cardio conditions Flashcards
1
Q
define an abdominal aortic aneurysm (AAA)
A
dilation of abdominal aorta, >50%
usually diameter >3cm
2
Q
epidemiology of AAA
A
M>F, more common elderly
3
Q
risk factors of AAA
A
increasing age
M
atheroscelrosis
obesity
hypertension
diabetes
connective tissue disorder
family history
4
Q
pathology of AAA
A
degradation of tunic media + adventitia= vessel dilation & loss of structural integrity
- mechanical stress on weakened tissue = dilation and rupture
-dilation of vessels disrupts laminar flow
AAA most commonly forms below level of renal arteries
5
Q
presentation of AAA
A
asymptomatic
Sxs of rupture:
palpable, pulsatile abdo mass
tachy + hypotension
abdo pain
bruising
severe epigastric pain
hypovelemic shock
6
Q
investigations for AAA
A
abdo ultrasound- >3cm/ ruptures= immediate management
CT angiogram
7
Q
management of AAA
A
ruptured= urgent surgical repair using either open or EVAR (endovascular aneurysm repair)
unruptured= sympto- urgent surgical repair
asympto- surveillance + risk management
8
Q
comps of AAA
A
AAA rupture
thromboembolism
fistula
abdo compartment syndrome
prog= 80 % mortality if ruptured
9
Q
define acute pericarditis
A
inflammation of the pericardium
10
Q
epidemiology of acute pericarditis
A
80-90% idiopathic
M>F
younger>older
11
Q
causes of acute pericarditis (6)
A
viral- aka enteroviruses eg mumps, HIV, coxsackievirus = most common
TB
rheumatoid arthritis
uraemia secondary 2 kidney disease
Dressler syndrome- past MI inflammation
hypothyroidism
malignancy
12
Q
risk factors for acute pericarditis
A
male
20-50 years
past MI
bacterial/viral infections
trauma
13
Q
pathology of acute pericarditis
A
inflammation= narrowed pericardial space
inflamed layers rub against each other - increasing inflammation
pericardial effusion since serous pericardium can’t remove fluid quick enough
effusion due to xtra fluid needed 2 compensate for friction
severe effusion=cardiac tamponade
14
Q
presentation of acute pericarditis
+ECG changes
A
sudden, sharp, severe & pleuritic chest pain
- pain is relieved sitting forward, worse when lying flat
pericardial rub- squeaky sound when patient leans forward, listen @ sternal edge
dyspnoea
hiccups due to irritated phrenic
tachycardia
tachypnoea
fever
ECG changes= saddle shape + concave ST elevation, PR depression
15
Q
investigations for acute pericarditis
A
ECG- saddle shape & concave ST elevation, PR depression, T wave flattening
chest xray-water bottle hear
echocardiogram- effusion
bloods (increased WCC + ESR)
other= serum troponin
16
Q
differential diagnosis for acute pericarditis
A
MI
pneumonia
pulmonary embolus
17
Q
management of acute pericarditis
A
sedentary activity until symptoms + ECG/CRP improve
1 NSAID/aspirin + colchicine (antinflammatory)
18
Q
complications of acute pericarditis
A
pericardial effusion
cardiac tamponade
chronic constrictive pericarditis
19
Q
define aortic dissection
A
tear in the intima of the aorta
20
Q
epidemiology of aortic dissection
A
M>F, 50-70 yrs
21
Q
pathology of aortic dissection
A
tear in the intima of the aorta- this causes blood to flow into new, false channel between tunica intima & tunica media
blood spreads thru false channel & can occlude flow thru branches of aorta
type A- tear in ascending aorta before brachiocephalic
type B - tear in descending aorta after L subclavian
22
Q
risk factors for aortic dissection
A
HYPERTENSION
smoking
family history
trauma
obesity + sedentary lifestyle
connective tissue disorders
narrowing of aorta
pregnancy
23
Q
presentation of aortic dissection
A
sudden + severe ripping/tearing chest pain
syncope
musc weakness
diff in BP between arms- >10mmHg
tachy + hypotension
diastolic murmur
radial pulse deficit
focal neurological deficit’s
inter scapular pain
24
Q
Investigations for aortic dissection
A
1st- ECG, ST depression
chest x-ray (widened mediastinum)
TTE echocardiogram
gold = contrast enhanced CT angiogram
other= transoesophageal echocardiogram
25
differential diagnosis for aortic dissection
MI, cardiac arrest, pericarditis
26
management of aortic dissection
Type A- urgent open surgical reapir/stenting
beta blocker eg IV labetalol
Type B- conservative management (bed rest + analgesia
beta blocker eg IV labetalol
TEVAR (thoracic endovascular aortic repair
27
complications of aortic dissection
aortic regurgitation
MI
stroke
renal failure
cardiac tamponade
haemorrhage and shock
28
define aortic regurgitation
leakage of blood into L ventricle during diastole due to ineffective closing of the aortic valve cusps
29
epidemiology of aortic regurgitation
M>F
40-60 yrs
30
causes of aortic regurgitation
rheumatic heart disease
infective endocarditis- causes valvular damage
connective tissue disorders eg, Marfan's, Ehlers-Danos
congenital
31
pathology of aortic regurgitation
as blood leaks from aorta into L ventricle- L vent blood vol increases, therefore stroke vol increases + systolic BP increases
during diastole- lower blood vol in atria
high systolic + low diastolic pressure= hyperdynamic circulation
overtime- increases in blood vol in L vent cause it to undergo eccentric ventricular hypertrophy
32
presentation of aortic regurgitation
bounding pulse/waterhammer pulse
wide pulse pressure
de musset's= head bobbing with each beat due to severe bounding pulses
Quincke's sign= pulsation of capillary beds in finger nails die to bounding pulses
Austin Flint murmur= rumbling diastolic murmur, fluttering of mitral valve due to regurgitant streams
LV hypertrophy seen on imaging
dyspnoea
chest pain
palpitations
syncope
33
investigations for aortic regurgitation
1st- ECG,(non spec ST/T wave changes) chest x-ray= cardiomegaly + enlarged aortic root
gold= echocardiogram- can see origin of regurgitant jet & its width, detection of aortic valve pathology & compensatory changes eg LV hypertrophy & function
34
differential diagnosis for aortic regurgitation
mitral regurgitation
aortic stenosis
infective endocarditis
35
management of aortic regurgitation
aortic valve replacement surgery (SAVR) if symptomatic or asymptomatic with ejection fraction >50%
if unsuitable can use TAVI (transcatheter aortic valve implantation)
vasodilators eg ACE inhibitors, ramipril (sympto only)
36
complications of aortic regurgitation
heart failure
pulmonary oedema & cardiogenic shock
37
