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Med Finals > Cardio Ix Mx > Flashcards

Cardio Ix Mx Flashcards

1
Q

Abdominal aortic aneurysm

A

Ix = USS (s/m/l = 3.5-4.5<m<5.5+)

Mx:
s/m = follow up in 1year/3 months,
L = surgery (open for young, endovascular repair EVAR for old)

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2
Q

Aortic dissection

A

Ix = 1st line, stable = CT angiography CAP (shows false lumen)
Unstable = TOE

Chest x-ray - widened mediastinum

Lesions in the descending aorta will usually present with normal heart sounds

Mx =

Type A(scending) = surgery (must control SBP to
100-120 mmHg whilst awaiting intervention)

Type B(descending) = conservative management (bed rest) + IV labetelol

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3
Q

Aortic regurgitation

Associated with;

Ankylosing spondylosis
Aortic dissection
Marfan syndrome
Rheumatic fever

A

Ix = ECG (LVH) + echo/dopplar

Mx = HF drugs (BA-SHeD up heart - BB, ACEi, Spironolactone, Hydralazine/GTN, Digoxin)

Surgery indications = (symptomatic) or (asymptomatic +LV systolic dysfunction)

Signs;

early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre
collapsing pulse
wide pulse pressure
Quincke’s sign (nailbed pulsation)
De Musset’s sign (head bobbing)
mid-diastolic Austin-Flint murmur in severe AR - due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams

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4
Q

Aortic stenosis

A

Ix = same for all urmurs (ECG+ echo/dopplar)

S - soft s2/4 + slow rising pulse
T - Tight pulse pressure
E - Ejection systolic murmur
N - Neck (heard in the carotids)

Mx = asymptomatic = observe, symptomatic = valve replacement

Asymptomatic but (valvular gradient > 40 mmHg) + (left ventricular systolic dysfunction) = aortic valve replacement (AVR)

Young/low risk = surgical AVR
High risk = transcatheter AVR (TAVR)

Cardiovascular disease may coexist. For this reason, an angiogram is often done prior to surgery so that the procedures can be combined

Children/adults not fit for replacement = balloon valvuloplasty

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5
Q

Arterial ulcers

A

Ix = Ankle-Brachial Pressure Index is reduced

A = Atrophy/punched out
R = Reindeer cold
T = Toes/heels
E = Excruciatingly painful

Mx = pain mx + prostaglandins

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6
Q

Atrial fibrillation/flutter - (stable + <48hrs< and unstable)

A

Ix = ECG

Mx = 1st = (rate + rhythm control) 2nd = anticoagulants for stroke risk

‘Offer rate control as the first‑line strategy to people with atrial fibrillation, unless;
1. the cause of AF is reversible(e.g.pneumonia)
2. The AF is new
3. AF has led to instability (HF)

Rate = bb/NRL-CCB (verapamil) if bb is CI
If 1 doesn’t control BP then -> digox ->amiodarone

Rhythm;

acute = Cardiovert (DC/flec/amiodarone)
long-term = bb, paroxysmal = (flec/amio in pocket)

  1. Anticoag = chadsvasc (assess the risk of a stroke if the AF pt is put on anticoagulants apix)

-> 0=echo, 1=male, 2=everyone anticoagulates! even in paroxysmal.

ORBIT looks at risk of bleeding when on anticoagulants

<48hrs since AF = LMWH (dalteparin/Fonda)*
>48hrs = anticoag (apixaban) for 7 weeks! (3 before ELECTRICAL cardioversion and 4 after)

If there is a high risk of cardioversion failure (e.g. Previous failure or AF recurrence) then it is recommend to have at least 4 weeks amiodarone or sotalol prior to electrical cardioversion

Long term = doac (-xaban)
ie.

AF, haemodynamic instability = cardio version

AF, haemodynamically stable = <48hrs (rate+rhythm control),

> 48hrs (rate control + anticoag for 3 weeks til cardioversion)

*if you’re ‘fond’ of the pt you’ll give fondaparinux asap (<48hrs)!

