Cardiology Flashcards
What is ACS subdivided into?
Unstable angina
NSTEMI
STEMI
What is the mechanism of angina pectoris?
Increase in myocardial oxygen demand exceeding oxygen supply
What is the most common cause of angina pectoris?
Atherosclerosis
What are the other causes of angina?
Atherosclerosis
Cocaine-induced coronary spasm
Arteritis
Emboli
What is a myocardial infarction?
Sudden occlusion of a coronary artery due to the rupture of an atheromatous plaque and thrombus formation
Which cells migrate into the subendothelial space to form foam cells?
Macrophages
How are foam cells formed in atherosclerosis?
Macrophages phagocytose oxidised LDL lipid within the subendothelial space to form foam cells
Which growth factors are released from foam cells resulting in the formation of atherosclerotic cells?
PDGF and TGF-B
What happens during the rupture of a thin fibrous cap?
Prothrombotic components are exposed to platelets and pro-coagulation factors leading to thrombus formation and clinical events
What are the risk factors for ACS?
Male Diabetes mellitus FHx Hypertension Hyperlipidaemia Smoking
What is presentation of ACS?
Chest pain (acute onset)
Central heavy tight ‘gripping’ pain that radiates to the left arm, jaw or epigastrium
Occurs at rest
Associated with breathlessness, sweating, nausea and vomiting
Where does the chest pain radiate to in angina?
Radiates to the left arm, jaw or epigastrium
What is the character of chest pain in angina?
Central heavy tight ‘gripping’ pain
What symptoms are associated with angina?
Breathlessness, sweating, nausea and vomiting
When is stable angina brought on?
On exertion and relieved by rest
How is stable angina resolved?
On rest or GTN within 5 minutes
What symptoms are associated with atypical angina?
Gastrointestinal discomfort and/or breathlessness and/or nausea
What is Prinzemetal angina?
The pain from variant angina is caused by a spasm caused by exposure to cold, smoking or stress
Which murmur is associated as a complication of an MI?
Pansystolic murmur due to mitral regurgitation (papillary muscle rupture)
Which cardiac enzymes are profiled in a suspected MI?
CK-MB
Troponin-T (remain elevated for 2 weeks)
How long does troponin-T remain elevated for a few hours of cardiac damage?
After 2 weeks
What ECG changes are seen in an NSTEMI?
ST-depression
T-wave inversion
Q waves reveal previous MIs
Describe the ST-elevation in limb leads (mm)
> 1mm
Describe the ST-elevation in chest leads
> 2mm
Which leads are associated with an anterior STEMI?
V1-V4
Which coronary arteries are associated with an anterior MI?
Left coronary artery and left anterior descending artery (LAD)
Which leads are associated with a lateral STEMI?
I, aVL, V5 and V6
Which coronary artery is associated with a lateral MI?
Left circumflex
Which leads are associated with an inferior STEMI?
II, III, AvF
Which leads are associated with a posterior MI?
V7-V9
Which leads are associated with a septal MI?
v1-v2
What type of ECG is performed in a patient suspected with ACS?
Exercise ECG testing
What is the difference between unstable angina and an NSTEMI?
Troponin is raised in an NSTEMI
What is the gold standard to detect for coronary stenosis or obstruction?
Coronary angiography
What scan i used to detect wall-motion abnormalities and left ventricular function in ACS?
Echocardiogram
Which type of echocardiogram is used to assess for an aortic dissection?
Transoesophageal echocardiogram
What type of echocardiogram is used to evaluate haemodynamically significant stenoses in ACS?
Stress echocardiography
What is the management of stable angina?
- Minimise cardiac risk factors: Control BP, hyperlipidaemia, and diabetes.
- Advice on smoking, exercise, weight loss and a low-fat diet.
- All patients to receive aspirin (75mg/day).
-Symptom relief using GTN
What loading dose of aspirin is given in ACS?
300mg Aspirin
What is the maintenance dose of aspirin in ACS?
75mg
What platelet therapy is administered in ACS?
Clopidogrel
ticagrelor
prasugrel
When is prasugrel given in ACS?
If the patient is already on a DOAC
What drugs are administered in the long-term for ACS?
Beta-blockers Calcium channel blockers Statins ACEis Anti-platelet therapy (DAPT) Nitrates
What is the definitive management of an MI within 12 hours?
A percutaneous coronary intervention PCI
When is a CABG indicated in the management of a STEMI?
in three-vessel disease
What is the MoA of HMG-CoAi?
Lower LDL-C levels and raise HDL levels (Atorvastatin)
How do bile acid sequestrants work?
The bile acid sequestrants block enterohepatic circulation of bile acids and increase faecal loss of cholesterol.
• Cholestyramine (Questran, LoCholest, Prevalite)
What is the MoA of CCBs?
Relaxes coronary smooth muscle and produces coronary vasodilation which in turns improves myocardial oxygen delivery.
• Amlodipine (Norvasc)
What is the MoA of BBs?
Inhibit sympathetic stimulation of the heart, reducing heart rate and contractility; this can decrease myocardial oxygen demand and thus prevent or relieve angina in patients with CAD.
What is Ranolazine?
Anti-anginal agents
Relieve ischaemic by reducing myocardial cellular sodium and calcium overload via inhibition of the late sodium current of the cardiac action potential.
What is the first-line management for symptomatic ACS?
Short-acting nitrate and 300mg Aspirin
When should a PCI be offered during the symptomatic presentation of ACS?
Within 12 hours
What should be offered in the management of ACS if PCI is not available?
Fibronlysis
What are the early complications after an MI?
• Death, cardiogenic shock, heart failure, ventricular arrhythmias, heart block, pericarditis, myocardial rupture, thromboembolism.
What are the late complications after an MI?
• Ventricular wall rupture, valvular regurgitation, ventricular aneurysms, tamponade, Dressler’s syndrome (pericarditis), thromboembolism.
What is aortic regurgitation?
Reflux of blood from the aorta into the left ventricle (LV) during diastole. Also known as aortic insufficiency.
What type of pulse is associated with aortic regurgitation?
Collapsing pulse and wide pulse pressure
What are the causes of aortic regurgitation?
Aetiology
• Aortic valve leaflet abnormalities or damage: Bicuspid aortic valve, infective endocarditis, rheumatic fever, trauma.
Aortic root/ascending aorta dilation:
• Systemic hypertension, aortic dissection, aortitis (syphilis, Takayasu’s arteritis), arthritides, Marfan’s syndrome, Ehrler’s Danlos syndrome, osteogenesis imperfecta.
What is the pathophysiology of aortic regurgitation?
Reflux of blood into the left ventricle during diastole Left ventricular dilation Increase in end-diastolic volume & stroke volume.
↑ Stroke, volume & low EDV pressure Collapsing pulse and wide pule pressure.
Which type of murmur is associated with aortic regurgitation?
Early diastolic murmur
How are murmurs of aortic regurgitation exaggerated?
When the patient is sitting forward and the breath is held in expiration
What is Quincke’s sign?
Visible pulsations on the nailbed
What is De Musset’s sign?
Head nodding in time with the pulse
What is the presentation of aortic regurgitation?
Chronic AR – initially asymptomatic.
• Symptoms of heart failure: Exertional dyspnoea, orthopnoea, fatigue + occasional angina.
• Severe acute AR: Sudden cardiovascular collapse.
Symptoms related to the aetiology: Chest or back pain in patients with aortic dissection.
What are the symptoms of acute heart failure?
Exertional dyspnoea, orthopnoea, fatigue + occasional angina.
What is the definitive investigation to confirm aortic regurgitation?
Echocardiogram
What is the definitive management of aortic regurgitation?
Aortic valve replacement
What is the ejection fraction in aortic regurgitation?
EF <50%
What is aortic stenosis?
The narrowing of the left ventricular outflow at the level of the aortic valve.
What is the aetiology of aortic stenosis?
Aetiology
1) Stenosis secondary to rheumatic disease
2) Calcification of a congenital bicuspid aortic valve – Mechanical stress is distributed between 2 aortic leaflets.
3) Calcification/degeneration of a tricuspid aortic valve in the elderly
The aortic valve is less than 1cm2 in diameter (3-4cm2).
What diameter of the aortic valve to categorise as aortic stenosis?
<1cm^2
Which congenital disorder is associated with aortic stenosis?
Congenital bicuspid aortic valve
What is the presentation of aortic stenosis?
Angina (Increased oxygen demand of the hypertrophied ventricles)
Syncope or dizziness on exercise
symptoms of heart failure (dyspnoea)
What type of anaemia is associated with aortic stenosis?
