cl in the thick ascending limb of loop of Henle more Na and water is excreted in urine -> lowers BP and blood volume increases loss of K
90
Give some examples of loop diuretics
furosemide bumetanide
91
What medications can be used instead of ACE inhibitors if poorly tolerated in HF?
angiotensin receptor blockers - e.g. candesartan
92
Which patients with HF should not be given ACE inhibitors?
if they have valvular disease
93
When are aldosterone antagonists used in HF?
reduced ejection fraction symptoms not controlled with ACE inhibitors and beta blockers
94
Why blood test should be done regularly for patients on HF medications? Why?
U&Es, renal function - ACEi, aldosterone antagonists and diuretics can cause electrolyte disturbances ACEi and aldosterone antagonists can cause hyperkalaemia
95
What specialist treatments can be used in patients with HF? When are they typically used?
used in LV fraction < 35% SGLT2 inhibitors - e.g. dapagliflozin sacubitril + valsartan ivabradine hydralazine + nitrate digoxin
96
What additional management is recommended in patients with HF?
vaccinations stop smoking optimise treatment of co-morbidities written care plan cardiac rehabilitation - personalised exercise programme
97
What surgical interventions can be used in patients with HF?
valve replacement - if valve disease inplantable cardioverter defibrillator - if previous VT / VF cardiac resynchronisation therapy - if ejection fraction < 35%, BBB heart transplant
98
What is cardiac resynchronisation therapy (CRT)? When is it used?
biventricular (triple chamber) pacemakers leads in RA, RV, LV objective - to synchronise the contractions to optimise heart function used in severe HF, with ejection fraction < 35% and widened QRS (e.g. in LBBB)
99
When is sacubitril-valsartan used in HF?
heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs LV fraction < 35% initiated after ACEi / ARB wash-out period
100
What is acute heart failure?
life-threatening emergency sudden onset or worsening of symptoms of HF decompensated AHF is more common caused by reduced cardiac output due to functional/structural abnormality
101
What are some causes of de-novo AHF?
increased cardiac filling pressures and myocardial dysfunction usually as a result of ischaemia viral myopathy toxins valve dysfunction
102
What are some causes of decompensated HF?
acute coronary syndrome hypertensive crisis acute arrhythmia valvular disease
103
What are the signs and symptoms of AHF?
SoB reduced exercise tolerance oedema fatigue cyanosis tachycardia elevated JVP displaced apex beat bibasal crackles, wheeze S3
104
How is AHF diagnosed?
bloods - anaemia, electrolyte abnormalities, infection CXR - pulmonary venous congestion, interstitial oedema, cardiomegaly echocardiogram - new onset HF, suspected post-MI or valvular problems, cardiogenic shock BNP - >100mg/L
105
How is HF acutely managed?
IV loop diuretics - furosemide, bumetanide O2 - if hypoxic (<94%) vasodilators - e.g. nitrites - only if hypertension, myocardial ischaemia or valve regurgitation - NOT in hypotension! CPAP - if respiratory failure
106
What sign is typical for cardiac tamponade?
pulsus paradoxus - abnormally large drop in BP during inspiration electrical alternans - alteration of QRS complex amplitudes on ECG absent Y descent in JVP (only X - TAMpaX)
107
What are the classical features of cardiac tamponade?
Beck's triad: hypotension raised JVP muffled heart sounds
108
How do patients with typical angina present?
all 3 of the following: - precipitated by physical exertion - constricting pain in anterior chest, neck, shoulder, jaw, or arms - relieved by GTN or rest in 5 minutes
109
How do patients with atypical angina present?
2 of the following: - precipitated by physical exertion - constricting pain in anterior chest, neck, shoulder, jaw, or arms - relieved by GTN or rest in 5 minutes and atypical symptoms: - GI discomfort / nausea / SoB
110
What factors make diagnosis of stable angina more likely?
- higher age - male - CV risk factors - history of coronary artery disease
111
What factors make diagnosis of stable angina less likely?
- continuous/prolonged pain - pain unrelated to activity - pleuritic pain - pain associated with dizziness, tingling, palpitations, difficulty swallowing
112
What bedside tests are used to investigate angina?
