Cardiology Flashcards
1
Q
What is ACS subdivided into?
A
Unstable angina
NSTEMI
STEMI
2
Q
What is the mechanism of angina pectoris?
A
Increase in myocardial oxygen demand exceeding oxygen supply
3
Q
What is the most common cause of angina pectoris?
A
Atherosclerosis
4
Q
What are the other causes of angina?
A
Atherosclerosis
Cocaine-induced coronary spasm
Arteritis
Emboli
5
Q
What is a myocardial infarction?
A
Sudden occlusion of a coronary artery due to the rupture of an atheromatous plaque and thrombus formation
6
Q
Which cells migrate into the subendothelial space to form foam cells?
A
Macrophages
7
Q
How are foam cells formed in atherosclerosis?
A
Macrophages phagocytose oxidised LDL lipid within the subendothelial space to form foam cells
8
Q
Which growth factors are released from foam cells resulting in the formation of atherosclerotic cells?
A
PDGF and TGF-B
9
Q
What happens during the rupture of a thin fibrous cap?
A
Prothrombotic components are exposed to platelets and pro-coagulation factors leading to thrombus formation and clinical events
10
Q
What are the risk factors for ACS?
A
Male Diabetes mellitus FHx Hypertension Hyperlipidaemia Smoking
11
Q
What is presentation of ACS?
A
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
12
Q
Where does the chest pain radiate to in angina?
A
Radiates to the left arm, jaw or epigastrium
13
Q
What is the character of chest pain in angina?
A
Central heavy tight ‘gripping’ pain
14
Q
What symptoms are associated with angina?
A
Breathlessness, sweating, nausea and vomiting
15
Q
When is stable angina brought on?
A
On exertion and relieved by rest
16
Q
How is stable angina resolved?
A
On rest or GTN within 5 minutes
17
Q
What symptoms are associated with atypical angina?
A
Gastrointestinal discomfort and/or breathlessness and/or nausea
18
Q
What is Prinzemetal angina?
A
The pain from variant angina is caused by a spasm caused by exposure to cold, smoking or stress
19
Q
Which murmur is associated as a complication of an MI?
A
Pansystolic murmur due to mitral regurgitation (papillary muscle rupture)
20
Q
Which cardiac enzymes are profiled in a suspected MI?
A
CK-MB
Troponin-T (remain elevated for 2 weeks)
21
Q
How long does troponin-T remain elevated for a few hours of cardiac damage?
A
After 2 weeks
22
Q
What ECG changes are seen in an NSTEMI?
A
ST-depression
T-wave inversion
Q waves reveal previous MIs
23
Q
Describe the ST-elevation in limb leads (mm)
A
> 1mm
24
Q
Describe the ST-elevation in chest leads
A
> 2mm
25
Which leads are associated with an anterior STEMI?
V1-V4
26
Which coronary arteries are associated with an anterior MI?
Left coronary artery and left anterior descending artery (LAD)
27
Which leads are associated with a lateral STEMI?
I, aVL, V5 and V6
28
Which coronary artery is associated with a lateral MI?
Left circumflex
29
Which leads are associated with an inferior STEMI?
II, III, AvF
30
Which leads are associated with a posterior MI?
V7-V9
31
Which leads are associated with a septal MI?
v1-v2
32
What type of ECG is performed in a patient suspected with ACS?
Exercise ECG testing
33
What is the difference between unstable angina and an NSTEMI?
Troponin is raised in an NSTEMI
34
What is the gold standard to detect for coronary stenosis or obstruction?
Coronary angiography
35
What scan i used to detect wall-motion abnormalities and left ventricular function in ACS?
Echocardiogram
36
Which type of echocardiogram is used to assess for an aortic dissection?
Transoesophageal echocardiogram
37
What type of echocardiogram is used to evaluate haemodynamically significant stenoses in ACS?
Stress echocardiography
38
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
39
What loading dose of aspirin is given in ACS?
300mg Aspirin
40
What is the maintenance dose of aspirin in ACS?
75mg
41
What platelet therapy is administered in ACS?
Clopidogrel
ticagrelor
prasugrel
42
When is prasugrel given in ACS?
If the patient is already on a DOAC
43
What drugs are administered in the long-term for ACS?
```
Beta-blockers
Calcium channel blockers
Statins
ACEis
Anti-platelet therapy (DAPT)
Nitrates
```
44
What is the definitive management of an MI within 12 hours?
A percutaneous coronary intervention PCI
45
When is a CABG indicated in the management of a STEMI?
in three-vessel disease
46
What is the MoA of HMG-CoAi?
Lower LDL-C levels and raise HDL levels (Atorvastatin)
47
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)
48
What is the MoA of CCBs?
Relaxes coronary smooth muscle and produces coronary vasodilation which in turns improves myocardial oxygen delivery.
• Amlodipine (Norvasc)
49
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.
50
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.
51
What is the first-line management for symptomatic ACS?
Short-acting nitrate and 300mg Aspirin
52
When should a PCI be offered during the symptomatic presentation of ACS?
Within 12 hours
53
What should be offered in the management of ACS if PCI is not available?
Fibronlysis
54
What are the early complications after an MI?
• Death, cardiogenic shock, heart failure, ventricular arrhythmias, heart block, pericarditis, myocardial rupture, thromboembolism.
55
What are the late complications after an MI?
• Ventricular wall rupture, valvular regurgitation, ventricular aneurysms, tamponade, Dressler’s syndrome (pericarditis), thromboembolism.
56
What is aortic regurgitation?
Reflux of blood from the aorta into the left ventricle (LV) during diastole. Also known as aortic insufficiency.
57
What type of pulse is associated with aortic regurgitation?
Collapsing pulse and wide pulse pressure
58
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.
59
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.
60
Which type of murmur is associated with aortic regurgitation?
