cardio to work on Flashcards
1
Q
What histological layer of the artery may be thinned by an atheromatous plaque?
A
Media
2
Q
Give 5 possible causes of angina
A
- atheroma/stenosis of coronary arteries
- valvular disease
- aortic stenosis
- arrhythmia
- anaemia
3
Q
Name 3 differential diagnoses for angina
A
- Pericarditis/myocarditis
- PE
- Chest infection
- Dissection of aorta
- GORD
4
Q
Describe type 1 MI
A
Spontaneous MI with ischaemia due to a primary coronary event
e.g. plaque erosion/rupture, fissuring or dissection
5
Q
Describe type 2 MI
A
MI secondary to ischaemia due to increased O2 demand or decreased supply such as in coronary spasm, coronary embolism, anaemia, arrhythmias, hypertension or hypotension
6
Q
Give 3 signs of MI
A
- Hypo/hypertension
- 3rd/4th heart sound
- Signs of congestive heart failure
- Ejection systolic murmur
7
Q
Name 3 possible differential diagnoses of MI
A
- Pericarditis
- Stable angina
- Aortic dissection
- GORD
- Pneumothorax
8
Q
What might the ECG of someone with NSTEMI show?
A
May be normal or might show T wave inversions and ST depression
Might also be R wave regression, ST elevation and biphasic T wave in lead V3
9
Q
Give 2 potential side effect of P2Y12 inhibitors
A
- Bleeding
- Rash
- GI disturbances - ulceration
10
Q
Give 5 potential complications of MI
A
- sudden death
- arrhythmias
- persistent pain
- heart failure
- mitral incompetence
- pericarditis
- cardiac rupture
- aneurysm
11
Q
what are the clinical features of PE?
A
SYMPTOMS
- Breathlessness
- Pleuritic chest pain
- signs/symptoms of DVT
SIGNS
- Tachycardia
- Tachypnoea
- pleural rub
12
Q
What is the treatment for a PE?
A
- LMW heparin,
- oral warfarin for 6 months
- DOAC - for outpatient with a relatively minor PE
- Treat cause if possible
- surgery for massive clot - embolectomy
13
Q
How would you describe an arterial thrombus?
A
Platelet rich (a ‘white thrombosis’)
14
Q
How would you describe a venous thrombosis?
A
Fibrin rich (a ‘red thrombosis’)
15
Q
Describe the aetiology of pericarditis
A
- Viral (common) - e.g. enteroviruses, adenoviruses
- Bacterial - e.g. mycobacterium tuberculosis
- Autoimmune - e.g. Sjören syndrome
- Neoplastic
- Metabolic - e.g. uraemia
- Traumatic and iatrogenic
- Idiopathic (90%)
- dressler’s syndrome
16
Q
Name 3 differential diagnoses for acute pericarditis
A
- MI
- Angina
- Pneumonia
- Pleurisy
- PE
- GORD
- pneumothorax
17
Q
What investigations might you do on someone who you suspect to have pericarditis?
A
- ECG - diagnostic
- CXR
- Bloods - FBC, ESR and CRP, Troponin
- Echocardiogram - usually normal, rule out silent pericardial effusion
18
Q
What might the ECG look like in someone with acute pericarditis?
A
- Saddle shaped ST elevation
2. PR depression
19
Q
What are the signs of Cardiac tamponade?
A
Beck’s triad:
- low BP but high HR
- Increased JVP
- Quiet S1 and S2
- Pulsus paradoxus = pulses fade on inspiration
- Kussmaul’s sign = rise in jugular venous pressure with inspiration
20
Q
Name 3 major predictive markers for complications for pericarditis
A
- Fever >38 degree
- Subacute onset
- Large pericardial effusion
- Cardiac tamponade
- Lack of response to aspirin or NSAIDs after at least 1 week of therapy
21
Q
what are the treatments for peripheral vascular disease?
A
Control risk factors:
- Smoking cessation
- Regular exercise
- Weight reduction
- BP control, DM control
- Statin
Antiplatelet therapy:
- Aspirin/clopidogrel
22
Q
Give 4 signs of critical ischaemia
A
- Rest pain
- Classically nocturnal
- Ulceration
- Gangrene
23
Q
what are the risk factors for heart failure?
A
- > 65 y/o
- African descent
- Men
- Obesity
- Previous MI
24
Q
what are the clinical signs of left heart failure?
A
- Pulmonary crackles
- S3 and S4 and murmurs
- Displaced apex beat
- Tachycardia
- fatigue
25
what are the clinical features of right HF?
1. Raised JVP
2. Ascites
3. peripheral oedema
26
what are the clinical features of heart failure?
SOFA PC
- shortness of breath
- orthopnea
- fatigue
- ankle swelling
- pulmonary oedema (due to backflow from decreased CO; produced cough with pink frothy sputum)
- cold peripheries
Raised JVP
End respiratory crackles
27
what is the management for chronic HF?
1st line = ACEi, beta blocker
2nd = ARB + nitrate
3rd = cardiac resynchronization or digoxin
4th = diuretics (furosemide)
5th = aldosterone antagonist (spironolactone)
28
What are the blood pressure readings for someone to be diagnosed with Stage 1 hypertension?
