Cardiology Flashcards

Question

Symptoms of STEMI

Answer 1

- Chest pain - >20 mins, doesn’t respond to GTN, radiates down L arm/neck/jaw - Pale, clammy, sweating - In elderly or diabetic = dyspnoea, fatigue, pre-syncope, syncope

Answer 2

- ST elevation >2mm (2 little squares) in 2 contiguous chest leads or >1mm (1 little square) in 2 contiguous limb leads (i.e. territorial) - Symptoms of ACS for >20 mins with persistent ECG features in 2 or more contiguous leads: • 2.5mm ST elevation in V2-3 in men under 40 • 2 mm ST elevation in V2-3 in men over 40 • 1.5 mm ST elevation in V2-3 in women • 1mm ST elevation in other leads • New LBBB

Answer 3

Left circumflex and right coronary arteries blocked. ST depression V1-V3 Tall broad R waves V1-V3 Dominant R wave in V2 Inverted T wave in aVR Posterior infarction is confirmed by putting on posterior chest leads - V7-V9

Answer 4

- ECG - Cardiac enzymes - Bloods - Transthoracic echocardiography (TTE)

Answer 5

Left anterior descending artery blocked ST elevation in V1 - V4

Answer 6

Left coronary artery blocked (that branches into LAD and circumflex artery) ST elevation in lead I, aVL and V3-V6