Early diastolic murmur
61
How are murmurs of aortic regurgitation exaggerated?
When the patient is sitting forward and the breath is held in expiration
62
What is Quincke's sign?
Visible pulsations on the nailbed
63
What is De Musset's sign?
Head nodding in time with the pulse
64
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.
65
What are the symptoms of acute heart failure?
Exertional dyspnoea, orthopnoea, fatigue + occasional angina.
66
What is the definitive investigation to confirm aortic regurgitation?
Echocardiogram
67
What is the definitive management of aortic regurgitation?
Aortic valve replacement
68
What is the ejection fraction in aortic regurgitation?
EF <50%
69
What is aortic stenosis?
The narrowing of the left ventricular outflow at the level of the aortic valve.
70
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).
71
What diameter of the aortic valve to categorise as aortic stenosis?
<1cm^2
72
Which congenital disorder is associated with aortic stenosis?
Congenital bicuspid aortic valve
73
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)
74
What type of anaemia is associated with aortic stenosis?
Microangiopathic haemolytic anaemia
75
How does microangiopathic anaemia occur in aortic stenosis?
Damage to erythrocytes being forced through the narrowed aortic valve Fragmentation into schistocytes Haemoglobinuria.
76
Describe the pulse in aortic stenosis
Slow rising pulse (Narrow pulse pressure)
Thrill in the aortic area
77
What murmur is auscultated in aortic stenosis?
Ejection systolic murmur at the aortic area
78
Where does aortic stenosis radiate to?
To the carotid arteries
79
What sound is heard on auscultation due a bicuspid valve?
An ejection click
80
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.
```
81
What ECG changes are seen in aortic stenosis?
Signs of left ventricular hypertrophy
Absent Q waves
LBBB
82
What signs are seen on a chest x-ray regarding aortic stenosis?
Post-stenotic enlargement of the ascending aorta
| Calcification of the aortic valve
83
What is the definitive management of aortic stenosis?
Aortic valve replacement
84
What option is available if AVR is not possible in aortic stenosis?
– Balloon dilation (valvoplasty).
85
Which type of valve replacement is recommended in patients who are young?
Metallic valve
86
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.
87
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.
88
What is the most common cause of mitral regurgitation?
Rheumatic heart disease and
| Mitral valve prolapse (Myxomatous degeneration)
89
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).
90
What is the acute presentation of MR?
Symptoms of left ventricular failure
91
What is the chronic presentation of MR?
Present with exertional dyspnoea, palpitations
92
What murmur is heard in mitral regurgitation?
Pansystolic murmur that radiates to the axilla
93
Which heart sound might be heard in mitral regurgitation?
S3 due rapid ventricular filling in early diastole
94
What is the surgical management for mitral valve regurgitation?
Mitral valve replacement/Repair
95
What is the target INR for Warfarin in patients with a mitral valve replacement?
INR 2-3
96
What is mitral valve stenosis?
Narrowing causes obstruction to blood flow from the left atrium to the left ventricle
97
What is the most common cause of mitral stenosis?
Rheumatic heart disease
98
What is the presentation of mitral stenosis?
Fatigue
Shortness of breath on exertion or lying down (Orthopnea)
Palpitations (Related to AF)
99
Malar flush is associated with which valvular pathology?
Mitral stenosis
100
Palpation of the apex beat in mitral stenosis will reveal what?
Parasternal heave (Right ventricular hypertrophy and pulmonary hypertension)
101
Auscultation of a patient with mitral valve stenosis will reveal what?
Loud first heart sound with an opening snap
Mid-diastolic murmur
102
Which type of murmur is associated with mitral stenosis?
Mid-diastolic murmur
103
Which ECG changes are associated with left atrial hypertrophy?
Broad bifid P waves
104
What are the complications of mitral stenosis on the right-side heart?
Right ventricular hypertrophy in the cases of severe pulmonary hypertension
105
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
106
What is the definitive investigation for mitral stenosis?
Echocardiography
107
What investigation measures the severity of heart failure?
Cardiac catheterisation
108
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
109
What is the surgical management for mitral stenosis?
Mitral valvuloplasty
Valvotomy
Mitral valve replacement
110
Define cardiac arrest
Acute cessation of cardiac function – a state of circulatory failure due to impaired systolic function.
111
What are the causes of cardiac arrest?
```
Hypoxia
Hypothermia
Hypovolaemia
Hypo or hyper-kalaemia
Tamponade
Tension pneumothorax
Thromboembolism
Toxins
```
112
What is the presentation of a cardiac arrest?
Patient unconsciousness
Absent breathing
Absent carotid pulse
113
For a pulseless ventricular tachycardia of ventricular fibrillation, what is the management in cardiac arrest?
Shockable rhythm after 30:2 chest compressions-rescue breaths
114
What drug is administered despite a third shock in cardiac arrest?
Amiodarone 300mg IV bolus is lidocaine
115
What is the management of asystole?
CPR for 2 minutes
Administer adrenaline (1mg IV) every 3-5 minutes
atropine
116
What is the emergency management of tension pnuemothorax?
Needle into the 2nd intercostal space, mid-clavicular line
117
What is tricuspid regurgitation?
The backflow of blood from the right ventricle to the right atrium during systole
118
What are the congenital causes of tricuspid regurgitation?
Ebstein anomaly (Mispositioned tricuspid valve)
119
What are the functional causes of tricuspid regurgitation?
Consequence of right ventricular dilation (in pulmonary hypertension)
Valve prolapse
120
What are the causes of tricuspid regurgitation?
Congenital
Functional
Rheumatic heart disease
Infective endocarditis
121
What is the most likely cause of tricuspid regurgitation?
Infective endocarditis
122
What is the presentation of tricuspid regurgitation?
