Cardiology Flashcards
1
Q
Define infective endocarditis (IE)F
A
- infection of endocardium or vascular endothelium of heart
2
Q
Difference between early and late prosthetics
A
Early - within 1 year of op
Late - after a year post op
3
Q
Give 4 risk factors for IE
A
- Poor dental hygiene
- young IV drug users
- young with congenital HD
- prosthetic valves
4
Q
Name 3 bacteria that can cause IE
A
staph aureus - drug users
strep viridans - poor dental health
Staph epidermis - prosthetic valve surgery
5
Q
Explain the pathophysiology of IE
A
Abnormal/ damaged endocardium have increased platelets deposition; bacteria adheres to this and causes vegetations
* typically around valves
* causing regurgitation
6
Q
Signs and symptoms of IE
A
New regurgitant heart murmur
Fever
Headache and fatigue
Night sweats, malaise
peripheral stigmata
7
Q
What are the peripheral stigmata of IE
A
- Osler’s nodes - small tender nodules found on tips of fingers or toes
- Splinter haemorrhages
- Roth spots - retinal haemorrhage
- Janeway lesions - non tender lesions on soles & palm
8
Q
5 ways in which IE is diagnosed
A
- ECG - long PR interval
- Urinalysis - proteinuria and blood
- Echocardiogram (ECHO) - Detecting vegetation
- High CRP and ESR
- Blood cultures: 3 cultures from 3 different sites at different times
9
Q
What is the scoring system for infective endocarditis
A
Duke’s criteria - definite/possible IE
10
Q
What are the 2 different echocardiogram (ECHO) methods
A
Transthoracic 2D echo (TTE)
Transoesophageal echo (TOE)
11
Q
PROS and CONS of TOE
A
TOE more invasive than TTE but has better visualisation sensitivity and specificity
12
Q
Treatment of IE caused by s.aureus
A
IV Flucloxacillin
or Vancomycin + rifampicin if MRSA
13
Q
Treatment of IE caused by s.viridans
A
Beta-lactam (e.g. benzylpenicillin, amoxicillin) + gentamicin
14
Q
How is IE treated if it is unable to be treated by antibiotics
A
Surgery
* remove incompetent valve and replace with prosthetic
* remove large vegetations before they embolise
* replace infected devices
15
Q
How long are patient’s with IE on antibiotics for
A
4-6 weeks
16
Q
Complications of IE
A
Heart failure
Aortic root abscess
Sepsis
emboli
Stroke
17
Q
Define aortic stenosis
A
Narrowing of the aortic valve
Normal valve area is 4cm²
Symptoms occur when area is 1/4th of normal
Systolic murmur
18
Q
Causes of aortic stenosis (AS)
A
Congenital bicuspid valve
Age-related degenerative calcification
19
Q
Explain the pathophysiology of AS
A
Narrowing of aortic valve
Decreased SV
Increased after load
increased LV pressure
Compensatory LVH
20
Q
Presentation of aortic stenosis
A
SAD:
Syncope (collapse, exertional)
Angina (increased myocardial O2 demand)
Dyspnoea (due to heart failure)
21
Q
Clinical signs of aortic stenosis
A
- Slow rising pulse and decreased pulse amplitude - severe
- Prominent S4 due to left ventricular hypertrophy
- Ejection systolic murmur radiating to carotids - crescendo-decrescendo
22
Q
How is AS investigated
A
ECG: LVH
ECHO:
* LV size and function: hypertrophy, dilation and ejection fraction
* Aortic valve area (Doppler derived)
23
Q
Treatment of AS
A
Healthy patient: open repair, valve replacement
At risk patient: TAVI (Transcatheter aortic valve implantation) - less invasive stents
24
Q
Define aortic regurgitation (AR)
A
Leakage of blood into LV during diastole due to ineffective aortic valve
Diastolic murmur
25
Causes of AR
Congenital Bicuspid aortic valve
Rheumatic heart disease
Infective endocarditis
26
Clinical signs of aortic regurgitation
* Wide pulse pressure
