Cardio Flashcards
1
Q
Average blood pressure?
A
120/80 mmHg
2
Q
Differential diagnosis of chest pain?
A
- Angina
- ACS
- Pulmonary embolism
- Pericarditis
- GORD
- Aortic dissection
- MI
3
Q
Conditions associated with peripheral chest pain?
A
- Pulmonary infarct
- Pneumonia
- Pneumothorax
- Herpes zoster
4
Q
Assessment of chest pain?
A
SOCRATES
Site
Onset
Character
Radiating
Associated symptoms
Timing
Exacerbating and relieving factors
Severity
5
Q
Examples of chest pain characteristics
A
Constricting, sharp, dull, crushing, prolonged
6
Q
Common symptoms of cardiovascular disease?
A
- Chest pain
- Dyspnoea
- Palpitations
- Syncope
7
Q
What is pleural pain?
A
Pain made worse by inspiration which suggests inflammation in the pleural cavity or pericardium or infarction
8
Q
Syncope?
A
Temporary impairment of consciousness due to inadequate cerebral blood flow
- if associated with limb weakness and dysarthria - could be a problem with the CNS
9
Q
What is a sinus rhythm?
A
Any cardiac rhythm where depolarisation begins at the SA node - if the P wave is visible
10
Q
How to calculate heart rate using an ECG?
A
300/ no. of big squares if regular and if irregular then its no. of QRS comples x 6
11
Q
Order of analysing an ECG?
A
Rate
Rhythm
Axis deviation
P wave
PR segment
QRS complex
ST-segment
T wave
J point
12
Q
Bradycardia and tachycardia ECG heart rate?
A
less than 60 for bradycardia and more than 100 for tachycardia
13
Q
Rhythm: 100% irregular?
A
VF or AF
14
Q
Rhythm: regular lengthening then shortening with respiration?
A
Sinus arrhythmia
15
Q
ECG pattern of A fib?
A
No P wave and irregularly irregular
16
Q
ECG pattern of A flut?
A
Sawtooth pattern of atrial depolarization
17
Q
ECG showing slow ventricular depolarisation?
A
QRS complex greater than 3 little boxes (wide)
18
Q
Normal cardiac axis range?
A
-30º to +90º
19
Q
If lead 1 is positive and lead 2 is negative, what is the axis deviation?
A
Left axis deviation
20
Q
What is the cardiac axis?
A
The overall direction of ventricular depolarisation on the ventricle plane measured from a 0 reference point
21
Q
Inferior leads?
A
II, III and aVF
22
Q
Septal leads?
A
V1 and V2
23
Q
Anterior leads?
A
V3 and V4
24
Q
Lateral leads?
A
I, aVL, V5 and V6
25
How above and below the isoelectric line should the ST segment be to be pathogenic?
\>1mm above and \>0.5mm below
26
What is the corrected QT interval and how do you calculate it?
Estimates QT interval at a standard heart rate of 60 beats per min
QT/ square root of R-R
27
Normal PR segment Range?
0.12 - 0.2 seconds
28
What does the PR segment show?
How fast AV conduction is
29
What is P mitrale an indication of?
Left atrial hypertrophy
30
What is P pulmonale an indication of?
Right atrial hypertrophy
31
What is the difference in appearance of the p wave between P mitrale and P pulomale?
Mitrale - bunny ears (bifid)
Pulmonale - Tall as 2.5mm
32
Difference between STEMI and NSTEMI?
STEMI
- common cause of MI
- Complete blockage of heart blood supply
NSTEMI
- Narrowing of blood supply to the heart and not as fatal
33
1st degree heart block on an ECG?
PR consistently wide (0.22 seconds) - no missed beats
34
What are the 2 types of 2nd degree Heart block?
Mobitz I - PR interval keeps getting wider and wider until QRS complex disappears then the pattern starts again
Mobitz II - 2:1 heartblock - P - QRS - P -- P -QRS
35
3rd degree heartblock on an ECG?
P wave and QRS complex are independent of each other so it means that the atria and ventricles are contracting when they feel like it
36
37
ECG abnormalities associated with MI?
- Peak P wave and ST elevation
- Initially tall T wave which then becomes inverted
- Pathological Q wave
38
ECG pattern showing Pulmonary embolism?
SI QII TIII
- Deep pathological and inverted
39
ECG showing Increased Calcium?
Short QT interval
40
ECG showing low Calcium?
Long QT interval
41
ECG showing raised potassium?
Peak T wave + No P wave + wide QRS
42
ECG showing Low potassium?
Flat T wave + Peak P wave + Big U wave
43
ECG showing LBBB?
Roll safe bunny ears
V1 - rS
V6 - bunny ears
44
ECG showing RBBB?
V1 rSR - M shape
V6 - slurred S
45
What is meant by a low voltage QRS complex?
\<5mm in limb leads and \<10mm in precordial leads
46
What factors can result in a low voltage QRS complex?
- Obesity
- COPD
- Hypothyroidism
- PE
- BBB
47
What is Bifascicular block?
RBBB + LB hemiblock = left axis deviation - one of the 2 fasciles are involved
48
What is trifascicular block?
RBBB + LB hemiblock + 1st degree HB caused by ventricular hypertrophy
49
What can Chest X-rays be used to identify?
- Cardiomegaly
- Pericardial effusions
- Dissection or dilatation of the aorta
- Calcification (pericardium or valves)
50
What is a cardiac CT used for?
Aorta and coronary artery disease/ Calcification and Stenosis
51
What are Echoes used for?
Use ultrasound to look at different structures of the heart
52
What is cardiac catheterisation used for?
- Angiograph
- Blood samples
- Measure intracardiac pressure
53
What is cardiac MR used for?
Anatomy and function of the myocardium
54
What is cardiac nuclear imaging used for?
Using radiotracers to measure perfusion at rest, exercise or pharmacologically induced stress after MI
- With a bit of stress is there still perfusion after MI or is it completely blocked
55
What is electrocardiography?
Strap someone to an ECG while rest, exercise or pharmacologically induced stress to increase myocardial O2 demand and looking at any changes in electrical activity of the herat
56
What is the tilt test used for?
Diagnose vasovagal syncope by replicating the action of standing to see if they pass out and quickly recover
- looking out of bradycardia and hypotension
57
How does a dopplar ultrasound work?
High frequency ultrasound waves bounce off red blood cells so can be used to measure blood flow through veins and arteries and pressure of blood moving through a valve
58
2 different types of echo?
Tranoesophageal
Transthoracic
59
What are some complications of cardiac catheterisation?
Tamponade
Loss of peripheral pulse
Contrast reaction
Haemorrhage
infection
Angina
Arrhythmia
60
What is ischaemic heart disease (IHD)?
Imbalance between supply of O2 and demand of O2 to cardiac muscle
61
Most common cause of IHD?
Coronary atheroma
62
Aside from coronary atheroma, what are some other causes of IHD?
- spasms
- Thrombosis
- Artritis
- Thyrotoxicosis
- Myocardial hypertrophy
63
Non-modifiable risk factors of MI?
- Age
- Gender
- Family history
64
Modifiable risk factors of IHD?
Hyperlipidaemia
DM
Smoking
Excessive alcohol
High cholesterol and fat
Psychosocial
Increased coagulation factors
65
What is the QRISK2?