- physical exam - ECG (can have signs of past MI, but can be normal) - FBC (anaemia) - U&E (before starting ACEi or other meds) - LFTs (before starting statins) - lipid profile - TFTs - HbA1C, fasting glucose
113
What are modifiable cardiovascular risk factors?
smoking high LDL levels lack of physical activity unhealthy diet high alcohol intake overweight / obesity
114
What are non-modifiable cardiovascular risk factors?
higher age male FH of CVD ethnic background (e.g. south Asian)
115
What ECG changes could indicate ischaemia / previous MI?
pathological Q waves LBBB (always abnormal) ST and T abnormalities
116
What is cardiac stress testing?
assessment of heart function during exertion - exercise (treadmill) - medication (dobutamine) assessment of heart function by - ECG - echocardiogram - MRI - myocardial perfusion scan
117
How can suspected angina be investigated?
cardiac stress testing CT coronary angiography invasive coronary angiography - catheter into femoral artery -> into coronary arteries under XR guidance -> injection of cotrast
118
What is gold standard investigation for coronary artery disease?
invasive coronary angiography
119
How is suspected angina managed?
RAMPS Referral to cardiology (rapid access chest pain clinic) Advise about diagnosis, management, safety netting Medications Procedural interventions Secondary prevention
120
What are the main aims of medical management options of angina?
immediate symptomatic relief long-term symptomatic relief secondary prevention
121
What are the medications for immediate symptomatic relief in angina?
sublingual GTN
122
How is GTN used in stable angina?
ake the GTN when the symptoms start Take a second dose after 5 minutes if the symptoms remain Take a third dose after a further 5 minutes if the symptoms remain Call an ambulance after a further 5 minutes if the symptoms remain
123
What are the main side effects of GTN?
hypotension tachycardia headaches flushing
124
How is long-term symptomatic relief achieved in angina?
either one or combination of - beta blocker (e.g. bisoprolol) - calcium channel blocker (diltiazem, verapamil) - AVOID in HFrEF if symptomatic still on monotherapy - increase to max dose if still symptomatic - add the second drug class
125
What calcium channel blockers are used in angina management and when? (monotherapy / combination therapy)
monotherapy - rate-limiting Ca blocker - verapamil, diltiazem combination with beta blockers - longer-acting dihydropyridine Ca blocker - amlodipine, modified release nifedipine
126
Why shouldn't verapamil be administered with beta blockers?
risk of complete heart block
127
What specialist treatments are available for long-term symptomatic relief in angina? When are they offered?
offered when on monotherapy, still symptomatic, and cannot tolerate addition of beta blocker / ca channel blocker - long-acting nitrates - isosorbide mononitrate - ivabradine - nicorandil - ranolazine Iva a Nico randili, Rano boli Lazy
128
What medications are used for secondary prevention in angina?
4A Aspirin - 75mg OD Atorvastatin 80mg OD ACEi - if HTN, DM, CKD, HF also present Already on beta blocker for symptomatic relief
129
What surgical options are available for angina management?
PCI - percutaneous coronary intervention CABG - coronary artery bypass grafting
130
What is PCI?
percutaneous coronary intervention - insertion of catheter into patients brachial / femoral artery - catheter passes into coronary arteries - injection of contrast - if areas of stenosis - balloon dilatation and stent insertion -> coronary angioplasty and stenting
131
What is CABG?
Coronary artery bypass graft offered in severe coronary artery stenosis midline sternotomy incision harvest of graft vessel: - saphenous vein - internal thoracic artery - radial artery
132
What are the advantages and disadvantages of PCI over CABG?
advantages: - faster recovery rate - lower rate of strokes disadvantages: - higher rate of requiring repeat revascularisation
133
What is ACS?
acute coronary syndrome umbrella term covering a number of acute presentations of ischaemic heart disease - ST elevation myocardial infarction (STEMI) - ST elevation + elevated biomarkers - non-ST elevation myocardial infarction (NSTEMI) - ECG changes, no ST elevation + elevated biomarkers - unstable angina - ischaemic symptoms suggestive of an ACS and no elevation in troponins, with or without electrocardiogram changes indicative of ischaemia
134
What is the typical presentation of ACS?
CHEST PAIN - central/left sided - radiating to jaw / left arm - heavy, constricting - may be abnormal / not be present in certain groups (e.g. diabetics, elderly) SoB sweating N+V observations might be normal or only slightly altered (e.g. tachycardia)
135
What are the most important investigations in ACS?