* Austin flint murmur - rumbling mid diastolic murmur at apex (severe)
* Early Diastolic blowing murmur - at left sternal border
* Collapsing pulse
27
Give 2 symptoms of aortic regurgitation
Exertional dyspnoea
Palpitations
28
Explain the investigation and diagnosis of AR
* Chest X-ray - enlarged cardiac silhouette and aortic root enlargement
* ECHO - evaluate AV and aortic root with measurements of LV dimensions
29
Treatment for AR
* IE prophylaxis
* Vasodilator - ACEi
* Surgical valve replacement if appropriate
30
Define mitral regurgitation
Backflow of blood from the LV to the LA during systole due to ineffective mitral valve
*Systolic murmur
31
State 3 causes of MR
Ischaemic MV
Rheumatic HD
Infective endocarditis
32
Risk factors of MR
Low BMI
Congenital HD
Mitral valve prolapse (floppy)
Female
33
Explain the pathophysiology of MR
Regurgitation into the left atrium 🡪 left atrial dilatation 🡪 left atrial enlargement 🡪 LVH (since ventricle needs to put in more effort to pump less blood) 🡪 pulmonary hypertension 🡪 right ventricular dysfunction
34
Presentation of MR
Exertion dyspnoea
Murmur: pansystolic murmur at the apex radiating to axilla
* Soft S1 & Prominent S3
* Chronic MR - intensity correlates with severity
* Displaced apical beat
35
3 investigations for mitral regurgitation
ECG - LA enlargement, AF & LVH with severe MR
Chest Xray - LA enlargement, central pulmonary artery enlargement
ECHO - est LA, LV size and function, Valve structure assessment
36
What drugs are used to treat MR
BB (atenolol), CCB - rate control
ACEi
Nitrates/ diuretics in acute MR
37
When is surgery for MR undergone
* Any symptoms at rest - valve replacement/repair
* ejection fraction <60%
38
Define mitral stenosis
Obstruction of LV inflow that prevents proper filling during diastole (diastolic murmur)
Normal MV area: 4-6 cm²
Symptoms begin at areas <2cm²
39
Causes of m.stenosis
Rheumatic heart disease (common)
Infective endocarditis
Mitral valve calcification
40
Explain the pathophysiology of m.stenosis
Thickening and immobility of valve > obstruction of blood flow from right atrium to right ventricle > left atrial pressure increases > LAH > pulmonary venous, arterial and right heart pressures increase > pulmonary oedema > pulmonary HTN > RVH > tricuspid regurgitation
41
Signs of m.stenosis
* pinkish-purple patches on cheeks
* prominent a wave in jugular venous pulsations
* Dyspnoea
42
Describe the diastolic murmur in mitral stenosis
Diastolic murmur:
* low-pitched diastolic rumble most prominent at apex
* heard best with patient lying on left side in held expiration
* intensity of murmur doesn't correlate with severity of stenosis
43
Apart from a diastolic murmur, what other heart sounds can be observed in MS
* Loud opening S1 snap: heard at apex when leaflets are still mobile
* shorter S2 to opening snap interval indicates more severe disease
44
How is MS diagnosed
* ECG - may show AF and LA enlargement
* CXR - LA enlargement and pulmonary congestion. Occas calcified MV
ECHO - Assess MV mobility, gradient and MV area
45
What drugs may be used in the treatment of MS
* BBs & CCBs which control heart rate
* Diuretics for fluid overload
46
Define pericarditis
inflammation of the pericardium with or without effusion
47
What are the types of pericarditis
Fibrinous - dry
Effusive (wet):
* Purulent serous exudate - infection/malignancy
* Haemorrhagic exudate - bleeding
48
Give 4 infectious causes of pericarditis with examples
* Viral (m.common) - CMV, EBV
* Bacterial - TB (common)
* Fungal (v.rare)