define aortic stenosis
obstruction of blood flow across aortic valve due 2 narrowing, therefore L vent can't eject blood properly in systole
can be supravavular- fibrous ridge above valve
or subvalvular - fibrous ridge is below valve
38
congenital causes of aortic stenosis
congenital bicuspid aortic valve, congenital aortic stenosis
39
risk factors for aortic stenosis
>60 yrs
hypertension
hypercholesterolaemia
smoking
diabetes
rheumatic heart disease
40
pathology of aortic stenosis
aortic valve doesn't fully open:
mechanical stress over time> damages endothelial> calcification + fibrosis=hardens valve & makes it more difficult to open completely
bicuspid valve- 2 leaflets instead of 3, therefore more stress on just 2
41
presentation of aortic stenosis
SAD:
-syncope
-angina
-dyspnoea
ejection click- valve snapping open due 2 high pressure from L vent
ejection systolic crescendo-decrescendo murmur
slow rising carotid pulse + decreased pulse amplitude
soft/ absent 2nd heart sound + prominent S4 heart sound
42
investigations for aortic stenosis
1st- ECG = L vent hypertrophy (deep S waves in V1 & V2, tall R waves in V5 &V6)
chest x-ray (pulmonary congestion)
gold- echocardiogram + doppler= L vent size + function & doppler derived gradient and valve area
43
differential diagnosis for aortic stenosis
hypertrophic cardiomyopathy, ischaemic heart disease
44
management of aortic stenosis
surgery if symptomatic
lower risk patients= SAVR (surgical aortic valve replacement
higher risk patients= TAVI (transcatheter aortic valve implantation
45
complications of aortic valve stenosis
heart failure
sudden cardiac death
infective endocarditis
ventricular arrhythmia
microangiopathic haemolytic anaemia
46
define atrial fibrillation (AF)
supraventricular tachycardia caused by uncoordinated, rapid and irregular atrial activity- results in an irregularly irregular ventricular pulse
47
causes of AF
heart failure
hypertension
coronary artery disease
valvular disease-mitral stenosis
cardiac surgery
cardiomyopathy
idiopathic
48
risk factors for AF
>60 yrs
hypertension
T2DM
heart failure
past MI
49
pathology of AF
disorganised electrical activity overrides sinoatrial node activity- causes uncoordinated, rapid and irregular contraction of atria
300-600 bpm
50
presentation of AF
irregular pulse
tachycardia
palpitations
ECG- no p waves & narrow QRS
apical pulse> radial rate
irregularly irregular ventricular contractions
thromboembolism
asymptomatic
chest pain
palpitations
dyspnoea
fainting
51
investigations for AF
ECG=
-absent p wave
-irregualr R-R intervals
-narrow QRS
other=FBC
clotting profiles, U&Es
52
differential diagnosis
atrial flutter
wolff-parkinson-white syndrome
atrial tachycardia
53
management of AF
haemodynamically unstable- direct current cardioverison, shocks AF to sinus rhythm
haemodynamically stable- rate control beta blockers (bisoprolol, metoprolol) or CCB (verapmil/diltiazem) + digoxin
rhythm control w electrical or pharmacological (flecainide)
cardio version + precardioversion anticoagulant
long term= catheter ablation
54
monitoring for AF
CHA2DS2- VASc score - 2 calculate stroke risk
if score= <2, anticoagulant required
55
complications of AF
acute stroke
MI
congestive heart failure
56
define atrial flutter
macro re-entrant atrial tachycardia caused by organised electrical activity in the atrium with a rate of 250-350 bpm
57
causes of atrial flutter
idiopathic
CHD
heart failure
hypertension
COPD
pericarditis
58
pathology of atrial flutter
originates from a re-entrant circuit around the tricuspid valve annulus
short circuit causes the atria to fire rapidly
59
presentation of atrial flutter
ECG=
flutter waves, saw tooth pattern (F waves)
often 2:1 block (2 p waves for every QRS
tachycardia (above 150bpm)
palpitations
dyspnoea
chest pain
dizziness
syncope
fatigue
60
investigations for atrial flutter
ECG= saw tooth pattern (flutter waves)
2:1 block (2 P waves for every QRS
other= FBC
61
differential diagnosis for atrial flutter
AF, atrial tachycardia
62
management of atrial flutter
haemodynamically unstable-= DC cardio version
haemodynamically stable=
1. rate control (beta blocker) + anticoagulant
2. electrical cardio version
3. pharmacological cardioversion
ongoing- catheter ablation 2 remove faulty electrical pathway
63
monitoring of atrial flutter
CHA2SD2-VASc for stroke risk
64
define bundle branch block
a block in the conduction of one of the bundle branches- therefore the ventricles don't receive impulses @ the same time
65
causes of RBBB
pulmonary embolism
ischemic heart disease
atrial or ventricular septal defect
66
causes of LBBB
ischemic heart disease
valvular disease
cardiomyopathy
cardiac surgery
67
pathology of RBBB
depolarisation only occurs through the LBB, LV depolarises normally
RV walls eventually depolarised by LBB in slower + less effective pathway
creates= second R wave in V1 + slurred S wave (V5-6)
68
pathology of LBBB
depolarisation only occurs in RBB, RV depolarises normally
LV walls eventually depolarised by RBB in slower + less effective pathway
creates= second R wave in V6 + slurred S wave (V1-2)
69
presentation of BBB
asymptomatic
syncope
70
investigations for BBB
William marrow
RBBB: MaRRoW
M in V1
W in V6 (slurred S)
wide QRS
LBBB: WiLLiaM
W in V1 (slurred S)
M in V6
wide QRS
71
management of BBB
usually no treatment
treat hypertension, pacemaker, cardiac resynchronisation therapy (CRT)
72
define cor pulmonale
right sided heart failure caused by respiratory disease
73
causes of cor pulmonale
COPD
pulmonary embolism
interstitial lung disease
cystic fibrosis
primary pulmonary hypertension
74
pathology of cor pulmonale
increased pressure + resistance in the pulmonary arteries (pulmonary arteries)= R vent unable to effectively pump blood out of vent + into pulmonary arteries - leads to back pressure of blood in R atrium + vena cava + systemic venous system
75
presentation of cor pulmonale
shortness of breath
peripheral oedema
chest pain
hypoxia
cyanosis
raised JVP
3rd heart sound
murmurs
hepatomegaly
syncope
76
investigations for cor pulmonale
1st=
ABG (hypoxia + hypercapnia)
spirometry
chest CT
echocardiogram
gold= right heart catheterisation
77
management of cor pulmonale
treat symptoms + underlying cause
long term O2 therapy
treat heart failure
venesection (reduces RBCs) if haemltocrit >55