Answer 7

Circumflex artery blocked ST elevation in Lead I, aVL and V5-6

Answer 8

Right coronary artery blocked ST elevation in II, II and aVF

Answer 9

``` - HEART Score • History • ECG • Age • Risk factors • Troponin ```

Answer 10

- MONA – initial management of STEMI • Morphine: only if needed and give with metoclopramide as it delays the absorption of antiplatelet drugs • Oxygen: only to maintain sats • Nitrates: sublingual or IV (used in cation in hypotensive patients) • Aspirin: 300mg stat - In ED: • Cardiac monitoring • Load with P2Y12 inhibitor – ticagrelor or prasugrel • 2nd line = clopidogrel • Anticoagulation – fondaparinux • Don’t give a beta blocker or ACEi at this stage without a specialist

Answer 11

- Primary PCI within 12 hours – better than thrombolysis, majority of patients come straight from ambulance. - thrombolysis - CI if after 24 hours from pain onset & other CIs remembered with AGAINST. Use streptokinase, alteplase or tenectaplase. - If no repercussion therapy = fondaparinux

Answer 12

• Clinic 1 month later • Transthoracic echocardiogram • Cardiac rehabilitation programme in community • Smoking cessation * DVT prophylaxis until fully mobile * Statin • GP to up titrate secondary prevention e.g. ramipril and bisoprolol * Clopidogrel for up to 1 year * continue aspirin 75mg • Don’t drive for 1 week after PCI, 4 weeks if no PCI

Answer 13

o Serum troponin T = most important cardiac-specific marker for myocardial necrosis. The levels remain elevated for up to 10 days. o Myoglobin is the first to rise. o CK-MB = useful to look for reinfarction as it returns to normal after 2-3 days (while troponin T stays elevated for 10 days)

Answer 14

1. Death 2. Heart failure 3. Pericarditis – ECG shows saddle shaped ST elevation +/- PR depression 4. Rupture – myomalacia cordis (means softening of the heart muscle) 5. Arrhythmias: SVT, VT, VF, Sinus bradycardia, AV block, Ventricular bradycardia 6. Aneurysm – ventricular 7. Embolism 8. Dressler’s syndrome

Answer 15

a. L ventricular free wall rupture – seen in 3% of Mis. Occurs 1-2 weeks after MI. Presentation = acute HF secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds). Mx = pericardiocentesis & thoracotomy b. Papillary muscle or chordae rupture: mitral regurgitation c. Septum rupture

Answer 16

a. AKA post myocardial infarction syndrome b. 2-3 weeks after MI c. Localised auto-immune response against antigenic proteins formed as the myocardium recovers that causes pericarditis d. Presentation = pleuritic chest pain, low grade fever, pericardial rub, pericardial effusion and pericardial tamponade

Answer 17

Global ST elevation and T wave inversion Echo = pericardial effusion Raised CRP and ESR

Answer 18

NSAIDs, prednisolone, pericardiocentesis to remove fluid from around heart

Answer 19

AAA is a permanent pathological dilation of the aorta with a diameter >1.5 times the expected anteroposterior diameter of that segment, given the patients sex and body size. Commonly adopted threshold = diameter of 3cm or more

Answer 20

They occur primarily because of elastic proteins within the extracellular matrix. Aneurysms typically represent dilation of all layers of the arterial wall. Most are caused by degenerative disease. Most are infrarenal (e.g., below the origin of the renal arteries)

Answer 21

- SMOKING - HTN & diabetes - Family hx - Male sex (men have a higher prevalence of AAA but women have a higher rate of AAA rupture than men) - Syphilis - Connective tissue diseases e.g., Elhers Danlos type 1, Marfan’s syndrome

Answer 22

- Palpable pulsative abdominal mass - Abdominal, flank or back pain - Hypotension - Frequently asymptomatic, presence of symptoms indicates rupture/impending rupture - LOC - Pallor - Abdominal distention - Fever

Answer 23

sudden collapse persistent severe central abdominal pain with developing shock (mortality is 80%). Grey Turners sign (flank bruising) if theres retroperitoneal bleeding

Answer 24

- For diagnosis = AORTIC USS - Other Ix to consider: o Cross match o Clotting screen o ESR / CRP o FBC o Blood cultures o CT angiography for planning surgery ECG = right coronary artery occlusion (inferior ECG changes: leads II, III and aVF)

Answer 25

– NHS screening for AAA for men over 65 yo, by abdominal USS. Findings dictate management: 1. <3cm = no further follow up 2. 3cm – 4.4 cm = yearly USS screening 3. 4.5cm – 5.4 cm = 3 monthly USS screening 4. >5.4 cm = urgent two week wait referral to vascular surgeons

Answer 26

a. If there’s rupture: 20% rupture anteriorly into the peritoneal cavity (poor prognosis) & 80% rupture posteriorly into the retroperitoneal space b. Surgical repair – endovascular aneurysm repair (EVAR) or open surgical repair c. Resuscitation measures d. Perioperative antibiotic therapy e. Analgesia f. VTE prophylaxis

Answer 27

a. Surveillance | b. Aggressive cardiovascular risk management

Answer 28

a. Elective surgical repair b. Preoperative cardiovascular risk reduction c. Perioperative antibiotic therapy d. Analgesia e. VTE prophylaxis

Answer 29

Aortic dissection = separation in the aortic wall intima, causing blood flow into a new false channel composed of the inner and outer layers of the media. TEAR IN THE TUNICA INTIMA OF THE WALL OF THE AORTA

Answer 30

Classification is anatomical, with 2 systems most used: 1. Stanford a. Type A = ascending aorta involved. 2/3rds cases. b. Type B = ascending aorta NOT involved. Is descending aorta distal to L subclavian artery. 1/3rd cases. 2. DeBakey a. Type I = involves ascending aorta, dissection extends into the arch and beyond b. Type II = limited to ascending aorta, proximal to brachiocephalic artery c. Type IIIa = involves descending thoracic aorta, distal to L subclavian artery, proximal to coeliac artery d. Type IIIb = involves descending thoracic aorta and abdominal aorta