ECG cardiac markers - e.g. troponins
136
Which leads will be affected on ECG in anterior MI? What artery is involved?
V1-V4 LAD artery
137
Which leads will be affected on ECG in inferior MI? What artery is involved?
II, III, aVF right coronary artery
138
Which leads will be affected on ECG in lateral MI? What artery is involved?
I, V5-V6 left circumflex artery
139
What are the main aims of ACS treatment?
prevent further deterioration (further occlusion) revascularise the occluded vessel treat pain
140
How is ACS treated?
MONA Morphine - if severe pain Oxygen if required (sats <94%) Nitrates - caution if hypotensive Aspirin
141
What is secondary prevention therapy in ACS?
aspirin second antiplatelet (e.g. clopidogrel) beta blocker ACEi statin
142
What are the diagnostic criteria for STEMI?
clinical symptoms consistent with ACS (lasting > 20 mins) with persistent (>20 mins) ECG changes in 2 or more contiguous leads: - ST elevation - new LBBB
143
In addition to the general ACS treatment, how is STEMI managed?
goal is to revascularise second antiplatelet - clopidogrel (if on oral anticoag), prasugrel (if not on oral anticoag), ticagrelor PCI - should be offered within 12 hrs of symptom onset - radial artery preferred - drug-eluting stents used fibrinolysis - within 12 hrs of symptom onset if significant delay in PCI provision - antithrombin drugs should also be given
144
In addition to the general ACS treatment, how is NSTEMI managed?
aspirin 300mg / fondaparinux (if no immediate PCI) use risk stratification tool (e.g. GRACE) - low risk -> conservative management: ticagrol (not high bleeding risk) or clopidogrel (high bleeding risk) - intermediate/high risk -> PCI (immediate if unstable, within 72 hrs if stable) + prasugrel/ticagrol + unfractioned heparin
145
What complications can arise as a result of MI?
cardiac arrest cardiogenic shock chronic HF tachyarrhythmias bradyarrhythmias pericarditis LV aneurysm acute mitral regurgitation - due to rupture of papillary muscles
146
What changes would you expect on a 12 lead ECG in posterior MI?
ST depression
147
What is aortic dissection?
tear in tunica intima of aortic wall
148
What other conditions is aortic dissection associated with? (risk factors)
cardiovascular RFs HTN trauma (including heavy lifting) bicuspid aortic valve (and other conditions affecting aorta - valve replacement, coarctation) collagen disorders - Marfan's, EDS pregnancy
149
How does aortic dissection typically present?
sudden onset ripping/tearing chest pain pulse deficit - weak or absent carotid / brachial / femoral pulse variation of 20+mmHg in systolic BP between arms aortic regurgitation HTN focal neuro deficit
150
How is aortic dissection classified based on the Stanford classification?
type A - ascending aorta (2/3 of cases) type B - descending aorta, distal to left subclavian origin
151
How is aortic dissection classified based on the DeBakey system?
type 1 - begins in the ascending aorta and involves at least the aortic arch, if not the whole aorta type 2 - isolated to the ascending aorta type 3a - begins in the descending aorta and involves only the section above the diaphragm type 3b - begins in the descending aorta and involves the aorta below the diaphragm
152
How is aortic dissection investigated?
CXR - widened mediastinum CT TAP angiography - false lumen (more suitable for stable patients) TOE (TransOesophageal Echocardiography) - for unstable patients ECG - to exclude other causes
153
How is aortic dissection managed?
analgesia - morphine beta blockers - to manage BP and HR intervention: ASS and BooBs Type A - systolic management and surgery Type B - beta blockers and bed rest - type A - open surgery (midline sternotomy) - synthetic graft to replace the damaged part of aorta - type B - TEVAR (Thoracic EndoVAascular Repair) - catheter via femoral artery with a stent graft (or conservative)
154
What are the possible complications of aortic dissection?
backward tear: - aortic regurgitation - MI - cardiac tamponade forward tear: - unequal arm pulses and BP - stroke - renal failure
155
What are some common causes of atrial fibrillation?
SMITH Sepsis Mitral valve pathology Ischaemic heart disease Thyrotoxicosis Hypertension
156
How does AF typically present?
palpitations SoB dizziness / syncope irregularly irregular pulse
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How is AF investigated?