consider heart-lung transplantation in young patients
78
complications of cor pulmonale
tricuspid regurgitation
hepatic congestion
cardiac cirrhosis
death
79
prognosis of cor pulmonale
50% 5 year survival
80
define deep vein thrombosis (DVT)
the formation of a blood clot in the deep veins of the leg or pelvis
81
causes of DVT
virchow's triad: reduced blood flow, endothelial injury, venous stasis
82
risk factors for DVT
virchow's triad
age, >40 yrs
smoking
drugs: combined contraceptive pill, HRT, tamoxifen
immobility
pregnancy
trauma
malignancy
polycythemia
antiphospholipid syndrome (thrombophilia)
83
pathology of DVT
majority occur in lower legs, below calf- can impede minor veins
more serious occur above calf, can occlude major veins eg superficial femoral, impeding distal flow
thrombus can embolise from deep veins 2 vena cava>R side of heart>pulmonary arteries and cause a pulmonary embolism
84
presentation of DVT
unilateral calf pain, redness and swelling
tenderness
pitting oedema
dilated superficial veins
erythema
cyanosis
85
investigations for DVT
measure circumference of calf 10cm below tibial tuberosity- more than 3cm diff= significant
1st- Wells score 2 calculate DVT risk, scores of ≥ 2= high risk
unlikely DVT- D-dimer test (looks 4 fibrin breakdown products + clotting problems)
if D-dimer raised- order doppler ultrasound of leg
likely DVT- order doppler ultrasound (unable to compress vein= clot)
86
management of DVT
1st- DOAC anticoagulation: apixaban or rivaroxaban
long term: LWMH (low molecular weight heparin)
DOAC (direct oral anticoagulants)/warfarin
compression stockings
treat underlying cause
87
prevention of DVT
compression stocking
calf exercises during periods if immobilisation
LMWH
88
define heart block
AV involves partial or complete interruption of impulse transmission from atria to ventricles
types:
1st degree
2nd degree Mobitz type1
2nd degree Mobitz type 2
3rd degree (complete)
89
causes of heart block
1st degree: AV blocking drugs, beta blockers, CCB,, digoxin
2nd degree Mobitz type 1: AV blocking drugs, inferior MI
2nd degree Mobitz type 2: drugs MI rheumatic fever
3rd degree: MI, hypertension, structural heart defect
90
risk factors for heart block
coronary artery disease
cardiomyopathy
fibrosis
91
pathology of diff types of heartblock
1st; consistent prolongation of PR interval due to delayed conduction via AV node- every P wave followed by QRS
2nd mobitz type 1; progressive prolongation of the PR interval until the atrial impulse isn't conducted and a QRS is dropped- AVN conduction begins with next beat and sequence repeats
2nd mobitz type 2; consistent prolonged PR interval duration with intermittently dropped QRS complexes due to failure of conduction, PR interval is constant, but every 3rd/4th QRS complex is dropped
3rd (complete); no communication between atria and ventricles due 2 complete failure of conduction. P waves and QRS complexes have no association due to atria and vents functioning independently
92
presentations of heart block
1st= asymptomatic
2nd mobitz type 1= asymptomatic/bradycardia, syncope, irregular pulse
2nd mobitz type 2= palpitations, syncope, regular irregular pulse
3rd= palpitations, syncope, irregular pulse, bradycardia, chest pain, shortness of breath
93
investigations for heart block
ECG:
1st- every P followed by QRS, prolonged PR (>200ms)
regular rhythm
2nd, type 1- progressive lengthening of PR interval until a QRS is dropped + cycle repeats with shorter PR interval, irregular rhythm
2nd, type 2- constant enlarged PR interval, every nth QRS is missing, irregular rhythm
3rd- P waves + QRS complexes= random
PR interval absent due 2 atria-ventricle dissociation
94
management of heart block
1st-
asymptomatic= no treatment
symptomatic= pacemaker
2nd, type 1= asymptomatic= no treatment
symptomatic= pacemaker
2nd, type 2= pacemaker
3rd= IV atropine/isoprenaline + permanent pacemaker
95
define general heart failure
inability of the heart to deliver oxygenated blood to tissues at a satisfactory rate for the tissues metabolic requirements
96
define systolic heart failure
failure of the heart to contract efficiently to eject adequate volumes of blood
ejection fraction= <40%
heart failure w reduced ejection fraction- HFrEF
97
define diastolic heart failure
inability of the ventricles to relax and fill normally- causes increased filling pressures
ejection fraction=>50%
heart failure w preserved ejection fraction- HFpEF
98
define right heart failure
inability of the right ventricle to pump adequate amount of blood leading to systemic venous congestion
99
define left heart failure
inability of left ventricle to pump adequate amount of blood leading to pulmonary circulation congestion and oedema
100
causes of heart failure
ischaemic heart disease, hypertension, cardiomyopathy, alcohol excess, valve disease
RHF: pulmonary hypertension, pulmonary embolism, COPD, cor pulmonale
LHF: CAD, valve defect, myocardial infarction, congenital heart defects, arrhythmias
101
risk factors for heart failure
older
M>F
obesity
previous MI
102
pathology of heart failure
stroke vol requires adequate preload 4 optimal myocardial contractility (Frank-Starling mechanism)+ decreased after load
-reduced cardiac output(heart failure)>decreased preload, decreased contractility, increased afteroad, decreased heart rate
2 maintain CO- compensatory changes needed=
increased SNS (increases HR + contractility
nattriuretic peptide (diuretic, hypotensive, vasodilators)
increased RAAS (increased fluid retention= increased preload)
compensatory mechanisms become exhausted + pathological=
SNS + RAAS also cause vasoconstriction > increases after load + myocardial work> increased cardiac work damages myocytes`. reduces CO= heart failure
103
presentation of LHF
pulmonary oedema
LHF: bibasal pulmonary crackles, 3rd & 4th heart sounds, cardiomegaly (displaced apex beat), tachycardia
dyspnoea
orthopnoea
poor exercise tolerance
fatigue
nocturnal cough (pink frothy sputum)
wheeze
cold peripheries
104
presentation of RHF
peripheral oedema
RHF: raised JVP, hepatomegaly, pitting oedema, weight gain (fluid)
ascites
nausea
anorexia
facial engorgement
epistaxis
105
investigations for heart failure
1st:
ECG
BNP (brain natriuretic peptide= elevated)- released from myocardial walls under stress