Answer 31

* Connective tissue disorders e.g., Marfan’s syndrome, Ehlers Danlos syndrome, osteogenesis imperfecta * Turner’s syndrome * Noonan’s syndrome * Bicuspid aortic valve * Metabolic disorders

Answer 32

* Arterial hypertension * Syphilitic aortitis * Pregnancy * Trauma * Iatrogenic – surgical aortic cannulation, aortic cross-clamp * Cocaine use

Answer 33

- Severe chest pain (tearing, maximal at onset) // asymptomatic - Cardiac tamponade = Beck’s triad (raised JVP, muffled heart sounds, hypotension) - Aortic regurgitation = diastolic murmur, wide pulse pressure, signs of heart failure - Back and abdominal pain - SOB - Syncope / collapse - Different BP L and R arm (>20 mmHg systolic) - Neurological deficit - Horner’s syndrome (miosis, ptosis, anhidrosis) - Absent peripheral pulses - Hypertension

Answer 34

Raised JVP, muffled heart sounds and hypotension Due to cardiac tamponade

Answer 35

1. CXR = widened mediastinum & L sided pleural effusion 2. ECG = no changes / non-specific changes 3. CT angiography CAP (definitive Ix)  False lumen = diagnostic  Good for planning surgery 4. Transoesophageal echocardiography (TOE)  Good if patient too risky to take to CT scanner

Answer 36

1. Stanford type A a. Emergency surgery in suitable patients b. Get BP 100-120mmHg whilst awaiting surgery 2. Stanford type B a. Uncomplicated = medical management – BP management (IV labetalol) and appropriate analgesia b. Emergency surgery in Stanford type B with: i. Intractable pain ii. Rupture or impending rupture iii. End organ damage / limb ischaemia iv. Rapid progression v. Marfan’s syndrome

Answer 37

- Backwards tear = aortic incompetence / regurgitation, MI | - Forwards tear = unequal arm pulses and BP, stroke, renal failure

Answer 38

heard after S2. Normal in young healthy people. Is caused by rapid ventricular filling that causes the chordae tendinae to pull to their full length and twang. In older patients = HF.

Answer 39

Heard directly before S1. Always abnormal. Stiff/hypertrophic ventricle = turbulent flow from an atria against a non-compliant ventricle.

Answer 40

Assessing a murmur: SCRIPT S = site – where the murmur is loudest C = character – soft/blowing/crescendo/decrescendo/crescendo-decrescendo R = radiation – over carotids or into L axilla? I = intensity – what grade is the murmur P = pitch – high or low pitched? – indicates velocity T = timing – is it systolic or diastolic

Answer 41

1. Difficult to hear 2. Quiet 3. Easy to hear 4. Easy to hear with palpable thrill 5. Hear with stethoscope barely touching chest 6. Hear with stethoscope off the chest

Answer 42

Mitral stenosis

Answer 43

Aortic stenosis

Answer 44

Mitral regurgitation

Answer 45

Aortic regurgitation

Answer 46

Rheumatic heart disease | Infective endocarditis

Answer 47

Mid-diastolic low pitched rumbling murmur Loud S1 Palpable tapping apex beat Malar flush AF

Answer 48

Idiopathic weakening of the valve with age IHD Infective endocarditis Rheumatic heart disease Connective tissue disorder – Elhers-Danlos/Marfan

Answer 49

Pansystolic high pitched whistling murmur that radiates to L axilla Possible S3 CCF

Answer 50

Age related calcification Rheumatic heart disease Bicuspid aortic valve

Answer 51

Ejection systolic high pitched murmur with crescendo-decrescendo character Murmur radiates to carotids Slow rising pulse and narrow pulse pressure Exertional syncope S4 - if ventricles hypertrophied

Answer 52

Idiopathic age related weakness Connective tissue disorder – Elhers-Danlos / Marfans Stanford type A aortic dissection Bicuspid aortic valve

Answer 53

Early diastolic soft murmur Austin-Flint murmur: heard at the apex, is an early diastolic rumbling murmur ``` Collapsing pulse (Corrigan’s pulse) HF ```

Answer 54

* Chest pain / angina * SOB * Syncope

Answer 55

Ix = ECHOCARDIOGRAM + DOPPLER - ECG = L ventricle hypertrophy (deep S waves in V1 and V2, tall R waves in V5 and V6) / LV strain (tall R waves, ST depression, T wave inversion in V4-6) / LBBB or complete AV block (due to septal calcification) - CXR = small heart, dilated ascending aorta, calcified AV especially on lateral films. - Bloods = FBC, U&E, lipids, glucose - Cardiac catheterisation and angiography - Exercise stress test

Answer 56

- Asymptomatic = observation - Symptomatic = valve replacement - If asymptomatic but valvular gradient >40 mmHg and there’s features like L ventricular systolic dysfunction = valvular replacement

Answer 57

1. Severe symptomatic AS 2. Severe asymptomatic AS with reduced ejection fraction (<50%) 3. Severe AS undergoing CABG or other valve operation

Answer 58

1. Bioprosthetic valves – can come from pigs (porcine bioprosthetic). Lifespan of 10 years 2. Mechanical valves – 20+ years lifespan & require anticoagulation with warfarin (target INR 2.5-3.5)  Starr Edwards Valve – ball in cage valve, highest risk of thrombus formation  Tilting disc valve – a single tilting disc  St Jude valve – two metal tilting discs, bileaflet valve, least risk of thrombus formation

Answer 59

o Thrombus formation o Infective endocarditis (caused by gram positive cocci e.g. staphylococcus, streptococcus or enterococcus) o Haemolysis causing anaemia – blood is churned up in the valve

Answer 60

• Mechanical heart valves cause a click: o Click replaces S1 for metallic mitral valve o Click replaces S2 for metallic aortic valve

Answer 61

1. Balloon valvuloplasty  High complication rate  Restenosis occurs in 6-12 months 2. Transcatheter aortic valve implantation (TAVI)  Insert catheter into femoral artery, feed a wire under x-ray guidance to location of aortic valve, inflate a balloon to stretch the stenosed valve then implant a bioprosthetic valve.  Long term outcomes unclear  No warfarin required

Answer 62