```
Fatigue
Breathlessness
Palpitations
Headaches
Nausea
Anorexia
Epigastric pain
```
123
What pulse is associated with tricuspid regurgitation?
Irregularly irregular due to atrial fibrillation
124
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
125
When is a pansystolic murmur due to TR heard loudest?
During inspiration at the lower left sternal edge
126
What ECG changes are seen in TR?
Tall p waves (right atrial hypertrophy)
127
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).
128
What kind of tachycardia is atrial fibrillation?
Supraventricular tachycardia caused by a re-entry circuit within the right atrium
129
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.
130
What is the most common conduction ratio of atrial flutter?
2:1
131
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.
132
What pulse is associated with AF?
Irregularly irregular pulse
133
What is the difference in the apical beat and radial pulse?
Apical > radial
134
What are the ECG changes for AF?
Uneven baseline with absent p waves
Irregular intervals between QRS complexes
135
What are the ECG changes in atrial flutter?
Narrow complex tachycardia
Saw tooth appearance
Loss of isoelectric baseline
136
What are the three steps of management for AF?
Rate control - Restores ventricular rate to a normal range
Rhythm control - Restores sinus rhytmn
Anticoagulation
137
What is the management for acute AF <48 hours that is haemodynamically stable?
Synchronised DC cardioversion under sedation
138
What is the management for acute AF <48 hours (Haemodynamically stable)?
Rate control
| beta-blockers
139
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.
140
Which calcium channel blockers are used in the rate control of AF?
Diltiazem and verapamil
141
Why are beta-blockers not prescribed alongside Diltiazem or verapamil?
Risk fo bradycardia
| Aim for rest rate <90 bpm
142
If BBs and CBBs are ineffective rate control for AF, what drug can be used?
Digoxin
143
How long should a patient be anti-coagulated for before elective cardioversion?
3 weeks using Warfarin
144
What is the first choice drug for Rhythm control if there is no structural heart disease?
Flecainide
145
In a patient with structural heart disease and AF, what is the drug for Rhytmn control?
IV amiodarone
146
What drug is prescribed for paroxysmal AF?
Flecainide or sotalol PRN
147
Which score is used to assess the risk of stroke in patients with AF?
CHA₂DS₂-VASc
148
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
```
149
When is a DOAC given for AF in a male?
1 or more
150
What is a a DOAC given for AF in a female?
2 or more
151
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.
152
What is 1st-degree AV block?
Prolonged conduction through the AV node
153
What is the normal PR interval?
120-200ms (3-5 squares)
154
What is the PR interval in 1-st degree AV block?
>200ms
155
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
156
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)
157
Describe the PR interval in a Mobitz-Type 2 AV block?
Fixed
158
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
159
What rhythm is associated with complete heart block?
Ventricular escape rhythm
160
What is the most common metabolic cause for AV block?
Hyperkalaemia
161
What 3 main ECG changes are seen in hyperkalaemia?
Tall tented T waves
Flattened P waves
Widened QRS complex
PR prolongation
162
What is the most common cause of AV block?
MI or ischaemic heart disease
163
What is the presentation of Mobitz Type 2 and 3rd degree heart block?
Dizziness, syncope, palpitations, chest pain and heart failure
Adams Attacks
164
What are Adams Attacks?
Syncope caused by ventricular asystole
165
Which waves are associated with a raised JVP in complete heart block?
Cannon A waves
166
What are cannon A waves?
Seen occasionally in the jugular vein due to simultaneous contraction of the atria and ventricles.
167
What ECG appearances are seen in first-degree AV block?
Prolonged PR interval >200ms
168
What ECG appearances are seen in Mobitz Type 1?
Progressive prolongation of the PR interval (Followed by a skipped beat)
169
What ECG appearances are seen in Mobitz type 2?
Intermittent p waves not followed by a QRS complex (regular pattern)
-Fixed PR interval
170
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).
171
What is the management of chronic block?
Permanent pacemaker insertion (PPM)
172
What is the management of acute AV block?
IV atropine
173
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
174
What kind of tachycardia is associated with an SVT?
Narrow Complex tachycardia
175
What is a normal QRS interval?
80 and 100 milliseconds
176
What is AVNRT and AVRT?
Atrioventricular nodal re-entry tachycardia (AVNRT)
Atrioventricular re-entry tachycardia (AVRT)
177
What is AVNRT?
A localised re-entry circuit forms around the AV node - conducts to the ventricles faster than the normal conduction pathway
178
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
179
What is a common form of AVRT?
Wolff-Parkinson-white Syndrome
180
Which accessory pathway is associated with WPWs?
Bundle of Kent
181
What are the risk factors for SVT?
```
Nicotine
Alcohol
Caffeine
Previous MI
Digoxin toxicity
```
182
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.
183
Why is polyuria associated with an SVT?
Due to increased atrial pressure causing ANP release
184
Which heart sound is associated with WPWs?
S3 gallop
RV heave
Displaced beat
185
Which ECG changes are present in AVRT?
Delta wave
186
What ECG appearances are seen in AVNRT?
Narrow complex tachycardia
P waves buried in QRS complex
Decreased PR interval
187
What ECG changes are seen in AVRT?
Narrow complex tachycardia
Shortened PR interval
P waves buried in QRS
188
What investigations are performed in SVT?
24 hour ECG monitoring
189
In a haemodynamically unstable patient what is the management of SVT?
DC cardioversion
190
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).
191
What drug is administered if vagal manoeuvres fail in acute SVT?
6mg bolus Adenosine
192
What is the definitive management of AVRT?
Radiofrequency ablation of the accessory pathway
193
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.
194
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
195
What is the presentation of WPWs?
Palpitations
Light-headedness
Syncope
196
What is paroxysmal SVT followed by?