Clinic BP = 140/90
| ABPM = 135/85
29
What are the blood pressure readings for someone to be diagnosed with Stage 2 hypertension?
Clinic BP = 160/100
| ABPM = 150/95
30
What are the blood pressure readings for someone to be diagnosed with severe hypertension?
Systolic BP = >180
| Diastolic BP = >110
31
Write an equation for BP
BP = CO x TPR
32
Give 4 functions of angiontensin II
1. Potent vasoconstrictor
2. Activated sympathetic nervous system - increased NAd
3. Activates aldosterone - Na+ retention
4. Vascular growth, hyperplasia and hypertrophy
33
what are the side effects of ACE inhibitors?
1. Hypotension
2. Hyperkalaemia
3. Acute renal failure
4. Teratogenic
5. cough - from build up of kinin
34
Give 4 potential side effect of ARBs
1. Hypotension
2. Hyperkalaemia
3. Renal dysfunction
4. Rash
Contraindicated in pregnancy
35
Give 3 potential side effects that are due to the vasodilatory ability of CCBs
1. Flushing
2. Headache
3. Oedema
4. Palpitations
36
Give 2 potential side effects that are due to the negatively chronotropic ability of CCBs
1. Bradycardia
2. Atrioventricular block
3. Postural hypotension
37
Give a potential side effect that is due to the negatively inotropic ability of CCBs
Worsening cardiac failure
38
Give 4 potential side effects of verapamil
1. Worsening of cardiac failure (-ve inotrope)
2. Bradycardia (-ve chronotrope)
3. Atrioventricular block (-ve chronotrope)
4. Constipation
39
Give 3 conditions in which Beta blockers can worsen them
1. Asthma or COPD
2. PVD
3. Heart failure
40
Give 5 potential side effects of diuretics
1. Hypovolaemia
2. Hypotension
3. Reduced serum Na+, K+, Mg+, Ca2+
4. Increased uric acid --> gout
5. Erectile dysfunciton
6. Impaired glucose tolerance
41
What are the functions of ANP and BNP?
1. Increased renal excretion of Na+ and water
2. Vasodilators
3. Inhibit aldosterone release
42
Why can Neprilysin (NEP) inhibitors work for heart failure treatment?
NEP metabolises ANP and BNP
| NEP inhibitors therefore increase levels of ANP and BNP in the serum
43
Give 2 potential side effects of nitrates
1. Headache
2. GTN syncope
3. Tolerance
44
Name two class 1 drugs of the Vaughan Williams classification
Class 1 are Na+ channel blockers
1a = disopyramide, quinidine
1b = lidocaine
1c = flecainide (tachycardias)
45
Name three class 2 drugs of the Vaughan Williams classification
Class 2 are Beta blockers
Propranolol
Atenolol
Bisoprolol
46
Name a class 3 drug of the Vaughan Williams classification
Class 3 rugs prolong the action potential
Amiodarone
Side effects are likely with these
47
Name two class 4 drugs of the Vaughan Williams classification
Class 4 drugs are calcium channel blockers (but NOT dihydropyridines as they don't effect the heart)
Verapamil
Dilitiazem
48
How does digoxin work?
Inhibits the Na+/K+ pump therefore making the action potential more positive and ACh is released from parasympathetic nerves
49
What are the main effect of digoxin?
1. Bradycardia
2. Reduced atrioventricular conduction
3. Increased force of contraction (positive inotrope)
50
Give 3 potential side effects of digoxin
1. Nausea
2. Vomiting
3. Diarrhoea
4. Confusion
Also has a narrow therapeutic range
51
In what disease is digoxin clinically indicated?
1. Atrial fibrillation
| 2. Severe heart failure
52
How does amiodarone work?
Prolongs action potential by delaying depolarisation
53
Name 4 potential effects of amiodarone
1. QT prolongation
2. Interstitial lung disease
3. Hypothyroidism
4. Abnormal liver enzymes
54
Name a disease that might cause flattening of the P wave
1. Hyperkalaemia
| 2. Obesity
55
Name a disease that might cause tall P waves
Right atrial enlargement
56
Name a disease that might cause broad notched P waves
Left atrial enlargement
57
What aspect of the heart is represented by leads II, III and aVF?
Inferior aspect
58
What might ST elevation in leads II, II and aVF suggest?
RCA blockage
| Leads represent inferior aspect of heart, RCA supplies inferior aspect
59
Give 3 effects hyperkalaemia on an ECG
GO - absent P wave
GO TALL - tall T wave
GO long - prolonged PR
GO wide - wide QRS
60
Give 2 effects of hypokalaemia on an ECG
1. Flat T waves
2. QT prolongation
3. ST depression
4. Prominent U waves
61
Give an effect go hypocalcaemia on an ECG
1. QT prolongation
2. T wave flattening
3. Narrowed QRS
4. Prominent U waves
62
Give an effect of hypercalcaemia on an ECG
1. QT shortening
2. Tall T wave
3. No P waves
63
Give 3 potential consequences of arrhythmia
1. Sudden death
2. Syncope
3. Heart failure
4. Chest pain
5. Palpitations
May also be asymptomatic
64
Give 2 causes of bradycardia
1. Conduction tissue fibrosis
2. Ischaemia
3. Inflammation/infiltrative disease
4. Drugs
65
Name 3 types of supraventricular tachycardia
1. Atrial fibrillation
2. Atrial flutter
3. AV node re-entry tachycardia
4. AV re-entry tachycardia (accessory pathway)
66
what is the clinical presentation of AV node re-entry tachycardia (AVNRT)?