``` SOB fatigue weakness orthopnoea PND pallor mottled extremities ```

Answer 63

Nailed pulsation seen in aortic regurgitation

Answer 64

1. Wide pulse pressure and collapsing pulse 2. S3 3. Long murmur 4. Austin Flint murmur 5. Decompensation = LVF

Answer 65

Head bobbing seen in Aortic Regurgitation

Answer 66

* Transthoracic echocardiography (TTE): can see abnormal aortic valve leaflets & regurgitant jet * Bloods: BNP (HF) and blood cultures (if suspecting infective endocarditis) * ECG: no specific signs but rules out other differentials * CXR – to look for pulmonary oedema or aortic dissection causing AR. Chronic AR can cause cardiomegaly.

Answer 67

• Manage HTN and HF • Do surgical valve replacement if: 1. Acute severe AR e.g., after aortic dissection 2. Symptomatic chronic AR 3. Asymptomatic chronic severe AR with reduced LVEF (<55%) or cardiac surgery happening for other reasons

Answer 68

o Pansystolic murmur o Prominent/giant V waves in JVP o Pulsatile hepatomegaly o L parasternal heave

Answer 69

``` o Right ventricular infarction o Pulmonary HTN e.g., COPD o Rheumatic heart disease o Infective endocarditis o Ebstein’s anomaly – congenital heart defect where tricuspid valve leaflets are malformed o Carcinoid syndrome ```

Answer 70

Insufficient blood supply to the skin due to peripheral arterial disease

Answer 71

Distal, affect the toes/dorsum of the foot Associated with peripheral arterial disease – absent pulses, pallor, intermittent claudication Smaller and deeper Well defined borders Punched out appearance Pale colour (due to poor blood supply) Less likely to bleed Painful Pain worse at night when horizontal Pain worse on elevating and improved by lowering leg

Answer 72

ABPI – used to assess for arterial disease Blood tests – - FBC: infection, anaemia - CRP: infection - HbA1C - Albumin: malnutrition Charcoal swabs – if infection suspected Skin biopsy – if squamous cell carcinoma is suspected (TTW)

Answer 73

Urgent referral to vascular surgeons for surgical revascularisation

Answer 74

Occur due to pooling of blood and waste products in the skin secondary to venous insufficiency

Answer 75

Occur in gaiter area (between top of foot and bottom of calf muscle) Chronic venous changes = hyperpigmentation, venous eczema, lipodermatosclerosis Occur after minor injury to leg Larger & more superficial Irregular, gently sloping borders More likely to bleed Less painful Pain relieved by elevation and worse on lowering leg

Answer 76

Refer to vascular surgery if mixed type suspected Refer to tissue viability/specialist leg ulcer clinics Dermatology if suspecting SCC Wound care from nurses: - Cleaning the wound - Debridement of the wound - Dressing the wound ``` Compression therapy (after arterial disease excluded with ABPI) Pentoxifylline (oral) – can improve healing ``` Abx for infections Analgesia for pain

Answer 77

* Diabetic neuropathy – unlikely to realise they’ve injured their feet * Damage to small & large blood vessels (PAD) = impaired blood supply * Raised blood sugar, immune system changes and autonomic neuropathy = ulceration & poor healing

Answer 78

osteomyelitis, cellulitis, gangrene

Answer 79

- Neuropathy | - Ischaemia – absent foot pulses, reduced ABPI, intermittent claudication

Answer 80

Screen on annual basis - Palpate dorsalis pedis and posterior tibial pulses - 10g monofilament on sole of foot for neuropathy

Answer 81

Reduced mobility with prolonged pressure on areas = reduced blood supply, reduced lymphatic drainage & deformation of tissues under pressure

Answer 82

- Malnourished - Incontinent - Lack of mobility - Pain

Answer 83

1 – non-blanchable erythema of intact skin 2 – partial thickness skin loss 3 – Full thickness skin loss with damage/necrosis of subcutaneous tissue that can extend to underlying fascia 4 – extensive destruction, tissue necrosis or damage to muscle/bone/supporting structures

Answer 84

- Risk assessment - Regular repositioning - Special inflating mattresses - Regular skin checks - Protective dressings and creams

Answer 85

``` Waterlow score • BMI • Nutritional status • Skin type • Mobility • Continence ```

Answer 86

- Hydrocolloid dressings to keep wound moist - Don’t swab, give abx on clinical findings - Tissue viability nurse - Surgical debridement

Answer 87

a sudden state of circulatory failure due to a loss of cardiac systolic function.

Answer 88

1. Ventricular tachycardia 2. Pulseless ventricular tachycardia 3. Pulseless electrical activity 4. Asystole

Answer 89

* Coronary artery disease * L ventricular dysfunction * Hypertrophic cardiomyopathy (HCM) * Long QT syndrome * Acute medical or surgical emergency * Illicit substances

Answer 90

- Unresponsive - Absent or agonal respiration - Absence of pulse - Cardiac rhythm disturbances: VT, pulseless VT, PEA, asystole

Answer 91

``` • Continuous cardiac monitoring: will show shockable or non-shockable rhythm 1. Shockable = VT or pulseless VT 2. Non-shockable = asystole or PEA • FBC: look for haemorrhage • U&E: hyperkalaemia/hypokalaemia • ABG • Cardiac biomarkers / echocardiogram ```

Answer 92

= monomorphic: regular, broad complex tachycardia with uniform QRS complexes in each lead. Polymorphic: QRS complexes vary in shape and amplitude.

Answer 93

no breathing, no pulse despite appearance of organised electrical activity on ECG

Answer 94

- CPR (see algorithm in notes) – 30 compressions to 2 breaths, with compression depth of at least 5 cm and allowing for full chest wall recoil - Defibrillation if pulseless VT or VT, attempted as soon as possible for witnessed arrest or after 5 cycles of CPR for unwitnessed arrest. Give one shock and follow with CPR if perfusing rhythm not restored. - Adrenaline – 1mg IV/IO every 3-5 minutes. - Amiodarone – for pulseless VT or VT that’s unresponsive to defibrillation - Magnesium – for cardiac arrest due to Torsades de pointes

Answer 95

clinical syndrome where the heart is unable to pump enough blood to meet the metabolic needs of the body. Usually, a result of structural or functional heart disease but also the term is sometimes used more broadly e.g., high output heart failure.

Answer 96

By ejection fraction By left right By chronic / acute + High output heart failure

Answer 97

L ventricular ejection fraction Measured with echocardiography Reduced LVEF = <35-40%

Answer 98

1. Heart failure with preserved ejection fraction (HF-pEF) o Normal left ventricular ejection fraction (LVEF) o 50% of patients with HF o The overlap isn’t perfect, but patients with HF-pEF have diastolic dysfunction (impaired ventricular filling during diastole)

Answer 99

 Hypertrophic obstructive cardiomyopathy (HOCM)  Restrictive cardiomyopathy  Cardiac tamponade  Constrictive pericarditis

Answer 100

o Abnormal left ventricular ejection fraction (LVEF) o 50% of patients with HF o The overlap isn’t perfect, but patients with HF-rEF typically have systolic dysfunction (impaired myocardial contraction during systole)

Answer 101

 Ischaemic heart disease  Dilated cardiomyopathy  Myocarditis  Arrhythmias

Answer 102

Left sided

Answer 103

- Increased L ventricular afterload = arterial HTN / aortic stenosis - Increased L ventricular preload = AR

Answer 104

• Pulmonary oedema = 1. Dyspnoea 2. Orthopnoea 3. Paroxysmal nocturnal dyspnoea 4. Bibasal fine crackles

Answer 105

- Increased R ventricular afterload = tricuspid regurgitation

Answer 106

* Peripheral oedema: ankle/sacral oedema * Raised JVP * Hepatomegaly * Weight gain due to fluid retention * Anorexia (cardiac cachexia)

Answer 107

A normal heart is unable to pump enough blood to meet the metabolic needs of the body

Answer 108

* Anaemia * Ateriovenous malformation * Paget’s disease * Pregnancy * Thyrotoxicosis * Thiamine deficiency

Answer 109

Life threatening emergency Sudden onset or worsening of the symptoms of HF AHF without hx of HF = de-novo AHF Decompensated AFH is more common – most have hx of HF

Answer 110