• Parasitic (v.rare)
49
Give 4 non-infectious causes of pericarditis with examples
* Autoimmune (common) - rheumatoid arthritis
* Neoplastic - 2 metastatic tumours (breast and lung cancer)
* Traumatic and latrogenic - pericardial injury syndromes (Dressler's syndrome)
* Chronic heart failure
50
What % of pericarditis cases are idiopathic
80-90%
51
Describe the type of chest pain in pericarditis
* Sharp, pleuritic chest pain in left anterior chest/epigastrium
* Chest pain radiates to trapezius ridge due to co-innervation of phrenic nerve
* Relieved by sitting forward and exacerbated by lying down
52
Apart from chest pain, describe other signs and symptoms of pericarditis
* Dyspnoea
* Hiccups
* Fever
* Cough
53
What is the main differential diagnosis for symptoms of pericarditis
Myocardial infarction/ischaemia
54
Describe the typical results of a clinical exam for pericarditis
Clinical exam:
* tachycardia
* pericardial rub - pathognomonic, crunching snow sound
* Signs of effusion
55
Describe the typical results of an ECG for pericarditis
* Widespread saddle shaped ST elevation
* PR depression
56
What may a chest X-ray show in someone with pericarditis show
* Normal in idiopathic
* Pneumonia common in bacterial
* Effusion may cause cardiomegaly
57
Treatment for pericarditis
* NSAIDS: Ibuprofen/ aspirin for 2w
* Colchicine for 3w - reduce recurrence
58
What are the possible complications of pericarditis
* Large pericardial effusion can lead to cardiac tamponade
* myocarditis
* constrictive pericarditis
59
Explain how pericardial effusion can lead to cardiac tamponade
Accumulation of fluid in pericardial space accompanying pericarditis. Large vol of fluid (enough to impair ventricle filling) = cardiac tamponade
60
Define cardiac tamponade
* The accumulation of pericardial fluid, blood, pus or air within the pericardial space
* This creates an increase in intra-pericardial pressure, restricting cardiac filling and decreasing CO
* Medical emergency
61
Signs of cardiac tamponade
* Beck's triad - Hypotension, increased jugular venous pressure, muffled S1 & S2 heart sounds
* Pulsus paradoxus - fall in sys BP during inspiration
62
Gold standard investigation for cardiac tamponade
ECHO - late diastolic collapse of right atrium
63
Describe the ECG findings of cardiac tamponade
electrical alternans - varying QRS amplitude due to heart bouncing back and fourth in increased fluid
64
Treatment for cardiac tamponade
* Pericardiocentesis - drain excess fluid using needle and catheter
* NSAIDs + PPi
65
Define abdominal aortic aneurysm
Permanent dilatation in vessel wall diameter of >50%, which typically means a diameter of >3 cm
66
Give 5 RFs of AAA
Smoking - MAJOR
CT disorders - Marfan's
Age
Atherosclerosis
Male
67
Explain the pathophysiology of AAA
* Inflammation and degeneration of smooth and elastic muscle (vascular tunica)
* Loss of structural integrity of the aortic wall and mechanical stress results in widening of the vessel
68
Difference between true and pseudoaneurysm
True - structural degeneration in all 3 layers of vascular tunica
Pseudo - not all 3 layers
69
Describe the presentation of AAA
* Usually asymptomatic till rupture
* If expanding fast: sudden central abdo pain radiating to flank,
* triad: abdo/back pain, pulsatile abdo mass and hypotension
* Cullen’s/ grey turners sign
70
What is the first line investigation for AAA and why
Abdo ultrasound
Cheap, easy, sensitive and specific
71
Where specifically are AAAs usually found
Below renal arteries (infrarenal)
72
Treatment for non-ruptured AAA