Rapid regular palpitations – abrupt onset, sudden termination
Chest pain and breathlessness
Neck pulsations
Polyuria
67
Describe the acute treatment of AV node re-entry tachycardia (AVNRT)
Vagal manoeuvre,
carotid sinus massage
catheter ablation and adenosine (block AVN to terminate the SVT)
68
What drugs might you give someone to suppress further episodes of AV node re-entry tachycardia (AVNRT)?
Beta blockers, CCB
69
Describe 3 characteristics of an ECG from someone with accessory pathway arrhythmia
1. Delta wave
2. Short PR interval
3. Slurred QRS complex
70
Give 4 causes of sinus tachycardia
1. Physiological response to exercise
2. Fever
3. Anaemia
4. Heart failure
5. Hypovolaemia
6. pain
71
What ECG changes might you see with someone with ventricular tachycardia?
Crescendo-decrescendo amplitude = torsades de pointes
72
What is long term treatment for ventricular tachycardia in high risk patients
Implantable cardioverter defibrillator (ICD)
73
What is the treatment for stable ventricular tachycardia?
IV beta blockers (bisoprolol) and IV amiodarone
74
what is the clinical presentation of atrial fibrillation?
can be asymptomatic
1. SOB
2. Chest pain
3. Palpitations
4. Syncope
5. fatigue
6. apical pulse greater than radial pulse
75
what are the causes of atrial fibrillation?
```
Idiopathic
Hypertension
Heart failure
Coronary artery disease
Valvular heart disease
Cardiac surgery
Cardiomyopathy
Rheumatic heart disease
```
76
Describe 2 characterics of an ECG taken from someone with atrial fibrillation
1. Absent P waves
2. Irregular and rapid QRS complexes
3. Fine oscillation of the baseline
'Irregularly irregular'
77
What score can be used to calculate the risk of stroke in someone with atrial fibrillation?
CHA2D2 VAS
78
What does the CHA2DS2 VASc score take into account
```
CHD
HTN
Age (>75) = 2 points
DM
Stroke (previous) = 2 points
Vascular disease
Age 65-74
Sex (female)
```
Score >1 = anticoagulation
79
Describe the treatment for atrial fibrillation
- cardioversion - LMWH (enoxaparin) and DC shock
- rate control - 1st line = beta blocker, 2nd line = CCB
- rhythm control - BB (bisoprolol), CCB (verapamil), digoxin, anti-arrhythmic (amiodarone)
- anti-coagulation
80
What might you give someone to help with rate control in atrial fibrillation?
BB, CCB, digoxin
81
What might you give someone to help restore sinus rhythm in atrial fibrillation?
Electrical cardioversion or pharmacological cardioversion using flecainide
82
What is the long term treatment for atrial fibrillation?
Catheter ablation
83
What is atrial flutter?
Fast but organised waves in the atrium
| Atrial rate 250-350 bpm
84
Describe the ECG pattern taken from someone with atrial flutter
1. Narrow QRS
| 2. Saw tooth flutter (F) waves
85
Describe the pathophysiology of atrial flutter
the P wave produces a sawtooth pattern with regular conduction to the ventricles
- Wave of contraction around the atria causing the repolarisation of the AV node
86
What are ectopic beats?
Non sustained beats arising from ectopic regions of atria or ventricles
Very common, generally benign arrhythmias caused by premature discharge
87
what are the causes of long QT syndrome?
1. Congenital
2. hypokalaemia,
3. hypocalcaemia
4. Drugs - amiodarone, tricyclic antidepressants
5. bradycardia
6. Acute MI
7. diabetes
88
what is the clinical presentation of long QT syndrome?
1. Palpitations
2. Syncope
- may progress to VF
89
what are the causes of heart block?
```
Athletes
Sick sinus syndrome
IHD – esp MI
Acute myocarditis
Drugs
Congenital
Aortic valve calcification
Cardiac surgery/trauma
```
90
What kind of heart block is associated with wide QRS complexes with an abnormal pattern?
Right bundle branch block (RBBB) and Left bundle branch block (LBBB)
91
What changes would you see on an ECG from someone with a LBBB?
WiLLiaM
slurred S wave in V1 (resembles W)
R wave in V6 (resembles M)
wide QRS with notched top in V6
92
What changes would you see on an ECG from someone with a RBBB?
MaRRoW
R wave in V1 (resembles M)
slurred S wave in V6 (resembles W)
wide QRS
RSR pattern in V1
93
what are the symptoms of aortic stenosis?