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7
Q

Cardiac arrest

A

Ix - is it reversible? (4 H’s + T’s)

Hypoxia
Hypovolaemia
Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders
Hypothermia

Thrombosis (coronary or pulmonary)
Tension pneumothorax
Tamponade – cardiac
Toxins

Mx = ALS pathway (CPR 30:2 -> is it shockable/non-shockable -> shock/resume CPR for 2mins -> assess rhythm -> repeat until ROSC)

Alteplase should be considered during CPR if a PE is suspected

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8
Q

Cardiac failure (acute and chronic)

A

Ix = NYHC (1-4, 1=no limitation, 4 = dyspnoea at rest)

Mx = BASHeD up heart - BB*, ACEi, Spironolactone, Hydralazine/GTN**, Digoxin

1st = BA, 2nd = S 3rd = H/N

*bisop/carvedilol
**Isosorbide mononitrate may be important in managing symptoms yet it has no proven mortality benefit following a myocardial infarction. It also needs to be given in a asymmetric dosing regime prevent nitrate tolerance

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9
Q

Cardiomyopathy (HOCM)

A

Ix = Echo (MR),
ECG (LVH, deep Q waves)
Ejection-Fraction (both dia+systolic volumes are reduced so its HF-pEF)

ECG finding of deep S waves in V1 and tall R waves in V6 with a combined amplitude of 40mm is suggestive of left ventricular hypertrophy

and T wave inversion in V5/V6 suggests left ventricular strain

Mx = A(miodarone), B(b), C(ardioversion), D(ual chamber pacemaker)

avoid nitrates/ACEi/ionotropes

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10
Q

Constrictive pericarditis

A

Ix = ECG (wide-spread PR-depression + saddle-shaped STE), TTE

Mx = treat cause1st line = NSAIDS + colchicine (reduces recurrent disease)

Difference between tamponade and constricitive pericarditis is that constrictive pericarditis presents with JVP paradoxically rising on inspiration (Kussmauls sign)

A commonly used mnemonic to remember the absent Y descent in the ECG of cardiac tamponade is TAMponade = TAMpaX

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11
Q

Deep vein thrombosis (DVT)

A

Ix = Well’s score

2+ = USS<4hrs (if >4hrs - D-dimer+DOAC dabi/apixa)
+ve = mx,
-ve = stop anticoag, if +ve d-dimer, repeat USS 1 wk later

0/1 = D-dimer, (if >4hrs - D-dimer+DOAC dabi/apixa)

D-dimer +ve -> USS -> USS -ve -> STOP anticoag, repeat USS 1 wk later

D-dimer -ve = not DVT

Unprovoked = CT AP for malignancy

Mx = 1st = DOAC (dabi/apix)

LMWH (enoxa/dalte) if renal impairment

DVT prophylaxis for a long haul flight:
low risk = nothing
moderate risk pt = compression stockings
high = don’t fly/specialist

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12
Q

Dyslipidaema (hypercholesterolaemia & hypertriglyceridaemia)

A

Ix = Full lipid profile

Mx

Q-risk (10yr risk of CVD) for pt<84yo, >85yo=RF

Q-risk > 10% / T1DM / eGFR<60 = 20mg atorvastatin

(titrate up if LDL hasn’t decreased by >40%)

Known IHD / CVD / peripheral artery disease = 80mg atorvastatin

The target 3 months after starting statins is a >40% reduction in non-HDL cholesterol !

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13
Q

Gangrene

A

Ix = acute, inflammed, extreme pain disproportionate to physical features. Necrosis is a late sign

Mx = surgical debridement + ab’s (IV vanc/clinda)

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14
Q

Heart block (1st, 2nd, 3rd degree)

Also, which coronary artery is most likely to be blocked?

A

Ix = ECG

1st = PR>0.2
2nd = Mobitz1 = progressive PR-eelongation until it drops, Mobitz2 = PR is constant but not always followed by a QRS
3rd = no association between p’s and QRS’s

RCA is most likely to be bloked as it supplies AVN and SAN!

1st-degree heart block is a normal variant in an athlete. It does not require intervention

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15
Q

Hypertension (+caveats)

A

Ix = 1st = ABPM, 2nd = HBPM

1 - Clinic BP >140/90 + average H/ABPM > 135/85
2 - Clinic BP >160/100 + average H/ABPM > 150/95
Severe - Clinic SBP >180 or DBP>110

Mx - see flow diagram

If new BP >= 180/120 mmHg + retinal haemorrhage or papilloedema then admit for specialist assessment!

or if new BP >= 180/120 mmHg + target organ damage is identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of H/ABPM

caveats;
CKD/DM =ACEi*,
Black = ARB,
can’t tolerate ACEi = ARB
gout = avoid thiazide-like diuretics

NICE recommend a blood pressure target of <130/80 in patients with diabetes and chronic kidney disease

After A+C+(tl)D;