* manage RFs - smoking cessation
* Asymptomatic and < 5.5cm = monitor
* Symptomatic and >5.5cm or expanding rapidly = surgery
73
What is the major complication of AAA and how is it treated
Rupture of AAA
* Urgent surgery - EVAR (endovascular aneurysmal repair)
* maintain ABCDE and fluids
100% mortality unless treated immediately
74
Describe the 2 types of surgery that could be done for AAA
* EVAR - stent inserted through fem/iliac a. + less invasive. - more post op comp
* Open surgery. + fewer Cx, - more invasive
75
Define aortic dissection
Tear in tunica intima of aorta which leads to a collection of blood between the intima and medial layers
76
Give 5 RFs for AD
* Men aged 50-70
* Hypertension - most common
* CT disorder - ehlers danlos
* Smoking
* Trauma
77
Explain the pathophysiology of AD
* Blood dissects media and intima and pools in false lumen
* Blood can propagate distally or proximally
* Flow through the false lumen can occlude flow to end organs = organ failure
78
Signs and symptoms of AD
* Sudden and severe tearing chest pain radiating to back
* hypotension (linked to cardiac tamponade)
* Lower limb pain (B)
* Pulse deficit and diastolic murmur (A)
79
Describe the Stanford classification of AD
* A - proximal, involves ascending aorta and/ or arch - mc and more severe
* B - distal, descending thoracic aorta
80
Explain the diagnosis of AD
* CXR - shows widened mediastinum (>8cm)
* TOE - classify as A or B, shows intimal flap and false lumen
* CT (chest, abdo, pelvis) - definitive image
* ECG - exclude STEMI
81
What is the surgical treatment for AD
A - open repair
B - endovascular aneurysm repair
82
What is the medical treatment for AD
* Beta blockers, e.g. IV labetalol or CBB if CI (Verapamil)
- BB and partial alpha blocker - prevents reflex tachycardia & lowers BP
* Opioid analgesia (morphine)
* Vasodilator (Na nitroprusside)
83
Complications of AD
Cardiac tamponade
Aortic regurgitation
Pre-renal AKI
84
Define hypertension
Abnormally high BP:
* >140/90 mmHg in clinic
* >135/85 home readings (A)
85
Types of HTN
1) Essential - idiopathic (95%)
2) Known underlying cause (5%)
86
Causes of HTN
'ROPE'
* Renal disease - CKD
* Obesity
* Pregnancy
* Endocrine - Conn's (mc) , Cushing's, phaeochromocytoma
Also: abnormal RAAS
87
Give 5 modifiable RFs of HTN
Sedentary lifestyle
High salt intake
Obesity
Alcohol intake
T2DM
88
Give 3 non-modifiable risk factors of HTN
* Age >65
* Family history
* Afro-caribb ethnicity
* Obstructive sleep apnoea
89
Describe the 3 stages of HTN
S1) 140/90 or 135/85(A)
S2) 160/100 or 150/95(A)
S3) 180/110 (immediate Tx)
90
Pathophysiology of HTN
Increased RAAS, sympathetic NS and TPR increases BP as BP = CO x TPR
91
Signs and symptoms of HTN
Mostly asymptomatic, found on screening
Malignant HTN:
* heart failure
* Blurred vision
* Headache
* Chest pain
* CKD
92
Describe the diagnosis of HTN
* Hospital bp reading >140/90mmHg
* ABPM (ambulatory) for 24h (as you move around) to confirm diagnosis - >135/85
Organ damage:
* Fundoscopy - papilloedema
* Bloods - HbA1C and lipid profile
* Urinalysis - proteinuria, high albumin = end organ damage
* ECHO/ ECG - LVH
93
When are CCB used in first step treatment for HTN
* Black origin
* >(=) 55
* No T2DM
94
When are ACEi (/ARB) used in first step treatment for HTN
* non-black origin
* <55
* T2DM
nb - DM takes precedence i.e. if black + T2DM take ACEi
95
Describe the 2nd and 3rd step of HTN treatment
2) ACEi (e.g. ramipril) / angiotensin 2 receptor blocker + CCB
3) ACEi + CCB + thiazide-like diuretic (e.g. Indapamide)