Assessment tool used in primary care to estimate the likelihood of a patient having a cardiovascular event in the next 10 years taking into account factors such as :
- Age, Gender, Smoking, DM, BMI, Cholesterol levels and others
66
Angina Pectoris?
Descriptive term for chest pain that arises from the heart as a result of myocardial ischaemia
67
Debicutus Angina?
Angina when laying down
68
Nocturnal angina?
Angina when sleeping
69
Variant/ Prinzmetal angina?
Angina due to coronary artery spasms
70
Unstable angina?
Critical angina with recent-onset and increasing in severity
71
Crescendo angina?
Critical ischaemia but not infarction
72
Coronary syndrome X angina?
+ve symptoms, +ve exercise test but normal coronary arteries on angiogram - functional abnormalities of coronary micro vascularization
73
Environmental Exacerbating factors for angina?
Cold
Heavy meal
Emotional stress
74
Exacerbating factors for angina?
**SUPPLY**: Anaemia, Hypoxia, Hypothermia, Hyper/hypovolaemia and polycythemia
**DEMAND**: Hypertension, tachycardia, VHD, Hyperthyroidism, Hypertrophic cardiomyopathy
75
What percentage of stenosis causes problems?
70%
76
OHM's law?
Change in pressure = Flow x Resistance
77
What does posuelle's law show us?
The greater the resistance the greater the pressure will be
78
Clinical features of angina?
Central crushing chest pain + breathlessness
- radiates to the arms and neck and is relieved by GTN spray
79
What investigations would be done to diagnose angina?
- Cardiac catheterisation to look at the state of coronary arteries
- ECG - ST depression and T wave flat or inverted
- Perfusion image testing/ pharmacological stress test for those who can't exercise
80
Management of angina?
**Immediate/ symptomatic treatment** - GTN spray
**Prophylactic treatment** - Beta blocker, CCB, Nitrates, ACEi (ivabradine last resort)
**Secondary prevention** - Antithrombin and antiplatelet ( aspirin, clopidogrel) and lipid-lowering (stains) exercise, no smoking, diet
**Revascularisation** - PCI + CABG
81
PCI?
stent, balloon with antiproliferative drugs + dual platelet therapy (aspirin and cliopidogrel) as a method of revascularisation
82
CABG
Coronary artery bypass grafting - L or R **internal mammary artery** joins the aorta to the other side of the blockage of a coronary artery
**Saphenous vein** joins AA to right coronary artery
83
ACS?
Acute coronary syndromes are a group of unstable coronary artery diseases due to rupture of atherosclerotic plaque (formation of clot of platelets - vasoconstriction - the release of serotonin and thromboxane A2 )
84
How would you differentiate between NSTEMI and Angina?
NSTEMI would have elevated levels of troponin and creatine kinase
85
Clinical features of ACS?
**Unbelievable** chest pain at rest
Minimal exertion pain
Syncope
Arrhythmia
86
Treatment of NSTEMI and Unstable angina?
Antiplatelet, Antithrombins, Anti-ischaemia, Plaque stabilisers
87
Examples of antiplatelet drugs?
Aspirin
Clopidogrel - Prasugrel - Ticugrelor
GPIIb/IIIa - e.g. abciximab (ab-six-see-mab)
88
Mechanism of action of Clopidogrel?
Irreversibly binds to the P2Y12 ADP receptors of platelets and prevents platelet aggregation
89
Examples of antithrombins?
**Heparin**
**Enoxaparin** - LMWH
**Synthetic Pentasaccharides** FONDAPARINUX
**Bivalirudin** - Binds and inhibits clot bound thrombus
90
Examples of anti-ischaemic drugs?
Nitrates
Beta Blockers
91
Examples of Plaque stabilisers?
Statins
ACEi
92
2 different types of risk stratifications used to predict the risk of STEMI/death in patients with UA and STEMI and used to provide a basis for therapeutic decision making?
**GRACE** - global registry of acute coronary events
**TIMI** - Thrombolysis in myocardial infarction
- both look at a range of factors to estimate risk of STEMI/death and to help choose the most appropriate combination of treatment
93
Risk stratification low?
Cardiac stress test followed by Exercise ECG
94
Risk stratification high?
PCI/ CABG
95
What is the most common cause of death in developed countries?
STEMI - rupture of atherosclerotic plaque - thrombosis and complete occlusion of a coronary artery
96
Clinical features of STEMI?
Chest pain radiating down arms, neck and jaw
Sweating
Breathless
Vomiting
_Some can be silent_
97
Investigations of MI?
- ECG - ST elevation, Tall T wave followed by inversion, pathological Q wave
- Cardiac markers - Creatine kinase, Troponin T and I
98
Emergency treatment of STEMI?
IV, Bloods, O2, GTN, Antiemetics and Morphine, Aspirin, Clopidogrel
99
100
Management of uncomplicated STEMI?
ECG
Secondary prevention - antiplatlets, statin, BB, ACEi and modification of CAD risk factor
Submaximal exercise
101
Methods of limiting the size of infarction?
PCI
Fibrinolytic agents - activate plasminogen to plasmin
Beta blockers - metoprolol
102
Examples of fibrinolytic agents?
Reteplase or Tenecteplase
Streptokinase - cheap but can develop antibodies against it
103
MI \<90 mins management?
Reperfusion - angioplasty + dual antiplatelet therapy
104
MI \>90 mins management?
Thrombolysis - reteplase or tenecteplase
105
Complications of MI?
Pericarditis (sharp chest pain and pericardial rub)
Atrial or ventricular arrhythmias
Heart block
Heart failure
Embolism
106
Post MI, what would be an indication to prescribe aldosterone antagonist?
Heart failure or if the ejection fraction \<40%
107
What is heart failure?
Structural or functional abnormalities of the heart meaning it can't pump or maintain sufficient cardiac output to meet the demands of the body
108
3 main causes of heart failure?
IHD, Dilated cardiomyopathy, Hypertension
109
Incidence of Heart failure?
10% of \>65 year olds
110
Pathophysiology of heart failure?
HF causes compensatory mechanisms to be overwhelmed and become pathological as heart failure develops
111
Compensatory mechanism of HF?
1. Activation of the sympathetic nervous system
2. RAAS
3. Natriuretic peptide
4. Ventricular dilatation
5. Ventricular remodelling
112
How does the overactivation of the sympathetic nervous system lead to heart failure?
vasoconstriction:
Venous - good as it increases venous return and so preload - grater stroke volume and force of contraction
Arteriolar constriction - increase afterload - so greater pressure that the heart has to work against to pump blood out of the body
113
How does the overactivation of the RAAS system lead to HF?
Due to decrease CO - RAAS causing retention of sodium and water - increase venous return and BP
- Too much salt and water resulting in peripheral and pulmonary oedema + dyspnoea
- Causes arteriolar constriction - increases afterload
114
What is the relationship between natriuretic peptide and HF?
Elevated Natureitic peptide is an indicator of heart failure - the aim is to lower blood pressure due to diuretic, natriuretic and hypotensive properties
Pro-BNP
115
Where are natureitic peptides formed?
- Atria
- Ventricles (brain)
- Vascular endothelium
116
How does ventricular dilatation lead to heart failure?