Occur when valve area is 1/4 of normal (normal - 3-4 cm2)
1. Exertional syncope
2. Angina
3. Exertional dyspnoea
94
what are the signs of aortic stenosis?
- ejection systolic murmur radiating to carotids and apex - crescendo-decrescendo
- sustained, heaving apex
- slow rising pulse
- narrow pulse pressure
- soft S2 if severe
95
What can cause mitral regurgitation?
1. Myxomatous degeneration (mitral valve prolapse) - most common cause
2. Ischaemic mitral valve
3. Rheumatic heart disease
4. IE
5. dilating left ventricle
96
what are the symptoms of mitral regurgitation?
palpitations
exertional dyspnoea
fatigue
weakness
97
Give 3 signs of mitral regurgitation
1. Pan-systolic murmur radiating to left axilla
2. Soft/absent S1
3. displaced, thrusting apex
4. atrial fibrillation
98
What is the management of mitral regurgitation?
- Mild is managed by following patient with echoes every 1-5yrs
- Beta-blockers - ATENOLOL
- Calcium channel blockers
- DIGOXIN
- Diuretics - FUROSEMIDE
- ACEIs - RAMIPRIL or HYDRALAZINE
- Surgical intervention if severe and symptomatic or
- If ejection fraction <60%
- New onset AF
99
What causes aortic regurgitation?
acute
- infective endocarditis
- rheumatic fever
- aortic dissection
chronic
- rheumatic disease
- bicuspid aortic valve
- aortic endocarditis
100
Give 3 symptoms of aortic regurgitation
- palpitations
- angina
- dyspnoea
101
Give 3 signs of aortic regurgitation
- early diastolic murmur - decrescendo
- water hammer (collapsing) pulse
- wide pulse pressure
- displaced apex
102
What investigations might you do in someone who you suspect to have aortic regurgitation?
CXR - cardiomegaly, aortic root enlargement
ECHO - assess severity
ECG - left ventricular hypertrophy
cardiac catheterisation
103
What investigation might you do in someone who you suspect to have aortic stenosis?
- Echocardiography
High gradient = severe stenosis
- CXR - prominence of ascending aorta
- ECG - depressed ST and T wave inversion
104
What investigations might you do in someone who you suspect to have mitral regurgitation?
1. ECG
2. CXR
3. Echo - estimates LA/LV size and function
4. doppler and colour flow doppler to measure severity
105
Describe the management for someone with aortic regurgitation
IE prophylaxis
ACEi (ramipril) = vasodilators
Regular echos - motion progression
Surgery if symptomatic
106
Name 3 causes of mitral stenosis
1. Rheumatic heart disease
2. IE
3. Mitral annular calcification - rarer
107
what are the symptoms of mitral stenosis?
1. progressive dyspnoea
2. Haemoptysis (coughing up blood)
3. palpitations (AF)
4. chest pain
108
what are the signs of mitral stenosis?
rumbling mid-diastolic murmur with opening snap - decrescendo-presystolic crescendo
1. malar flush
2. AF
3. tapping apex beat
4. low volume pulse
5. loud snapping S1
109
What investigations might you do in someone who you suspect to have mitral stenosis?
1. ECG - AF, left atrial hypertrophy causes bifid P wave
2. CXR - large L atrium, pulmonary oedema
3. Echo - gold standard for diagnosis
110
Describe the management for mitral stenosis
If mild treatment is not required
Beta blockers control HR - ATENOLOL and DIGOXIN
Diuretics for fluid overload - FUROSEMIDE
Percutaneous balloon valvotomy to increase size of mitral valve opening
Mitral valve replacement
111
In what type of valvular heart disease would you hear a mid-diastolic murmur and a 1st heart sound snap
Mitral stenosis
112
In what type of valvular heart disease would you hear a pan systolic murmur?
Mitral regurgitation
113
In what type of valvular heart disease would you hear an ejection systolic murmur?
Aortic stenosis
114
In what type of valvular heart disease would you see a wide pulse pressure and hear an early diastolic blowing murmur and systolic ejection murmur?
Aortic regurgitation
115
Name 4 types of infective endocarditis
1. Left sided native IE
2. Left sided prosthetic IE
3. Right sided IE
4. Device related IE (pacemaker, defibrillators)
116
what are the risk factors for infective endocarditis?
- IV drug use
- poor dental hygiene
- skin and soft tissue infections
- dental treatment
- IV cannula
- cardiac surgery
- pacemaker
- immunocompromised
117
Which bacteria are most likely to cause infective endocarditis?
1. Staphylococcus aureus
2. Staphlococcus epidermidi (coagulase negative staph)
3. Streptococcus viridian's (alpha haemolytic)
118
Give 3 groups of people who are at risk of infective endocarditis
```
more common in developing countries
males > females
1. Elderly
2. IV drug users
3. Those would prosthetic valves
4. Those with rheumatic fever
5. Young with congenital heart disease
```
119
Name 2 sites where vegetation is likely in infective endocarditis
1. Atrial surface of AV valves
| 2. Ventricular surface of SL valves
120
Give 4 signs of infective endocarditis
1. Splinter haemorrhages - on nails
2. Osler's nodes - on hands
3. Janeway lesions - on hands
4. Roth spots - in eyes
5. embolic skin lesions - skin
6. petechiae - skin
7. Heart murmurs
anaemia
splenomegaly
clubbing
valve disease
121
Name the criteria that is used in the diagnosis of infective endocarditis
Duke's criteria
122
What investigations might you do in someone who you suspect to have infective endocarditis?
