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PACES Y6 > Cardio + resp > Flashcards

Cardio + resp Flashcards

1
Q

Non-murmur signs in aortic stenosis

A

Narrow pulse pressure
Slow rising pulse
Thrill

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2
Q

Non-murmur signs in aortic regurgitation

A

Wide pulse pressure
Collapsing pulse
Quincke’s sign (nailbed pulsation)
De Musset’s sign (head bobbing)

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3
Q

Non-murmur signs in mitral stenosis

A

Malar flush
Dyspnoea
Haemoptysis

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4
Q

Causes of different murmurs

A

Aortic stenosis: rheumatic fever, bicuspid valve, calcification
Aortic regurgitation: rheumatic fever, bicuspid valve, connective tissue disorder
Mitral regurgitation: rheumatic fever, calcification, connective tissue disorder
Mitral stenosis: rheumatic fever

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5
Q

Different cardiothoracic incicions

A

Midline sternotomy
Clamshell incision (for widespread traumatic chest injury)
Sub-clavicular incision

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6
Q

Indication for midline sternotomy

A

Open valve surgery
Coronary artery bypass grafting
Cardiac transplant

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7
Q

Different types of valve replacements procedures and valves

A

Procedures:
Transcatheter aortic/pulmonary valve implantation (usually biological)
Surgical aortic valve replacement

Valves:
Metallic - younger patients (last longer, tolerate anticoagulation therapy)
Biological - older patients (usually porcine/bovine, or homograft more durable but less widely available)

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8
Q

Drugs you need to be on after valve replacement

A

Only needed in metallic heart valve, or biological if there is atrial fibrillation

LMWH for bridging
Warfarin
Not recommended to use DOACs regardless of AF

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9
Q

Murmur investigations

A

Bedside: obs for pulse pressure, ECG for ventricular strain
Bloods: BNP, FBC, CRP and blood cultures for infective endocarditis, risk factors e.g. lipids, HbA1c
Imaging: TTE

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10
Q

Murmur management

A

MDT for regular follow-up
Conservative e.g. cardiovascular lifestyle
QRISK to determine whether statins, etc. are needed
Valve replacement

Regurgitations: reduce afterload with ACEi, BB, diuretics

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11
Q

What is a QRISK score?

A

QRISK3 (the most recent version of QRISK) is a prediction algorithm for cardiovascular disease that uses traditional risk factors

A QRISK over 10 (10% risk of CVD event over the next ten years) indicates that primary prevention with lipid lowering therapy (such as statins) should be considered

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12
Q

Indications for valve replacement

A

Asymptomatic and valve gradient >40mmHg or valve area <1cm2
Symptomatic

Balanced with patients history, overall health, and risk/benefits
Take into account the cause e.g. infective endocartditis

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13
Q

Heart failure signs

A

Left signs:
- dyspnoea
- orthopnoea
- paroxysmal nocturnal dyspnoea

Right signs:
- raised JVP
- peripheral oedema
- hepatomegaly, ascites

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14
Q

Heart failure causes

A

Myocardial (coronary artery disease, HTN)
Valvular
Pericardial (constrictive)
Arrhythmias

Non-cardiac: high output (sepsis), volume overload (CKD, nephrotic syndrome)

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15
Q

New York Heart Association classification for heart failure

A

1 - no limitation
2 - dypnoea on activity
3 - marked limitation on activity
4 - dyspnoea at rest

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16
Q

Ejection fraction classification for heart failure

A

HFpEF: >= 50% (LV unable to relax)
HFrEF: <40% (LV unable to contract properly)

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17
Q

Heart failure investigations

A

Bedside - ECG for LVH
Bloods - BNP: 400-2000 (TTE within 6 weeks), >2000 (TTE within 2 weeks)
CXR - alveolar oedema, Kerley B lines, cardiomegaly, upper lobe diversion, pleural effusion

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18
Q

Heart failure management

A

Conservative
1. ACE inhibitor, ARB, or beta-blocker
2. Spironolactone, SGLT-2 inhibitor (e.g. dapagliflozin) or entresto (sacubitril/valsartan) if HFrEF
3. Hydralazine with nitrate