Normally FS mechanism - When you have decreased ejection fraction the heart works to increase preload and so the force of contraction
**pathological** - Increase venous return so increased volume size but the force of contraction isn't increasing causing the ventricle to become dilated (plateau on a graph)
=
peripheral and pulmonary oedema and increased tension
117
How does ventricular remodelling lead to heart failure?
Hypertrophy leads to loss of myocytes and increases scar tissue - becomes non-compliant
118
What can cause ventricular remodelling?
- Multifactorial
- Apoptosis of myocytes
- Changes in cardiac gene expression
119
Most common type of heart failure?
Left sided heart failure
120
What differences would you see between LV systolic dysfunction and RV systolic dysfunction?
Left - IHD, Hypertension, Pulmonary hypertension
Right - secondary to LVSD because it has to work harder since the left is moving mad - peripheral oedema and abdominal pain due to hepatic congestion
121
Symptoms of heart failure?
External dyspnoea
Orthopnoea
Paroxysmal nocturnal dyspnoea
Fatigue
122
Signs of heart failure?
- Tachycardia
- Elevated JVP
- Cardiomegaly
- Extra heart sounds
- Lung crackles
- Pleural effusions
- Ascites
- Ankle oedema
123
Investigations used to diagnoses HF?
CXR
ECG
BLOODS
ECHO
124
What factors will you be looking ar in terms of blood to diagnose HF?
Anaemia, Liver biochem, U+E, TFT, BNP or pro-BNP
125
How is heart failure managed?
_Drugs_ - ACEi or AG2A, Vasodilators, BB, Diuretics, **Digoxin** - increases the force of contraction but slows down rate, **Inotropes**
_Surgery_ - revascularisation, cardiac resynchronisation therapy, transplant
_General_ - Education, exercise, diet, smoking
126
Some clinical features of acute HF?
Pulmonary oedema
hypertension
Cardiogenic shock
High output cardiac failure
Right heart failure
127
What is systemic hypertension?
Chronic high blood pressure
128
Difference between essential and secondary hypertension?
Essential - No known identifiable cause as it is multifactorial (lifestyle factors) - treatment is usually modifying lifestyle
secondary - caused by another known identifiable disease that sometimes could be treated e.g CKD, Diabetic nephropathy, Endocrine (adrenals), correction of aorta, Drugs (oestrogen-containing oral contraceptives, steroids, NSAIDS, vasopressin)
129
Clinical features of hypertension?
- can be asymptomatic
- Fibroid necrosis - END ORGAN DAMAGE:
- Kidneys - haematuria, proteinuria and KD
- Brain - cerebral abscess, haemorrhage
- Retina - flame-shaped haemorrhage, Cotton wool spots, hard exudate and papilloedema
- Cardio - Acute HF and aortic dissection
130
Examination of Hypertension?
- Chronic BP
- Signs relating to the cause
- End organ effects
131
Grading or severity of retinal abnormalities?
**1.** Turosity and reflectiveness of retinal arteries (bending due to atherosclerosis)
**2**. (1 +) arteriovenous nipping - when an arteriole crosses a vein causing it to be compressed and bulge
**3.** (2+) flame-shaped haemorrhages and cotton spots
**4.** (3+) papilloedema - swelling of the optic disc
132
What is classed as high blood pressure?
140/90
133
Stage 1 hypertension BP?
CBP \>140/90 and AMBP or HBP - \>135/85
134
When would you offer treatment to a stage 1 hypertensive?
- Over 80 years old
- 1 of the following risk factors:
End organ damage
CVD
REnal disease
DM
Qrisk2 \>20%
135
Stage 2 hypertensive?
CBP \>160/100 or AMBP/HBP \>150/95
136
Stage 3 hypertensive BP?
\>180/110
137
What are the 2 key players in hypertension?
RAAS system and the sympathetic nervous system
138
Why would Caucasians be given ACEi instead of CCB to treat hypertension?
Caucasians have higher levels of renin than other ethnicities
139
Group A hypertensives examples and MOA?
ACEi - Ramipril, Enalapril
Inhibit A1 to A2 and inhibit the breakdown of bradykinin to inactive peptides
ACE enzyme also associated with perfusion and filtration of kidneys so when inhibited the kidneys become affected
140
CI of ACEi?
Renal artery stenosis
141
Side effects of ACEi?
Decreased A2 - First does hypotension, Acute renal failure, Tetragenic effects on pregnancy
Increased Bradykinin - Dry cough, urticaria, anaphylactoid rash due to decreased leukocytes
142
Group B hypertensives examples and MOA?
ARB - For patients who can't tolerate ACEi - Valsartan, Losartan, Irbesartan
Angiotensin 2 receptor antagonists prevent it causing an increase in peripheral resistance and cardiac output
143
CI of ARB?
Pregnancy
144
Side effects of ARB?
Symptomatic hypotension (dehydration or volume depletion)
Increase potassium
potential renal dysfunction
Angio-oedema
145
Group C hypertensives examples and MOA?
CCB - Dihydropyridine, Phenylalkylamine and Benzothiazempines
Block L type calcium channels so that smooth muscle can relax
146
MOA of dihydropyridines and examples?
AMLODIPINE, NIFEDIPINE, FELODIPINE, LACIDIPINE
- Affect vascular smooth muscle and cause peripheral arterial vasodilation
147
MOA of phenylakylamines and example?
VERAPAMIL
- Decrease heart rate and force of contraction (chronotropic and ionotropic)
148
MOA of benzothiazepines and example?
DILTIAZEM
- Affects both heart and peripheral (HR and FC) and peripheral vasodilation
149
What are the side effects of CCB?
Flushing
Ankle swelling
Headache and palpitations (brain thinks low blood volume so increases HR and BP)
Bradycardia
AV block
150
Group D hypertensives examples?
DIURETICS - Increase water and sodium excretion by blocking reabsorption of ions
LOOP - FUROSEMIDE (Na/Cl/K ascending loop of henle)
THIAZIDE - HYDRCHOLORTHIAZIDE (Na/Cl but increase calcium)
K+ SPARRING/ ALDOSTERONE ANTAGONIST - SPIRONOLACTONE (Na)
151
Side effects of diuretics?
Hypovolaemia, hypotension and loss of electrolytes
Build up of uric acid
erectile dysfunction
impaired glucose tolerance
152
MOA beta blockers?
They inhibit noradrenaline receptors and so decrease the effect of the sympathetic nervous system
153
When are beta blockers contraindicated?
Asthma, COPD, PVD
154
Give an example of an Alpha receptor blocker?
DOXASOZIN
155
Give an example of a central acting antihypertensive?
MOXONIDINE AND METHYLDOPA
156
Give an example of a renin inhibitor?
Aliskiren
157
In an emergency, why would you give the BB and CCB orally rather than IV or sublingual?
It would decrease the BP too much and too fast and the patient is at risk of cerebral infarction
158
What is a cardiac arrhythmia?
Abnormal cardiac rhythm
159
What is a sinus rhythm?
Waves of depolarisation that control cardiac rhythm originating from the SA node
160
What is sinus arrhythmia?
Fluctuations in parasympathetic tone (autonomic) resulting in phasic changes in sinus discharge
e.g. Inspiration = increase HR = Decrease parasympathetic tone
Expiration = Decrease HR = Increase parasympathetic tone
161
What is the result of sinus arrhythmia?