1. Blood cultures - essential
2. Echo - TTE ot TOE
3. Bloods - raised ESR and CRP, normochromic normocytic anaemia
4. ECG - long PR interval, MI
123
Describe the treatment for infective endocarditis
1. Antibiotics based on cultures
2. Treat any complications
3. Surgery - remove and replace valve
124
Give 4 indications for surgery in IE
1. Antibiotics not working
2. Complications
3. To remove infected devices
4. To replace valve after infection cured
5. To remove large vegetations before they embolism
125
Name 2 drugs that can prolong the QT interval
1. Sotalol
| 2 Amiodarone
126
What additional property makes propranolol the most useful beta blocker to help control the arrhythmias which occur immediately following a heart attack?
It can also block sodium channels
127
What are the 4 main features of tetralogy of fallot?
1. Ventricular septal defect
2. Over-riding aorta
3. RV hypertrophy
4. Pulmonary stenosis
128
Would a baby born with tetralogy of fallot be cyanotic?
YES
RV pressure higher than LV
Blood passes from RV to LV so patients are blue = cyanosis
129
Briefly decscribe the pathophysiology if Eisenmengers syndrome
High pressure pulmonary blood flow damages pulmonary vasculature --> increase in resistance to blood flow (pulmonary hypertension) --> RV pressure increase --> shunt direction reverses (RV to LV) = cynanosis
130
What are the risks associated with Eisenmengers syndrome?
1. Risk of death
2. Endocarditis
3. Stroke
131
Describe the pathophysiology behind coarctation of the aorta
Excessive sclerosing that normally closes the ductus arteriosus extends into the aortic wall leading to narrowing
stronger perfusion to upper body than lower body causes decreased renal perfusion - leads to systemic hypertension
132
How does mild coarctation of the aorta present?
Presents with hypertension
Incidental murmur
Should be repaired to try to prevent problems in the long term
133
What long term problems can occur due to coarctation of the aorta?
Hypertension - early CAD, early stroke, subarachnoid haemorrhage
Re-coarctation requiring repeat intervention
Aneurysm formation at the site of repair
134
How does a patient present with pulmonary stenosis?
```
Right ventricular failure
Collapse
Poor pulmonary blood flow
right ventricular hypertrophy
Tricuspid regurgitation
```
135
How is pulmonary stenosis treated?
Ballon valvuloplasty
Open valvotomy
Open trans-annular patch
Shunt (to bypass blockage)
136
What are 3 problems with a bicuspid aortic valve?
1. Degenerate quicker than normal valves
2. Become regurgitant earlier than normal valves
3. Associated with coarctation and dilation of ascending aorta
137
Name 3 congenital heart defect that are not cyanotic
1. VSD
2. ASD
3. PDA
Left to right shunt
138
Name a congenital heart defect that is cyanotic
1. Tetralogy of Fallot
| Right to left shunt
139
Why does mitral stenosis cause AF?
Increased LA pressure
| Stretches myocytes in the atria and irritates pacemaker cells --> AF
140
What is Dressler's syndrome?
Myocardial injury stimulates formation of autoantibodies against the heart
Cardiac tamponade may occur
Dressler's is a secondary form of pericarditis
141
Give 3 symptoms of Dressler's syndrome
1. Fever
2. Chest pain
3. Pericardial rub
Occurs 2-10 weeks after MI
142
Write an equation for mAP
mAP = DP + 1/3PP
143
Give the equation for stroke volume
SV = EDV - ESV
144
Give 2 diseases that result from stress induced ischaemia
1. Exercise induced angina
| 2. Intermittent claudication
145
Give 2 disease that result from ischaemia due to structural/functional breakdown
1. Critical limb ischaemia
| 2. Vascular dementia
146
Name 2 diseases that are due to moderate ischaemia
1. Angina
| 2. Intermittent claudication
147
Name 3 causes of an aneurysm
1. Atherosclerotic (most common)
2. Ateriomegaly
3. Collagen disease - Marfans, vascular Ehlers Danlos
4. tobacco smoking
148
Describe the pathophysiology of an aortic dissection
Tear in intimal lining of aorta --> column of blood under pressure enters aortic wall forming haematoma --> separates intima from adventitia --> false lumen
False lumen extends --> intimal tears
149
Mitral regurgitation, what murmur do you hear?
a. Early diastolic murmur
b. Early systolic click murmur
c. Ejection systolic crescendo-decrescendo murmur
d. End diastolic murmur
e. Pansystolic murmur
What are the others murmurs of?
e. Pansystolic murmur = occurs throughout duration of systole = Mitral regurgitation
a. Early diastolic murmur = Mitral stenosis
b. Early systolic click murmur = Mitral valve replacement (click = replacement as metal)
c. Ejection systolic crescendo-decrescendo murmur = Aortic stenosis
d. End diastolic murmur
e. Pansystolic murmur = occurs throughout duration of systole = Mitral regurgitation
150
what are the risk factors for acute coronary syndromes?