Followed by a period of polyuria due to atrial dilation and release of ANP
197
What are the classical findings in WPSs (ECG)?
Short PR interval
Broad QRS complex
Delta-waves
198
What type of tachycardia is ventricular fibrillation?
Irregular broad-complex tachycardia
199
What is the aetiology of Vfib?
Ventricular fibres contract haphazardly causing complete failure of ventricular function due to disorganised electrical activity
200
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
201
What is the presentation of V fib?
Chest pain
Fatigue
Palpitations
Cardiac arrest
202
What are the ECG appearances in V fib?
Chaotic irregular deflections of varying amplitude, no identifiable p waves
203
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
204
What is the management of Vfib?
Requires urgent defibrillation and cardioversion (Non-synchronised DC shock)
205
What kind of DC shock is administered in VFIB?
Non-synchronised DC shock
206
What may be the chronic management for Vfib?
Implantable cardioverter defibrillator (ICD)
Empirical beta-blockers
207
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
208
Definition of ventricular tachycardia?
A regular broad complex tachycardia, originating from the ventricles
Rate >120bpm
209
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.
210
What are the risk factors of Vtachy?
* Coronary heart disease
* Structural heart disease
* Electrolyte deficiencies (Hypokalaemia, hypocalcaemia, hypomagnesaemia)
* Use of stimulant drugs (Caffeine, cocaine).
211
What is the presentation of vtachy?
Chest pain
Palpitations
Dyspnoea
Syncope
212
What are the signs of haemodynamic instability in Vtachy?
* Respiratory distress
* Bibasal crackles
* Raised JVP
* Hypotension
* Anxiety
* Agitation
* Lethargy
* Coma
213
What are the ECG changes in Vtachy?
Rate >100bpm
Broad QRS complexes
AV dissociation
214
What is the management for Vtachy?
Pulseless VT - ALS
| + Unsynchronised DC cardioversion
215
What is the management for a stable VT?
Synchronised DC shock
| Amiodarone
216
What drug is used in the management of stable VT?
Amiodarone
217
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.
218
What are the complications of VT?
* Congestive cardiac failure
* Cardiogenic shock
* VT may deteriorate into VF.
219
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
220
What are the two types of aortic dissection?
Type A - Ascending Aorta
| Type B - Descending Aorta
221
What is a Type A aortic dissection?
Ascending Aorta (Most common-70%)
222
What is a type B aortic dissection?
Descending aorta (Distal to the left subclavian artery)
223
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
224
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
225
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
226
What is the main presentation of aortic dissection?
Sudden central tearing chest pain radiating to the back (in between the shoulder blades)
227
What symptoms are associated with obstruction of the carotid artery in aortic dissection?
Hemiparesis
Dysphasia
Blackout
228
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
229
What is pulsus paradoxus?
Abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration
230
What is the first-line imaging for aortic dissection?
CT thorax - Reveals false lumen
231
What is the definitive imaging for an aortic dissection?
Transoesophageal echocardiogram
232
What would a CXR show in an aortic dissection?
Widened mediastinum in acute or chronic dissection
233
What is the management of a haemodynamically unstable aortic dissection?
ALS
Supplemental oxygen
IV resus
234
What is the management of a Type A aortic dissection?
Beta-blocker (Labetalol) and Endovascular repair
235
What is the 1st line management of a Type B aortic dissection?
IV labetalol
Opioid analgesia
Vasodilator (IV sodium nitroprussie)
236
What are the two main types of chronic limb ischaemia?
Intermittent claudication
| Critical limb ischaemia
237
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
238
When does pain occur in critical limb ischaemia?
Pain occurs at rest - most severe manifestation of peripheral vascular disease
239
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
240
Define acute limb ischaemia?
A sudden decrease in arterial perfusion in a limb due to thrombotic or embolic causes or post-angioplasty
241
What is the treatment for acute limb ischaemia?
Medical emergency
| -Revascularisation within 4-7 hours
242
When is intermittent claudication relieved?
At rest
243
What is claudication distance?
Distance walked resulting in cramping pain
244
Which vessel is concerned with calf claudication?
Femoral
245
Which vessel is associated with buttock claudication?
Iliac
246
What are the features of critical limb ischaemia?
Ulcers
Gangrene
Rest pain
Night pain (Relieved by dangling leg over the edge of the bed)
247
What is Leriche Syndrome?
Aortoiliac occlusive disease
- Buttock claudication
- Impotence (ED)
- Absent/weak distal pulses
248
What are the 6Ps of acute limb ischaemia?
```
Pain
Pulseless
Pale
Paralysis
Paraesthesia
Perishingly coLD
```
249
What are the other symptoms of PVD?
Atrophic skin
Hairless
Punched-out ulcers (Painful)
Colour change when raising leg
250
What are the first-line investigations for peripheral vascular disease?
Ankle Brachial index (ABI)
251
What ABI parameters are indicative of PAD?
0.50-0.90
252
What ABI measurement is associated with critical limb ischaemia?
<0.5
253
What is the gold standard investigation for PVD?
MRI/CT angiogram
254
What is the first-line management for acute limb ischaemia?
Revascularisation
255
What is the management of a non-viable limb in acute limb ischaemia?
Amputation
256
What anti-platelet therapy is administered in ALI?
Aspirin (75-352mg Orally OD), or clopidogrel
Anticoagulation - UFH Heparin
257
What is the first-line therapy for claudication?
Antiplatelet therapy
Exercise therapy
Symptom relief
258
Define arterial ulcer
Arterial ulcers are a localised area of damage and breakdown of the skin due to an inadequate arterial blood supply
259
Where are arterial ulcers found?
Feet of patients
260
What is the aetiology of arterial ulcers?
The ulcers are caused by compromised blood flow to the capillary beds to the lower extremities
261
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
```
262
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
263
What is the appearance of an arterial ulcer?