Irregular pulse
162
What is sinus bradycardia?
Slow and regular heartbeat
163
4 broad causes of sinus bradycardia?
Extrinsic
Intrinsic
Sick sinus syndrome
Neural mediated - vasovagal attacks
164
Extrinsic causes of sinus bradycardia?
- Beta blockers
- Digoxin
- other antiarrhythmics
165
Intrinsic causes of sinus bradycardia?
- ischaemia or infarction of SA node
- Fibrosis of atria or SA node
166
Sick sinus syndrome?
Caused by fibrosis of the SA node or depolarization from the SA node doesn't travel out of perinodal tissue to atria
167
What is heart block?
Slow heart rate or abnormal rhythm due to electrical conduction abnormalities
168
Explain 1st degree AV heart block?
Delayed AV conduction
ECG: consistent prolonged PR intervals (\>0.22 seconds) and heart rate maintained
169
What is the difference between Mobitz 1 and Mobitz 2?
baso both have missing ventricular contractions - the difference is if PR interval progressively gets longer or remains constant - when _some_ atrial conductions fail to reach the ventricles
- Mobitz 1 - PR interval progressively gets longer then no QRS showing no conduction followed by ventricles missing a contraction
- Mobitz 2 - PR interval constant with occasional QRS complex missing so conduction to ventricles is occasionally blocked
170
Explain 3rd degree AV heart block?
Complete heart block - no communication between the atria and ventricles - P and QRS doing whatever they want
- spontaneous ventricular contractions
171
In 3rd-degree heart block - how different would the ECG appear if ventricular contractions originated in the bundle of his compared to the Purkinje fibres?
Bundles of his - Narrow QRS complexes at 50-60 bpm
Purkinje fibres - Broad QRS complexes at 40bpm
172
What is supraventricular tachycardia?
Tachycardia that arises from the atria or AV junction
173
What is sinus tachycardia?
Fast consistent heart beat \>100bpm
- physiological response to excitement and exercise
174
2 types of atrioventricular junctional tachycardia?
AV nodal re-entry tachycardia
AV reciprocating tachycardia (WPW)
175
What are atrioventricular junctional tachyarrhythmias?
Re-entry circuits resulting in 2 separate pathways of impulse conduction - often seen in younger people
176
Describe AVNRT?
- Bundle of fibres in the AV node
- Each have own **conduction times and refectory periods** = local re-entry circuit
- The **atrial rate is stimulated by re-entrant impulses** which causes an increase in ventricular contraction rate = PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA
177
Describe AVRT?
- Accessory pathway (global re-entry) - bundle of kent - between atria and ventricles
- P wave, Short PR interval + delta wave
- Resting ECG of WPW - atrial depolarisation to pass to the ventricles before it gets to the AV node due to accessory pathway
178
Different between orthodromic and antidromic AVRT?
Orthodromic follows the normal direction and so has a narrower QRS complex than antidromic
179
Symptoms of atrioventricular junctional tachycardia?
SUDDEN
- Rapid regular palpitations
- Dizziness
- Dyspnoea
- Central chest pain
- Nausea
180
Acute management of AV junction tachycardia?
maintain and restore sinus rhythm if haemodynamically stable
- Valsalva - forced exhalation against a closed airway
- Carotid sinus massage
**DRUGS**: Adenosine (block AV conduction), BB, CCB
181
Long term management of AV junctional tachycardia?
Cardiac catheter ablation - making small scars in heart tissue to prevent abnormal electrical signals moving through the heart
182
General causes of atrial tachyarrhythmia?
Obesity
Hypertension
Age
183
Endocrine causes of atrial tachyarrhythmia?
DM
Thyrotoxicosis
184
Metabolic causes of atrial tachyarrhythmia?
Alcohol
Electrolyte imbalance
185
What is Atrial fibrillation?
Irregularly irregular - missing P waves
- AV node conducts a _proportion_ of atrial impulses to produce an irregular ventricular response
186
A complication of atrial fibrillation?
Thromboembolism that forms in the atria (x5 more likely to get a stroke)
187
Symptoms of AF?
Fatigue due to decreased CO and palpitations
Can be asymptomatic
188
How does the management of AF differ if you found it \<48 hours or \>48 hours?
\<48 - Heparin
\>48 - DC cardioversion - amiodarone - cardioversion - amiodarone
189
Management of chronic Atrial fibrillation?
Control rate and rhythm
**_Rate_**: BB, CCB, Digoxin
**_Rhythm_**: Cardioversion, Anti-arrhythmic (amiodarone or propafenone), Catheter ablation
'pill in pocket' - propafenone, Flecainide, sotalol
190
What indication are the indications to give a patient Rhythm controlling drugs for AF?
\>65
Highly symptomatic
Onset AF or Heart failure
191
What is the assessment for anticoagulation?
CHA2DS2-VaSc
C - Congestive HF
H - Hypertension
A - Age (64-74 or \>74)
D- Diabetes
S - Stroke or TIA
Va - Vascular disease
S - Sex - female
also look at time and any issues with valves
192
What is the difference between atrial fibrillation and atrial flutter?
A fib - AV node conducts a proportion of atrial impulses to the ventricles causing an irregular ventricular rhythm
A flut - AV node conducts every second flutter - atrial rate is 300bpm while ventricular rate is 150bpm
ECG difference - missing P wave and irregularly irregular compared to sawtooth
193
How can you clearly identify A flut on an ECG?
Do ECG after giving a carotid sinus massage which impairs AV conduction
194
Management of A flut?
DC cardioversion
Amiodarone
Catheter ablation
195
Different types of ventricular tachyarrhythmias?
Ventricular ectopic beats
Sustained VT
Non-sustaine VT
V fib
Long QT syndrome
196
What are ventricular ectopic premature beats?
- Extrasystole
- Ectopic electrical activity not conducted to ventricles through normal conducting tissue
197
Clinical presentation of a patient with ventricular ectopic premature beats?
could be asymptomatic or have extra/missed/heavy beats
ECG - QRS complex wide and bizarre
198
Management of ventricular ectopic premature beats?
Beta blockers
199
What is the difference between sustained and non-sustained ventricular tachycardia?
SUSTAINED: VT lasts \>30 seconds
NON-SUSTAINED: VT\> 30 seconds but \<5 consecutive beats and caused by heart disease
200
Management of ventricular tachycardia?
Beta blockers
Cadioversion or intracadiovater defibrillation
201
What is ventricular fibrillation?
Very rapid or irregular ventricular activation with no mechanical effect so no cardiac output
202
Clinical presentation of ventricular fibrillation?
Palpitations
**Syncope**
**Respiration ceases**
CAN CAUSE CARDIAC ARREST - sudden loss of blood flow
203
Management of ventricular fibrillation?
Defibrillation
204
What is long QT syndrome
QT interval represents ventricular systole - ventricular depolarisation and repolarisation
- Ventricular repolarisation is prolonged - Heart muscle takes longer than normal to recharge for next contraction = dangerous arrhythmias
205
What are some causes of long QT syndrome?
- Congenital - mutation of Na/K channels
- Electrolyte disturbances - Low K/Ca/Mg
- Drugs - Tricyclic antidepressants
206
Clinical presentation of Long QT syndrome?