96
SEs of ACEi
* Teratogenic effects
* Acute renal failure
* Hyperkalaemia
* Dry cough
97
Describe the 4th step of HTN treatment
ACEi + CCB + TLD + 1/2
* 1 - If k+ >4.5 mmol/L = a/b blocker
* 2 - If k+ < 4.5 = spironolactone (K sparing)
98
Give some possible complications of HTN
Heart failure
Increased IHD risk
CKD
Retinopathy - papilloedema
99
Define peripheral vascular disease (PVD)
Narrowing of peripheral blood vessels
PAD - arterial
Peripheral venous disease
100
Give 4 RFs of PVD
Smoking
>40
Diabetes
HTN
101
Explain the pathophysiology of PVD
* Least severe: commonly atherosclerosis leading to claudication of vessels
* Most severe: severe occlusion, blood supply barely adequate to meet metabolic demand = critical limb ischaemia
102
What are the 6 signs of acute limb ischaemia
Pulselessness
Pallor
Pain
Paralysis
Perishing with cold
Paraesthesia - tingling/numbness
103
What usually causes limb ischaemia
Embolic/thrombotic formation at site of critical limb ischaemia lesion
104
Signs and symptoms of P. venous disease
* red
* swollen
* warm
* Dull, achy, constant pain
105
Sx of PAD
Most patient are asymptomatic
* Intermittent claudication - limp
*Thigh/buttock pain that is quickly relieved on rest
106
How is PAD investigated
* Ankle brachial pressure index (ABPI): <0.9
* CT angiogram - stenosis or occlusions
107
How is peripheral venous disease investigated
D-dimer (blood clotting) and doppler ultrasound (blood flow)
108
How are PVDs treated
*ABPI <0.9 = Percutaneous transluminal angioplasty
* Anti-coagulants - heparin
* Anti-platelets - aspirin or clopidogrel
109
Complications of PAD
Acute limb ischaemia -> loss of limb
110
Complications of PVD
pulmonary embolism
111
What is ischaemic heart disease
Term used to describe heart problems caused by narrowed coronary arteries which leads to cardiac myocyte damage due to insufficient blood supply
* MI + angina
112
What is stable angina
Chest pain caused by an insufficient blood supply to the myocardium
113
Give 3 characteristics of stable angina
* Central constricting chest pain that may radiate to arms/jaw
* Brought on by exertion of stress
* always relieved by rest or GTN (glyceryl trinitrate)
114
6 RFs of angina
* Obesity
* T2DM
* HTN
* Smoking
* Age
* Male
115
Explain the pathophysiology of angina
Atherosclerosis leads to narrowing of coronary arteries that results in ischaemia
116
Symptoms of angina
Nausea
Breathlessness
Sweating
117
Describe the investigations and diagnosis of stable angina
1st line = ECG - Normal or ST depression
GS: CT Angiography - stenosed atherosclerotic arteries (70-80% occluded)
118
Treatment for stable angina
* Episodes of chest pain - GTN spray
* Modify RFs - smoking cessation, exercise, weight loss
* Asprin 75mg
* Atrovastatin
* BB (e.g. propranolol) or CCB (not HF)
* Revascularisation
119
Describe the 2 types of coronary revascularisation
* PCI (Percutaneous coronary intervention): balloon stent. Less invasive but risk of stenosis
* CABG (coronary artery bypass graft): bypass graft. Has better prognosis but is more invasive
120
What physical characteristics identifies a patient who's had a previous CABG
A midline sternotomy scar
121
Differential diagnosis for stable angina
Pericarditis
Chest infection
GORD
122
What are acute coronary syndromes (ACS)
Umbrella term that includes:
* Unstable angina
* ST elevation MI (STEMI)
* Non-ST elevation MI (NSTEMI)
123
What is unstable angina
Chest pain that occurs at rest and is not relieved by GTN. Episodes occur more frequently and last longer (>20 mins)