Punched-out
| Clearly defined edges
264
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
265
What are the investigations for an arterial ulcer?
Duplex ultrasonography of the lower limbs
ABPI
Percutaneous angiography
266
What is the management of arterial ulcers?
Revascularisation
267
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
268
Where are venous ulcers predominantly found?
Superior to the medial malleoli
269
What is the main cause of venous ulcers?
Incompetent valves
270
Describe the appearance of venous ulcers
Large shallow, relatively painless ulcer with an irregular margin situated superior to the medial malleoli
271
What investigations are performed for venous ulcers?
ABPI
272
What is the management for venous ulcers?
Graduated compression stockings
273
What is pericarditis?
Defined as inflammation of the pericardium
| -Characterised clinically by a triad of chest pain, pericardial friction rub and serial ECG changes
274
What are the two layers of the pericardium?
Visceral and parietal pericardium
275
What is the visceral layer of the pericardium?
Adherent to the myocardium and secretes pericardial fluid
276
What is the parietal pericardium?
Composed of collagen fibres with interspersed elastin fibrils (Highly innervated)
277
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
```
278
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
279
When is pericarditis pain worse?
Worse on inspiration or coughing
280
When is pericarditis pain relieved?
When sitting forward
281
What are the examination findings of pericarditis?
```
Fever
Pericardial friction rub
Beck's triad
-Raised JVP
-low blood pressure
-Muffled heart sound
```
282
What is Beck's triad?
- Raised JVP
- low blood pressure
- Muffled heart sound
283
Where is the pericardial friction rub heard best?
Lower left sternal edge with the patient leaning forward
284
What is Kussmaul's sign?
A rise in JVP that occurs during inspiration
285
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
286
What ECG appearances are seen in pericarditis?
Wide-spread Saddle-shaped (concave) ST elevation
Tachycardia
PR depression followed by T wave flattening and inversion
287
What is the acute management of cardiac tamponade?
Emergency pericadiocentesis (Aspiration of fluid from pericardial space_
288
What is the medical management for pericarditis?
NSAIDs (+Colchicine)
| May require PPI protection
289
What is the surgical management for constrictive pericarditis?
Pericardiectomy
290
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
291
What is the presentation of constrictive pericarditis?
Graduate onset of symptoms
| Right heart failure signs
292
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
293
A CXR in constrictive pericarditis will reveal what?
Small heart +/- calcification of the pericardium.
294
What is the definitive management of constrictive pericarditis?
Complete pericardiectomy
| NSAIDs
295
What is myocarditis?
Acute inflammation and necrosis of the cardiac muscle (myocardium)
296
What is the most common cause of myocarditis?
Coxsackie B virus
297
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
298
What heart sounds are associated with myocarditis?
S4 gallop
| Soft S1
299
What is the first-line investigation for myocarditis?
ECG
300
What is the definitive investigation for myocarditis?
Pericardial fluid drainage
-Measures glucose, protein, cytology, culture and sensitivity
Helps identify the causative organism
301
Which blood test confirms the diagnosis of myocarditis?
Troponin I or T
302
Which cardiac enzyme is raised in myocardiits?
Troponin
303
What is the management of myocarditis?
ACEi
Beta-blockers
Diuretics
Aldosterone antagonists
Steroids and immunosuppressants (Methylpredinsolone)
304
What is an aortic aneurysm?
A permanent pathological dilation of the aorta with a diameter of x1.5 or >3cm
305
What is the normal diameter of the aorta?
2cm
306
How do unruptured aneurysms occur?
Degeneration of elastic lamellae and smooth muscle loss
307
What connective tissue disorders are associated with an aortic aneurysm?
Marfan’s syndrome, Ehlers-Danlos syndrome
308
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
309
On palpation of the abdominal aorta, describe an AAA?
Pulsatile and laterally expansile mass on bimanual palpation
310
What is the first-line investigation for an AA?
Aortic ultrasound -defined dilation of >1.5x the expected anterior-posterior diameter
311
What imaging modality can identify the site of rupture for an AA?
CT contrast
312
What is the management of a ruptured AAA?
Urgent surgical repair-EVAR
313
What is Virchow's triad?
Vessel injury, venous stasis and activation of the clotting system
314
What is DVT?
DVT is the development of a blood clot in a major deep vein of the leg, thigh, pelvis or abdomen.
315
Where do most blood clots in DVT form?
Above or behind the venous valve
316
Which fibrinolytic breakdown product is raised in acute thrombi?
D-dimer
317
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.
318
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)
```
319
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.
320
What is homan's sign in DVT?
Forced passive dosriflexion of the ankle causes deep calf pain
321
Which criteria is used to risk stratify DVT?
Well's Criteria
322
Which scoring threshold of Wells Criteria indicates a D-dimer test?
A score <2
323
A raised D-dimer in DVT will indicate what investigation?
Duplex USS
324
What is the gold standard investigation for DVT?
Doppler Ultrasound (Duplex USS)
325
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.
326
What is the management of DVT?
Low molecular weight heparin
Warfarin INR 2-3
IVC filter
327
What is the prophylaxis for DVT?
Graduated compression stockings
328
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.
329
What type of heart failure is associated with dilated cardiomyopathy?
Systolic heart failure
330
What type of heart failure is associated with hypertrophic cardiomyopathy?
Diastolic heart failure
331
What is hypertrophic cardiomyopathy?
Thickening of the cardiac muscle - impairing compliance
332
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.
333
What are the causes of restrictive cardiomyopathy?
* Amyloidosis
* Sarcoidosis
* Haemochromatosis
* Scleroderma
* Loffler’s eosinophilic endocarditis
* Endomyocardial fibrosis
334
What are the symptoms associated with hypertrophic cardiomyopathy?