Palpitations
Syncope
ECG - **Torsade de pointes** - rapid irregularly shaped QRS complexes that alternate for upright to inverted
207
208
Management of Long QT syndrome?
**ISOPRENALINE** - Non-selective beta-adrenoreceptor **agonist** - used for bradycardia so increases heart rate - increase HR and FOC while lowering peripheral vascular resistance
209
MOA atropine?
Blocks muscarinic receptors so to do the opposite of parasympathetic system - used for sinus bradycardia
210
Beta 2?
Bronchodilation and vasoconstriction
211
What is cardiac arrest?
No effective cardiac output presented as loss of consciousness and abnormal or absent breathing
212
Cardiac arrest resuscitation?
CPR 30:2 - Asses the rhythm
Shockable? Normal? or Asystole (flatline)?
213
What is an aneurysm?
Abnormal dilation of an artery of \>50% of its original size due to weakness in the blood vessel wall
214
Where are 95% of aneurysms?
Below renal arteries and above the bifurcation
215
Difference between a true and pseudoaneurysm?
True - involves all layers of the blood vessel wall due to weakness in the wall (like a balloon initially hard to inflate then it becomes easier to inflate)
Pseudo - Small hole in the wall and blood enters that hold to form a blood-filled pocket but it doesn't involve all the layers of the wall
216
What is a barry aneurysm also know as?
Asymmetrical/ secular
217
Causes of aneurysms?
Atherosclerosis
Hypertension
Tertiary syphilis
Thick walls of the aorta
Infection - embolic bacteria break off and get stuck in small arteries causing the vessel walls to become weaker
Connective tissue disorders - Marfans (fibrilin) or Ehlers-Danlos (collagen proteins)
218
How does atherosclerosis lead to aneurysm?
O2 can't pass the thick plaque causing the cells of the wall to become ischaemic
219
How does tertiary syphilis lead to an aneurysm?
Endarthritis obliterans which is inflammation of the intima (leading to fibrosis) which causes the lumen of Vasa Vasorum to become narrow and therefore ischaemic
220
Risk factors of aneurysms?
Male
\>60
Hypertension
Smoking
Obese
Family history
221
Clinical features of aneurysms?
Pain - chest, left flank, lower back, groin
Hypotension
Pulsating mass with HB in that region or abdominal pulsating mass
222
What investigations would be used to confirm an aneurysm?
Ultrasound
CT
MRI
223
Complications of an aneurysm?
Rupture
Thrombus
Embolism
Pressure on surrounding structures
Fistulae
224
At what size of an intact aneurysm would surgical intervention be required?
\>5.5cm
225
Consequences of a ruptured blood clot?
**Occlusion**
**Internal bleeding** - cells then become an ischaemic and hypovolaemic shock
**Aortic insufficiency** if the aneurysm is above the valve - its then unable to close
Irritated meninges and increased pressure due to blood build up in subarachnoid space - headache and can't flex head forward
Bloodclot
226
What is an aortic dissection?
Tear in the tunica intima of aorta and blood begins to flow between the intima and media separating them, creating a false lumen
227
Aetiology of aortic dissection?
Chronic hypertension
Coarctation of aorta
Connective tissue abnormalities causing wall of aorta to be weak - Ehlers-Danlos
228
Type A aortic dissection?
Found on the first 10cm of the aorta (ascending)
229
Symptoms of aortic dissections?
Hemiplegia
Quadriplegia
Unequal arm pulses and weak downstream pulse
**Sharp stabbing pain radiating to the back**
Anuria
Hypotension and shock
230
Complications of aortic dissection?
Pericardial tamponade
Bleeding into mediastinum
Blood re-enters true lumen
Continues to build up between intima and media until it reaches a branching point and puts pressure on it e.g. flow to arms or kidneys
231
Investigations to confirm aortic dissection?
Wide aorta on CXR
Transoesophageal Echo - determine the true and false lumen
232
Management of Aortic dissection?
**A**- Surgery
- Remove dissected area
- Block the entry of blood into the wall
Reconstruct wall with graft
**B**- Beta-blockers and nitroprusside (decrease BP)
233
What is peripheral arterial disease?
Due to multifactorial modifiable and non-modifiable factors, atherosclerosis develops resulting in stenosis of the arteries supplying limbs
234
Most identifiable clinical feature of PAD?
Claudication - cramping muscle pain in the legs triggered by exercise and relieved by rest
235
Symptoms of PAD?
Cramp in calf (femoral), thigh and butt (illiac) after walking and is relieved by rest
Ischaemic limb pain - burning pain made better by raising the legs - ulceration, gangrene and foot pain at rest
236
What is critical ischaemia?
severe obstruction of blood flow to extremities resulting in ischaemic pain in hands, legs and feet. It can wake up individuals during the night
237
238
Different types of critical ischaemia?
Leriche's syndrome - Butt claudication and impotence due to build up of plaque in the iliac arteries
Buerger's Disease - Found in young and heavy smokers
- Thromboganitis obliterans resulting in progressive inflammation, swelling and clots in medial and small arteries and veins of the hands
239
Fontaine classification of PAD?
1. Asymptomatic
2. Intermittent claudication
3. Ischaemic rest pain
4. Ulceration and gangrene
240
Signs of peripheral arterial disease?
- Absent femoral, popliteal or foot pulse
- Cold, white legs
- Atrophic skin
- Painful ulcers
- Postural dependant colour change
- Burgers leg - lift leg and it goes pale, the lower the angle the more severe
241
Investigations used to confirm PAD?
**Ankle-brachial pressure index** - the ratio of blood pressure in the ankle BP to BP in the upper arm
Normal - 1-1.12
PAD - 0.5-0.9
Critical ischaemia - \<0.5
- screen for **thrombophilia**
- Measure **Haemocystein** - AA found in blood and increased association with the early development of heart disease
242
Why must you not only do the ankle-brachial pressure index alone to confirm diagnosis of PAD?
Severe atherosclerosis can give false reading of BP as they can calcify and become really hard
243
Management of stable PAD?
Colour duplex ultrasound - non-invasive method of measuring blood flow through veins and arteries
Risk modification - lifestyle and antiplatlet
Manage claudication - exercises and vasoactive drugs
244
Management of acute PAD?
- Percutaneous transmural angioplasty
- Surgical reconstruction using dacron graft
- Amputation
245
What is the pericardium?
Fibroelastic sac filled with a thin layer of fluid that surrounds the heart and great vessels and prevents friction between the visceral ad parietal pericardium
246
Normal volume of fluid in the pericardium?
50mL
247
What is acute pericarditis?
Inflammation of the pericardium characterised by sharp retrosternal chest pain made worse by inspiration and relieved by leaning forward accompanied with a fever
248
Causes of acute pericarditis?
Hypothyroidism
Secondary viral infections
Post-MI
Uraemia - excess uria and other waste products usually removed by the kidneys
Autoimmune rheumatic disease - conditions of connective tissue
Drugs
TRauma
Infection
Malignancy
249
Infections that can cause pericarditis?
Bacteria, TB, Funi and pneumonia
250
Viruses that can cause pericarditis?
Coxsackie B, Echo and HIV
251
What is BehÇet's Disease?