chest x-ray (ABCDE- alveolar oedema, Kerley B lines, cardiomegaly, dilated upper lobe vessels, effusions (pleural)
gold: echocardiogram
other= FBC
106
management of heart failure
1st= ABAL
A- ACE inhibitor (ramipril)
B- Beta blocker (bisoprolol)
A- aldosterone antagonist (spironolactone)
L- loop diuretic (furosemide)
consider cardiac resynchronsiation therapy
surgery= LVAD, cardiac transplantation
107
complications of heart failure
pleural effusion
actue kidney injury
sudden cardiac death
108
prognosis for heart failure
50% die within 5 years of diagnosis
109
define hypertension
persistent elevation of arterial BP
≥140/90 mmHg in clinic
≥ 135/85 mmHg for ambulatory or home readings
primary or secondary
110
non modifiable risk factors for hypertension
age
Family history
ethnicity (afro-caribbean)
111
modifiable risk factors for hypertension
obesity
sedentary life style
alcohol excess
smoking
high sodium intake (>1.5g/day)
stress
112
pathology of primary hypertension
no known underlying cause- 90-95% of cases
some contributing factors=
-genetics
-excessive SNS activity
-abnoramlities of Na+/K+ membrane transport
-high salt intake
-abnormalities in RAAS
113
pathology of secondary hypertension
indicates an unknown underlying cause including:
-renal diseases
-endocrine disorders
-medications (glucocorticoids, contraception)
-pregnancy (pre-eclampsia)
114
presentation of hypertension
most often asymptomatic
malignant hypertension- ≥180/120 mmHg
- headache
-visual disturbance
-cardiac symptoms
-oliguria/polyuria
secondary hypertension- signs of the underlying cause eg hyperthyroidism causes weight loss, sweating, palpitations, etc
115
investigations for hypertension
measure BP:
stage 1=
≥140/90 - clinic
≥135/85- ABPM
stage 2=
≥160/90-clinic
≥150/95- ABPM
stage 3=
≥180/120- clinic
ambulatory BP- worn 24hrs
other=
fundoscopy (HTN retinopathy
albumin:creatinine ratio(proteinuria)
bloods (HbA1c, GFR, lipids)
ECG
116
management of hypertension
1- lifestyle mods
T2DM or <55 yrs= give ACWI eg ramipril
>55 yrs or black/ afro caribbean= CCB (calcium channel blocker) eg amlodipine
2 ACEi + CCB
3 ACEi + CCB + thiazide-like diuretic
4. if k+ >4.5 add alpha or beta blocker to 1,2 & 3
if K+ <4.5 add aldosterone antagonist eg spironolactone
other= direct renin inhibitors for patients intolerant to norm antihypertensives
117
monitoring of hypertension
measure BP every 5 yrs
more often for patients on borderline of diagnosis (140/90)
118
complications of hypertension
CAD
cerebrovascular incident
congestive heart failure
CKD
hypertensive retinopathy
119
define infective endocarditis (IE)
infection of heart valves + other endocardial lined structures of the heart (chord tendineae, sites of septal defects etc)
types=
-left sided native (mitral or aortic)
-left sided prosthetic
-right sided
-device related, eg pacemaker, defibrillator
120
epidemiology of infective endocarditis
elderly
young IV drug users
congenital heart disease
anyone w prosthetic valve
rheumatic fever
surgery
poor dental hygiene
iv catheter
immunosuppression
121
what causes infective endocarditis
bacteria
s.aureus (common in IVDU, T2DM, surgery)-normally acute
s. viridans (poor dental hygiene)-normally subacute
enterococci/s. bovis
HACEK organisms
fungi
122
pathology of infective endocarditis
abnormal/damaged endocardium creates turbulent flow- endothelium is damaged> exposes underlying collagen + tissue factor- platelets + fibrin adhere= forms a thrombus (nonbacterial thrombotic endocarditis)
if bacteria attach to thrombus (vegetation)- becomes ineffective endocarditis
123
presentation of infective endocarditis
heart murmur- due 2 turbulent blood flow
splint haemorrhages -red lines under nails
Osler's nodes- painful nodules on fingers/toes
Janeway lesions- painless plaques on palms & soles
Roth's spots- retinal haemorrhages
fever
weight loss, fatigue
valve disfunction therefore arrhythmia + heart failure
embolism
night sweats
124
investigations for infective endocarditis
1st=
inflammatory markers- raised WCC, ESR,CRP
blood cultures (positive)
transthoracic echo- vegetation
FBC- anaemia, neutrophilic
ECG- prolonged PR interval
Duke's criteria:
needs 2 major OR 1 major & 3 minor OR 5 minor
MAJOR=
positive blood culture organisms typical of IE
evidence of endocardial involvement
MINOR=
risk factors
fever
vascular phenomena
immune phenomena
microbio evidence
other= transoesophageal echo if transthoracic doesn't show IE
125
management of infective endocarditis
1st- IV antibiotics based on cultures via either central line or PICC
s.aureus= beta lactam/vancomycin + rifampicin + gentamicin
s.viridans= beta lactam/vancomycin + gentamicin
s.bovis/enterococci= beta lactam/vancomycin + amino glycoside
surgery 2 remove infective tissue + repair and replace infected valves, remove large vegetations before they embolism
126
complications of infective endocarditis
vegetations embolising causing stroke, MI, PE, heart failure, sepsis
regurgitation due 2 damaged valves
127
define mitral regurgitation
incompetence of the valve leading to back flow of blood from the LV to LA during systole
128
risk factors for mitral regurgitation
F
>age
connective tissue disorders (marfans, Ehlers-danlos)
prior mi
infective endocarditis
rheumatic fever
cardiomyopathies
medications
myxomatous degeneration (floppy valve)
129
pathology of mitral regurgitation
mitral valve prolapse=
myxomatous degeneration (weakening of connective tissue)
when high pressure on valve- chordae tendinae are stretched/rupture- leaflet can fold back up into LA
damage to papillary muscles post MI= they can no longer anchor chordae tendinae
L ventricle overload due 2 hypertension
L sided heart failure
130
presentation of mitral regurgitation
mid-systolic click (in mitral prolapse)
pan-systolic murmur- leaking of blood in LA
soft S1- incomplete closure of valve
additional S3 sound- rapid filling of dilated vent
apex beat displaced laterally
systolic thrill
tachycardia
signs of heart failure
dyspnoea + orthopnoea due 2 pulmonary hypotension
fatigue + malaise due reduced CO
palpitations
exercise intolerance
131
investigations for mitral regurgitation
1st
ECG- LA enlargement (M shaped P waves)
chest x-ray= LA enlargement, pulmonary oedema in acute
gold= echo
estimation of LA, LV size and function
132
management of mitral regurgitation