```
age
male
family history
smoking
hypertension
diabetes mellitus
obesity and sedentary lifestyle
```
151
what is the management for an NSTEMI?
- use grace score to predict 6 month mortality and risk of further cardiac events
- fondaparinux
- low risk = ticagrel and aspirin
- high risk = angiography and PCI
- prasugrel and aspirin
152
what is the role of preload in heart failure?
- heart failure causes decreased volume of blood ejected with each heart beat
- the myocardial fibres stretch and don't contract as much
153
what is the role of afterload in heart failure?
- increased afterload causes increased EDV
- this causes decreased SV and decreased CO
- this is a vicious circle and continues to exacerbates the problem
154
what additional investigations should be undertaken for acute heart failure?
- BNP
- serum troponin
- D-dimer
155
what are the causes of cor pulmonale?
- chronic lung disease
- pulmonary vascular disorders
- neuromuscular and skeletal diseases
156
what are the signs of cor pulmonale?
- cyanosis
- tachycardia
- raised JVP
- RV heave
- pan-systolic murmur due to tricuspid regurgitation
- hepatomegaly
- oedema
157
what are the symptoms of cor pulmonale?
- dyspnoea
- fatigue
- syncope
158
what investigations should be undertaken for cor pulmonale?
arterial blood gas
- hypoxia
- sometimes shows hypercapnia
159
what is the management for cor pulmonale?
- treat the underlying cause
- oxygen
- diuretics
- venesection if haematocrit >55
- heart-lung transplant in young patients
160
what are the causes of atrial flutter?
- idiopathic
- CHD
- hypertension
- heart failure
- COPD
- pericarditis
- obesity
161
what are the risk factors for atrial flutter?
- atrial fibrillation
162
what is the management for atrial flutter?
- Cardioversion
- Give a LMWH
- Shock with defibrillator
- Catheter ablation = definitive treatment – creates a conduction block
- IV Amiodarone – restore sinus rhythm
163
what are the risk factors for AVNRT?
```
exertion
emotional stress
coffee
tea
alcohol
```
164
what is malignant hypertension?
markedly raised diastolic BP usually over 120mmHg and progressive renal disease
usually evidence of acute haemorrhage and papilledema
165
what are the consequences of malignant hypertension?
- cardiac failure (LVH)
- blurred vision (papilledema)
- haematuria - due to fibrinoid necrosis of glomeruli
- severe headache and cerebral haemorrhage
166
what is the treatment for recurrent pericarditis?
- The first line treatment is oral NSAIDs e.g. Ibuprofen
- Colchicine has been proven to be more effective than Aspirin alone
- In resistant cases, oral corticosteroids e.g. -Prednisolone may be effective, and in some patients, pericardiectomy (removal of part/most of the pericardium) may be appropriate
167
what is the clinical presentation of pericardial effusion?
- Symptoms of a pericardial effusion commonly reflect the underlying pericarditis
- Soft & distant heart sounds
- Apex beat obscured
- Raised jugular venous pressure
- Dysponea
168
what are the risk factors of MI?
Age, male, history of CVD, FHx
Premature menopause
DM, smoking, hypertension, hyperlipidaemia, obesity, sedentary lifestyle
169
what is an aortic dissection?
Aortic Dissection is a tear in the intimal layer of the aorta which leads to a collection of blood between the intima and medial layers.
170
what are the risk factors of aortic dissection?
```
Hypertension- most common risk factor
Trauma
Vasculitis
Cocaine use
Connective tissue disorders- cause Aortic Dissection in younger adults
```
171
what are the clinical features of aortic dissection?
- Sudden and severe tearing pain in chest radiating to back
- Hypotension
- Asymmetrical blood pressure
- Syncope
- Aortic regurgitation, coronary ischaemia, cardiac tamponade
- Peripheral pulses may be absent
172
what are the investigations of aortic dissection?
- ECG/cardiac enzymes - rule out MI
- Chest x-ray - widening mediastinum
- CT scanning- definitive imaging
- echo - TTE/TOE
- gold standard = CT angiography
173
what is the management of aortic dissection?
-Maintain hemodynamic stability- fluid resuscitation, inotropes, noradrenaline
-Opioid analgesia for pain control - MORPHINE
-Surgical intervention:
Endovascular stent-graft repair
-Put patient on antihypertensives following surgery and recovery - IV METAPROLOL (beta-blockers) or IV GTN (vasodilators)
174
what is the treatment for critical limb ischaemia?
Revascularisation (e.g. stenting, angioplasty, bypassing)
| Amputation if unsuitable
175
what are the risk factors of mitral stenosis?
- history of rheumatic fever
| - untreated strep infections
176
what are the risk factors for mitral regurgitation?