``` • Iatrogenic – aggressive IV fluids • Sepsis • MI • Arrhythmias * HTN crisis ```

Answer 111

- Rapid onset breathlessness - Cough – frothy white/pink sputum - Look unwell

Answer 112

- Increased RR - Reduced O2 sats - Tachycardia - S3 - Bilateral bibasal crackles - Hypotension in severe cases with shock - Cyanosis If there’s also right sided heart failure = raised JVP & peripheral oedema

Answer 113

- Clinically, if it looks like acute HF then treat before waiting for investigations - ECG – ischaemia/ arrhythmias - ABG - Bloods – infection, kidney function, BNP, troponin - Echocardiography – measure ejection fraction (above 50% = normal) - CXR: alveolar oedema, Kelley B lines, Cardiomegaly, dilated upper lobe vessels, pleural effusion

Answer 114

o B type natriuretic peptide – hormone released from heart ventricles when myocardium is stretched beyond the normal range. High result = heart is overloaded in HF. ``` Other causes of raised BNP:  Tachycardia  Sepsis  PE  Renal impairment  COPD ```

Answer 115

diameter of the widest part of the heart is more than half the diameter of the widest part of the lung fields

Answer 116

Continue normal medication for HF e.g., b blockers and ACEi Pour SOD - Pour away (stop) their fluids - Sit up - Oxygen - Diuretics – IV furosemide 40mg - + monitor fluid balance In severe acute pulmonary oedema/cardiogenic shock: - IV opiates (vasodilation) – not routinely used now - NIV CPAP - Inotropes e.g., dobutamine [need to be on ICU] - Vasopressor e.g., noradrenaline [need to be on ICU]

Answer 117

- SOB worse on exertion - Cough – frothy white/pink sputum - Orthopnoea - Cardiac wheeze - Paroxysmal nocturnal dyspnoea: sudden waking at night feeling acutely SOB, with a cough and wheeze - Peripheral oedema - Weight loss – cardiac cachexia - R sided HF = raised JVP, ankle oedema, hepatomegaly

Answer 118

* Clinical picture * BNP blood test – N-terminal pro-B-type natriuretic peptide NT-proBNP * Echocardiogram * ECG * CXR

Answer 119

ABCDE 1. A – alveolar oedema (bat wing opacities) 2. B – kerley B lines 3. C – cardiomegaly 4. D – dilated upper lobe vessels 5. E – pleural effusion

Answer 120

- Ischaemic heart disease - Valvular heart disease (commonly AS) - HTN - Arrhythmias (commonly AF)

Answer 121

New York Heart Association Classification of chronic HF: 6. NYHA class I  No symptoms  No limitation on exercise 7. NYHA class II  Mild symptoms  Slight limitation of physical activity – get fatigue/palpitations/dyspnoea on exercising 8. NYHA class III  Moderate symptoms  Marked limitation of physical activity – comfortable at rest but little activity causes symptoms 9. NYHA class IV  Severe symptoms  Unable to carry out any physical activity without discomfort with symptoms present at rest

Answer 122

1. 1st line = ACEi + b blocker a. Start one drug at a time b. B blockers = bisoprolol, carvedilol and nebivolol 2. 2nd line = aldosterone antagonist (for HF-rEF) a. Spironolactone and eplerenone 3. 3rd line = one of these started by a specialist: a. Ivabradine b. sacubitril-valsartan c. hydralazine + nitrate d. digoxin e. Cardiac resynchronisation therapy 4. Loop diuretics (furosemide) can improve symptoms 5. Offer annual influenza vaccine and one off pneumococcal vaccine 6. Surgical tx for severe AS or MR 7. Stop smoking 8. Optimise co-morbidities 9. Exercise as tolerated 10. Monitor U&Es because ACEi and aldosterone antagonists can cause hyperkalaemia Remember with ABAL = ACEi, b blocker, aldosterone antagonist, loop diuretic

Answer 123

Hypertension = high blood pressure: 140/90 in clinic or 135/85 with ambulatory or home readings.