Recurrent multisystemic inflammatory disease that can also cause pericarditis
252
What antiarrhythmic drug has been associated with pericarditis?
Procainamide
253
Clinical features of acute pericarditis?
**Pericardial rub** - scratchy sound as the 2 layers of the pericardium rub (1S2D) - as the patient holds their breath and leans forward
Sharp chest pain made worse by inspiration
Radiating to neck and shoulders
**Low fever**
254
How will an ECG confirm pericarditis?
Saddle shaped ST elevation (concave upwards)
255
Management of acute pericarditis?
- NSAIDS and treatment of the underlying cause
- Systemic corticosteroids or immunosuppressants
- Colchicine - used to treat inflammation and pain
256
Complications of acute pericarditis?
Chronic pericarditis
Pericardial effusion
257
258
Pericardial effusion?
Accumulation of fluid in the pericardial sac which can be due to pericarditis which can affect ventricular function (even hyperthyroidism)
259
Pericardial tamponade?
Medical emergency where large amounts of fluid in the pericardial sac restrict elastic ventricular filling resulting in decreased CO
260
Clinical features of Pericardial tamponade/effusion?
Hypotension
Kussamul signs - elevated jugular venous pressure due to limited RV filling during inspiration (pulsates)
Invariable pulsus paradox - Decrease in BP during inspiration
261
Explain the invariable pulsus paradox?
BP decreased by 10mmHg during inspiration
- Increase venous return to the right side of the heart
- Increases ventricular volume but rigid pericardium
- The decrease in CO and blood just occupies more space in the heart so less is actually able to return
262
Investigations used to diagnose Pericardial effusion/ tamponade?
CXR - large globular heart
ECG - Low voltage complexes and sinus tachycardia
Pericardiocentesis - collect fluid
Pericardial biopsy
263
Management of pericardial effusion?
- can sometimes resolve on its own or you drain fluid from the pericardial sac using a needle
**IF RECURRENT - EXCISION OF PERICARDIAL SEGMENT SO FLUID CAN BE ABSORBED THROUGH PLEURAL AND MEDIASTINAL LYMPHATICS**
264
What is constrictive pericarditis?
Heart becomes encased in rigid fibrotic pericardial sac which prevents adequate diastolic filling of the ventricles
265
Causes of constrictive pericarditis?
Idiopathic or intrapericardial haemorrhage during cardiac surgery
266
clinical features of constrictive pericarditis?
- Similar to right side heart failure
- Kussamail sign
- Increase JVP
- Pulsus paradoxus
- Oedema
- AF
**PERICARDIAL KNOCK DUE TO RAPID VENTRICULAR FILLING**
267
What can constrictive pericarditis be mistaken for?
Restrictive cardiomyopathy - both cause haemodynamic changes due to restrictive filling
268
Investigations used to diagnose constrictive pericarditis?
CXR - normal heart + pericardial calcification
CT/MRI - pericardial thickening and calcification
269
Management of constrictive pericarditis?
Surgical excision of pericardium
270
On which side are you more likely to have valvular heart disease?
Left side
271
What is a murmur?
Sounds on auscultation caused by turbulent flow
272
Causes of innocent murmurs?
Pregnancy
Anaemia
Thyrotoxicosis
273
How is a dopplar echo useful for diagnosis VHD?
Measures direction and velocity of blood flow - pressure across the valve
274
Treatment of VHD?
Valve replacement
Valve repair
Valvotomy
275
Why would a patient choose a mechanical valve over a biosynthetic valve?
Mechanical - last longer but a greater chance of thromboembolism so lifelong anticoagulation
Biosynthetic - lasts about 10 years before it needs replacing and no need for anticoagulants
276
Different types of mechanical valves?
Ball and chain
Single tilting disc
Double tilting disc
277
Different types of biosynthetic valves?
Bovine - cow
Porcine - pig
Homograft - human
278
Complications of mechanical valves?
Thromboembolism
Infective endocarditis
Haemolytic anaemia
279
What is mitral stenosis?
Stiff mitral valve leading to obstruction of blood flow from the left atrium to the left ventricle
280
a complication of mitral stenosis?
Pulmonary hypertension and pulmonary oedema -- Right ventricular hypertrophy/ dilation = RV failure
AF
281
Aetiology of mitral stenosis?
Rheumatic heart disease
282
Symptoms of mitral stenosis?
exertional dyspnoea
Cough with blood
AF
RH failure - fatigue and lower limb pain
Pulmonary oedema
283
Signs of mitral stenosis?
mitral facies
Irregular or low volume pulse - A
Auscultation - loud first heart sound followed by rumbling mid-diastolic murmur
284
How would the auscultation change of a patient with mitral stenosis if they had a sinus rhythm?
The murmur is louder because of increased blood flow through a narrow lumen
285
Mitral stenosis and loud second heart sound?
Pulmonary hypertension due to RV overload
- Increased JVP and ascites
286
Aim of the investigations when diagnosing mitral stenosis?
Estimate the severity of stenosis and look for pulmonary hypertension
287
CXR mitral stenosis?
Pulmonary venous hypertension
calcified mitral valve
Enlarged left atrium
288
ECG mitral stenosis?
P mitrale (bunny ears)
289
What is classed as severe mitral stenosis?
when the remaining area for blood to pass is \<1cm2
290
Management of mitral stenosis?
mild - leave alone or treat complications so antiarrhythmics (arrhythmia), diuretics (heart failure) and anticoagulants (AF)
Percutaneous balloon valvotomy
Mitral valve replacement
291
What is mitral regurgitation?
Leakage of blood through the mitral valve from LV to LA during ventricular contraction resulting in haemodynamic changes
292
Position of all 4 valves?
Aortic - 2IC right
Pulmonary - 2IC left
Tricuspid - 5IC left
Mitral - 5IC left mid clavicular line
293
Causes of mitral regurgitation?
**Mitral valve prolapse**
Rheumatic HD
Infective endocarditis
Calcification with age
Post MI - Papillary muscles no work
Cardiomyopathy
294
Clinical features of mitral regurgitation?
Fatigue
Diaphoresis - Excessive sweating
Dyspnoea on exertion
Low extremity oedema
295
How would the auscultation look for a patient with mitral regurgitation?
pansystolic murmur - eventhought the mitral valve is closed blood is still whooshing through
S1 sound weak
S3 due to rapid filling of the ventricles
Apex sounds moving towards the axilla
296
ECG of a patient with mitral regurgitation?
AF
297
Management of mitral regurgitation?
Diuretics and ACEi - peripheral oedema
Valve repair or replacement
Valvuloplasty
Annuloplasty - a plastic ring that supports the mitral valve
Intra-aortic balloon counterpulsation - so more blood comes out of aorta than the mitral valve
298
What is meant by a prolapsed mitral valve?
1 or more of the mitral valve leaflets is prolapsed back into the left atrium during ventricular contraction
299
Clinical features of prolapsed valve?
Atypical chest pain
Palpitations caused by axilla
Mid-systolic click followed by a murmur
300
Investigations of prolapse valve?
ECHO
301
Management of mitral prolapse?
Chest pain and palpitations - beta blockers
Mitral regurgitation and AF - Anticoagulation
302
What is the difference between mitral stenosis and mitral regurgitation?