Microangiopathic haemolytic anaemia
How does microangiopathic anaemia occur in aortic stenosis?
Damage to erythrocytes being forced through the narrowed aortic valve Fragmentation into schistocytes Haemoglobinuria.
Describe the pulse in aortic stenosis
Slow rising pulse (Narrow pulse pressure)
Thrill in the aortic area
What murmur is auscultated in aortic stenosis?
Ejection systolic murmur at the aortic area
Where does aortic stenosis radiate to?
To the carotid arteries
What sound is heard on auscultation due a bicuspid valve?
An ejection click
What is the definitive investigation for aortic stenosis?
Transthoracic echocardiography (Including Doppler): • Visualises structural changes of the valves and level of stenosis. • An elevated aortic pressure gradient. • Assessment of left ventricular function.
What ECG changes are seen in aortic stenosis?
Signs of left ventricular hypertrophy
Absent Q waves
LBBB
What signs are seen on a chest x-ray regarding aortic stenosis?
Post-stenotic enlargement of the ascending aorta
Calcification of the aortic valve
What is the definitive management of aortic stenosis?
Aortic valve replacement
What option is available if AVR is not possible in aortic stenosis?
– Balloon dilation (valvoplasty).
Which type of valve replacement is recommended in patients who are young?
Metallic valve
What medical management should be administered alongside an aortic valve replacement?
Medical
• Antibiotic prophylaxis against infective endocarditis.
• Long-term anticoagulation for patients with mechanical prosthetics (with a Vitamin-K antagonist). DOACs are not recommended.
• ACEis for TAVR.
What is mitral regurgitation?
The mitral valve has two leaflets and consists of chordae tendinea and papillary muscles.
• In mitral regurgitation, during ventricular systole, the blood reflows back through the left ventricle into the left atrium.
What is the most common cause of mitral regurgitation?
Rheumatic heart disease and
Mitral valve prolapse (Myxomatous degeneration)
What are the causes of mitral regurgitation?
- Rheumatic heart diseases (most common)
- Infective endocarditis
- Mitral valve prolapse
- Papillary muscle rupture or dysfunction
- Chordal rupture is associated with connective tissue diseases (osteogenesis imperfecta, Ehrler’s-Danlos syndrome, Marfan syndrome, SLE).
What is the acute presentation of MR?
Symptoms of left ventricular failure
What is the chronic presentation of MR?
Present with exertional dyspnoea, palpitations
What murmur is heard in mitral regurgitation?
Pansystolic murmur that radiates to the axilla
Which heart sound might be heard in mitral regurgitation?
S3 due rapid ventricular filling in early diastole
What is the surgical management for mitral valve regurgitation?
Mitral valve replacement/Repair
What is the target INR for Warfarin in patients with a mitral valve replacement?
INR 2-3
What is mitral valve stenosis?
Narrowing causes obstruction to blood flow from the left atrium to the left ventricle
What is the most common cause of mitral stenosis?
Rheumatic heart disease
What is the presentation of mitral stenosis?
Fatigue
Shortness of breath on exertion or lying down (Orthopnea)
Palpitations (Related to AF)
Malar flush is associated with which valvular pathology?
Mitral stenosis
Palpation of the apex beat in mitral stenosis will reveal what?
Parasternal heave (Right ventricular hypertrophy and pulmonary hypertension)
Auscultation of a patient with mitral valve stenosis will reveal what?
Loud first heart sound with an opening snap
Mid-diastolic murmur
Which type of murmur is associated with mitral stenosis?
Mid-diastolic murmur
Which ECG changes are associated with left atrial hypertrophy?
Broad bifid P waves
What are the complications of mitral stenosis on the right-side heart?
Right ventricular hypertrophy in the cases of severe pulmonary hypertension
What signs are revealed by a Chest X-ray in mitral stenosis?
Left atrial enlargement
Cardiac enlargement
Pulmonary congestion
Calcified mitral valve in rheumatic cases
What is the definitive investigation for mitral stenosis?
Echocardiography
What investigation measures the severity of heart failure?
Cardiac catheterisation
What is the medical management for mitral stenosis?
Anticoagulation for atrial fibrillation
Treat dyspnoea and heart failure with diuretics
Antibiotic cover for dental/invasive covers
Cardioversion of AF considered
What is the surgical management for mitral stenosis?
Mitral valvuloplasty
Valvotomy
Mitral valve replacement
Define cardiac arrest
Acute cessation of cardiac function – a state of circulatory failure due to impaired systolic function.
What are the causes of cardiac arrest?
Hypoxia Hypothermia Hypovolaemia Hypo or hyper-kalaemia Tamponade Tension pneumothorax Thromboembolism Toxins
What is the presentation of a cardiac arrest?
Patient unconsciousness
Absent breathing
Absent carotid pulse
For a pulseless ventricular tachycardia of ventricular fibrillation, what is the management in cardiac arrest?
Shockable rhythm after 30:2 chest compressions-rescue breaths
What drug is administered despite a third shock in cardiac arrest?
Amiodarone 300mg IV bolus is lidocaine
What is the management of asystole?
CPR for 2 minutes
Administer adrenaline (1mg IV) every 3-5 minutes
atropine
What is the emergency management of tension pnuemothorax?
Needle into the 2nd intercostal space, mid-clavicular line
What is tricuspid regurgitation?
The backflow of blood from the right ventricle to the right atrium during systole
What are the congenital causes of tricuspid regurgitation?
Ebstein anomaly (Mispositioned tricuspid valve)
What are the functional causes of tricuspid regurgitation?
Consequence of right ventricular dilation (in pulmonary hypertension)
Valve prolapse
What are the causes of tricuspid regurgitation?
Congenital
Functional
Rheumatic heart disease
Infective endocarditis
What is the most likely cause of tricuspid regurgitation?
Infective endocarditis
What is the presentation of tricuspid regurgitation?
Fatigue Breathlessness Palpitations Headaches Nausea Anorexia Epigastric pain
What pulse is associated with tricuspid regurgitation?
Irregularly irregular due to atrial fibrillation
What examination findings are evident in patients with tricuspid regurgitation?
Raised JVP with giant V waves
Parasternal heave
Pansystolic murmur heard best at the lower left sternal edge -louder on inspiration
When is a pansystolic murmur due to TR heard loudest?
During inspiration at the lower left sternal edge
What ECG changes are seen in TR?
Tall p waves (right atrial hypertrophy)
What is Atrial fibrillation?
Atrial fibrillation is characterised by rapid and ineffective atrial electrical conduction at 300-600bpm often subdivided into:
• Permanent
• Persistent (>1 week without self-terminating).
• Paroxysmal (Intermittent <1 week).
What kind of tachycardia is atrial fibrillation?
Supraventricular tachycardia caused by a re-entry circuit within the right atrium
What are the causes of Atrial fibrillation?
Heart • Mitral valve disease • Myocardial infarction (Seen in 22%). • Heart disease • Rheumatic heart disease • Cardiomyopathy • Ischaemic heart disease • Pericarditis • Atrial myxoma
Lung causes
• Bronchial carcinoma
• Pulmonary embolism
• Pneumonia
Other: Caffeine, alcohol, post-operative.
What is the most common conduction ratio of atrial flutter?
2:1
What are the symptoms of AF?
Often asymptomatic in patients.
• Patients experience palpitations
• Syncope (Cardiac output decreases by 10-20%, as the ventricular filling is ineffective).
• Symptoms of the cause of AF.
What pulse is associated with AF?
Irregularly irregular pulse
What is the difference in the apical beat and radial pulse?
Apical > radial
What are the ECG changes for AF?
Uneven baseline with absent p waves
Irregular intervals between QRS complexes
What are the ECG changes in atrial flutter?
Narrow complex tachycardia
Saw tooth appearance
Loss of isoelectric baseline
What are the three steps of management for AF?
Rate control - Restores ventricular rate to a normal range
Rhythm control - Restores sinus rhytmn
Anticoagulation
What is the management for acute AF <48 hours that is haemodynamically stable?
Synchronised DC cardioversion under sedation
What is the management for acute AF <48 hours (Haemodynamically stable)?
Rate control
beta-blockers
What are the signs of haemodynamic instability in AF?
rapid pulse (greater than 150 beats per minute) and/or low blood pressure (systolic blood pressure less than 90 mmHg), loss of consciousness, severe dizziness or syncope, ongoing chest pain, or increasing breathlessness.
Which calcium channel blockers are used in the rate control of AF?
Diltiazem and verapamil
Why are beta-blockers not prescribed alongside Diltiazem or verapamil?