1st= surgery if symptomatic/ asymptomatic with ejection fraction <60% or LV end-systolic diameter >40mm
surgery = valve repair OR replacement
medication:
BB eg atenolol/calcium channel blockers/digoxin
vasodilators ef ACE inhibits (ramipril or hydralazine)
antigoacualtion for AF
diuretics for fluid overload eg furosemide or spironolactone
cardiac resynchronisation therapy (CRT)
133
complications of mitral regurgitaiton
L sided heart failure
AF
infective endocarditis
congestive heart failure
134
define mitral stenosis
narrowing of mitral valve orifice, making it difficult for blood to flow from the LA to LV in diastole
135
risk factors for mitral valve stenosis
s. pyogenes infection leading 2 rheumatic heart disease
M>F
136
causes of mitral stenosis
rheumatic fever- inflammation cause leaflets to fuse together
congenital
mitral annular calcification
137
pathology of mitral stenosis
increased vol of blood in LA= higher pressure in LA- causes LA to dilate + allows blood to back up into pulmonary circulation (pulmonary congestion + oedema)
-resulting in pulmonary hypertension & R sided heart failure
as LA dilates- must walls stretch + pacemakers become more irritable - increases risk of AF
138
presentation of mitral stenosis
AF
malar flush (due to vasoconstriction responding 2 reduced CO)
sign of right sided heart failure
signs of pulmonary hypertension
loud S1 snap- valve opening under high pressures
dyspnoea
reduced exercise tolerance
haemoptysis- (coughing up blood) due to ruptured bronchial vessels from elevated bronchial pressure
angina
dysphagia- if atria presses on oesophagus
partner syndrome- horse voice due to dilated atria causing left recurrent laryngeal nerve palsy
139
investigations for mitral stenosis
1st=
ECG- AF + LA enlargement, M shaped p waves
chest x-ray- LA enlargement
pulmonary vessel congestion
gold=
echo- asses mitral valve mobility, gradient + orifice area, hockey stick shaped mitral deformity
140
treatment for mitral stenosis
diuretics 2 relieve LA pressure
BB eg atenolol & digoxin (control heart rate + prolong diastolic filling)
CCB
anticoagulants due to risk of thrombus formation
surgery= mitral balloon valvotomy, valve replacement
141
define an NSTEMI
Non-ST-elevated myocardial infarction is part of ACS (acute coronary syndrome)
it is an acute ischaemic event causing myocardial cell necrosis and troponin release
142
non-modifiable risk factors for an NSTEMI
age >65 yrs
male
family history
premature menopause
143
modifiable risk factors for an NSTEMI
smoking
DM
hyperlipidaemia
hypertension
obesity
sedentary lifestyle
recreational drug use
144
pathology of an NSTEMI
atherosclerotic plaque rupture and thrombosis cause partial occlusion to coronary artery> this causes necrosis of cardiac tissue and infarction to sub endothelium
145
presentation of an NSTEMI
central, crushing chest pain radiating down arms, jaw & neck - lasts longer than 20 mins + not relieved by rest or GTN spray
impending doom feeling
tachycardia
high/low BP
4th heart sound
signs of heart failure
shortness of breath
sweating/clammy
nausea
palpitations
146
investigations for an NSTEMI
1st=
ECG- ST depression, T wave inversion
elevated troponin
other= CT angiography, bloods
147
management of an NSTEMI
immediate management= MONA (morphine, oxygen <92%, nitrates, aspirin)
then invasive coronary angiography and PCI
GRACE score- 6 month risk of death or repeat MI after NSTEMI
prevention= aspirin, clopidogrel (antiplatelet), statin (atorvastatin), metoprolol (BB or CBB). ACEi
modify risk factors
148
complications of an NSTEMI
heart failure
ruptured infarcted ventricle
rupture interventricular septum
mitral regurgitation
arrhythmias
heart block
post MI pericarditis (Dressler syndrome)
149
define pericardial effusion and cardiac tamponade
pericardial effusion= accumulation of fluid in the pericardial sac
cardiac tamponade= the pericardial effusion is large enough to raise the inter-pericardial pressure leading to reduced filling of the ventricles during diastole- resulting in reduced CO in systole
150
causes of cardiac tamponade
idiopathic
pericarditis
transudative effusions from increased venous pressure causing restricted drainage of the pericardial space- congestive heart failure, pulmonary hypertension
rupture of heart /aorta causing bleeding in pericardial space eg aortic dissection
malignancy:
-lung
-breast
-haematological
trauma eg knife wound
151
pathology of cardiac tamponade
pericardial effusion causes raises interpericardial pressure- compresses chambers of heart= reduced stroke vol + CO
- causes hypotension, heart tries to compensate by beating faster
152
presentation of cardiac tamponade
Beck's triad:
-hypotension
-Kussmaul's sign: raised JVP & distended jugular veins
-muffled heart sounds
pulses paradoxus: systolic BP reduction of >10mmHg on inspiration
tachycardia
prolonged capillary refill time
cool peripheries
dyspnoea
coughing
chest discomfort
lightheadedness
peripheral oedema
confusion
153
investigations for cardiac tamponade
1st=
ECG- electrical alternans (QRS complex varies in amplitude as heart moves in fluid)
chest x-ray- (enlarged globular heart)
gold= transthoracic echo - will show 'dancing heart'
other=
FBC- raised WBC, raised ESR showing inflammation
154
management of pericardial effusion & cardiac tamponade
just pericardial effusion=
treat underlying cause, pericarditis - aspirin NSAIDS, colchicine
drain the effusion- needle pericardiocentesis or surgical drainage
pericardial effusion + cardiac tamponade=
urgent pericardiocentesis (pericardial fluid aspirated to relieve intrapericardial pressure
155
complications of cardiac tamponade
cardiac arrest
constrictive pericarditis
156
modifiable risk factors for PAD
obesity
diabetes
hypertension
high LDL
smoking
157
pathology of PAD
arterial obstruction normally due 2 atherosclerosis/thrombosis> reduced blood supply + ischaemia in lower limbs
when muscle becomes ischaemic- cells release adenosine, causes pain in nearby nerves (lactic acid production also contributes 2 pain)
intermittent claudication: ischaemia in limb during exertion- relieved @ rest
acute limb iscahemia- rapid onset of iscahemia in limb due 2 thrombus blocking blood supply
critical limb ischaemia: blood supply barely adequate to meet metabolic demands of tissue- end stage of PVD, can cause gangrene + complete limb loss