ECG - absent P waves - narrow QRS tachycardia - irregularly irregular ventricular rhythm echocardiogram - used if signs of: - valvular heart disease - heart failure - or if cardioversion is planned
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What is paroxysmal AF?
episodes of atrial fibrillation that reoccur and spontaneously resolve back to sinus rhythm episodes can last between 30 seconds and 48 hours
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How can paroxysmal AF be investigated?
24 hrs Holter monitoring cardiac event recorder (1-2 weeks)
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What is valvular AF?
AF with significant mitral stenosis or a mechanical heart valve
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What are the principles of AF management?
rate control - HR < 100 rhythm control anticoagulation
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What treatment - rate or rhythm control - should be offered in patients with AF as first line? When is it different?
all patients should be offered rate control as first line except: - reversible cause of AF - new onset AF (last 48hrs) - HF caused by AF - symptoms despite effective rate control
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What are the options for rate control in AF?
1. beta blocker - atenolol, bisoprolol 2. Ca channel blocker - diltiazem, verapamil 3. digoxin can do a combination of 2 if one drug is not providing adequate rate control
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What patients should be offered rhythm control first in AF?
R - eversible cause A - atrial flutter thought to be treatable with ablation N - ew onset < 48 hours C - linician thinks rhythm control is more suitable H - eart failure thought to be primarily due to AF
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What options exist for rhythm control in AF?
cardioversion long-term pharmacological rhythm control
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What main categories of cardioversion can be used in AF?
immediate - if either: - AF present for < 48hrs - life-threatening haemodynamic instability delayed - anticoag for 3 weeks prior
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What are the two main types of immediate cardioversion?
pharmacological - flecainide - amiodarone electrical - under sedation/GA
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What factors favour rhythm control as first line in AF?
Age <65 years First presentation of AF Symptomatic.
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What is paroxysmal SVT?
episodes of sudden onset narrow complex tachycardia typically AVNRT (but can be AVRT or junctional as well)
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What are the acute management options for SVT?
1. vagal manoeuvres - Valsalva, carotid sinus massage 2. IV adenosine - rapid bolus of 6mg - >12 if unsuccessful -> 18 if unsuccessful 3. electrical cardioversion
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What are the options for prevention of SVT episodes?
beta blockers radio frequency ablation
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What are the ECG features of hypokalaemia?
U waves small / absent T waves (can be inverted) prolonged PR interval ST depression long QT
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What medication should be given to a patient with AF post stroke?
warfarin or NOAC
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What conditions is S3 (3rd heart sound) associated with?
caused by diastolic filling of the ventricle normal in < 30 y.o. present in - LV failure - dilated cardiomyopathy - constrictive pericarditis - mitral regurgitation
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How is delayed cardioversion in AF performed?
patient anticoagulated for at least 3 weeks usually electrical cardioversion
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What are the options for long-term pharmacological rhythm control in AF?
1. beta blockers 2. dronedarone - used for maintenance of normal rhythm post-cardioversion 3. amiodarone - for patients in HF / LV dysfunction
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When is catheter ablation performed in AF?
if antiarrhythmics not effective / tolerated / patient wants to avoid them
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What are the options for catheter ablation in AF?
LA ablation - ablation of region between pulmonary veins and LA AV node ablation - permanent pacemaker required
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How should patients suitable for catheter ablation for AF anticoagulated?
4 weeks prior to procedure + during the procedure
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What are the risks associated with catheter ablation for AF?
cardiac tamponade stroke pulmonary vein stenosis
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What is CHA2DS2-VASc?
tool for assessing the need of anticoagulation in patients with AF the higher the score, the higher the risk of TIA/stroke Congestive HF Hypertension Age > 75 (2 points) Diabetes Stroke / previous TIA (2 points) Vascular disease Age 65-74 Sex - female
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When is anticoagulation recommended, based on the CHA2DS2-VASc score?
0 - not needed 1 - consider anticoagulation in men 2 - offer anticoagulation
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What score is used to assess the need for anticoagulation in AF patients?
CHA2DS2-VASc
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What score is used to assess the risk of major bleeding in patients with AF on anticoagulation?
ORBIT
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What factors does the ORBIT score consist of?