Stenosis is caused by rheumatic HD and blood doesn't move back into the atria
Regurgitation is caused by mitral valve proplase and blood moves back into the atria during ventricular contraction
303
What is atrial stenosis?
Narrowing of the aortic valve restricting blood flow from the left ventricle to the aorta - myocardial ischaemia - angina and arrhythmia
304
Causes of atrial stenosis?
Calcification + deterioration of the aortic valve
Calcification of congenital bicuspid valve
Rheumatic heart disease (scar tissue and valves fuse together)
305
Pathophysiology of aortic stenosis?
Obstruction of LV emptying
Concentric hypertrophy - muscle becomes thicker
Increased myocardial O2 demand - ischaemia due to decreased CO
Angina and arrhythmia
306
Symptoms of aortic stenosis?
Angina - chest pain, syncope and dyspnoea
307
Signs of aortic stenosis?
Harsh systolic ejection murmur that radiates to the neck (systolic crescendo decrescendo murmur)
Plateau carotid pulse - slowly rising
S2 soft and difficult to hear
308
Investigations used to diagnose aortic stenosis?
CXR - calcification
ECG - LV hypertrophy and LV strain
ECHO - pressure gradient across the valve
CARDIAC CATHETERISATION - rule out any coronary artery disease
309
Management of aortic stenosis?
Aortic valve replacement
Transcatheter aortic implantation - wedge a replacement valve onto the old aortic valve and its transported to the aorta through arteries
310
What is aortic regurgitation?
When the aortic valves don't full close so blood moves back from the aorta to the left ventricle
311
Causes of aortic regurgitation?
Aortic root dilation - holds the leaflets apart and they don't close properly (dissection, aneurysm, tertiary syphilis)
Valvular damage - infective endocarditis or rheumatic fever (fibrosis so baso stuck)
312
Pathophysiology of aortic regurgitation?
The increased volume of the LV causing it to dilate by eccentric hypertrophy causing the heart muscle to become weak
Increased pulse pressure as systolic increases and diastolic decreases
313
Why do you get an increased pulse pressure with aortic regurgitation?
Increased systolic - Increased preload due to increased stroke volume
Decreased diastolic - Decreased aortic pressure
314
Symptoms of aortic regurgitation?
Dyspnoea
Orthopnoea (laying down)
Fatigue
315
Signs of Aortic regurgitation?
- Hyperdynamic circulation (wide PP) and collapsing pulse (warhammer)
- Early diastolic decrescendo
- Thrusting apex beat moving laterally
316
Investigations of aortic regurgitation?
CXR - cardiomegaly and dilation of ascending/ root of the aorta
ECG - left ventricular hypertrophy
ECHO - the severity of aortic regurgitation
CARDIAC CATETERISATION
317
Management of aortic regurgitation?
Decrease preload/ LV workload - Vasodilators and diuretics
ACEi
Aortic valve replacement
318
What causes tricuspid stenosis?
Rheumatic fever
319
Wa=hat causes pulmonary stenosis?
Congenital lesion
320
Signs of pulmonary stenosis?
RV failure
Syncope
Fatigue
321
What causes tricuspid regurgitation?
Secondary to the dilation of the RV
322
Signs of tricuspid regurgitation?
Pansystolic murmur
Increased JVP
Enlarge liver and pulse during systole
Peripheral oedema and ascites
323
Management of Tricuspid regurgitation?
Diuretics
324
325
Causes of pulmonary regurgitation?
Pulmonary hypertension
Dilation of valve rings
Endocarditis
326
What is infective endocarditis?
Infection of the endocardium - can be acute or insidious
327
Where can infective endocarditis occur?
- Valves with congenital defects or acquired defects
- Normal valves with virulent bacteria
- Right side valves in IVD
- Prosthetic valves (within 60 days early) (late following septicaemia)
Associated with VSD or persistent ductus arteriosis
328
Pathophysiology of infective endocarditis?
Mass of fibrin, platelets and infective organisms form vegetations of the edges of the valves
Virulent organisms destroy the valve = regurgitation and worsening heart failure
329
Clinical features of infective endocarditis?
systemic features of infection
Splenomegaly
Valve destruction - heart failure and murmur
Vascular phenomena - The vegetations embolise and occlude blood vessels
Metatstatic abscess in brain, spleen and kidney
Right sided endocariditis - pneumonia and pulmonary infarction
330
What immune complex depositions arise in blood?
Vasculitis and petechial haemorrhages
Splinter haemorrhages
Roths spots - in retina
Oslar's nodes - tender subcutaneous nodes on fingers
Janeway lesions - on palms
Deposits in joints too!
331
332
Major complication found in \>70% of patients with infective endocarditis?
Microscopic haematuria
333
Investigations done to confirm infective endocariditis?
- 6 blood cultures - 3 sets taken over 24 hours
- TTE - vegetation and valve destruction (TOE for prosthetic)
- SEROLOGICAL TESTING
- CXR - heart failure
- ECG - infection affecting conduction
- BLOOD COUNT - Normocytic normochormatic anaemia _ leukocytosis
- URINE STIX - Haematuria
- SERUM IMMUNIGLOBULINS AND DECREASED COMPLEMENT
334
Management of infective endocarditis?
DRUGS - IV antibiotics - benzylpenicillin and gentamicin
SURGERY - valve replacement
335
Which groups of people are at the greatest risk pf infective endocarditis?
IVD, prosthetic valves and immunosuppressants
336
What is rheumatic fever?
Autoimmune reaction of Group A streptococci causing inflammatory disease in people aged between 5-15 years old - can result in rheumatic valvular disease
337
Epidemiology of rheumatic fever?
More common in women than men
decreased prevalence due to sanitation, antibiotics and virulence of microorganisms
338
Clinical features of rheumatic fever?
Carditis of heart layers
Polyarthritis
Skin manifestations - erythema
Sydenham's chorea - uncontrollable movements
339
Investigations done to confirm rheumatic fever?
FBC - leukocytes, ESR
Diagnosis based on revised duckett Jones criteria
340
Management of rheumatic fever?
High dose aspirin
Penicillin - long term patients with cardiac damage
341
What can cause myocarditis?
Coxsackievirus, Diphtheria, Rheumatic fever, radiation injury and some drugs - associated with HIV
342
Clinical features of myocarditis?
- Fever
- Biventricular failure
- Cardiac arrhythmia
- Pericarditis
343
Investigations to confirm myocarditis?
CXR - cardiac enlargement
ECG - arrhythmias and ST changes
Serum viral titres and cardiac enzymes
344
Management of myocarditis?
Bed rest ad treatment of heart failure
345
What is shock?
Circulating failure resulting in inadequate organ perfusion
346
Clinical presentation of shock?
BP \<90mmHg
Low/ no urine output
MAP \<65
Elevated serum lactate
347
Types of shock caused by inadequate CO?
Hypovolaemic
Pump failure: cardiogenic or secondary to PE, Pneumothorax or tamponade
348
Types of shock caused by peripheral circulation failure?
Baso things getting in the blood
**Sepsis** - vasodilation caused by infection and the release of cytokines in response to G-ve endotoxin release
**Anaphylactic** - severe allergic reaction - Type 1 IgE mediated hypersensitivity - mass release of histamine
Neruogenic - SCI
**Endocrine failure** - addisons or hypothyroidism
349
350
What drugs can cause shock?