Answer 124

remember causes with ROPE: o R = renal disease. Most common. Think renal artery stenosis if BP very high/doesn’t respond to Tx. Glomerulonephritis, chronic pyelonephritis, adult polycystic kidney disease. o O = Obesity o P = Pregnancy induced HTN / Pre-eclampsia o E = endocrine. Hyperaldosteronism (Conn’s syndrome) – do renin:aldosterone ratio blood test. Pheochromocytoma, Cushing’s, Liddle’s syndrome, congenital adrenal hyperplasia, acromegaly. o Other causes: Glucocorticoids, NSAIDs, coarctation of the aorta, COCP.

Answer 125

- Asymptomatic - Symptoms when very high (>200/120) o Headaches o Visual disturbances o Seizures

Answer 126

- 1st = 24-hour blood pressure ambulatory monitoring – 2 measures per hour & average calculated from at least 14 readings (>135/85) - 2nd = home blood pressure readings – take 2 readings at least 1 minute apart, in the morning and evening for 4-7 days - 3rd = clinic reading (>140/90)

Answer 127

Clinic reading = >140/90 Ambulatory/home reading = >135/85

Answer 128

Clinic reading = >160/100 Ambulatory/home reading = >150/95

Answer 129

Clinic reading >180/120

Answer 130

Screen for HTN every 5 years (or annually in T2DM)

Answer 131

- Check for end organ damage / cause: o Fundoscopy – to check for hypertensive retinopathy o Urine dipstick / U&Es – to check for renal disease (cause or consequence) – urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria o ECG – to check for LV hypertrophy or IHD o HbA1C – to check for co-existing DM o Lipids - hyperlipidaemia

Answer 132

- IHD - CVA - Hypertensive retinopathy - Hypertensive nephropathy - Heart failure

Answer 133

a. Stop smoking b. Healthy diet c. Reduce alcohol d. Reduce caffeine and salt intake e. Regular exercise

Answer 134

a. All patients with stage 2 HTN b. All patients under 80yo with stage 1 HTN who also have a Q-risk score of 10% or more, diabetes, renal disease, CVD or end organ damage

Answer 135

a. ACEi or ARB b. ACEi/ARB + CCB/thiazide like diuretic c. ACEi/ARB + CCB + thiazide like diuretic d. ACEi/ARB + CCB + thiazide like diuretic + spironolactone (if K<4.5) or alpha/beta blocker (if K>4.5)

Answer 136

a. CCB b. CCB + ACEi/ARB/thiazide like diuretic c. ACEi/ARB + CCB + thiazide like diuretic d. ACEi/ARB + CCB + thiazide like diuretic + spironolactone (if K<4.5) or alpha/beta blocker (if K>4.5)

Answer 137

Monitor U&Es regularly: spironolactone + ACEi = hyperkalaemia (+ thiazide like diuretics can cause electrolyte imbalances)

Answer 138

Ramipril 1.25-10mg OD Lisinopril 10mg OD Dry cough Angioedema Hyperkalaemia

Answer 139

Bisoprolol 5-20mg OD Metoprolol 50mg OD Carvedilol 6.25mg BD Bradycardia Fatigue Erectile dysfunction Bronchoconstriction = CI in asthma

Answer 140

Amlodipine 5-10mg OD Nifedipine 30-60mg OD Flushing Headaches Peripheral oedema Gingival hyperplasia

Answer 141

Indapamide 2.5mg OD Hydrochlorothiazide 12.5-25mg OD Hypokalaemia Hyponatraemia Can exacerbate diabetes, gout and SLE

Answer 142

Candesartan 8-32mg OD Losartan 25-50mg OD Hyperkalaemia

Answer 143

Doxazosin Prazosin Terazosin GI disturbance Dizziness, palpitations ad headache Sexual dysfunction

Answer 144

Spironolactone Hypovolaemia Hyponatraemia Hyperkalaemia Gynaecomastia

Answer 145

<80 yo = <140/90 | >80 yo = <150/90

Answer 146

an infection involving the endocardial surface of the heart, including valvular structures, the chordae tendineae, sites of septal defects or the mural endocardium.

Answer 147

Fever + new murmur = endocarditis until proven otherwise Any fever >1 week in those with risk factors = do blood cultures

Answer 148

- History of infectious endocarditis - Artificial prosthetic heart valves - Congenital heart disease - Post heart transplant - Skin breaches – dermatitis, IV lines, wounds - IVDU: typically causing a tricuspid lesion - Renal failure - Immunosuppression

Answer 149

* Staphylococcus aureus: most common (IVDU especially) * Streptococcus viridians: poor dental hygiene/developing world * Staphylococcus epidermidis: indwelling lines/prosthetic valve surgery * Streptococcus bovis: colorectal cancer = need colonoscopy

Answer 150

1. SLE | 2. Malignancy – marantic endocarditis

Answer 151

HACEK – culture negative 1. Haemophilus 2. Actinobacillus 3. Cardiobacterium 4. Eikenella 5. Kingella

Answer 152

• Septic signs = fever, rigors, night sweats, malaise, weight loss, anaemia, splenomegaly and clubbing • New murmur / change to pre existing murmur • Immune complex deposition: 1. Vasculitis 2. Microscopic haematuria 3. Glomerulonephritis 4. AKI 5. Roth spots – boat shaped retinal haemorrhages with pale centre 6. Osler’s nodes – painful pulp infarcts in fingers and toes • Embolic phenomena: 1. Abscesses in brain, heart, kidney, spleen, gut 2. Janeway lesions – painless palmar or plantar macules