Risk fo bradycardia
Aim for rest rate <90 bpm
If BBs and CBBs are ineffective rate control for AF, what drug can be used?
Digoxin
How long should a patient be anti-coagulated for before elective cardioversion?
3 weeks using Warfarin
What is the first choice drug for Rhythm control if there is no structural heart disease?
Flecainide
In a patient with structural heart disease and AF, what is the drug for Rhytmn control?
IV amiodarone
What drug is prescribed for paroxysmal AF?
Flecainide or sotalol PRN
Which score is used to assess the risk of stroke in patients with AF?
CHA₂DS₂-VASc
What is the CHA₂DS₂-VASc score?
Congestive heart failure = 1 Hypertension = 1 Age (>75) = 2 Diabetes = 1 Stroke = 2 Vascular disease (PVD) =1 Age (65-74) =1 Sex (Female) = 1
When is a DOAC given for AF in a male?
1 or more
What is a a DOAC given for AF in a female?
2 or more
What is heart block?
Heart block is defined as an impairment of the atrioventricular node impulse conduction, as represented by the interval between P waves and the QRS complex.
What is 1st-degree AV block?
Prolonged conduction through the AV node
What is the normal PR interval?
120-200ms (3-5 squares)
What is the PR interval in 1-st degree AV block?
> 200ms
What is 2nd-Degree AV block (Type 1)?
Mobitz type 1
-Progressive prolongation of the AV node conduction until one atrial pulse fails to be conducted through the AV node.
- There is a skipped beat and the cycle begins again
What is Mobitz-Type 2 AV block?
Fixed PR interval in duration but not every P wave is followed by a QRS complex
Defined as the number of normal conductions per failed on (2:1, two p waves for each QRS complex)
Describe the PR interval in a Mobitz-Type 2 AV block?
Fixed
What is 3rd degree (Complete heart block)?
There is no relationship between atrial and ventricular contraction
Failure of conduction through the AV node leads to ventricular contraction generated by a focus of depolarisation within the ventricle
What rhythm is associated with complete heart block?
Ventricular escape rhythm
What is the most common metabolic cause for AV block?
Hyperkalaemia
What 3 main ECG changes are seen in hyperkalaemia?
Tall tented T waves
Flattened P waves
Widened QRS complex
PR prolongation
What is the most common cause of AV block?
MI or ischaemic heart disease
What is the presentation of Mobitz Type 2 and 3rd degree heart block?
Dizziness, syncope, palpitations, chest pain and heart failure
Adams Attacks
What are Adams Attacks?
Syncope caused by ventricular asystole
Which waves are associated with a raised JVP in complete heart block?
Cannon A waves
What are cannon A waves?
Seen occasionally in the jugular vein due to simultaneous contraction of the atria and ventricles.
What ECG appearances are seen in first-degree AV block?
Prolonged PR interval >200ms
What ECG appearances are seen in Mobitz Type 1?
Progressive prolongation of the PR interval (Followed by a skipped beat)
What ECG appearances are seen in Mobitz type 2?
Intermittent p waves not followed by a QRS complex (regular pattern)
-Fixed PR interval
What ECG appearances are seen in third-degree heart block?
No relationship between P waves and QRS complex
If QRS is initiated by focus in the Bundle of His – QRS is narrow.
More distally Wide and slow rate (~30 beats/min).
What is the management of chronic block?
Permanent pacemaker insertion (PPM)
What is the management of acute AV block?
IV atropine
What is supraventricular tachycardia?
SVT refers to any tachyarrhythmia arising from above the level of the Bundle of His, usually at the atria or the AV node
What kind of tachycardia is associated with an SVT?
Narrow Complex tachycardia
What is a normal QRS interval?
80 and 100 milliseconds
What is AVNRT and AVRT?
Atrioventricular nodal re-entry tachycardia (AVNRT)
Atrioventricular re-entry tachycardia (AVRT)
What is AVNRT?
A localised re-entry circuit forms around the AV node - conducts to the ventricles faster than the normal conduction pathway
What is AVRT?
Occurs when there is normal AV conduction as well as an accessory pathway being present
Forming a re-entry circuit between atria and ventricles
What is a common form of AVRT?
Wolff-Parkinson-white Syndrome
Which accessory pathway is associated with WPWs?
Bundle of Kent
What are the risk factors for SVT?
Nicotine Alcohol Caffeine Previous MI Digoxin toxicity
What is the presentation of SVT?
- Palpitations
- Light-headedness
- Polyuria (Due to increased atrial pressure causing ANP release).
- Abrupt onset and termination of symptoms
- Other symptoms: Fatigue, chest discomfort, dyspnoea, syncope.
Why is polyuria associated with an SVT?
Due to increased atrial pressure causing ANP release
Which heart sound is associated with WPWs?
S3 gallop
RV heave
Displaced beat
Which ECG changes are present in AVRT?
Delta wave
What ECG appearances are seen in AVNRT?
Narrow complex tachycardia
P waves buried in QRS complex
Decreased PR interval
What ECG changes are seen in AVRT?
Narrow complex tachycardia
Shortened PR interval
P waves buried in QRS
What investigations are performed in SVT?
24 hour ECG monitoring
In a haemodynamically unstable patient what is the management of SVT?
DC cardioversion
What is the initial management of SVT, if haemodynamically stable?
Vagal manoevures - Valsalva, carotid massage
• Adenosine 6 mg bolus (Can increase to 12 mg) Contraindicated in asthma as it can cause bronchospasm (Use verapamil).
What drug is administered if vagal manoeuvres fail in acute SVT?
6mg bolus Adenosine
What is the definitive management of AVRT?
Radiofrequency ablation of the accessory pathway
What is WPWs?
A congenital abnormality can result in supraventricular tachycardias that use an accessory pathway (Bundle of Kent).
• Pre-excitation syndrome: Early activation of the ventricles due to impulses bypassing the AV node via the accessory pathway.
Why are there delta waves in WPWs?
pre-excitation syndrome
Early activation of the ventricles due to impulses bypassing the AV node via the accessory pathway
What is the presentation of WPWs?
Palpitations
Light-headedness
Syncope
What is paroxysmal SVT followed by?
Followed by a period of polyuria due to atrial dilation and release of ANP
What are the classical findings in WPSs (ECG)?
Short PR interval
Broad QRS complex
Delta-waves
What type of tachycardia is ventricular fibrillation?
Irregular broad-complex tachycardia
What is the aetiology of Vfib?
Ventricular fibres contract haphazardly causing complete failure of ventricular function due to disorganised electrical activity
What are the risk factors for Vfib?
- Coronary artery disease – most common
- Atrial fibrillation
- Hypoxia
- Ischaemia
- Pre-excitation syndrome
- Cardiomyopathy
- Drugs
- Electrolyte imbalance
- Brugada syndrome
- Long QT-syndrome
What is the presentation of V fib?
Chest pain
Fatigue
Palpitations
Cardiac arrest
What are the ECG appearances in V fib?
Chaotic irregular deflections of varying amplitude, no identifiable p waves
What investigations are performed in V fib?
ECG
Cardiac enzymes- Troponin to identify any recent ischaemic events
Electrolytes - Derangement can cause arrhythmia, including VF
Drug levels and toxicology screen - Anti-arrhytmic can cause arrythmia, as can various recreational drugs
TFTs - Hyperthyroidism
What is the management of Vfib?
Requires urgent defibrillation and cardioversion (Non-synchronised DC shock)
What kind of DC shock is administered in VFIB?
Non-synchronised DC shock
What may be the chronic management for Vfib?
Implantable cardioverter defibrillator (ICD)
Empirical beta-blockers
What are the complications of V fib?
- Ischaemic brain injury due to loss of cardiac output
- Myocardial injury
- Post-defibrillation arrhythmias
- Aspiration pneumonia
- Skin burns
- Death
Definition of ventricular tachycardia?
A regular broad complex tachycardia, originating from the ventricles
Rate >120bpm
What is the aetiology of vTachy?
Electrical impulses arise from a ventricular ectopic focus – an excitable group of cells within the atria/ventricles that cause a premature heartbeat outside the normally functioning circulation.
• Can impair cardiac output – causing hypotension, collapse, and acute cardiac failure.
What are the risk factors of Vtachy?
- Coronary heart disease
- Structural heart disease
- Electrolyte deficiencies (Hypokalaemia, hypocalcaemia, hypomagnesaemia)
- Use of stimulant drugs (Caffeine, cocaine).
What is the presentation of vtachy?
Chest pain
Palpitations
Dyspnoea
Syncope
What are the signs of haemodynamic instability in Vtachy?