Older age (75+) Renal impairment (eGFR < 60) Bleeding previously (Hx of GI / intracranial bleed) Iron (low Hb or haematocrit) Taking antiplatelet medication
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What is LA appendage occlusion?
option for patients with contraindications to anticoagulation and a high stroke risk LA appendage is a common site for thrombus formation LA appendage occlusion - insertion of catheter via femoral vein -> RA -> LA insertion of plug into LA appendage
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How is HTN managed in patients < 55y.o. or T2DM?
1. ACE inhibitor (-pril) or angiotensin receptor blocker (-sartan) 2. add Calcium channel blocker (-dipine; verapamil, diltiazem) or thiazide-like diuretic (indapamide) 3. add either Ca channel blocker or thiazide-like diuretic
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How us HTN managed in patients > 55y.o. or African-Caribbean?
1. Ca channel blocker (-dipine; verapamil, diltiadem) 2. add angiotensin receptor blocker (African-Caribbean) (-sartan) or ACE inhibitor (-pril) or thiazide-like diuretic (indapamide) 3. add Ca channel blocker or thiazide-like diuretic
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What ECG variations are considered normal in athletes?
sinus bradycardia junctional rhythm first degree heart block Mobitz type 1
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How is hypertrophic obstructive cardiomyopathy managed?
Amiodarone Beta blockers / verapamil Cardioverter defibrillator Dual chamber pacemaker Endocarditis prophylaxis
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Which drugs should be avoided in hypertrophic obstructive cardiomyopathy?
nitrates ACE inhibitors inotropes
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What are the echo signs of hypertrophic obstructive cardiomyopathy?
MR SAM ASH MR - mitral regurgitation SAM - systolic anterior motion of anterior mitral valve leaflet ASH - asymmetric hypertrophy
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When should you offer ambulatory BPM or home BPM?
if BP > 140/90
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What are the next steps if BP is > 180/120?
1. admit for specialist assessment if - signs of retinal haemorrhage or papilloedema or - life-threatening symptoms ( new onset confusion, chest pain, HF signs, AKI) - suspect phaeochromocytoma 2. urgent investigations for end-organ damage (ECG, bloods, urine dip) - if organ damage -> immediate antihypertensives - if no organ damage - > repeat readings within 7 days
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Which patients with NSTEMI/unstable angina should have coronary angiography (with follow-on PCI if necessary)?
immediate: patient who are clinically unstable (e.g. hypotensive) within 72 hours: patients with a GRACE score > 3% i.e. those at intermediate, high or highest risk coronary angiography should also be considered for patients if ischaemia is subsequently experienced after admission
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What are some poor prognostic factors in ACS?
age HF (new or Hx) peripheral vascular disease reduced systolic BP elevated initial cardio markers cardiac arrest on admission
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What anticoagulants are preferred in patients with mechanical valves?
warfarin
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What are the two most common causative organisms of endocarditis?
staphylococcus aureus staphylococcus epidermis - if < 2 months post valve surgery
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What valve is most commonly affected in endocarditis in IVDU?
tricuspid valve (don't TRI drugs)
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Which drugs reduce mortality in LV failure?
ACE-inhibitors Beta-blockers Angiotensin receptor blockers Aldosterone antagonists Hydralazine and nitrates
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How is chronic HF managed?
BASHeD Beta blockers ACEi / ARB Spironolactone Hydralazine + nitrates Digoxin
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What complication (blood) can arise from prosthetic valves?
haemolytic anaemia
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What patients can receive nitrates in acute HF?
NOT hypotensive hypertension myocardial ischaemia valve regurg
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How are patients with acute HF and hypotension / cardiogenic shock managed?
inotropic agents - e.g. dobutamine vasopressors - e.g. norepinephrine mechanical circulatory assistance - e.g. intra-aortic balloon counterpulsation, ventricular assist devices
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Should regular HF medications be stopped or continued in acute HF?
continued beta blockers - stopped if HR < 50
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If acute HF is not responding to treatment, what should you do?
CPAP
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What cardiomarker is used to look for re-infarction?
CK-MB - returns to normal after 2-3 days while troponin remains elevated for up to 10 days
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When do you give ivabradine in HF?
patient has sinus rhythm > 75/min and a LVEF < 35% and have not responded to to ACE-inhibitor, beta-blocker and aldosterone antagonist therapy
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What, other than HF, can cause raised BNP?
myocardial ischaemia valvular disease CKD
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