K+<4.5 = spironolactone
K+>4.5 = bb/ab

ARB’s cause hyperkalaemia

*even if they’re >55yo

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16
Q

Infective endocarditis

A

Ix = TOE + blood cultures

2 majors or 1 major+3minor or 5 minors

Dukes;

Minor;

F (ever)>38C
E (cho findings not on majors list)
V (ascular phenomenen - Janeway, splinter haemmorrhages, embolisms
E (mmunological stuff - osler/roth, RhF, glomerulonephritis)
R (isk factors - IVDU/heart condition)

Major;

B (acteraemia - 2 cultures, 12hrs apart)
E (cho - vegetations, murmur, abscess, prosthetic valve)

Mx - blind = amox -> vanc
staphylococci = fluclox
streptococci = benpen/vanc

most common cause (particularly in IVDU’s!) = Staph aureus

poor dental hygiene = viridans

colorectal cancer = strep bovis

Antibiotic prohylaxis to prevent infective endocarditis is not routinely recommended in the UK for dental and other procedures

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17
Q

Mitral regurgitation

Mitral valve prolapse is associated with polycystic kidney disease

A

Ix = same for all murmurs (ECG+ echo/dopplar)

ECG - (broad P wave, indicative of atrial enlargement)
Echocardiography - crucial to diagnosis and to assess severity

Mx = asymptomatic = observe/medical, symptomatic = valve repair>replacement

Medical = nitrates, diuretics, positive inotropes and an intra-aortic balloon pump to increase cardiac output??? (purposely decreasing BP, to increase HR?)

If patients are in heart failure, ACE inhibitors may be considered along with beta-blockers and spironolactone

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18
Q

Mitral stenosis

most common cause = Rheumatic fever

Commonly associated with AF

A

Ix = same for all murmurs (ECG+ echo/dopplar)

Diastolic Murmur
Length of murmur increases
opening snap becomes closer to S2

Mx =

  • Associated AF = anti-coagulate! (warfarin)*
  • Asymptomatic = regular echo monitoring
  • Symptomatic patients = replacement or percutaneous mitral balloon valvotomy/commissurotomy

*The SIGN guidelines state a patient suffering from rheumatic mitral valve
disease with/without atrial fibrillation should have a target INR of 2.5 with
a range between 2.0 and 3.0

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19
Q

Myocarditis

A

Ix = bloods (CRP/ESR, Trops BNP), ECG (tachy, STE, TWI)

Mx = treat the cause + supportive treatment (e.g. of heart failure or arrhythmias)

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20
Q

Peripheral vascular disease (acute and chronic limb ischaemia)

A

Ix = ABPI of < 0.5 = Critical limb ischaemia

Critical limb ischaemia = 1+ of:

Resting pain in foot for 2+ weeks
Ulceration
Gangrene

Acute limb ischaemia = 6P’s (painful, pulseless, paraesthesia, perishingly cold, pale, paralysed)

Mx =

Initial management
ABC, analgesia, heparin

Definitive = embolectomy/thrombolysis, angioplasty-balloon, bypass surgery, amputate

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21
Q

Pulmonary embolism

‘breathing problems with a clear chest - think PE’

Use of the contraceptive pill should be ceased before an operation to prevent a pulmonary embolism

A

Ix: 1st = CXR

2nd = Well’s score

> 4 = CTPA (V/Q if renal failure)
+ve = DOAC (dabi*/apixa) (LMWH dalte/enox if eGFR<15)
-ve = USS of leg

If scan can’t be performed immediately, give DOAC in interim

<4 = D-Dimer, +ve => CTPA, -ve = alt diagnosis + stop DOAC

Mx:

Stable = DOAC (un/provoked = 6/3 months)

Unstable = dalte + Alteplase

Pts with repeat PE’s/PE due to a malignancy = LMWH for life!

*Bleeding on dabigatran? Can use idarucizumab to reverse

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22
Q

Rheumatic fever

A

Ix = Evidence of recent streptococcal infection + Jones’

(2 major criteria) or (1 major with 2 minor criteria)

Evidence of recent streptococcal infection (strep ag’s/ab’s or +ve throat swab)

Major = CASES

C (arditis)
A (rthritis)
S (ydenhams chorea)
E (rythema marginatum)
S (ubcutaneous nodules)

Minor criteria

P (rolonged PR interval)
I (nflam markers(ESR+CRP)
F (ever)

Mx: oral pencillin + NSAIDS

antibiotics: oral penicillin V
anti-inflammatories: NSAIDs
treatment of any complications that develop e.g. heart failure

23
Q

Supraventricular tachycardia

A

Ix: ECG (narrow-complex tachy)

Mx:

Regular = amiodarone route
Irregular = cardiac specialist

Unstable = adrenaline & amiodarone

HD-stable;

1st: Valsalva manoeuvre (equalise middle ear pressure)

2nd: Carotid sinus massage

3rd: Intravenous 16G large bore cannula of adenosine* 6 ->12->18mg (CI in asthmatics, so give verapamil)

4th: BB/verapamil

5th: Electrical cardioversion (up to 3 shocks)

Long-term prevention = BB’s or radio-ablation of conduction system in heart?