Answer 153

``` - Blood cultures o 3 sets at different times from different sites at peak of fever - Blood tests o Normochromic, normocytic anaemia o Neutrophilia o High ESR/CRP o RF positive (immunological phenomenon) - Urinalysis o Microscopic haematuria - CXR o Cardiomegaly o Pulmonary oedema - Regular ECGs o Look for heart block - Echocardiography o TTE may show vegetations - CT o To look for emboli e.g., in spleen or brain ```

Answer 154

Modified Duke Criteria for infective endocarditis | - Can diagnose if 2 major or 1 major + 3 minor or all 5 minor

Answer 155

o Positive blood culture –  Typical organism in 2 separate cultures or  Persistently +ve blood cultures from 2 blood cultures taken >12 hours apartor  Single positive blood culture for Coxiella burnetiid o Endocardium involved –  Positive echocardiogram (vegetation, abscesses, pseudoaneurysm, dehiscene of prosthetic valve)  Abnormal activity around prosthetic valve on PET/CT/SPECT/CT  Paravalvular lesions on cardiac CT

Answer 156

o Predisposition – cardiac lesion, IVDU etc o Fever >38 o Vascular phenomenon e.g., emboli, Janeway lesions, clubbing, splenomegaly, petechiae, purpura o Immunological phenomenon e.g., glomerulonephritis, Osler’s nodes o Positive blood culture that doesn’t meet major criteria

Answer 157

a. Initial blind therapy = amoxicillin [vancomycin if pen allergic] b. Initial blind therapy if prosthetic valve = vancomycin + rifampicin + low dose gentamicin

Answer 158

i. Native valve = flucloxacillin [vancomycin + rifampicin if pen allergic] ii. Prosthetic valve = flucloxacillin + rifampicin + low dose gentamicin [vancomycin instead of flucloxacillin if pen allergic]

Answer 159

i. Benzylpenicillin [vancomycin + low dose gentamicin if pen allergic]

Answer 160

i. Severe valvular incompetence ii. Aortic abscess = lengthening PR interval iii. Infections resistance to abx iv. Fungal infection v. Cardiac failure refractory to medical treatment vi. Recurrent emboli after abx

Answer 161

- Staphylococcus aureus - Prosthetic valve - Culture negative endocarditis - Low complement levels

Answer 162

lack of blood flow through the mesenteric vessels supplying the intestines which results in intestinal ischaemia.

Answer 163

1. Coeliac artery: foregut [stomach, part of duodenum, biliary system, liver, pancreas, spleen] 2. Superior mesenteric artery: midgut [distal duodenum to first ½ transverse colon] 3. Inferior mesenteric artery: hindgut [second ½ transverse colon to rectum]

Answer 164

Intestinal angina

Answer 165

narrowing of mesenteric blood vessels by atherosclerosis

Answer 166

- Intermittent abdominal pain: central, colicky, after eating (starts 30 mins after eating and lasts for 1-2 hours) - Weight loss due to food avoidance - Abdominal bruit on auscultation

Answer 167

* Increased age * Family hx * Smoking * DM * HTN * High cholesterol

Answer 168

CT angiography

Answer 169

- Reducing modifiable risk factors - Secondary prevention = statins and antiplatelets - Revascularisation to improve blood flow to intestines o Endovascular procedure e.g., percutaneous mesenteric artery stenting o Open surgery – endartectomy, reimplantation or bypass grafting

Answer 170

rapid blockage in blood flow through the superior mesenteric artery caused by a thrombus that has developed inside the artery or is an embolus from another site.

Answer 171

Atrial fibrillation

Answer 172

- Acute non specific abdominal pain that is disproportionate to examination findings - Shock - Peritonitis - Sepsis - Necrotic bowel tissue = perforation

Answer 173

contrast CT + metabolic acidosis + raised lactate (ischaemia)

Answer 174

- Remove necrotic bowel | - Remove/bypass the thrombus in the blood vessel = open surgery or endovascular procedure

Answer 175

Definition = inflammation of the myocardium. | Is often associated with pericardial inflammation = myopericarditis

Answer 176

- Idiopathic (50% of cases) - Viral: coxsackie B, HIV - Bacteria: diphtheria, clostridia - Spirochaetes: Lyme disease - Protozoa: Chagas’ disease, toxoplasmosis - Autoimmune - Drugs: doxorubicin - Toxins: cocaine, lithium, alcohol, lead, arsenic

Answer 177

- Young patient - Acute history - Chest pain – ACS like symptoms - HF symptoms – dyspnoea - Arrhythmias - Palpitations - Tachycardia - Soft S1 - S4 gallop

Answer 178

1. Bloods a. Raised inflammatory markers in 99% b. Raised cardiac enzymes c. Raised BNP 2. ECG a. Tachycardia b. ST changes – elevation c. T wave inversion d. Arrhythmias – atrial e. Transient AV block f. QT prolongation 3. Echocardiogram a. Diastolic dysfunction b. Regional wall abnormalities 4. Cardiac MR

Answer 179

Endomyocardial biopsy

Answer 180

* Treat underlying cause e.g., abx for bacterial causes * Supportive tx: HF and arrhythmias * Avoid exercise, can precipitate arrhythmia

Answer 181

- HF - Arrhythmia – possibly leading to sudden death - Dilated cardiomyopathy (late complication, even years)

Answer 182

inflammation of the pericardium, acute form is new onset inflammation lasting <4-6 weeks. Clinical triad: chest pain, pericardial friction rub, and serial ECG changes.

Answer 183

1. Fibrinous (dry) | 2. Effusive (with purulent, serous, or haemorrhagic exudate)

Answer 184

- Male aged 20-50 - Transmural MI - Cardiac surgery - Neoplasm - Viral/bacterial infection

Answer 185

* Viral: coxsackie * TB * Uraemia – causes fibrinous pericarditis * Trauma * Most MI = Dressler’s syndrome * Connective tissue disease * Hypothyroidism * Malignancy

Answer 186

- Chest pain – pleuritic chest pain, relieved by sitting forwards - Non-productive cough - Dyspnoea - Flu like symptoms: fever, myalgias - Pericardial rub: grating to and fro sound produced by friction of the heart against the pericardium - Tachypnoea - Tachycardia

Answer 187

ECG | TTE - to look for pericardial effusion

Answer 188

 Global saddle shaped ST elevation |  Global PR depression (most specific marker for pericarditis)

Answer 189

- Treat underlying cause | - Acute idiopathic/viral pericarditis = NSAIDs + COLCHICINE

Answer 190

= a range of arterial syndromes that are caused by atherosclerotic obstruction of the lower extremity arteries.

Answer 191

symptom of ischaemia in a limb, occuring during exertion and relieved by rest.

Answer 192

end stage of peripheral arterial disease, there is inadequate blood supply to the limb to allow it to function normally at rest.

Answer 193

rapid onset of ischaemia in a limb, caused by a thrombus.

Answer 194

the death of the tissue, due to inadequate blood supply

Answer 195

- Atherosclerosis (typically asymptomatic until 50% stenosis) - Vasculitis - Fibromuscular dysplasia

Answer 196

- Smoking - Blood pressure - DM - Hyperlipidaemia - Reduced exercise - FH and PMH - Male - Older age - Genetics

Answer 197

1. Cramping pain after walking a fixed distance 2. Pain rapidly relived by rest 3. Calf pain = superficial femoral disease (commonest) 4. Buttock pain = iliac disease 5. Muscle fatigue when walking beyond a certain intensity

Answer 198

1. Rest pain in foot for more than 2 weeks 2. Ulceration 3. Gangrene 4. Hang legs out of bed at night to ease pain 5. 6 Ps:  Pain  Pallor  Pulseless  Paralysis  Paraesthesia  Perishing cold

Answer 199