* Usually, asymptomatic
* Syncope
* Angina
* Arrhythmias
* Dyspnoea
* Palpitations
* Family history of sudden cardiac death
335
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
336
What murmur is associated with hypertrophic cardiomyopathy?
Ejection systolic murmur
337
What heart sound is associated with hypertrophic cardiomyopathy?
S4
338
What is Kussmaul's sign?
Rise in JVP on inspiration due to restricted filling of the ventricles
339
What CXR signs reveal heart failure?
Pulmonary oedema
340
What ECG appearances are associated with hypertrophic cardiomyopathy?
Left Axis deviation
| Signs of left ventricular hypertrophy (Tall R waves)
341
What appearances are revealed on an echocardiogram for dilated cardiomyopathy?
Dilated ventricles with global hypokinesia and low ejection fraction
342
What echocardiogram appearance is seen for restrictive cardiomyopathy secondary to amyloidosis?
Sparkling appearance
343
What is the management for cardiomyopathy?
Treat heart failure and arrythmias
ICD for recurrent VTs
344
What is the definition of systolic heart failure?
The inability of the ventricles to contract normally - decreased cardiac output
Ejection fraction <40%
345
What are the main causes of systolic heart failure?
IHD, MI, cardiomyopathy
346
What is diastolic heart failure?
The inability of the ventricle to relax and fill adequately. - Increased filling pressure (Reduced EDV) - Preserved ejection fraction
347
Acute or decompensated heart failure is associated with what?
Pulmonary and peripheral oedema
348
What are the causes of left heart failure?
* Ischaemic heart disease
* Hypertension
* Cardiomyopathy
* Aortic valve disease
* Mitral regurgitation
349
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
350
What are the causes of high-output cardiac failure?
• Anaemia, Beriberi, pregnancy, Paget’s disease, Hyperthyroidism, Arteriovenous malformation.
351
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
```
352
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.
353
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
```
354
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)
355
What heart sound is associated with left heart failure?
s3 gallop
356
Auscultation of the chest reveals what in acute heart failure?
Bilateral basal crackles
357
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).
358
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)
359
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
360
What doe Kerley B lines represent?
Interstitial oedema
361
What imaging modality is used to assess ventricular function in heart failure?
Echocardiogram
362
What EF is associated with systolic dysfuncgion?
EF <40%
363
What investigation is used to measure end-diastolic pressures?
Swan-Ganz catheter
364
What is the acute management for heart failure?
```
Sit the patient up
60-100% oxygen
Diamorphine
GTN infusion
IV furosemide
```
365
What inotropes are given to treat cardiogenic shock?
Dobutamine
366
What is the treatment for chronic heart failure?
Vasodilators
ACEis ARBS
Diuretics
367
Which diuretic is commonly used in acute heart failure?
Furosemide
368
What vasodilators are used in heart failure?
Hydralazine and nitrate
369
What aldosterone antagonist is used in acute heart failure?
Spironolactone
370
What are the indications for cardiac resynchronisation therapy in acute heart failure?
LEF <35% and QRS >120msec
371
What are the adverse effects of beta-blockers?
Bradycardia, hypotension, fatigue, dizziness
372
What are the adverse effects of ACEi?
Hyperkalaemia, renal impairment, dry cough, light-headedness, fatigue, GI disturbances, angioedema.
373
What are the adverse effects of spironolactone?
Hyperkalaemia, renal impairment, gynecomastia, breast tenderness/hair growth in women, changes in libido.
374
What are the adverse effects of hydralazine/nitrate?
Headache, palpitation, flushing
375
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
376
What is the most common causative organism for infective endocarditis?
Strep Viridian and Bovis
| Staph Aureus
377
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.
378
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.
379
What two symptoms suspect endocarditis?
A fever and a new murmur
380
What is the acute course of infective endocarditis?
Acute heart failure and emboli
381
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.
```
382
What is the presentation of infective endocarditis?
* Pyrexia
* Tachycardia
* Signs of anaemia
* Clubbing
* Splenomegaly
* Any new murmur or changing the previous murmur.
383
What axial deviation is associated with pulmonary embolism?
Right axis deviation
384
What is the most common ECG finding with a pulmonary embolism?
Sinus tachycardia
385
What vasculitis changes are associated with infective endocarditis?
Roth spots on the retina
Osler's nodes
Splinter haemorrhages
Janeway Lesions
Glomerulonephritis
386
What are Osler's nodes?
Tender nodules on the finger/toe pads
387
What are roth spots?
White centred retinal haemorrhage
388
What are splinter haemorrhages?
A longitudinal red-brown haemorrhage under the nail
389
What are Janeway lesions?
Irregular non-tender haemorrhaging macules located on the palms (Embolic)
390
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
391
What is the definitive diagnostic investigation for infective endocarditis?
A transoesophageal echocardiogram
392
what does a TOE reveal in IE?
Reveals vegetation
Abscess valve perforation
Mobile mass
Dihesnce of the prosthetic valve
393
What criteria is used for the diagnosis of infective endocarditis?
Duke's criteria
394
What are the major criteria for Duke's?
Positive blood cultures for IE- 2 separate
Echocardiogram findings
Coxiella Brunetti infection
395
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
396
What is the management for IE?
Abx for 4-6 weeks
397
What ABx are used for a staph IE?
* Flucloxacillin/Vancomycin
| * Gentamicin
398
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.
399
What is the most common cause of fainting?
Vasovagal syncope
400
What can precipitate vasovagal syncope?
* Emotions: Fear, severe pain, blood phobia
| * Orthostatic stress (prolonged standing, hot weather).
401
What is situational syncope?
Acute haemorrhage, a cough, a sneeze, gastrointestinal stimulation (swallow, defecation, visceral pain), micturition, post-exercise.