Anaesthetics
Antihypertensives
Cyanide poisoning
351
Management of anaphylactic shock?
Steroid, antihistamine, Adrenaline, Salbutamol
352
What is sepsis?
Life-threatening organ dysfunction caused by deregulated host response to infection
353
Signs of septic shock?
Multiple organ failure
Elevated lactate despite fluid restriction
Patient needs vasopressin to sustain MAP
354
Things to look out for during shock?
Resp rate
Urine output
Organ failure
BP
Fever and sweating
Mottled skin
355
What is used to diagnose a structural heart defect during pregnancy?
Foetal echocardiography
356
What the 4 heart defects found in tetralogy of fallot?
1. Stenosis of RV outflow tract -harder for deoxygenated blood to go to the lungs due to stenosis
2. Right ventricular hypertrophy - boot shaped CXR
3. Ventricular septal defect - but blood move from the RV to LV so deoxygenated blood goes into circulation
4. Aorta overrides the septal defect - so can be right on it or far left
357
What is the most critical feature of tetralogy of fallot?
Pulmonary stenosis
The severity of obstructing influences the direction of shunting
Increased obstruction = RV to LV
358
What is the most common cyanotic congenital heart defect?
Tetralogy of fallot
359
What causes tetralogy of fallot?
Chromosome 22 deletion
Di George syndrome
360
Clinical presentation of tetralogy of fallot?
Cyanosis
Clubbing - finger and toes
Decreased O2 - feeding difficulty, failure to gain weight and failure to develop normally
THESE SYMPTOMS COME IN SPELLS
361
Management of cyanosis?
O2
Squat or raise knees to the chest - Kinks femoral arteries and increases vascular resistance - increase pressure in left ventricle so blood moves more from LV to RV
362
Treatment of tetralogy of fallot?
Surgery in the first year of life
Close septal defect
Enlarge RV outflow tract
363
Explain how abnormal embryology leads to ventricular septal defects?
Muscular ridges grow upwards from the apex
The membranous region grows downwards from the endocardial cushion
VSD = they don't fuse
364
What percentage of CHD are VSD?
20%
365
What other conditions are VSD associated with?
Foetal alcohol syndrome and downs
366
Pathophysiology of VSD?
Greater pressure in the LV so blood moves from LV to RV and you get increased blood flow to the lungs
367
What is eisehmenger syndrome?
Due to VSD and greater pressure in LV - Blood moves LV to RV
Increase pressure on the delicate pulmonary vasculature and increase RV pressure
Blood now ends up moving RV to LV = deoxygenated blood moving through the body
368
Clinical signs of ventricular septal defects?
Small, breathless, skinny
Increased resp rate
Tachycardia
Holosystolic Murmur - blood going through septum
369
What are the names of the 2 atrial openings during foetal development?
Fossa ovale
Ostium primum
370
What is an ASD?
When the septum remains open after birth and blood moves between the atria due ostium primum
371
Clinical features of ASD?
Acyanotic - LA to RA
Increased O2 sats in right arm, right ventricle and pulmonary artery
Delayed pulmonary closure - splitting S2 sound
Cardiomegaly
Big pulmonary arteries
372
What are AV septal defects?
A hole in the very centre of the heart - ASD, VSD and fusion of the mitral + tricuspid valve to from a common valve
(can be complete or partial)
373
Clinical presentation of AV septal defects?
Poor feeding + weight loss
Breathlessness
More blood going to the lungs so the heart pumps faster to pump more blood around the body
374
What is a patent ductus arteriosus?
Maintained open connection between the aorta and pulmonary artery so blood from the aorta goes to the lungs instead
375
Clinical presentation of patent ducuts arteriosus?
Asymptomatic
Tired
Prone to pneumonia
Cardiomegaly
Breathless
376
Management of patent ducuts arteriousus?
Surgery to occlude the opening
377
What is coarction of the aorta?
Narrowing of the aorta and the site of insertion of ductus arteriosus
378
What is the disadvantage of a bicuspid aortic valve?
Degenerate faster, stenosis and regurgitation - unable to handle the stress meant for 3 leaflet aortic valve
379
Complications of pulmonary stenosis?
RV hypertrophy - collapse
Regurgitation
Poor pulmonary blood flow
380
What is cardiomyopathy?
A group of diseases of the myocardium that affect the mechanical or electrical function of the heart
381
Examples of mechanical cardiomyopathy?
Hypertrophic
Dilated
Primary restrictive
Arrhythmogenic right ventricular
382
What is hypertrophic cardiomyopathy?
Random AF - **Ventricular hypertrophy in the absence of abnormal loading conditions** e.g. hypertension or vascular disease
HYPERTROPHIC AND NON-COMPLIANT VENTRICLES = Decreased ventricular filling and so decreased SV
383
Causes of hypertrophic cardiomyopathy?
Genetics - mutations of genes that code for sarcomeric proteins
384
Clinical features of hypertrophic cardiomyopathy?
Breathless
Angina
Syncope
Jerky carotid pulse
385
The most common cause of sudden death in young adults?
Hypertrophic cardiomyopathy
386
Management of hypertrophic cardiomyopathy?
Amiodarone
ICD
BB and verapamil - chest pain and dyspnoea
Decrease outflow tract gradient
387
What is the difference between hypertrophic and dilated cardiomyopathy?
Dilated - Dilated left ventricle that contracts poorly
Hypertrophic - Both ventricles are just dilated in the absence of abnormal loading conditions
388
Consequence of Dilated cardiomyopathy?
Shortness of breath
Embolism
Decreased ejection fraction
389
What is primary restrictive cardiomyopathy?
Rigid myocardium restricting diastolic ventricular filling and the clinical features resemble constrictive pericarditis
390
Diagnosis of primary restrictive cardiomyopathy?
Cardiac catheterisation - endomyocardial biopsy
391
What is arrhythmogenic right ventricular cardiomyopathy?
Right ventricular wall is replaced by progressive fibro adipose tissue resulting in tachycardia and sudden death
No treatment and poor prognosis
392
Clinical features of pulmonary hypertension?
RVF - peripheral oedema and abdo pain due to hepatic congestion
Dyspnoea
Lethargy and fatigue
Hepatomegaly
Pleural effusion
Increased JVP
393
Causes of pulmonary hypertension?
Increased pulmonary vascular resistance or blood flow
Secondary to lung disease or L heart disease
394
What is a pulmonary embolism?
Thromboembolism from a DVT travels through the veins to the right side of the heart and becomes lodged in the blood vessels of the lungs
395
Pathophysiology of pulmonary embolism?
Obstruct RV outflow - Increase PVR - RH failure
Pulmonary infarct - VQ mismatch
396
Clinical features of pulmonary embolism?
Breathless
Chest pain
Haemoptysis
Tachypnoeic
Exudative pleural effusion
397
Confirmation of DVT?
Hoan's sign - Calf pain at dorsiflexion of the foot
398
CXR showing PE?
Raised hemidiaphragm
399
Scoring system tool used to investigate PE?
Revised geneva score
400
Management of PE?
Thrombolysis
Surgery to remove clot
Vena cava filter
401
What is the leading cause of maternal death in developed countries?
PE - they are given LMWH because warfarin is tertragenic
402