Influenza and pneumococcal vaccine

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19
Q

Types of pacemakers and indications

A

Single-chamber: lead in right atrium OR ventricle (heart block affecting one chamber)
Dual-chamber: lead in right atrium AND ventricle (heart block affecting both chambers)
Biventricular/cardiac resynchronisation: lead in right atrium and both ventricles
Leadless: small and inside right ventricle, used for bradycardic patients, can’t have traditional surgery or complications with leads

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20
Q

CHADSVASc vs ORBIT

A

CHADSVASc for anticoagulation determination
0 - no treatment
1 - consider anticoagulation in males
2 - offer anticoagluation

Congestive heart failure
Hypertension / treated
Age >= 75 (2)
Age 65-74 (1)
Diabetes
Previous stroke, TIA, thromboembolism
Vascular disease
Sex - female

ORBIT for bleeding risk, to consider whether anticoagulation is in the best interests of the patient, no formal rules, depends on individual patient factors (e.g. alcohol or drug abuse, how bad their bleeding history is)
Low haemoglobin (2)
Age > 74
Bleeding history e.g. GI bleed
Renal impairment
Antiplatelets

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21
Q

Which anticoagulation is recommended for reducing stroke risk in atrial fibrillation?

A
  1. DOAC e.g. apixaban
  2. Warfarin

NOT aspirin

22
Q

Infective endocarditis signs

A

Clubbing
Splinter haemorrhages
Osler’s nodes (tender)
Janeway lesions (non-tender)
Roth spots (fundoscopy)
Splenomegaly

23
Q

Infective endocarditis investigations

A

Bedside: obs, ECG
Bloods: infection including blood cultures, inflammation
Imaging: echo

Cover Duke’s criteria (2 major, 1 major + 3 minor, 5 minor)
Major = positive blood culture, echo findings or new regurgitation

24
Q

Infective endocarditis management

A

Antibiotics
Initial blind - native: amoxicillin, sepsis or allergic: vancomycin + gentamicin, prosthetic: vancomycin + gentamicin + rifampicin
Treat according to culture after

Surgery
- severe incompetence
- aortic abscess (long PR interval)
- cardiac failure
- resistant to abx

25
Q

CABG indication and procedure

A

Severe coronary artery disease, failed PCI, very high risk

Put on heart-lung bypass machine, healthy vessel taken from leg, chest or arm, and attach to heart to bypass blockage

26
Q

Atrial fibrillation management

A

Haemodynamically stable < 48 hours
Rate control
1. BB (bisoprolol) or rl-CCB (verapamil)
2. Digoxin

OR

Rhythm control
1. Electrical cardioversion
2. Pharmacological cardioversion (flecainide, amiodarone)

Haemodynamically stable > 48 hours

Rate control
1. BB (bisoprolol) or rl-CCB (verapamil)
2. Digoxin

ORBIT score

Start anticoagulation for 3 weeks (DOAC - apixaban, or warfarin)

Electrical cardioversion

If you can’t wait: LMWH + echo to rule out left atrial thrombus

Haemodynamically unstable

Electrical cardioversion

27
Q

DVLA for ACS, CABG, pacemaker and ICD insertion

A

ACS: 4 weeks off (or 1 week if angioplasty)
CABG: 4 weeks off
Pacemaker: 1 week off
ICD: 6 months if ventricular arrhytmia, 1 month if prophylactic

28
Q

What is an ICD?

A

Implantable cardioverter-defibrillator

Treat tachyarrhytmias and life-threatening rhythms (pacemaker is for slow or irregular rhythms) e.g. VT and VF
Delivers shocks in addition to pacing the heart

29
Q

Causes of clubbing

A

Cardiovascular
- infective endocarditis
- congenital cyanotic heart disease
- brachial arteriovenous fistula

Respiratory
- pulmonary fibrosis
- bronchiectasis
- bronchial carcinoma
- mesothelioma
- TB

Gastrointestinal
- IBD
- Coeliac disease
- Liver/bowel cancer
- Cirrhosis

30
Q

Investigations for pulmonary fibrosis

A

Bedside: ECG for right ventricular strain, spirometry (FVC decreased, so FEV1/FVC increased)
Bloods: ABG, ANA, infection, inflammation
Imaging: CXR and HrCT

31
Q

Management of pulmonary fibrosis

A

Acutely: supportive and high-dose corticosteroids

Long-term:
Pulmonary rehabilitation (exercise, breathing techniques, education, psychosocial support, nutritional counseling for overall health, stop smoking)
Antifibrotics: pirfenidone
Supplemental oxygen if hypoxic