*can also cause a transient feeling of warmth/flushing

24
Q

Tricuspid regurgitation

A
25
Q

Varicose veins

A

Ix = venous duplex ultrasound: this will demonstrate retrograde venous flow

Mx: Majority of pt’s do not require surgery

Conservative treatments include:
leg elevation
weight loss
regular exercise
graduated compression stockings

Reasons for referral to secondary care = pain, bleeding, skin changes, thrombophlebitis, active/healed ulcer

26
Q

Venous ulcers

A

Ix = ABPI (to exclude arterial which would be low)

Mx:

1st = stockings (vasodilator + moisturiser)
2nd = skin graft

27
Q

Ventricular tachycardia

A

Ix = ECG (broad-comlpex tachy)

Mx =

Regular - amiodarone,
Irregular = cardiac specialist

Unstable = ALS (ie. 3 shocks!) -> adrenaline & amiodarone

HD-stable + regular rhythm = cardiac specialist - 300mg amiodarone (IV central line) over 20mins, then 900 over 24hrs

If witnessed/on a monitor = 3 shocks! -> CPR -> amiodarone

No verapamil in VT!

28
Q

Wolff–Parkinson–White syndrome

A

Ix: ECG (short P-R, wide QRS, slurred upstroke delta wave, LAD)

Mx = Radiofrequency ablation of the accessory pathway

medical therapy: sotalol***, amiodarone, flecainide

sotalol should be avoided if pt has AF

29
Q

Tamponade (fluid in pericardium)

A

Ix = Becks (fluid in pericardium - muffled heart sounds, hypotension, raised JVP)

In tamponade there is an abnormally large drop in BP during inspiration, known as pulsus paradoxus

30
Q

Stable angina (aka classic/exertional angina)

A

Ix = sharp, caused by exertion, relieved by GTN

contrast-enhanced CT-coronary angiography

Mx: AAA - aspirin, atorvastatin, atenolol (stAble AnginA). consider ACEi too.

1st = GTN + bb/ccb(amlodipine, not verap!)
2nd = GTN + bb+ccb
3rd = Long-acting nitrate (ivabradine, nicorandil, ranolazine)

31
Q

Acute coronary syndrome ACS (ie. UNstable angina - MI) ACUTE

(aka crescendo angina)

Cardiogenic shock (low bp) is a poor prognostic indicator in acute coronary syndrome

Ventricular fibrillation is the most common cause of death following a myocardial infarction!

A

Ix = ECG Features in ≥ 2 contiguous leads

STE in V2+3;

Men < 40yo = 2.5 mm (i.e ≥ 2.5 small squares)

Men > 40yo = ≥ 2.0 mm (i.e ≥ 2 small squares)

Women = 1.5 mm

1 mm ST elevation in other leads

new LBBB (LBBB should be considered new unless there is evidence otherwise)

Mx;

Initial (for any acute chest pain) = MONA & GRACE

1st = - 300mg aspirin for everyone!
- Oxygen only if pt<94% oxygen
- Don’t give nitrates if pt is hypotensive

Then after aspirin, follow flow diagram;

GRACE score

low risk = ticagrelor

high risk =
if hd-unstable -> immediate PCI,
if stable -> can wait 72hours for a PCI- give pras+tic+dalte

Is a PCI* possible in <120mins?

yes = prasugrel, 2nd = tic
no = alteplase (fibrinolysis) + antithrombin (dalte/enoxa/fonda)

Takes a long time (>120mins) to roll a fat person to PCI - F ondaparinux A lteplase T icegraleur

If patients treated with PCI for MI are experiencing pain or haemodynamic instability post PCI, urgent coronary artery bypass graft (CABG) is recommended!

if Hb<80g/L = give packed red cells!