- Respiratory distress
- Bibasal crackles
- Raised JVP
- Hypotension
- Anxiety
- Agitation
- Lethargy
- Coma
What are the ECG changes in Vtachy?
Rate >100bpm
Broad QRS complexes
AV dissociation
What is the management for Vtachy?
Pulseless VT - ALS
+ Unsynchronised DC cardioversion
What is the management for a stable VT?
Synchronised DC shock
Amiodarone
What drug is used in the management of stable VT?
Amiodarone
What are the indications of an ICD in VT?
- Sustained VT causing syncope
- Sustained VT with ejection fraction <35%
- Previous cardiac arrest due to VT or VF
- MI complicated by non-sustained VT.
What are the complications of VT?
- Congestive cardiac failure
- Cardiogenic shock
- VT may deteriorate into VF.
What is an aortic dissection?
An aortic dissection is characterised by a separation in the aortic wall intima, causing blood flow into a new false lumen
What are the two types of aortic dissection?
Type A - Ascending Aorta
Type B - Descending Aorta
What is a Type A aortic dissection?
Ascending Aorta (Most common-70%)
What is a type B aortic dissection?
Descending aorta (Distal to the left subclavian artery)
What is the aetiology of an aortic dissection?
An aortic dissection is usually preceded by degenerative changes in the smooth muscle of the aortic media
What are the risk factors for aortic dissection?
- Hypertension (Main)
- Aortic atherosclerosis
- Connective tissue disease (Marfan’s, Ehler’s Danlos, SLE).
- Congenital cardiac abnormalities (Coarctation of the aorta).
- Aortitis
- Iatrogenic
- Trauma
- Crack cocaine
Why does aortic dissection cause symptoms?
Expansion of the false lumen - obstruction of branches of the aorta
Hypoperfusion of the target organs of these major arteries can give rise to other symptoms
What is the main presentation of aortic dissection?
Sudden central tearing chest pain radiating to the back (in between the shoulder blades)
What symptoms are associated with obstruction of the carotid artery in aortic dissection?
Hemiparesis
Dysphasia
Blackout
On examination findings what is seen in an aortic dissection?
Murmur on the back below the left scapula
Hypertension
Blood pressure difference between the two arms >20mmHg
Wide pulse pressure
What is pulsus paradoxus?
Abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration
What is the first-line imaging for aortic dissection?
CT thorax - Reveals false lumen
What is the definitive imaging for an aortic dissection?
Transoesophageal echocardiogram
What would a CXR show in an aortic dissection?
Widened mediastinum in acute or chronic dissection
What is the management of a haemodynamically unstable aortic dissection?
ALS
Supplemental oxygen
IV resus
What is the management of a Type A aortic dissection?
Beta-blocker (Labetalol) and Endovascular repair
What is the 1st line management of a Type B aortic dissection?
IV labetalol
Opioid analgesia
Vasodilator (IV sodium nitroprussie)
What are the two main types of chronic limb ischaemia?
Intermittent claudication
Critical limb ischaemia
What is intermittent claudication?
Calf pain on exercise - increases muscle demand which cannot be satisfied by supply
Cramping pain in the calf, thigh, or buttock after walking for a given distance
When does pain occur in critical limb ischaemia?
Pain occurs at rest - most severe manifestation of peripheral vascular disease
What are the consequences of critical limb ischaemia?
Can lead to tissue loss - gangrene/ulceration
Gangrene - Death of tissue from poor vascular supply
Arterial ulcers - Abnormal breaks in an epithelial surface
Define acute limb ischaemia?
A sudden decrease in arterial perfusion in a limb due to thrombotic or embolic causes or post-angioplasty
What is the treatment for acute limb ischaemia?
Medical emergency
-Revascularisation within 4-7 hours
When is intermittent claudication relieved?
At rest
What is claudication distance?
Distance walked resulting in cramping pain
Which vessel is concerned with calf claudication?
Femoral
Which vessel is associated with buttock claudication?
Iliac
What are the features of critical limb ischaemia?
Ulcers
Gangrene
Rest pain
Night pain (Relieved by dangling leg over the edge of the bed)
What is Leriche Syndrome?
Aortoiliac occlusive disease
- Buttock claudication
- Impotence (ED)
- Absent/weak distal pulses
What are the 6Ps of acute limb ischaemia?
Pain Pulseless Pale Paralysis Paraesthesia Perishingly coLD
What are the other symptoms of PVD?
Atrophic skin
Hairless
Punched-out ulcers (Painful)
Colour change when raising leg
What are the first-line investigations for peripheral vascular disease?
Ankle Brachial index (ABI)
What ABI parameters are indicative of PAD?
0.50-0.90
What ABI measurement is associated with critical limb ischaemia?
<0.5
What is the gold standard investigation for PVD?
MRI/CT angiogram
What is the first-line management for acute limb ischaemia?
Revascularisation
What is the management of a non-viable limb in acute limb ischaemia?
Amputation
What anti-platelet therapy is administered in ALI?
Aspirin (75-352mg Orally OD), or clopidogrel
Anticoagulation - UFH Heparin
What is the first-line therapy for claudication?
Antiplatelet therapy
Exercise therapy
Symptom relief
Define arterial ulcer
Arterial ulcers are a localised area of damage and breakdown of the skin due to an inadequate arterial blood supply
Where are arterial ulcers found?
Feet of patients
What is the aetiology of arterial ulcers?
The ulcers are caused by compromised blood flow to the capillary beds to the lower extremities
What are the risk factors fo arterial ulcers?
Coronary heart disease History of stroke or TIA Diabetes mellitus Peripheral arterial disease (Intermittent claudication, critical limb ischaemia) obesity and immobility
What is the presentation of arterial ulcers?
Often distal - at the dorsum of the foot or between the toes.
Punched out appearance
Elliptical with clearly defined edges
The ulcer contains grey and granulated tissue
What is the appearance of an arterial ulcer?
Punched-out
Clearly defined edges
When does the pain of arterial ulcers arise?
Pain is worse when supine as arterial blood flow is further reduced when supine
Night pain
Pain is relieved by dangling the affected leg off the end of the bed
What are the investigations for an arterial ulcer?
Duplex ultrasonography of the lower limbs
ABPI
Percutaneous angiography
What is the management of arterial ulcers?
Revascularisation
What are venous ulcers?
Large shallow ulcers were predominantly found superior to the medial malleoli
They are caused by incompetent valves in the lower limbs leading to venous stasis and ulceration
Where are venous ulcers predominantly found?
Superior to the medial malleoli
What is the main cause of venous ulcers?
Incompetent valves
Describe the appearance of venous ulcers
Large shallow, relatively painless ulcer with an irregular margin situated superior to the medial malleoli
What investigations are performed for venous ulcers?
ABPI
What is the management for venous ulcers?
Graduated compression stockings
What is pericarditis?
Defined as inflammation of the pericardium
-Characterised clinically by a triad of chest pain, pericardial friction rub and serial ECG changes
What are the two layers of the pericardium?
Visceral and parietal pericardium
What is the visceral layer of the pericardium?
Adherent to the myocardium and secretes pericardial fluid
What is the parietal pericardium?
Composed of collagen fibres with interspersed elastin fibrils (Highly innervated)
What is the aetiology of pericarditis?
- Idiopathic
- Infective
- Connective tissue disease (Sarcoidosis, SLE, Scleroderma)
- Post-MI (Within 24-72 hours of MI – occurs in up to 20% of patients).
- Dressler’s Syndrome – Pericarditis occurring weeks/months after acute MI
- Malignancy- Lung, breast, lymphoma, leukaemia, melanoma
- Radiotherapy
- Thoracic surgery
- Drugs (Hydralazine, isoniazid)
- Others: Uraemia, rheumatoid arthritis, myxoedema, trauma
Most common causative organisms • Coxsackie B • Echovirus • Mumps • Streptococci • Fungi • Staphylococci • TB
Describe the chest pain in pericarditis?
Sharp and central , radiating to the neck or shoulders
Worse when coughing or deep inspiration
Relieved by sitting forward
Worse when lying flat
When is pericarditis pain worse?
Worse on inspiration or coughing
When is pericarditis pain relieved?
When sitting forward
What are the examination findings of pericarditis?
Fever Pericardial friction rub Beck's triad -Raised JVP -low blood pressure -Muffled heart sound
What is Beck’s triad?
- Raised JVP
- low blood pressure
- Muffled heart sound
Where is the pericardial friction rub heard best?
Lower left sternal edge with the patient leaning forward
What is Kussmaul’s sign?