32
Q

Investigations of bronchiectasis

A

Bedside: sputum culture (pseudomonas aerigunosa most common)
Bloods: superimposed infection, inflammation
Imaging: CXR, HrCT

33
Q

Causes of bronchiectasis

A

Post-infective e.g. TB, pneumonia
Cystic fibrosis
Obstruction e.g. lung cancer

34
Q

Management of bronchiectasis

A

Exercise - airway clearance
Inhaled bronchodilator e.g. salbutamol
Mucoactive agent e.g. nebulised saline or mucolytic like acetylcysteine
Antibiotics for exacerbation

35
Q

Investigations of COPD

A

Bedside - sputum culture, post-bronchodilator spirometry FEV1/FVC ratio <0.7
Bloods - FBC (secondary polycythaemia from hypoxia)
Imaging - CXR

36
Q

Management of COPD

A

Exacerbation:
A-E
24% venturi mask
Nebulised salbutamol + ipratropium
IV hydrocortisone
IV abx

Long-term:
1. SABA or SAMA (ipratropium)
2. No asthmatic features: add LABA (salmeterol) and LAMA (tiotropium). Asthmatic features: LABA + ICS
Switch SAMA to SABA if taking.
3. LABA + (LAMA + ICS)

37
Q

Additional management of CREST (that has pulmonary HTN/RHF)

A

For CREST
Exercise, stop smoking, physiotherapy
Immunosuppression: methotrexate
ACE inhibitor if renal involvement

38
Q

More specific investigations of lung cancer

A

CXR
CT chest
Bronchoscopy
PET scanning

39
Q

Management of lung cancer

A

Small-cell
- Surgery if small
- Most are metastasised: radio and chemo (or just palliative chemo)

Non-small cell
- Surgery if small
- radiotherapy
- poor response to chemo

40
Q

Types of lung scars and their indications

A

Posterolateral thoracotomy
Anterolateral thoracotomy (goes under pec)

May be done for:
Lobectomy: malignancy, recurrent localised infection (CF, bronchiectasis)
Pneumonectomy
Single lung transplant (double is through clamshell)
Bullectomy in COPD (bulla space >1cm)

41
Q

Causes of pulmonary fibrosis

A

Occupational
- Asbestosis
- Silicosis

Infection
- Aspergillosis
- TB

Drugs
- Methotrexate
- Amiodarone

Radiation fibrosis
Idiopathic

42
Q

CXR/CT changes of pulmonary fibrosis

A

bilateral interstitial shadowing (typically small, irregular, peripheral opacities - ‘ground-glass’ - later progressing to ‘honeycombing’)

43
Q

Differentiation between asthma and COPD in investigations

A

Asthma has post-bronchodilator reversibility

COPD has post-bronchodilator FEV1/FVC <0.7

44
Q

Peak flow results in different lung conditions

A

Asthma: usually 20-30% lower
Bronchiectasis: usually 20-30% lower
COPD: lower than asthma due to airway obstruction
Pulmonary fibrosis: lowest due to restrictive lung disease

45
Q

Investigations for pleural effusion

A

PA x-ray
USS
CXR
CT for underlying disease

USS guided pleural aspiration
>30g/L = exudate
<30g/L = transudate

46
Q

Management of pleural effusion

A

Treat underlying cause

Recurrent aspiration
Indwelling catheter
Opioids for dyspnoea

47
Q

Signs of CO2 retention

A

Flap
Bounding pulse
Narcosis (drowsiness)

48
Q

Signs of cor pulmonale

A

Lung disease -> right ventricular hypertrophy

Peripheral oedema
Raised JVP
Systolic parasternal heave

49
Q

Upper and lower lobe causes of pulmonary fibrosis

A

Upper: COPD, silicosis, tuberculosis
Lower: idiopathic, systemic sclerosis, hypersensitivity

50
Q

What FiO2 is 1L and other L

A

1L = 24%
2L = 28%
(increases by 4%)

15L = 80%

51
Q

Which vessels are used for CABG?

A

Saphenous vein
Internal mammary artery (best)
Radial artery
Gastroepiploic artery

PACES Y6 (6 decks)

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