```
female
lower BMI
advancing age
renal dysfunction
prior MI
```
177
what is the clinical presentation of atrial flutter?
```
Palpitations
Breathlessness
chest pain
Dizziness
Syncope
fatigue
```
178
what are the risk factors for atrial fibrillation?
```
Over 60
Diabetes,
Hypertension
coronary artery disease
previous MI
structural heart disease
```
179
what are the causes of RBBB?
Pulmonary embolism
IHD
Atrial ventricular septal defect
180
what is the pathophysiology of RBBB?
Right bundle doesn’t conduct
Impulse spreads from left ventricle to right
Late activation of RV
181
what is the clinical presentation of RBBB?
Asymptomatic
| syncope/presyncope
182
what is the treatment for RBBB?
Pacemaker
CRT – cardiac resynchronisation therapy
Reduce blood pressure
183
what is the clinical presentation of LBBB?
Asymptomatic
| syncope/presyncope
184
what is the pathophysiology of LBBB?
Left bundle doesn’t conduct
Impulse spreads from right ventricle to left
Late activation of LV
185
what is the treatment for LBBB?
Pacemaker
CRT – cardiac resynchronisation therapy
Reduce blood pressure
186
what are the causes of LBBB?
IHD
| Aortic valve disease
187
what is the clinical presentation of Mobitz type 1 second degree heart block?
light-headedness
dizziness
syncope
188
what is the clinical presentation of Mobitz type 2 second degree heart block?
SOB
postural hypotension
chest pain
189
what is the clinical presentation of third degree heart block?
dizziness
| blackouts
190
what is the presentation of first degree heart block?
asymptomatic
191
what are the risk factors for abdominal aortic aneurysm?
- Smoking- MAJOR
- Family history
- Connective tissue disorders- Marfan’s, Ehlers-Danlos
- Age
- Atherosclerosis
- Male
192
what is the clinical presentation of an unruptured abdominal aortic aneurysm?
- often asymptomatic
- causes symptoms if expanding rapidly
- pain in abdomen, loin or groin
- pulsatile abdominal swelling
- bruit on ascultation
193
what is the clinical presentation of a ruptured abdominal aortic aneurysm?
- intermittent/continuous abdominal pain - radiates to back, iliac fossa or groin
- painful pulsatile mass
- hypovolaemic shock
- syncope
- nausea, vomiting
- profound anaemia
- sudden death
194
what are the investigations for abdominal aortic aneurysm?
- Abdominal ultrasound – can assess aorta to degree of 3mm
| - CT or MRI angiography
195
what antibiotics are used for endocarditis?
staph = vancomycin
if MRSA add rifampicin
other bacteria = benzylpenicillin and gentamycin
196
what is the clinical presentation of tetralogy of fallot?
```
central cyanosis
low birthweight and growth
dyspnoea on exertion
delayed puberty
systolic ejection murmur
```
197
what are the investigations of tetralogy of fallot?
CXR shows boot shaped heart
| Echocardiogram
198
what is the management of tetralogy of fallot?
- Full surgical treatment during first 2 years of life due to the progressive cardiac debility and cerebral thrombosis risk
- Often get pulmonary valve regurgitation in adulthood and require another surgery
199
what are the signs of pericardial effusion?
- Muffled heart sounds - effusion obscures apex beat, and heart sounds are soft
- Kussmaul’s sign – elevated jugular pressure that rises with inspiration
- Fall in BP of more that 10mmHg on inspiration (result of increased venous return to right side of heart)
- Bronchial breathing at left base
200
what are the investigations for pericardial effusion?
- Chest x ray shows large globular heart
- ECG - low voltage QRS complexes with sinus tachycardia
- Echocardiography is diagnostic - echo-free space around heart
201
what is the management for pericardial effusion?
- Most effusions resolve naturally
- Underlying cause should be sought and treated
- If effusion recurs despite treatment of underlying cause, excision of pericardial segment allows fluid to be absorbed
- Pericardiocentesis - Diagnostic or therapeutic
202
what are the investigations for cardiac tamponade?
- CXR – large globular heart
- Beck’s triad – falling BP, rising jugular venous pressure, muffled heart sounds
- ECG – low voltage QRS complexes with sinus tachycardia
- Echocardiography is diagnostic – echo-free space around heart
203
what are the causes of AVRT?
```
Congenital
Hypokalaemia
Hypocalcaemia
Drugs: amiodarone, tricyclic antidepressants
Bradycardia
Acute MI
Diabetes
```
204
what is the clinical presentation of AVRT?
Palpitations
Severe dizziness
Dyspnoea
Syncope
205
what are the investigations for AVRT?
ECG - pre excitation
- short PR interval
- delta waves (wide QRS complex that begins slurred)
206
what is the treatment for AVRT?
```
Vagal manoeuvre
Breath holding
Carotid massage
Valsalva manoeuvre
IV adenosine
Surgery – catheter ablation of pathway
```
207
what is the pathophysiology of AVNRT?