A rise in JVP that occurs during inspiration
What are the signs of constrictive pericarditis?
- Kussmaul’s sign – Paradoxical increase in JVP that occurs during inspiration.
- Pulsus paradoxus
- Hepatomegaly
- Ascites
- Oedema
- Pericardial knock (Due to rapid ventricular filling) – early diastolic sound.
- Atrial fibrillation
What ECG appearances are seen in pericarditis?
Wide-spread Saddle-shaped (concave) ST elevation
Tachycardia
PR depression followed by T wave flattening and inversion
What is the acute management of cardiac tamponade?
Emergency pericadiocentesis (Aspiration of fluid from pericardial space_
What is the medical management for pericarditis?
NSAIDs (+Colchicine)
May require PPI protection
What is the surgical management for constrictive pericarditis?
Pericardiectomy
What is constrictive pericarditis?
Chronic inflammation of the pericardium with thickening and scarring of the pericardial layers
- Limits the ability of the heart fo functional normally -encased in a rigid pericardium
What is the presentation of constrictive pericarditis?
Graduate onset of symptoms
Right heart failure signs
what are right heart failure signs?
- Peripheral oedema
- Raised JVP
- Kussmaul’s sign
- Pulsatile hepatomegaly
- Soft diffuse apex beat
- Quiet heart sounds, S3
- Diastolic pericardial knock
- Splenomegaly
- Ascites
- Oedema
A CXR in constrictive pericarditis will reveal what?
Small heart +/- calcification of the pericardium.
What is the definitive management of constrictive pericarditis?
Complete pericardiectomy
NSAIDs
What is myocarditis?
Acute inflammation and necrosis of the cardiac muscle (myocardium)
What is the most common cause of myocarditis?
Coxsackie B virus
What is the presentation of myocarditis?
Prodromal flu-like illness with fever, malaise, fatigue and lethargy
Breathlessness (Due to pericardial effusion/myocardial dysfunction)
Palpitations
Sharp chest pain
What heart sounds are associated with myocarditis?
S4 gallop
Soft S1
What is the first-line investigation for myocarditis?
ECG
What is the definitive investigation for myocarditis?
Pericardial fluid drainage
-Measures glucose, protein, cytology, culture and sensitivity
Helps identify the causative organism
Which blood test confirms the diagnosis of myocarditis?
Troponin I or T
Which cardiac enzyme is raised in myocardiits?
Troponin
What is the management of myocarditis?
ACEi
Beta-blockers
Diuretics
Aldosterone antagonists
Steroids and immunosuppressants (Methylpredinsolone)
What is an aortic aneurysm?
A permanent pathological dilation of the aorta with a diameter of x1.5 or >3cm
What is the normal diameter of the aorta?
2cm
How do unruptured aneurysms occur?
Degeneration of elastic lamellae and smooth muscle loss
What connective tissue disorders are associated with an aortic aneurysm?
Marfan’s syndrome, Ehlers-Danlos syndrome
What is the presentation of a ruptured aneurysm?
Pain in the abdomen radiating to the back, iliac fossa or groin
pain is sudden/severe
Syncope
Shock
On palpation of the abdominal aorta, describe an AAA?
Pulsatile and laterally expansile mass on bimanual palpation
What is the first-line investigation for an AA?
Aortic ultrasound -defined dilation of >1.5x the expected anterior-posterior diameter
What imaging modality can identify the site of rupture for an AA?
CT contrast
What is the management of a ruptured AAA?
Urgent surgical repair-EVAR
What is Virchow’s triad?
Vessel injury, venous stasis and activation of the clotting system
What is DVT?
DVT is the development of a blood clot in a major deep vein of the leg, thigh, pelvis or abdomen.
Where do most blood clots in DVT form?
Above or behind the venous valve
Which fibrinolytic breakdown product is raised in acute thrombi?
D-dimer
What are the risk factors for DVT?
- Age
- COCP (Synthetic oestrogen)
- Post-surgery
- Prolonged immobility – Travel history
- Obesity
- Pregnancy
- Dehydration
- Smoking
- Polycythaemia
- Thrombophilia (Protein C deficiency)
- Malignancy
- Trauma
- Past DVT.
What is the presentation of DVT?
Swollen limb (calf swelling) Mild fever Localised pain along the deep venous system (From groin to the adductor canal and in the popliteal fossa)
What are the examination findings for DVT?
• Local erythema, warmth and swelling, tenderness
• Measure leg circumference (Increased)
• Varicosities (Swollen/tortuous vessels)
• Skin colour changes
• Mild fever
• Examine for PE – Check RR, pulse oximetry and pulse rate.
N.B: Homan’s sign – Forced passive dorsiflexion of the ankle causes deep calf pain.
What is homan’s sign in DVT?
Forced passive dosriflexion of the ankle causes deep calf pain
Which criteria is used to risk stratify DVT?
Well’s Criteria
Which scoring threshold of Wells Criteria indicates a D-dimer test?
A score <2
A raised D-dimer in DVT will indicate what investigation?
Duplex USS
What is the gold standard investigation for DVT?
Doppler Ultrasound (Duplex USS)
What are the findings on a Doppler USS for DVT?
- Inability to compress lumen of the vein using an ultrasound transducer
- Reduced or absent spontaneous flow, lack of respiratory variation, intraluminal echoes or colour flow patency.
What is the management of DVT?
Low molecular weight heparin
Warfarin INR 2-3
IVC filter
What is the prophylaxis for DVT?
Graduated compression stockings
What is dilated cardiomyopathy?
A dilated heart of the unknown cause. Thinning of inner layers of heart chambers, heart muscles stretch and weaken. There is an impairment of contractility (Systolic failure) – left ventricular failure.
What type of heart failure is associated with dilated cardiomyopathy?
Systolic heart failure
What type of heart failure is associated with hypertrophic cardiomyopathy?
Diastolic heart failure
What is hypertrophic cardiomyopathy?
Thickening of the cardiac muscle - impairing compliance
What is restrictive cardiomyopathy?
The cardiac cells become replaced with abnormal tissue (Scar tissue) – stiffening of ventricular wall Abnormal filling phase Impaired compliance and diastolic function.
What are the causes of restrictive cardiomyopathy?
- Amyloidosis
- Sarcoidosis
- Haemochromatosis
- Scleroderma
- Loffler’s eosinophilic endocarditis
- Endomyocardial fibrosis
What are the symptoms associated with hypertrophic cardiomyopathy?
- Usually, asymptomatic
- Syncope
- Angina
- Arrhythmias
- Dyspnoea
- Palpitations
- Family history of sudden cardiac death
What are the symptoms associated with dilated cardiomyopathy?
- Raised JVP
- Displaced apex beat
- Functional mitral and tricuspid regurgitations
- Third heart sound
- Tachycardia
- Pleural effusion
- Oedema
- Jaundice
- Hepatomegaly
- Ascites
- AF
What murmur is associated with hypertrophic cardiomyopathy?
Ejection systolic murmur
What heart sound is associated with hypertrophic cardiomyopathy?
S4
What is Kussmaul’s sign?
Rise in JVP on inspiration due to restricted filling of the ventricles
What CXR signs reveal heart failure?
Pulmonary oedema
What ECG appearances are associated with hypertrophic cardiomyopathy?
Left Axis deviation
Signs of left ventricular hypertrophy (Tall R waves)
What appearances are revealed on an echocardiogram for dilated cardiomyopathy?
Dilated ventricles with global hypokinesia and low ejection fraction
What echocardiogram appearance is seen for restrictive cardiomyopathy secondary to amyloidosis?
Sparkling appearance
What is the management for cardiomyopathy?
Treat heart failure and arrythmias
ICD for recurrent VTs
What is the definition of systolic heart failure?
The inability of the ventricles to contract normally - decreased cardiac output
Ejection fraction <40%
What are the main causes of systolic heart failure?
IHD, MI, cardiomyopathy
What is diastolic heart failure?
The inability of the ventricle to relax and fill adequately. - Increased filling pressure (Reduced EDV) - Preserved ejection fraction
Acute or decompensated heart failure is associated with what?
Pulmonary and peripheral oedema
What are the causes of left heart failure?
- Ischaemic heart disease
- Hypertension
- Cardiomyopathy
- Aortic valve disease
- Mitral regurgitation
what are the causes of right heart failure?
- Secondary to left heart failure Congestive heart failure
- Infarction
- Cardiomyopathy
- Pulmonary hypertension/embolus/valve disease
- Chronic lung disease
- Tricuspid regurgitation
What are the causes of high-output cardiac failure?