124
What is silent MI and who are they more likely to be seen in
May not experience typical chest pain during an ACS. More likely in women and diabetics
125
Additional symptoms of ACS that aren't seen in stable angina
* Anxiety - Impeding sense of doom
* Same symptoms but at rest and more severe
* >20 mins of symptoms
126
What tests are done to investigate ACS
ECG
Troponin
CT coronary angiogram - extent of occlusion
127
How does unstable angina clinically present
ECG: normal or may show some ST depression/ T wave inversion
Troponin: normal
128
Clinical presentation of NSTEMI
* ECG: ST depression, pathological Q waves and T wave inversion
* Troponin: Raised
* Partial occlusion of major CA or complete occlusion of minor CA
129
Describe findings of ECG, troponin and CT angiography of STEMI
* ECG: ST elevation in leads consistent with an area of ischaemia / new LBBB
* Raised troponin
* Complete occlusion of a major coronary artery
130
Treatment for acute STEMI
Patient presenting within 12h of onset:
* PCI: If available within 2 hours of medical contact
* Fibrinolytic agent (alteplase): if PCI not available
131
Treatment for acute NSTEMI (batman)
* Beta blockers - bisoprolol
* Aspirin
* Ticagrelor - (clopidogrel alternative if high bleeding risk)
* Morphine
* Anticoagulant
* Nitrates - GTN
give 02 if saturation is <94%
132
Describe the GRACE Score
Score to assess for PCI in NSTEMI
* Low risk (<5%) = monitor
* High risk (>10%) = immediate angiogram and consider PCI
133
Complications of MI
* Heart failure
* Death - ventricular fibrillation mc cause (24h)
* LV free wall rupture
* Arrhythmia/ aneurysm
* Dressler's syndrome - autoimmune-mediated pericarditis occurring 2-6 weeks after a myocardial infarction
134
Define and describe prinzmetal angina
* Chest pain due to coronary vasospasm not vessel atherogenesis
* Often seen in cocaine users
* ECG = ST elevation
135
RFs of MI
DM
Male
Smoking
HTN
Obesity
136
Define heart failure
The inability of the heart to deliver blood and O2 at a satisfactory rate for the tissue's metabolic requirements
Syndrome not diagnosis
137
State 6 RFs of HF
* IHD - mc
* HTN
* >65
* Obesity
* AF
* DM
138
Define Cor pulmonale
Right sided heart failure caused by disease of lungs and/or pulmonary vessels
Right sided hypertrophy
139
Causes of Cor pulmonale
* COPD (mc)
* Pulm embolism
* Cystic fibrosis
140
Signs of cor pulmonale
* Hypoxia
* Shortness of breath
* Cyanosis
* peripheral oedema
* enlarged liver
141
Symptoms of HF
* Breathlessness
* Tiredness
* Ankle swelling
* Increased weight
* Wheeze
142
Treatment of cor pulmonale
Treat underlying cause
Give O2 to treat respiratory failure
143
5 Signs of HF
* Orthopnoea (worse dyspnoea lying flat)
* Displaced apex beat
* peripheral and sacral oedema
* 3rd and 4th heart sounds
* raised JVP
144
Describe the NY heart association classification for HF
Class:
1) No limit on physical activity (asymptomatic)
2) Slight limit (mild HF)
3) Marked limit (symptomatically moderate HF)
4) Inability to carry out physical activity without discomfort (symptomatically severe HF)
145
What is the range of a normal ejection fraction
50-70%
146
Describe HF with reduced EF
• LV systolic impairment with LVEF <40%
• systolic failure
147
Describe HF with preserved EF
* LVEF>50% with dilatated LA and LVH
* diastolic failure
* mc in women
148
Features of right sided HF
* Fluid build up in veins leading to peripheral oedema
* Increased JVP
* Hepatomegaly
149
Give one sign specific to left sided HF
* Paroxysmal nocturnal dyspnoea - suddenly waking up at night short of breath