158
presentation of PAD
fontine classification:
stage1- aysmptomatic, lack of palpable pulse
stage2- intermittent claudication
-aching/burning leg muscles relieved w rest
the 6 Ps= pain, pale, pulseless, perishing cold,paraesthesia, paralysis
-ankle brachial pressure index <0.9
stage 3- critical limb ischaemia
-rest pain (relived by dangling leg over bed @ night)
-imminent risk of limb loss
stage 4- tissue loss
ulceration or gangrene
159
what is buerger's test for PAD
raise foot= pale
put foot down= blue (deoxy blood returns to foot)> then dark red (reactive hyperaemia)
160
investigations for PAD
1st ankle-brachial pressure index (0.5-0.9= mild PAD, <0.5= severe PAD)
fontaine classification
1 asymptomatic
2 intermittent claudication
3 ischaemic rest pain
4 ischaemic ulcers eg gangrene
gold= CT angiogram 2 show occlusions
other= duplex ultrasound (shows speed + vol of blood flow)
161
management of PAD
intermittent claudication: risk factor management (smoking, excercise, statins, anti platelet-aspirin eg clopidogrel)
chronic limb ischaemia : risk factor management, revascularisation surgery (stenting & angioplasty, vein bypassing), amputation if severe
acute limb ischaemia: urgent surgery (end-vascular thrombolysis, endarterectomy, bypass surgery) amputation
162
define a pulmonary embolism
obstruction to the pulmonary vasculature, secondary to an embolus
163
what 3 things make up Virchow's triad
reduced blood flow
endothelial injury
hypercoagulability
164
risk factors for pulmonary embolism
virchow's triad:
-venous stasis
-vascular injury
-hypercaogulability (pregnant, COPD, malignancy, oestrogen therapy, thrombophilia- predispose to clots eg antiphospholipid syndrome)
165
pathology of a pulmonary embolism
clot forms> increased pressure on vein causes it 2 break free (thromboembolus)- travels 2 lungs + becomes stuck
- decreased blood flow2 lung tissue = V/Q mismatch
can cause cor pulmonate due 2 increased pulmonary resistance
166
presentation of a pulmonary embolism
hypoxia + cyanosis
DVT (swollen calf)
sudden, onset pleuritic chest pain
dyspnoea
fever
tachypnoea + tachycardia
crackles
hypotension
elevated JVP
haemoptysis
syncope
167
investigations for a pulmonary embolism
1st=
Wells score (risk of DVT or PE)
1. <4 =unlikely PE, order D-dimer (looks for fibrin breakdown products & clotting problems)
2. >4= likely PE, order CT pulmonary angiogram
gold= CT pulmonary angiogram 2 get direct visual of thrombus in pulmonary artery
other=
ECG- sinus tachycardia, S1Q3T3 pattern= cor pulmonale, T wave inversion in Lead III
V/Q scan
ABG- low O2, low CO2
168
management of pulmonary embolism
prevention=
compression stockings, frequent calf exercises, prophylactic treatment w low molecular weight heparin (LMWH)
massive PE=
thrombolysis (alteplase/streptokinase)- fibrinolytic medication 2 rapidly dissolve clots
non massive PE=
LMWH, DOAC or warfarin
169
complications of a pulmonary embolism
pulmonary infarction
cor pulmonale
sudden death if both pulmonary arteries blocked
resp alkalosis
cardiac arrest
170
define angina pectoris (stable angina)
central crushing chest pain due to decreased coronary artery blood flow causing oxygen supply/demand mismatch in exertion
171
causes of angina pectoris
narrowing of coronary artery by atherosclerosis
rare= reduced O2 carrying capacity (anaemia), peripheral resistance (LV hypertrophy), coronary artery spasm
172
non-modifiable and modifiable risk factors for angina pectoris
non-modifiable:
age
gender- M>F
race
modifiable=
diabetes
hypertension
obesity high LDL
smoking
173
pathology of angina pectoris
narrowing of coronary arteries from atherosclerotic plaques reduces blood flow- on exertion, higher O2 demand that cannot be met > myocardial ischaemia> angina
174
explain the stages of the formation of an atherosclerotic plaque
* High levels of cholesterol damages endothelium.
* LDLs pass in and out of the arterial wall in excess and accumulate in it, and there is undergoes oxidation and multiplies, leading to inflammation
* The inflammation releases chemoattractants, which attracts Macrophages try to break down, LDLs, turning into foam cells, which produce a LIPID CORE/FATTY STREAK
* This inflammatory reaction leads to tissue repair, so the smooth muscle proliferates forming a fibrous cap that encloses the lipid core.
175
presentation of pectoris angina
angina precipitated by exertion, heavy meals, cold weather & emotion
-cause central crushing chest pain which can radiate to jaw, neck, arms > relieved with GTN spray/ 5 min rest
dyspnoea
nausea
sweating
syncope
176
investigations for angina pectoris
1st=
ECG (normal)
gold= CT angiography (presence of luminal narrowing & plaques
other= echocardiogram, exercise tolerance test, invasive angiography, bloods, lipid profile, HbA1c
177
management of angina pectoris (need to check this)
immediate symptomatic relief= GTN spray
anti-anginal medication:
1st- BB or non hydropyridine CCB (amlodipine)
2nd- BB + non hydropyridine CCB
3rd- add additional anti-anginal med
eg. nitrates, ivabradine,nicorandfil, ranolazine
revascularisation:
PCI (percutaneous coronary intervention)
CABG (coronary artery bypass graft)
secondary prevention:
lifestyle changes
aspirin + a statin
ACE inhibitor (angina + diabetes)
178
complications of angina pectoris
MI
chronic heart failure
stroke
179
define a STEMI
ST elevated myocardial infarction (part of ACS)
ischaemic event leading 2 death of heart tissue + troponin release
180
non-modifiable + modifiable risk factors for STEMI
non-modifiable=
age
gender- M>F
race
modifiable=
hypertension
diabetes
obesity
high LDL
smoking
181
pathology of STEMI
atherosclerotic plaque rupture + thrombosis= complete occlusion of coronary artery leading 2 transmural injury and myocardial infarction
182
presentation of STEMI
central crushing chest pain radiating down arms jaw and neck- not relieved by rest or GTN spray
persists >20mins
impending doom feeling
tachycardia
high/low BP
4th heart sound
sweating
dyspnoea
fatigue
palpitations
183
investigations for STEMI
1st + gold= ECG- ST elevation in anterolateral leads, after some time- T wave inversion, deep broad Q waves, LBBB
biomarkers- troponin elevated
other= CT angiography, bloods
184
management of STEMI