• Anaemia, Beriberi, pregnancy, Paget’s disease, Hyperthyroidism, Arteriovenous malformation.
What is the presentation of left heart failure?
Left Heart failure – Symptoms caused by pulmonary congestion. • Orthopnoea • Paroxysmal nocturnal dyspnoea • Fatigue • Poor exercise tolerance • Nocturnal cough (+/- pink frothy sputum) • Wheeze • Nocturia • Cold peripheries • Weight loss • Muscle wasting
What classification is used to scale Dyspnoea?
Dyspnoea (Based on NYHA Classification).
• 1- No dyspnoea
• 2- Dyspnoea on ordinary activities
• 3 – Dyspnoea on less than ordinary activities
• 4 – Dyspnoea at rest.
What is the presentation of right heart failure?
Right heart failure – Venous congestion • Swollen ankles • Fatigue • Increased weight (Due to oedema) • Reduced exercise tolerance • Anorexia • Nausea
What are the examination findings for left heart failure?
- Tachycardia
- Tachypnoea
- Displaced apex beat (LV dilatation)
- Bilateral basal crackles
- S3 gallop (Caused by rapid ventricular filling)
- Pansystolic murmur (Due to functional mitral regurgitation)
What heart sound is associated with left heart failure?
s3 gallop
Auscultation of the chest reveals what in acute heart failure?
Bilateral basal crackles
What are the examination findings for acute left ventricular failure?
- Tachypnoea
- Cyanosis
- Tachycardia
- Peripheral shutdown
- Gallop rhythm
- Wheeze
- Fine crackles throughout lung
- Pulsus alternans – Arterial pulse waveforms showing alternating strong and weak beats (Sign of left ventricular systolic impairment).
What are the examination findings for right heart failure?
- Raised JVP
- Hepatomegaly
- Ascites
- Ankle/sacral pitting oedema
- Signs of functional tricuspid regurgitation – pulsation in neck and face.
- Facial engorgement
- Epistaxis
- RV heave (Pulmonary hypertension)
What are the CXR findings for acute heart failure?
Alveolar oedema (Shadowing - Bat’s wings)
Kerley B lines (Interstitial oedema)
Cardiomegaly (Seen in PA film)
Dilated prominent upper lobe vessels (Upper lobe diversion)
Pleural effusion - Blunt costophrenic angles
What doe Kerley B lines represent?
Interstitial oedema
What imaging modality is used to assess ventricular function in heart failure?
Echocardiogram
What EF is associated with systolic dysfuncgion?
EF <40%
What investigation is used to measure end-diastolic pressures?
Swan-Ganz catheter
What is the acute management for heart failure?
Sit the patient up 60-100% oxygen Diamorphine GTN infusion IV furosemide
What inotropes are given to treat cardiogenic shock?
Dobutamine
What is the treatment for chronic heart failure?
Vasodilators
ACEis ARBS
Diuretics
Which diuretic is commonly used in acute heart failure?
Furosemide
What vasodilators are used in heart failure?
Hydralazine and nitrate
What aldosterone antagonist is used in acute heart failure?
Spironolactone
What are the indications for cardiac resynchronisation therapy in acute heart failure?
LEF <35% and QRS >120msec
What are the adverse effects of beta-blockers?
Bradycardia, hypotension, fatigue, dizziness
What are the adverse effects of ACEi?
Hyperkalaemia, renal impairment, dry cough, light-headedness, fatigue, GI disturbances, angioedema.
What are the adverse effects of spironolactone?
Hyperkalaemia, renal impairment, gynecomastia, breast tenderness/hair growth in women, changes in libido.
What are the adverse effects of hydralazine/nitrate?
Headache, palpitation, flushing
What is infective endocarditis?
Infective endocarditis is an infection involving the endocardial surface of the heart, including the valvular structures, the chordae tendinea, and sites of septal defects
What is the most common causative organism for infective endocarditis?
Strep Viridian and Bovis
Staph Aureus
What is the pathophysiology of infective endocarditis?
The mitral and aortic valves are typically affected given that these areas are susceptible to sustained endothelial damage secondary to turbulent flow.
• Platelets and fibrin adhere to the underlying collagen surface to form a prothrombotic milieu.
• Bacteriaemia leads to colonisation of the thrombus, perpetuating further fibrin deposition and platelet aggregation Infected vegetation.
• Vegetations destroy valve leaflets, invade the myocardium or aortic wall leading to abscess cavities.
• Activation of immune system Formation of immune complexes Vasculitis, glomerulonephritis, arthritis.
What are the risk factors for infective endocarditis?
- Abnormal valves (Congenital calcification, rheumatic heart disease).
- Prosthetic heart valves – Can occur during surgery or later
- Turbulent blood flow (Patent ductus arteriosus)
- Recent dental work/poor dental hygiene (Source of S. Viridans)
- Dermatitis
- IV injections
- Renal failure
- Organ transplantation
- Post-operative wounds.
What two symptoms suspect endocarditis?
A fever and a new murmur
What is the acute course of infective endocarditis?
Acute heart failure and emboli
What is the presentation of infective endocarditis?
Fever with sweats/chills/rigours (May be relapsing and remitting). • Weight loss • Malaise • Arthralgia • Myalgia • Confusion • Skin lesions • Ask about recent dental surgery or IV drug use.
What is the presentation of infective endocarditis?
- Pyrexia
- Tachycardia
- Signs of anaemia
- Clubbing
- Splenomegaly
- Any new murmur or changing the previous murmur.
What axial deviation is associated with pulmonary embolism?
Right axis deviation
What is the most common ECG finding with a pulmonary embolism?
Sinus tachycardia
What vasculitis changes are associated with infective endocarditis?
Roth spots on the retina
Osler’s nodes
Splinter haemorrhages
Janeway Lesions
Glomerulonephritis
What are Osler’s nodes?
Tender nodules on the finger/toe pads
What are roth spots?
White centred retinal haemorrhage
What are splinter haemorrhages?
A longitudinal red-brown haemorrhage under the nail
What are Janeway lesions?
Irregular non-tender haemorrhaging macules located on the palms (Embolic)
How many blood cultures should be taken for the diagnosis of infective endocarditis?
Obtain 3 sets of blood cultures from different venipuncture sites taken at 30-minutes prior to antibiotic therapy
What is the definitive diagnostic investigation for infective endocarditis?
A transoesophageal echocardiogram
what does a TOE reveal in IE?
Reveals vegetation
Abscess valve perforation
Mobile mass
Dihesnce of the prosthetic valve
What criteria is used for the diagnosis of infective endocarditis?
Duke’s criteria
What are the major criteria for Duke’s?
Positive blood cultures for IE- 2 separate
Echocardiogram findings
Coxiella Brunetti infection
What are the minor criteria for IE?
Predisposing heart condition or IV drug use
Fever over 38
Vascular changes - Janeway lesions, major arterial emboli, septic pulmonary infarcts
Immunological changes - Osler nodes, Roth spots, RF
What is the management for IE?
Abx for 4-6 weeks
What ABx are used for a staph IE?
- Flucloxacillin/Vancomycin
* Gentamicin
What is vasovagal syncope?
Vasovagal syncope is defined as a loss of consciousness due to a transient decrease in blood flow to the brain caused by excessive vagal damage.
What is the most common cause of fainting?
Vasovagal syncope
What can precipitate vasovagal syncope?
- Emotions: Fear, severe pain, blood phobia
* Orthostatic stress (prolonged standing, hot weather).
What is situational syncope?
Acute haemorrhage, a cough, a sneeze, gastrointestinal stimulation (swallow, defecation, visceral pain), micturition, post-exercise.
What vagal symptoms are associated with vasovagal syncope?
sweating, dizziness, light-headedness prior to passing out,
What is the presentation of a vasovagal syncope?
- Loss of consciousness lasting a short time
- Vagal symptoms – sweating, dizziness, light-headedness prior to passing out,
- Twitching of limbs during the blackout
- Recovery is normally very quick.
- Nausea
- Pallor
What investigations are performed in a presentation of vasovagal syncope?
12-lead ECG
• Rules out AV block, bradycardia, asystole, long QT, bundle branch block.
Echocardiogram
• Exclude for outflow obstruction
Lying/standing blood pressure – Check for orthostatic hypotension
Fasting blood glucose – Check for DM/hypoglycaemia.
FBC
• Haemoglobin – anaemia
Cardiac enzymes
• Troponin specific for cardiac muscle damage (3-hour delay for TnT to rise). CK-MB levels rise faster and remain elevated for 2-3 days.
D-dimer – Exclude pulmonary embolism
Serum cortisol – Exclude adrenal insufficiency
What is the management for vasovagal syncope?