402
What vagal symptoms are associated with vasovagal syncope?
sweating, dizziness, light-headedness prior to passing out,
403
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
404
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
405
What is the management for vasovagal syncope?
Counter-pressure manoeuvre and tilt training
Fludrocortisone for volume-expansion
406
What is an arterial thrombus?
An arterial embolism is characterised as a sudden interruption of blood flow to an organ, because of an embolus.
407
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
408
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
```
409
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
```
410
What is the medical management of an arterial thrombus?
Anticoagulants – Warfarin or heparin
Thrombolytic therapy – Streptokinase
Anti-platelets - Aspirin or clopidogrel
411
What is gangrene?
Gangrene is a complication of necrosis characterised by the decay of body tissues resulting from:
• Ischaemia
• Infection
• Trauma
412
What are the two types of gangrene?
Infectious wet gangrene
| Ischaemic dry gangrene
413
What is wet gangrene?
Tissue death and infection
414
What is dry gangrene?
Necrosis in the absence fo an infection and occurs secondary to chronically reduced blood flow
415
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
416
What is Gas gangrene?
Subset of necrotising myositis caused by spore-forming Clostridial species.
417
Which bacteria is associated with gas gangrene?
spore-forming Clostridial species.
418
What is necrotising fasciitis?
A life-threatening infection of deep fascia causing necrosis of subcutaneous tissue.
419
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)
420
What are the appearances of wet gangrene?
Tissue becomes boggy with associated pus and strong odour caused by the activity of anaerobes
421
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).
422
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).
423
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
424
What is the management of necrotising fasciitis?
Surgical debridement and local irrigation with bacitracin infused saline
ABx
Surgical emergency
425
What antibiotics are associated with necrotising fasciits?
Vancomycin, linezolid and piperacillin
426
What is the management fo gas gangrene?
* Intensive supportive care
* Surgical debridement (+/- amputation)
* Intravenous antibiotics
427
What is the management of ischaemic gangrene?
* Intravenous heparin
* Surgical revascularisation
* Percutaneous transluminal angioplasty
* Thrombolytic therapy
428
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.
429
What is the presentation of pulmonary hypertension?
* Progressive breathlessness
* Weakness/tiredness
* Exertional dizziness and syncope
* Late-stage- Oedema and ascites
* Angina and tachyarrhythmia
* Cyanosis
430
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
431
What ECG appearances are associated with pulmonary hypertension?
Right ventriocular hypertrophy and strain
432
What is the gold-standard investigation for pulmonary hypertension?
Right heart catherisation - directly measure pulmonary pressure and confirm the diagnosis
433
What is management for pulmonary hypertension?
Vasodilators
| Guanylate cyclase stimulators
434
What ECG changes are associated with hypokalaemia?
T wave inversion
ST depression
Prominent U wave
435
What ECG changes are associated with hypocalcaemia?
QTc prolongation
436
What ECG changes are associated with hypercalcaemia?
J waves, Osborne waves
| Shortening of the QTc interval
437
What murmur is associated with HOCM?
Systolic ejection murmur
438
What is Brugada Syndrome?
Sodium channel-patties
439
What ECG changes are associated with digoxin?
Downsloping ST depression
T-wave changes
biphasic and shortened QT interval
PR interval prolongation
Prominent U waves
440
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
441
What ECG changes are seen in sick sinus syndrome?
Sinus bradycardia
Sinoatrial block
Periods of sinus arest
442
Which cardiac biomarker is suggestive of heart failure?
NT-pro-BNP
443
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
444
A high-pitched pansystolic murmur heard loudest on inspiration and at the left lower sternal edge is consistent with what valvular defect?
Tricuspid regurgitation
445
What murmur is associated with HOCM?
Ejection systolic murmur, heard loudest on expiration
446
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.
447
What type of heart block is associated with athletes?
First-degree heart block
448
What is a non-cardioselective beta blocker?
Propanolol
449
Which drug can cause Raynaud's phenomenon?
Non-cardioselective betablockes - Propanolol
450
What type of beta-blocker is propanolol?
Non-cardioselective
451
What drug is used for treating new-onset AF with a history of asthma?
rate-limiting calcium channel blocker.
| Diltiazem
452
In acute heart failure which drug improves symptoms but not mortality?
Furosemide
453
What ECG changes are seen in LBBB?
W in lead V1 and M in V6
454
What ECG changes are seen in RBBB?
M in lead V1 and W in v6
455
A new acute LBBB is a sign of what acute condition?
STEMI
456
What is the management of bradycardia?
IV atropine
457
What is the management of Mobitz-I heart block in a healthy athlete?
Reassurance and safety net
458
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.
459
What ECG appearances are associated with a posterior myocardial infarction?
Progressive Tall R waves beginning in V1 V2
460
What is an important cause of VT?
Hypokalaemia
461
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
462
In intermittent claudication, when does pain occur?
Pain on exertion (Claudication distance)
463
Where does intermittent claudication typically occur in the body?
Buttock, Calf or thigh
464
When does critical limb ischaemia occur?
Pain at rest
465
What are the RFs for peripheral vascular disease?
```
Hypertension
Smoking
Elderly
Male
Hyperlipidaemia
```
466
What is the presentation of acute limb ischaemia?
```
Pain
Pale/pallor
Paraesthesia
Pulselessness
Paralysis
Perishingly cold
```
467
What are the signs of chronic limb ischaemia?
```
Hair loss
Numbness in feet/legs
Brittle/slow-growing toenails
Ulcers
Absent pulses
Atrophic skin
```
468
Which test is used to indicate severe limb ischaemia?
Beurger's test
469
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
470
What is the first-line investigation for PVD?
Full cardiovascular risk assessment
BP and HR
Bloods (GBC, fasting glucose, lipids)
471
What is the gold-standard investigation for the diagnosis of PVD?