acute treatment= MONA (morphine, O2 <92%, nitrates, aspirin)
primary PCI if available within 12 hours of symptoms , if unavailable, fibrinolysis 2 breakdown clot eg alteplase
secondary prevention= aspirin, anti platelet eg clopidogrel, statin eg atorvastatin, metoprolol (BB OR CCB), ACEi
modify risk factors
185
complications of a STEMI
heart failure
rupture of infarcted vent
rupture of inter ventricular septum
heart block
arrhythmias
mitral regurgitation
post MI pericarditis (dressler's syndrome)
186
define unstable angina
myocardial ischaemia at rest or on minimal exertion with the absence of myocardial injury
-not relieved with GTN spray or rest
187
presentation of unstable angina
central crushing pain radiating to arms, neck and jaw- not relieved by GTN spray or rest
persists longer than 20 mins
crescendo chest pain
sweating
dyspnoea
nausea
syncope
palpitations
188
investigations for unstable angina
1st= history, ECG (sometimes ST depression and T wave inversion)
biomarkers- NO TROPONIN
other = CT angiography
189
management of unstable angina
immediate= MONA
GRACE score (6 month risk of death or repeat MI after NSTEMI)
prevention:
aspirin, antiplatelet eg clopidogrel, statin eg atorvastatin, metoprolol (BB OR CCB), ACEi
modify risk factors
high risk= angiography + PCI
190
(yellow) define atriotentricular node re-entry tachycardia (AVNRT)
tachycardia due to the presence of 2 functionally and anatomically distinct conduction pathways in the AV node
191
causes of AVNRT
cardiomyopathy
iscchaemic heart disease
hyperthyroidism
cocaine
excess alcohol
192
pathology of AVNRT
electrical signal re-enters the atria from the ventricles through the AV node
-once signal back in atria, travels thru AV node + causes another ventricular contraction
creates a self-perpetuating loop w no end point= fast + narrow QRS complex tachycardia
193
presentation of AVNRT
tachycardia (140-280bpm)
paroxysmal attacks (sudden onset/offset palpitations)
neck pulsation
chest pain
shortness of breath
fatigue + weakness
194
investigations for AVNRT
1st= ECG
- p waves included in QRS complex, narrow QRS followed by T wave repeated
195
management of AVNRT
1st= vagal manoeuvres (valsalva, carotid sinus massage)
2nd= IV adenosine
prevention= BB, CCB, flecainide
196
what is coarctation of the aorta
narrowing of the aorta at the site of the insertion of the ductus arteriosus
197
causes of coarctation of the aorta
congenital malformation
Turner's syndrome
198
pathology of coarctation of the aorta
(infant +adult form)
infant form=
ductus arterioles still open
- due 2 low pressure in aorta below constriction, blood moves through ductus arteriosus into aorta, bypassing pulmonary arteries> causes cyanosis as deoxygenated blood travels into systemic circulation
adult form=
no patent ductus arteriosus
- pressure = high upstream of coarctation + low downstream of coarctation
therefore increased pressure in upper extremities + head
decreased bp in lower extremities
199
presentation of coarctation of the aorta
hypertension
Diff upper body and lower body BP
diminished pulse in Lower extremities
tachypnoea
bruits over scapulae & back
systolic ejection murmur
200
investigations for coarctation of the aorta
1st- chest x-ray (rib notching
ECG- L vent hypertrophy
gold= echo (narrowing in aorta, pressure gradient across narrowing
201
management of coarctation of the aorta
surgical repair of stenting
prostaglandin E to keep ductus arteriosus open while awaiting surgery
202
define dilated cardiomyopathy
cardiomyopathy= group of myocardial diseases that affect the affect the mechanical and electrical function of the heart
dilated cardiomyopathy= walls of the chambers of the heart are dilated, thick muscle wall stretches- becoming thinner + weaker therefore contractions are weaker
203
causes of dilated cardiomyopathy
genetic (autosomal dominant- Duchenne muscular dystrophy)
alcohol
thyroid dsiorder
ischaemic heart disease
infection
204
pathology of dilated cardiomyopathy
ventricular enlargement and poor contraction
dilation of the ventricle disrupts the heart's ability to contract leading 2 progressive heart failure
-there is diffuse interstitial fibrosis and systolic dysfunction between the ventricles
205
presentation of dilated cardiomyopathy
heart failure presentation:
-dyspnoea
-fatigue
-peripheral oedema
-raised JVP
larger heart on imaging
systolic murmur due 2 regurgitation
S3 gallop
arrhythmia
low BP
chest pain
206
investigations for dilated cardiomyopathy
ECG=
tachycardia, LBBB, T wave inversion, Q waves
chest x-ray= enlarged heart
gold -echo= dilated heart + low ejection fraction
207
management of dilated cardiomyopathy
bed rest
diuretics - 4 oedema
BB- control HR
ACE inhibitors- dilate vessels 2 improve blood flow
anticoag- due 2 increased thrombus risk
ICD- (implantable cardioverter defibrillator for high risk arrhythmia patients)
LVAD (L vent assist device)
xtreme= heart transplant
208
define hypertrophic cardiomyopathy
cardiomyopathy = group of mycocardium diseases affecting heart's mechanical/electrical function
hypertrophic CM= L vent hypertrophy causing obstruction to the outflow tract
209
causes of hypertrophic cardiomyopathy
genetic autosomal domination mutation In sarcomere proteins troponin T, beta-myosin
210
risk factors for Hypertrophic cardiomyopathy
family history of HCM
Friedreich's ataxia
211
pathology of hypertrophic cardiomyopathy
L vent hypertrophy caused by genetic dysfunction of sarcomere proteins
consequences of L vent hypertrophy=
-walls take up more room- less room 4 blood
-walls are more stiff+ less compliant so can't stretch 2 fill w more blood
> therefore SV + CO reduced
hypertrophy also leads to abnormal Mitral valve which obstructs L vent outflow tract
212
presentation of hypertrophic cardiomyopathy
ejection-systolic murmur- crescendo-decrescendo character due 2 blood flow thru obstructed L vent outflow tract
bifid pulse
S4 sound
arrhythmias
sudden death
chest pain
palpitations
syncope
dyspnoea
213
investigations for hypertrophic cardiomyopathy
1st= ECG
-can see LVH from progressive T wave inversion
-deep Q waves
-ST depression
chest x-ray= cardiomegaly
echo= L vent hypertrophy, asymmetrical septal hypertrophy
other= genetic testing
214
management of hypertrophic cardiomyopathy
1st= BB/CCB (dilimiazem/verapamil) - (no digoxin as contraindications)