Counter-pressure manoeuvre and tilt training
Fludrocortisone for volume-expansion
What is an arterial thrombus?
An arterial embolism is characterised as a sudden interruption of blood flow to an organ, because of an embolus.
What are the risk factors for an arterial thrombus?
- Atrial fibrillation
- Injury or damage to an artery wall (Atherosclerosis)
- Conditions that increase blood clotting (thrombophilia)
- Mitral stenosis
- Endocarditis
What is the presentation of an arterial thrombus?
- Pallor
- Pulselessness
- Pain
- Paraesthesia
- Perishingly cold
- Paralysis
Later symptoms • Blisters of the skin fed by the affected artery • Shedding of skin • Skin erosion (ulcer) • Tissue necrosis
What investigations are performed in an arterial thrombus?
- Angiography of the affected extremity
- Duplex doppler ultrasound exam
Blood • D-dimer • Factor VIII assay • Isotope study of the affected organ • Plasminogen activator inhibitor-1 activity • Platelet aggregation test
What is the medical management of an arterial thrombus?
Anticoagulants – Warfarin or heparin
Thrombolytic therapy – Streptokinase
Anti-platelets - Aspirin or clopidogrel
What is gangrene?
Gangrene is a complication of necrosis characterised by the decay of body tissues resulting from:
• Ischaemia
• Infection
• Trauma
What are the two types of gangrene?
Infectious wet gangrene
Ischaemic dry gangrene
What is wet gangrene?
Tissue death and infection
What is dry gangrene?
Necrosis in the absence fo an infection and occurs secondary to chronically reduced blood flow
What are the main causes of dry gangrene?
Atherosclerosis - in association with peripheral arterial disease
Thrombosis - In association with vasculitis and hypercoagulable sate
Vasospasm - In association with cocaine use and Raynaud’s
What is Gas gangrene?
Subset of necrotising myositis caused by spore-forming Clostridial species.
Which bacteria is associated with gas gangrene?
spore-forming Clostridial species.
What is necrotising fasciitis?
A life-threatening infection of deep fascia causing necrosis of subcutaneous tissue.
What is the presentation of gangrene?
Sudden onset of pain
Discolouration of affected area – Black
- Painful area with an erythematous region around gangrenous tissue (Black because of haemoglobin breakdown products)
What are the appearances of wet gangrene?
Tissue becomes boggy with associated pus and strong odour caused by the activity of anaerobes
What are the appearances of gas gangrene?
Spreading infection and destruction of tissues causes overlying oedema, discolouration, and crepitus (due to gas formation by the infection).
What is the presentation of necrotising fasciitis?
- Pain – Severe, and out of proportion to the apparent physical signs
- Predisposing event – trauma, ulcer, surgery
- Area of erythema and oedema
- Haemorrhagic blisters may eb present
- Signs of systemic inflammatory response and sepsis (high/low temperature, tachypnoea, hypotension).
What investigations are performed in gangrene?
FBC
• WBC >15.4 x 109/L – Leucocytosis
• Haemoglobin <135 g/l
Gas gangrene – Raised serum LDH + X-ray (Gas production).
Blood cultures and wound swab – For infectious gangrene
What is the management of necrotising fasciitis?
Surgical debridement and local irrigation with bacitracin infused saline
ABx
Surgical emergency
What antibiotics are associated with necrotising fasciits?
Vancomycin, linezolid and piperacillin
What is the management fo gas gangrene?
- Intensive supportive care
- Surgical debridement (+/- amputation)
- Intravenous antibiotics
What is the management of ischaemic gangrene?
- Intravenous heparin
- Surgical revascularisation
- Percutaneous transluminal angioplasty
- Thrombolytic therapy
What is pulmonary hypertension?
Pulmonary hypertension is characterised by an elevation in mean arterial pressure, caused by a variety of causes:
• Idiopathic
• Problems affecting the small branches of the pulmonary arteries
• Left ventricular failure
• Lung disease (COPD, interstitial lung disease)
• Thromboses/emboli
N.B: Cor pulmonale is right heart failure caused by chronic pulmonary arterial hypertension.
What is the presentation of pulmonary hypertension?
- Progressive breathlessness
- Weakness/tiredness
- Exertional dizziness and syncope
- Late-stage- Oedema and ascites
- Angina and tachyarrhythmia
- Cyanosis
What signs are associated with pulmonary hypertension?
- Right ventricular heave
- Loud pulmonary second heart sound (S2)
- Murmur – Pulmonary regurgitation
- Tricuspid regurgitation
- Raised JVP
- Peripheral oedema
- Ascites
What ECG appearances are associated with pulmonary hypertension?
Right ventriocular hypertrophy and strain
What is the gold-standard investigation for pulmonary hypertension?
Right heart catherisation - directly measure pulmonary pressure and confirm the diagnosis
What is management for pulmonary hypertension?
Vasodilators
Guanylate cyclase stimulators
What ECG changes are associated with hypokalaemia?
T wave inversion
ST depression
Prominent U wave
What ECG changes are associated with hypocalcaemia?
QTc prolongation
What ECG changes are associated with hypercalcaemia?
J waves, Osborne waves
Shortening of the QTc interval
What murmur is associated with HOCM?
Systolic ejection murmur
What is Brugada Syndrome?
Sodium channel-patties
What ECG changes are associated with digoxin?
Downsloping ST depression
T-wave changes
biphasic and shortened QT interval
PR interval prolongation
Prominent U waves
What ECG morphology is associated with digoxin toxicity?
“slurred”, “sagging” or “scooped” and resembling either a “reverse tick”, “hockey stick” or even Salvador Dali’s moustache
What ECG changes are seen in sick sinus syndrome?
Sinus bradycardia
Sinoatrial block
Periods of sinus arest
Which cardiac biomarker is suggestive of heart failure?
NT-pro-BNP
Which cardiac biomarker should be monitored for a reinfarction?
Creatine kinase (CK-MB) remains elevated for 3 to 4 days following infarction. Troponin remains elevated for 10 days. This makes CK-MB useful for detecting re-infarction in the window of 4 to 10 days after the initial insult
A high-pitched pansystolic murmur heard loudest on inspiration and at the left lower sternal edge is consistent with what valvular defect?
Tricuspid regurgitation
What murmur is associated with HOCM?
Ejection systolic murmur, heard loudest on expiration
What murmur is associated with a ventricular septal defect?
Ventricular septal defects may also cause a pansystolic murmur at the lower left sternal edge. However, this murmur is harsh, rather than high-pitched, and would not tend to be augmented by inspiration.
What type of heart block is associated with athletes?
First-degree heart block
What is a non-cardioselective beta blocker?
Propanolol
Which drug can cause Raynaud’s phenomenon?
Non-cardioselective betablockes - Propanolol
What type of beta-blocker is propanolol?
Non-cardioselective
What drug is used for treating new-onset AF with a history of asthma?
rate-limiting calcium channel blocker.
Diltiazem
In acute heart failure which drug improves symptoms but not mortality?
Furosemide
What ECG changes are seen in LBBB?
W in lead V1 and M in V6
What ECG changes are seen in RBBB?
M in lead V1 and W in v6
A new acute LBBB is a sign of what acute condition?
STEMI
What is the management of bradycardia?
IV atropine
What is the management of Mobitz-I heart block in a healthy athlete?
Reassurance and safety net
What ECG appearances are associated with left ventricular hypertrophy?
ECG shows–
-large R waves in the left-sided leads (V5, V6) and
-deep S-waves in the right-sided leads (V1, V2).
ST elevation in leads V2-3.
These findings are consistent with left ventricular hypertrophy. Furthermore, there is also T-wave inversion present in leads V5 and V6, known as the left ventricular ‘strain’ pattern.
What ECG appearances are associated with a posterior myocardial infarction?
Progressive Tall R waves beginning in V1 V2
What is an important cause of VT?
Hypokalaemia
What are the three types of peripheral vascular disease?
Acute limb ischaemia
-Sudden decrease in limb perfusion
Intermittent claudication - pain on exertion
Critical limb ischaemia
-Pain at rest
In intermittent claudication, when does pain occur?
Pain on exertion (Claudication distance)
Where does intermittent claudication typically occur in the body?
Buttock, Calf or thigh
When does critical limb ischaemia occur?
Pain at rest
What are the RFs for peripheral vascular disease?
Hypertension Smoking Elderly Male Hyperlipidaemia
What is the presentation of acute limb ischaemia?
Pain Pale/pallor Paraesthesia Pulselessness Paralysis Perishingly cold
What are the signs of chronic limb ischaemia?