*PCI is a non-surgical procedure that uses a catheter to place a small structure called a stent to open up blood vessels in the heart that have been narrowed by atherosclerosis. Stent options include drug-eluting and bare metal. Drug-eluting stents are now the preferred option

32
Q

Acute coronary syndrome (ie. UNstable angina - MI) LONG TERM

A

Mx = ABCD’s

A (CEi’s)
B (B’s)*
C (ardiac rehab)
D (APT for 12months - Aspirin+tic/clop or asp+tic/pras if after PCI)
S (tatins)

*Nicorandil is a second-line drug treatment for angina pectoris if first-line drugs (beta-blockers or calcium channel blockers) are contraindicated or not tolerated. But they cause ulceration - if this occurs it should be immediately stopped!

33
Q

Mechanical valve drugs?

Prosthetic heart valves may result in haemolytic anaemia

A

All patients with mechanical valves require
treatment with aspirin and warfarin*

Low molecular weight heparin is used as
bridging anti-coagulation but not long-term

*and have an INR target of 3-4 to prevent thrombosis

34
Q

Sinus Bradycardia

with adverse features! (shock, syncope, heart failure or myocardial infarction)

A

Mx = 500mcg IV Atropine!

Atropine = ACh-r inhibitor - blocks parasympathetic conduction to the heart

If there is an unsatisfactory response the following interventions may be used:

  1. Atropine, up to a maximum of 3mg
  2. Transcutaneous pacing
  3. soprenaline/adrenaline infusion titrated to response
  4. transVENOUS pacing (specialist)
35
Q

What does CHA2DS2-VASc score stand for?

Used to determine most appropriate anticoagulation strategy (considering risk of getting a stroke if no anticoagulation is taken)

A

C Congestive heart failure 1
H Hypertension (or treated hypertension) 1
A2 Age >= 75 years 2
Age 65-74 years 1
D Diabetes 1
S2 Prior Stroke, TIA or thromboembolism 2

V Vascular disease (including ischaemic heart disease and peripheral arterial disease) 1
S Sex (female) 1

0 = No treatment
1 = Males: Consider anticoagulation
Females: No treatment (this is because their score of 1 is only reached due to their gender)
2+ = Offer anticoagulation

Remember that if a CHA2DS2-VASc score suggests no need for anticoagulation it is important to ensure a transthoracic echocardiogram has been done to exclude valvular heart disease, which in combination with AF is an absolute indication for anticoagulation.

36
Q

What are the SE’s of thiazide-like diuretics?

A

Hypokalemia. …
Hyponatremia. …
Metabolic alkalosis. …
Hypercalcemia. …
Hyperglycemia. …
Hyperuricemia. …
Hyperlipidemia. …
Sulfonamide allergy

37
Q

Acute mitral regurg (post inferior MI) -> papillary muscle rupture

A

Ix:

Acute hypotension and pulmonary oedema may occur

An early-to-mid systolic murmur is typically heard

Mx:

Patients are treated with vasodilator therapy but often require emergency surgical repair

38
Q

What is face/neck swelling, distended neck veins, cough, dyspnea, orthopnea, upper extremity swelling, distended chest vein collaterals, and conjunctival suffusion?

Ix and mx?

A

Superior vena cava obstruction syndrome

Ix = CT chest

Mx = Endovascular stenting

Small cell lung cancer may benefit from radical chemotherapy or chemo-radiotherapy rather than stenting

39
Q

What does WiLLiaM MaRRoW refer to wrt bundle branch block

A

LBBB (the
“L”s in WiLLiaM) is reported by a broad S-wave (or deep Q- and S-waves)
in the right-hand leads (forming a “W” in the QRS of V1–3, mainly V1)
and a pair of R-waves in the left-hand leads (forming an “M” in the QRS of
V4–6, mainly V6). Either way, the QRS complexes will be broad, even if the
“W”s and “M”s are not obvious.

Right bundle branch block (RBBB) reports
the reverse: an “M” in the QRS of leads V1–3 and a “W” in the QRS of
V4–6

40
Q

What is used if rapid lowering of hypertension is required? Where monitoring is available

A

sodium nitroprusside.

BB’s and GTN are used if monitoring isn’t available

41
Q

NSTEMI mx

A

Ix: unstable angina picture with raised trops but with STD

mx:

300mg aspirin
Fondaparinux if no PCI is planned + no risk of bleeding

GRACE score

No PCI planned;
low risk = tic
high risk = clop

PCI planned;

unstable - immediate

stable = pras/tic + UFH + wait 72hrs

If pt is high bleeding risk;

swap pras for tic, or tic for clop

If pt is on anticoagulants;

use clop instead

42
Q

What to do re metformin, gliclazie and insulin when a T2D has an MI?