anti-arrhythmic meds eg amidarone
anticoagulation
prevention= implantable cardioverter-defib
215
define restrictive cardiomyopathy
scar tissue replaces the normal heart muscle and the ventricles become rigid so don't contract properly
216
cause of restrictive cardiomyopathy
idiopathic
granulomatous diseases (amyloidosis, sarcoidosis)
end-myocardial fibrosis
217
pathology of restrictive cardiomyopathy
restricted ventricles = decreased vol > bi-atrial enlargement
rigid fibrous myocardium fills poorly + contracts poorly causing decreased CO
218
presentation of restrictive cardiomyopathy
3rd + 4th heart sounds
signs of heart failure:
-dyspnoea
-fatigue
-peripheral oedema
-increased JVP
-hepatomegaly
ascites
219
investigations for restrictive cardiomyopathy
1st=
ECG- low amplitude QRS
chest x-ray
echo- thickened vent walls, atria & septa
gold=
cardiac catheterisation
220
management of restrictive cardiomyopathy
no direct treatment
-treat underlying cause
-heart transplant
221
define tetralogy of Fallot
congenital cardiac malformation with 4 existing pathologies:
1. vent septal defect
2. overriding aorta
3. pulmonary valve stenosis
4. right ventricular hypertrophy
222
describe the 4 four pathologies of congenital cardiac malformation
1. ventral septal defect allows blood to shunt between ventricles
2. overriding aorta=entrance to the aorta is placed further to the R than normal, above the VSD- therefore when the R vent contracts greater proportion of deoxygenated blood enters aorta
3. pulmonary stenosis= creates resistance against blood flow from the R vent- creates R 2 L shunt, therefore deoxygenated blood enters L vent and systemic circualtion
4. increased strain on the R vent trying 2 pump against resistance cause hypertrophy
223
presentation of Tetralogy of Fallot
cyanosis
systolic ejection murmur
Tet spells (R 2 L shunt temporarily worsened)
tachypnoea
clubbing
poor feeding, poor weight gain
squatting posture
reduced SpO2
224
investigations for Tetralogy of Fallot
1st=
chest x-ray- boot shaped heart due 2 RV thickening
gold= echo (shows blood flow route)
other= hyporexia test
225
management of tetralogy of Fallot
full surgical repair within 2 years of life
226
define Wolff-Parkinson-White syndrome (AVRT)
AVRT= atrioventricular re-entry tachycardia
-there is an accessory pathway for impulse conduction caused by a congenital connection between the atria and ventricles- not through the AV node
caused by congenital abnormality
227
pathology of AVRT
an accessory pathway between atria and ventricles allows electrical conduction 2 bypass the AV node so that the ventricles and stimulated prematurely > leads 2 double exciting of the ventricles
secondary pathway in AVRT= bundle of Kent, since conduction not regulated by AV node
228
presentation of AVRT
palpitations
tachycardia
dizziness
dyspnoea
ECG: short PR interval, wide QRS, slurred upstroke of QRS complex=delta wave
229
investigations for AVRT
ECG=
short PR interval
wide QRS
slurred upstroke of QRS complex= delta wave
230
management of AVRT
1st= vagal manoeuvre 2 slow heart: valsalva manoeuvre, carotid sinus massage
2.if unsuccessful give IV adenosine 2 slow conduction thru heart- 6mg then 12mg
3.cardioversion Long term- catheter ablation (remove faulty electrical pathway
231
RED= define atrial septal defect
abnormal connection between the 2 atria
congenital - down syndrome, foetal alcohol syndrome
small = asymptomatic
large= significant inc in blood flow thru RH & lungs
ECG= tall p waves showing R atrial enlargement
chest x-ray shows enlarged heart + pulmonary arteries
echo 4 shunt visuals
will need surgical closure if closure isn't spontaneous
232
brugada syndrome
sodium channelopathy causing dangerously fast arrhythmias
gene mutation
syncope, palpitations, dyspnoea, chest pain
ECG= coved ST elevation in chest leads V1-3
manage with implantable cardiac defib
233
long QT syndrome
ventricular tachyarrhythmia characterised by prolonged QT interval on ECG >480ms
syncope, palpitaions
correct electrolyte disturbances + remove causative factors, BB, pacemaker, implantable defib
234
patent ductus arteriosus
ductus arteriosus fails to close at birth
congenital/premature
large= cont machine like murmur, cardiomegaly, pulmonary hypotension, poor feeding, failure 2 thrive
chest x ray 4 cardiomegaly
ECG- deep Q waves + r waves= L atrial enlargement
echo 2 see shunt/ventricle hypertrophy
spontaneous/surgical closure
indomethacin (prostaglandin inhibitor) may close PDA
235
prinzmetal angina
angina due 2 coronary artery spasm + narrowing
no correlation w exertion
central crushing pain @ rest- resolved w GTN spray
dyspnoea, sweating, nausea
ECG- ST elevated during acute episode
biomarkers= not elevated
coronary angiography
use GTN spray 1st, other = CCB + long acting nitrates
reduce risk factors
236
rheumatic fever
systemic infection from Group A beta-haemolytic streptococcus- mainly s.pyogenes
antibodies against streptococcus bacteria also attack body tissues (rheumatic heart disease)
murmur, pericardial rub, jerky movements, pink rings/rash on torso & limbs
diagnose using JONES criteria & FEAR
ESR/CRP= raised ECG= prolonged PR
throat swab 4 antistreptococcal antibodies
treat w antibiotics- IV benzylpenicillin then phenoxymethicillin for 10 days
237
torsades de pointes
polymorphic ventricular tachycardia- QRS amplitude varies
long QT interval
-will either terminate spontaneously + revert back 2 sinus rhytmn or progress into ventricular tachycardia
palpitations, dizziness, syncope, tachycardia
correct electrolyte imbalance or remove cause
Mg infusion
defib if V-fib occurs
238
ventricular ectopics
premature ventricular beats caused by random electrical discharges from the ventricles before an electrical impulse can be made by the atrium
random brief palpitations, abnormal beat, syncope
ECG= individual random, abnormal, broad QRS complexes
self-monitoring, BB OR CCB
ablation 2 stop normal signals
239
ventricular septal defect
congenital abnormal connection between the 2 ventricles
congenital- Down'a, Turner's
small VSD= asymptomatic
large= exercise intolerance, harsh pansystolic murmur , breathless, poor feeding, high pulmonary blood flow,
chest x ray 4 pulmonary plethora, cardiomegaly
echo- shows stunting across VSD
small= no treatment
large= surgical repair
240