Ankle-Brachial pressure index (ABPI)
| -Normal range: 0.9-1.2
472
how do you measure ABPI?
Measure systolic blood pressure in ankle/brachial
473
What is an abnormal ABPI?
<0.9
474
What ABPI parameter is associated with critical limb ischaemia?
<0.5
475
What investigation directly visualises the site of stenosis in PVD?
Colour duplex ultrasound scan and magnetic resonance angiogram
476
Which syndrome is referred to aortoiliac occlusive disease?
Leriche syndrome
477
What are the symptoms of Leriche syndrome?
Buttock claudication
Impotence
Absent weak distal pulses
478
What syndrome is characterised as buttock claudication, impotence and absent/weak distal pulses?
Leriche syndrome (Aortoiliac occlusive disease)
479
What are the three types of ulcers?
Arterial ulcers
Venous ulcers
Neuropathic ulcers
480
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
481
What are the signs of an arterial ulcer?
Hair loss, shinny and pale skin
Calf muscle wasting
Absent pulses
Night pain
482
At what time of the day are arterial ulcers painful?
Night pain
483
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)
484
What are the signs of venous insufficiency?
- Stasis eczema
- Lipodermatosclerosis (Champagne bottle)
- Atrophy blanche
- Hemosiderin deposition
485
What is lipodermatosclerosis?
Inflammation of the layer of fat deep to the skin
- Classic champagne appearance
- Redness and swelling with tapering around the ankles
486
What is atrophy blanche?
Areas of white and shiny skin that is atrophic
| -Surrounded by small dilated capillaries
487
What is hemosiderin deposition?
Decreased blood flow in the limbs leads to congestion- blood leaks out resulting in discolouration of the skin
488
What is the gold-standard investigation for arterial and venous ulcers?
Duplex USS of the lower limbs
489
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)
490
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
491
What investigations are performed in arterial ulcers?
Duplex USS of lower limbs
ABPI
Percutaneous angiography
492
What is a Marjolin's ulcer?
A squamous cell carcinoma of the skin, developing from areas of chronic injury and inflammation
493
What is the management for venous ulcers?
Graded compression stockings - reduces venous stasis
Debridement and cleaning
ABx
Moisturising cream
494
What is the definition of AAA?
Diameter >3cm or 50% larger than normal diameter
495
What are the two forms of true aneursysms?
Saccular
| Fusiform
496
What is a saccular anerusysm?
All three layers are pushed out
497
What is a false anerusysm,?
Tear in blood vessel, therefore blood is flowing into the false lumen
498
What are the risk factors for AAA?
```
Smoking
Male
Connective tissue disorder
Old age
Hypertension
Inflammatory disorders - pro-aneurysm state
```
499
What is the screening programme for AAA?
Male >65 years
500
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
501
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
502
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)
503
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
504
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
505
What are the two types of aortic dissection?
Type A - Ascending
| Type B - Descending
506
What are the RFs for aortic dissection?
```
Male
Connective tissue disorder
Smoking
Hypertension
Coarctation of the aorta
Cocaine
```
507
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
508
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
509
Which murmur is associated with aortic dissection?
Aortic regurgitation
| -Early diastolic murmur
510
What are the four investigations performed in suspected aortic dissection?
1- Bloods
2- ECG
3- CXR
4- CT angiogram
511
What is the gold-standard investigation for diagnosing an aortic dissection?
CT angiogram
512
What signs are found on a CXR for aortic dissection?
Loss of contour of aortic knuckle
Widened mediastinum
Globular heart
513
How do you describe an early-diastolic murmur?
Decrescendo murmur
514
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)
515
Describe the blood flow in varicose veins?
Turbulent- reducing venous return to the heart
516
What are the primary causes of varicose veins?
Idiopathic valvular incompetence
517
What are the causes of venous outflow obstruction?
Pregnancy
Ascites
Ovarian cysts
Pelvic malignancy
518
What are the secondary causes of varicose veins?
DVT
Venous outflow obstruction
AV malformations
519
What are the symptoms of varicose veins?
Visible dilation of veins
```
Leg aching (worse with prolonged standing)
-Gravity induced
```
Swelling and itching
Bleeding
520
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
521
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
522
What is the gold-standard investigation for varicose veins?
Duplex ultrasound
523
What are the conservative measures for varicose veins?
Compression stockings
Lifestyle changes - weight loss, exercise and leg elevation
524
What are the endovascular treatments for varicose veins?
Radiofrequency ablation
Endovenous laser ablation
Microinjection scleropathy
525
What is the surgical management for varicose veins?
Stripping of the long saphenous veins
Saphenofemoral ligation
Avulsion of varicosities
526
Which vein is most commonly affected in varicose vein?
Long saphenous vein
527
What are the complications with varicose vein surgery?
```
Haemorrhage
Infection
Recurrence
Paraesthesia
Peroneal nerve injury
```
528
What is gangrene?
Tissue necrosis, either wet with superimposed infection, dry or gas gangrene.
529
What bacteria causes gas gangrene?
Clostridium perfringens
530
What causes gangrene?
Tissue ischaemia and infarction or physical trauma
531
What is the presentation of dry gangrene?
Painful black tissue affecting extremities and areas of high pressure
532
Signs and symptoms of DVT?
Erythema, warmth, painless, varicosities and swollen limb
533
What is Homan's signin DVT?
Dorsiflex of the ankle causes deep calf pain
534
What criteria is used to for DVT?
Well's criteria
535
What is the first-line investigaiton for DVT?
Doppler ultrasound
536
What is the management for DVT?
DOACs for 3 months
| -Apixaban and rivaroxaban
537
What is the prophylactic treatment for DVT?
Compression stocking
| Advice physical activity and mobilisation