A

Stop metformin and gliclazide and give IV insulin

43
Q

ECG signs indicating infarction in cardiac terratories

A

Anteroseptal = V1-V4
Left anterior descending

Inferior = II, III, aVF
Right coronary

Anterolateral = V1-6, I, aVL Proximal left anterior descending

Lateral = I, aVL +/- V5-6
Left circumflex

Posterior = V1-3

Reciprocal changes of STEMI are typically seen:
horizontal ST depression
tall, broad R waves
upright T waves
dominant R wave in V2

Posterior infarction is confirmed by ST elevation and Q waves in posterior leads
(V7-9) Usually left circumflex, also right coronary

44
Q

Name 4 causes of ST elevation?

A

Causes of ST elevation

  • myocardial infarction
  • pericarditis/myocarditis
  • normal variant - ‘high take-off’
  • left ventricular aneurysm
  • Prinzmetal’s angina (coronary artery spasm)
  • Takotsubo cardiomyopathy
  • rare: subarachnoid haemorrhage
45
Q

Hyperkalaemia ECG signs

A

ECG findings;

Brown sauce supporting lvbt (High Potassium = LVBT)

L oss of P waves

V entricular fibrillation

B road QRS complexes

T all-tented’ T waves (occurs first)

S inusoidal wave pattern

46
Q

ECG indications of myocardial ischaemia

A

Acute myocardial infarction (MI)

hyperacute T waves are often the first sign of MI but often only persists for a few minutes

ST elevation may then develop

the T waves typically become inverted (in the leads relevant to the cardiac territory) within the first 24 hours.

The inversion of the T waves can last for days to months

‘Global’ T wave inversion (not fitting a coronary artery territory) - think non-cardiac cause of abnormal ECG

pathological Q waves develop after several hours to days. This change usually persists indefinitely

47
Q

ToF vs VSD vs ebsteins vs coarctation of the aorta

A
48
Q

Torsades de pointes

A

Twisting of the points

crazy scribble ECG

A polymorphic VT with long QT

mx = IV mag sulph

49
Q

Postural Hypotension

A

Causes

hypovolaemia

autonomic dysfunction: diabetes, Parkinson’s

drugs: diuretics, antihypertensives, L-dopa, phenothiazines, antidepressants, sedatives

alcohol

50
Q

Heart Sounds

loud 1st
3rd
4th
pansystolic
end-diastolic

A

3rd heart sound = atrial myxoma (‘tumour plop’
is heard along with a mid-diastolic murmur) or Left heart failure!

An end-diastolic murmur = mitral or tricuspid stenosis,

Pansystolic murmur = mitral regurgitation and ventral septal defects.

A loud first heart sound = mitral stenosis and Wolff–Parkinson–White syndrome.

A fourth heart sound = ventricular hypertrophy, which can be due to a number of causes such as chronic
hypertension, aortic stenosis and congestive heart failure

51
Q

Signs of right and left heart failure? criteria for urgent 2 week echo?

A

Right = Raised JVP, ankle oedema and hepatomegaly

Left = pulmonary oedema

Patients with clinical signs of heart failure and raised BNP greater than 400 pg/ml should have a transthoracic doppler echo within 2 weeks

52
Q

How does warfarin affect PTT and APTT?

A

Warfarin affects factor X, IX, VII and II. The extrinsic pathway, affecting the PT, involves factor VII. The intrinsic pathway, affecting the APTT, involves factors XII, XI, IX, VIII.

Because Warfarin reduces the levels of factor VII, the PT is prolonged with therapeutic doses of Warfarin.

In theory, as Wafarin affects the levels of factor IX, you would expect the APTT to be prolonged also. This is not the case as Warfarin affects factor IX less prominently than factor VII!

As such, the APTT will usually be normal in patients taking Warfarin with a prolonged PT.

The exception to this would be in an overdose of Warfarin, where you would expect both the PT and APTT to be prolonged.

53
Q

Wellens syndrome

A

Critical stenosis of the left anterior descending artery and is a medical emergency, requiring urgent PCI as per ACS protocol.

A history of self-resolving cardiac chest pain on a background of ischaemic heart disease is typical of Wellen’s syndrome.

ECG commonly shows;

  • Deeply inverted T-waves in leads V2-V3 (which may extend to V1-V6)
  • no or minimal ST-elevation and
  • preserved R wave progression.

Med Finals (14 decks)

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