- 2 pathways in AVN in this pathway
- 1 has short refractory period and slow conduction
- 1 has longer effective refractory period and fast conduction
- In sinus rhythm the atrial impulse usually conducts through fast pathways
- If impulse occurs early when the fast pathway is still refractory the slow pathway takes over
- Once the fast pathway is out of refractory the same impulse can travel back up the fast pathway
- By this time the slow pathway is out of refractory and the signal can go back down the slow pathway
This sets up a re-entry loop – heart rate of 100-250bpm
Atria contract quickly in one cycle then slow in the next
208
what are the investigations for AVNRT?
Sometimes ECG QRS complexes will show BBB
P wave not visible or seen immediately before (normal) or after QRS complex due to simultaneous atrial and ventricular activation
209
what is the clinical presentation of coarctation of the aorta?
- right arm hypertension
- bruits over scapulae and back
- Murmur
- headaches and
- nosebleeds
- hypertension in upper limbs
- discrepancy in bp in upper and lower body
210
what are the investigations for coarctation of the aorta?
CXR - dilated aorta indented at the site of the coarctation
ECG - left ventricular hypertrophy
CT - can accurately demonstrate coarctation and quantify flow
211
what is the epidemiology of coarctation of the aorta?
men > women
| associated with turner's syndrome, patent ductus arteriosus
212
what are the causes of left sided heart failure?
```
Coronary artery disease
Myocardial infection
Cardiomyopathy
Congenital heart defects
Valvular heart disease
Arrhythmias
```
213
what are the causes of right sided heart failure?
```
Right ventricular infarct
Pulmonary hypertension
Pulmonary embolism
COPD
Progression of left sided heart failure
Cor Pulmonale
```
214
what are the causes of systolic heart failure?
Ischaemic heart disease
Myocardial infection
Cardiomyopathy
215
what are the causes of diastolic heart failure?
aortic stenosis
| chronic hypertension
216
what murmur is heard with mitral stenosis?
rumbling mid-diastolic murmur with opening snap
217
what murmur is heard with mitral regurgitation?
pan systolic murmur radiating to the left axilla
218
what murmur is heard with aortic stenosis?
ejection systolic murmur radiating to carotids and apex
219
what murmur is heard with aortic regurgitation?
early diastolic murmur (best heard on expiration with patient sat forwards)
heard loudest at left sternal edge
220
ECG changes in which regions indicates a lateral MI?
lead I
aVL
V5
V6
221
ECG changes in which regions indicates an inferior MI?
lead II
lead III
aVF
222
ECG changes in which regions indicates a septal MI?
V1
| V2
223
ECG changes in which regions indicates an anterior MI?
V3
| V4
224
ECG changes in lateral regions are caused by which artery in an MI?
lateral = circumflex
225
ECG changes in inferior regions are caused by which artery in an MI?
inferior = RCA
226
ECG changes in anterior regions are caused by which artery in an MI?
anterior = LAD
227
A blockage in the LAD will cause ECG changes in which regions?
anterior - V3, V4
| septal - V1, V2
228
A blockage in the RCA will cause ECG changes in which regions?
inferior - leads II, III, aVF
229
A blockage in the circumflex artery will cause ECG changes in which regions?
lateral - lead I, aVL, V5, V6
230
what pharmacological treatments can be used for mitral stenosis?
- beta blockers - atenolol
- digoxin
- diuretics - furosemide
231
what pharmacological treatments can be used for mitral regurgitation?
Vasodilation
- ACEi - ramipril
- hydralazine - smooth muscle relaxer
HR control
- B blockers - atenolol
- CCB
- digoxin
fluid overload
- loop diuretic - furosemide
AF/atrial flutter
- anticoagulation
232
which tool is used to estimate the risk of bleeding in patients on anticoagulation?
HAS-BLED
233
which tool is used to estimate the risk of developing a heart attack or stroke in the next 10 years?
QRISK3
234
what is the management for SVT?
1st line = valsalva manoeuvre
2nd = carotid sinus massage
3rd = cardioversion with adenosine
4th = DC cardioversion with defibrillator
235
what is the mechanism of action for adenosine?
- causes transient AV node heart block
- very short half life of 8-10 seconds
- feeling of impending doom
236
which abnormal heart rhythm are people with long QT syndrome at risk of developing?
torsades de pointes
237
which congenital heart defects are common in people with trisomy 21 (downs syndrome)?
VSD - 30% (heard as a pansystolic murmur)
ASD - 10%
tetralogy of fallot - 5%
PDA - 5%
238
what type of murmur is heard in a ventricular septal defect?
pansystolic
239
which microorganism causes rheumatic fever?
group A streptococcus - s.pyogenes
240
what is the mechanism of action for apixaban?
DOAC - inhibits factor Xa
241
what is hypertrophic cardiomyopathy?
genetic disorder characterised by left ventricular hypertrophy -> causes diastolic ventricular malfunction
242
what is the pathophysiology of hypertrophic cardiomyopathy?
thickened septum below aortic valve causes outflow tract obstruction -> causes left ventricular hypertrophy
243
what is the most common cause of secondary hypertension?
primary hyperaldosteronism - Conn's syndrome
244
What are the side effects of colchicine?
Diarrhoea and nausea