Hair loss Numbness in feet/legs Brittle/slow-growing toenails Ulcers Absent pulses Atrophic skin
Which test is used to indicate severe limb ischaemia?
Beurger’s test
What is Beurger’s test?
Lie patient flat on bed and lift leg up to 45 degrees
Limb develops pallor indicates arterial insufficiency
<20 degrees is Beurger’s angle and indicates severe limb ischaemia
patient then swings leg over the bed, reactive hyperaemia is seen due to arteriolar dialtation in response to anaerobic
What is the first-line investigation for PVD?
Full cardiovascular risk assessment
BP and HR
Bloods (GBC, fasting glucose, lipids)
What is the gold-standard investigation for the diagnosis of PVD?
Ankle-Brachial pressure index (ABPI)
-Normal range: 0.9-1.2
how do you measure ABPI?
Measure systolic blood pressure in ankle/brachial
What is an abnormal ABPI?
<0.9
What ABPI parameter is associated with critical limb ischaemia?
<0.5
What investigation directly visualises the site of stenosis in PVD?
Colour duplex ultrasound scan and magnetic resonance angiogram
Which syndrome is referred to aortoiliac occlusive disease?
Leriche syndrome
What are the symptoms of Leriche syndrome?
Buttock claudication
Impotence
Absent weak distal pulses
What syndrome is characterised as buttock claudication, impotence and absent/weak distal pulses?
Leriche syndrome (Aortoiliac occlusive disease)
What are the three types of ulcers?
Arterial ulcers
Venous ulcers
Neuropathic ulcers
What is the appearance of arterial ulcers?
Punched out - deeper than venous ulcer
-Distal (Dorsum of the foot and between toes)
- Well defined edges
- Pale base -grey granulation tissue
What are the signs of an arterial ulcer?
Hair loss, shinny and pale skin
Calf muscle wasting
Absent pulses
Night pain
At what time of the day are arterial ulcers painful?
Night pain
What is the appearance of venous ulcers?
Large and shallow
-Sloping and less well-defined sides
- More proximal than AU (gaiter region)
- Other symptoms. of venous insufficiency (swelling, itching and aching)
What are the signs of venous insufficiency?
- Stasis eczema
- Lipodermatosclerosis (Champagne bottle)
- Atrophy blanche
- Hemosiderin deposition
What is lipodermatosclerosis?
Inflammation of the layer of fat deep to the skin
- Classic champagne appearance
- Redness and swelling with tapering around the ankles
What is atrophy blanche?
Areas of white and shiny skin that is atrophic
-Surrounded by small dilated capillaries
What is hemosiderin deposition?
Decreased blood flow in the limbs leads to congestion- blood leaks out resulting in discolouration of the skin
What is the gold-standard investigation for arterial and venous ulcers?
Duplex USS of the lower limbs
What is the advantage with using a duplex USS in arterial and venous ulcers?
Visualisation and topography of blood flow to identify specific pathological location (Arterial narrowing or valve degeneration)
What is the gold-standard investigation for a venous ulcer?
Duplex USS of lower limbs and measure surface area of ulcer (To monitor progression)
Swab for infection
Biopsy
What investigations are performed in arterial ulcers?
Duplex USS of lower limbs
ABPI
Percutaneous angiography
What is a Marjolin’s ulcer?
A squamous cell carcinoma of the skin, developing from areas of chronic injury and inflammation
What is the management for venous ulcers?
Graded compression stockings - reduces venous stasis
Debridement and cleaning
ABx
Moisturising cream
What is the definition of AAA?
Diameter >3cm or 50% larger than normal diameter
What are the two forms of true aneursysms?
Saccular
Fusiform
What is a saccular anerusysm?
All three layers are pushed out
What is a false anerusysm,?
Tear in blood vessel, therefore blood is flowing into the false lumen
What are the risk factors for AAA?
Smoking Male Connective tissue disorder Old age Hypertension Inflammatory disorders - pro-aneurysm state
What is the screening programme for AAA?
Male >65 years
What are the signs of unruptured AAA?
Usually asymptomatic
Often an incidental finding
May have pain in the back, abdomen or groin
- Pulsatile and laterally expansile mass on palpation
- Abdominal bruit
What is the presentation of a ruptured AAA?
Sudden, severe pain in the back, abdomen and groin
- Syncope
- Shock
Pulsatile and laterally expansile mass on palpation
Abdominal bruit
Grey-Turner’s sign (ruptured)
Medical emergency
What is the gold-standard investigation for AAA?
Abdominal ultrasound - can detect the presence of AAA but not whether it has ruptured or not
-Can measure AA diameter (>3cm)
What investigation is used to assess whether an AAA is ruptuted?
CT angiogram - visualise blood flow outside the abdominal aorta
MR angiogram - if patient has renal impairment or contrast allergy
What is an aortic dissection?
A condition where there is a tear in the aortic intima- allowing for blood to flow into a new false channel in between the inner and outer layers of the tunica media
What are the two types of aortic dissection?
Type A - Ascending
Type B - Descending
What are the RFs for aortic dissection?
Male Connective tissue disorder Smoking Hypertension Coarctation of the aorta Cocaine
What is the presentation of aortic dissection?
Sudden central tearing pain radiating to the back (Interscapular)
- Symptoms caused by blockages to branches of the aorta:
- Carotid artery- Blackout and dysphasia
- Coronary artery - angina
- Subclavian artery - LOC
- Renal artery - Anuria, renal failure
What are the signs of aortic dissection?
Hypertension
Blood pressure difference between two arms
Murmur on the back
Signs of aortic regurgitation
Signs of connective tissue disease
Which murmur is associated with aortic dissection?
Aortic regurgitation
-Early diastolic murmur
What are the four investigations performed in suspected aortic dissection?
1- Bloods
2- ECG
3- CXR
4- CT angiogram
What is the gold-standard investigation for diagnosing an aortic dissection?
CT angiogram
What signs are found on a CXR for aortic dissection?
Loss of contour of aortic knuckle
Widened mediastinum
Globular heart
How do you describe an early-diastolic murmur?
Decrescendo murmur
What is the definition of varicose veins?
Subcutaneous permanently dilated veins >3mm in diameter when measured in a standing position (often the superficial veins of the lower limb)
Describe the blood flow in varicose veins?
Turbulent- reducing venous return to the heart
What are the primary causes of varicose veins?
Idiopathic valvular incompetence
What are the causes of venous outflow obstruction?
Pregnancy
Ascites
Ovarian cysts
Pelvic malignancy
What are the secondary causes of varicose veins?
DVT
Venous outflow obstruction
AV malformations
What are the symptoms of varicose veins?
Visible dilation of veins
Leg aching (worse with prolonged standing) -Gravity induced
Swelling and itching
Bleeding
What are the signs of varicose veins?
Veins feel tender or hard
Tap test - tap proximally in the vein and feel thrill in the distal vein
Auscultation for bruits
Trendelenburg test
What is the Trendelenburg test in varicose veins?
Allow to localise the site of valvular incompetennce
Supine and leg is lifted to empty the veins, tourniquet is applied
-Blood fills veins - if filled quickly - there is incompetence
What is the gold-standard investigation for varicose veins?
Duplex ultrasound
What are the conservative measures for varicose veins?
Compression stockings
Lifestyle changes - weight loss, exercise and leg elevation
What are the endovascular treatments for varicose veins?
Radiofrequency ablation
Endovenous laser ablation
Microinjection scleropathy
What is the surgical management for varicose veins?
Stripping of the long saphenous veins
Saphenofemoral ligation
Avulsion of varicosities
Which vein is most commonly affected in varicose vein?
Long saphenous vein
What are the complications with varicose vein surgery?
Haemorrhage Infection Recurrence Paraesthesia Peroneal nerve injury
What is gangrene?
Tissue necrosis, either wet with superimposed infection, dry or gas gangrene.
What bacteria causes gas gangrene?
Clostridium perfringens
What causes gangrene?
Tissue ischaemia and infarction or physical trauma
What is the presentation of dry gangrene?
Painful black tissue affecting extremities and areas of high pressure
Signs and symptoms of DVT?
Erythema, warmth, painless, varicosities and swollen limb
What is Homan’s signin DVT?
Dorsiflex of the ankle causes deep calf pain
What criteria is used to for DVT?
Well’s criteria
What is the first-line investigaiton for DVT?
Doppler ultrasound
What is the management for DVT?
DOACs for 3 months
-Apixaban and rivaroxaban
What is the prophylactic treatment for DVT?
Compression stocking
Advice physical activity and mobilisation