```  Pain  Pallor  Pulseless  Paralysis  Paraesthesia  Perishing cold ```

Answer 200

Rapid onset of 6 Ps

Answer 201

1. Thigh/buttock pain 2. Absent femoral pulses 3. Male impotence

Answer 202

a. 1 = normal b. 0.6-0.9 = claudication c. 0.3-0.6 = rest pain d. <0.3 impending e. >1.3 = calcification of the arteries that makes them difficult to compress – common in diabetics

Answer 203

1. ABPI 2. Duplex USS 3. Angiography (CT / MRI)

Answer 204

``` - Lifestyle o Stop smoking o Optimise management of HTN, DM o Exercise training - Medical treatments o Atorvastatin o Clopidogrel o Naftidrofuryl oxalate – peripheral vasodilator - Surgery o Endovascular angioplasty and stenting o Endartectomy o Bypass surgery o Amputation ```

Answer 205

``` o Endovascular thrombolysis o Endovascular thrombectomy o Surgical thrombectomy o Endartectomy o Bypass surgery o Amputation ```

Answer 206

thrombus formation in the pulmonary arteries, usually due to DVT that has embolised.

Answer 207

- Immobility - Recent surgery - Long haul flight - Pregnancy - Hormone therapy with oestrogen - Malignancy - Polycythaemia - SLE - Thrombophilia

Answer 208

``` o Chest pain - pleuritic o ECG can look like an MI o Troponin can look like an MI o SOB o Cough +/- haemoptysis o Hypoxia o Tachycardia o Raised RR o Low grade fever o Haemodynamic instability o Signs of DVT o ABG = respiratory alkalosis (high RR = blow off CO2) ```

Answer 209

PESI score (PE severity index) = helps to decide whether to admit a patient

Answer 210

- CTPA if Wells score predicts likely PE - D-dimer if Wells score predicts unlikely PE - Ventilation perfusion (VQ) scan

Answer 211

- Oxygen, analgesia, monitoring - Anticoagulate: DOAC or LMWH (dalteparin) - Thrombolysis - Long term anticoagulation with DOAC or warfarin o 3 months if obvious cause o 3+ months if unlear cause o 6 months if active cancer

Answer 212

- High flow O2 - Sit forwards - Decide if shocked or not - ^BP, need critical care input - Vasodilation – 5mg IV diamorphine stat & GTN either sublingual or as IV infusion - Diuresis e.g. furosemide 80mg IV stat (vasodilates before diuresis) - Consider CPAP - Treat underlying cause o ?ACS treatment o Is there a STEMI? o Discuss with cardiology

Answer 213