150
Describe the investigations and diagnosis of HF
* Brain natriuretic peptide (BNP): Increases when there is myocardial stress. Correlates with severity of HF
* ECG - LVH, AF
* CXR
* TTE: establish structure and function of LV
* Hypervolaemic hyponatraemia
151
Describe the chest Xray findings in HF
ABCDE
Alveolar batwing oedema
Kerley B lines
Cardiomegaly
Dilated upper lobe vessels
Effusions (pleural)
152
Treatment for HF
* Pharm: ACEi, diuretics (furosemide), BB
* Surgery: revascularisation, transplant, valve surgery
* Lifestyle changes
153
Define tachycardia
Abnormally high heart rate of >100bpm
154
What are the 4 different types of supraventricular tachycardia
* Atrial fibrillation (AF)
* Atrial flutter
* Atrioventricular nodal re-entrant tachycardia (AVNRT)
* Atrioventricular re-entrant tachycardia (AVRT)
155
Describe the difference between AVRT and AVNRT
* AVRT - when the re-entry point is an accessory pathway (Wolff-Parkinson-White syndrome)
* AVNRT - when the re-entry point is back through the AV node
156
Define AF
Type of SVT where contraction of the atria is rapid, uncoordinated and irregular
157
Give 6 RFs of AF
* >60
* HTN
* DM
* valve disease - rheumatic HD
* HF
* Coronary artery disease
158
Describe the typical presentation of AF
* Irregularly irregular pulse rate
* Palpitations
* Chest pain
* Shortness of breath
159
Describe the ECG signs of AF
* Irregular and rapid QRS complexes (<120ms)
* Absent P waves
160
How is acute AF treated
* heparin then DC cardioversion synchronised to R wave
* IV amiodarone if unsuccessful
* If >48h give anticoagulants for 3w before cardioversion or rate control: BB (oral bisoprolol) or rate limiting CCB ( IV verapamil)
* Long-term anticoagulant - apixaban
161
How is paroxysmal or persistent AF treated
* Rate control: BB, rate limiting CCB. IF it falls: digoxin then consider amiodarone
* Anticoagulants - apixaban
* DC cardioversion if haemodynamically unstable
162
How is permanent AF treated
* Anticoagulants - apixaban
* Rate control - propranolol or verapamil
163
Difference between acute and chronic AF
To do with the duration
* Acute - less than 48 hours
* Chronic - can be paroxysmal (episodic), persistent (>7 days) or permanent
164
What are some complications of AF
HF
Ischaemic stroke
165
Define atrial flutter
Abnormal and organised atrial firing
Rate: 250-350bpm
166
Give 3 RFs of atrial flutter
* AF
* Post surgical scarring of atria
* Increasing age
167
Explain the pathophysiology of atrial flutter
Fast atrial ectopic firing causes atrial spasm
168
3 symptoms of atrial flutter
* Palpitations
* Breathlessness
* Fatigue
169
Describe the ECG signs of atrial flutter
* Continuous regular electrical activity mc a saw-tooth pattern
* Narrow complex tachycardia
170
Which condition is atrial flutter treated the same as
AF
171
What is wolff-parkinson white syndrome
When an extra electrical pathway exists for impulse conduction
Often hereditary
172
What is the common name of the extra pathway in WPW
Bundle of kent
173
Symptoms of WFWs
*Dizziness
* Dyspnoea
174
Describe the ECG presentation for WPWs
* Delta waves - slurred upstroke on QRS
* Short PR interval (<120ms)
* Wide QRS (>120)
175
Treatment for WPWs
* Valsalva - hold nose, close mouth, exhale hard while straining
* Rapid atrial pacing
* Catheter ablation
* IV Adenosine
* DC cardioversion
176
Describe long QT syndrome
* Ventricular tachycardia
* Typically congenital
* Long QT interval (>480ms)
177
Causes of long QT syndrome
* Hypokalaemia + Hypocalcaemia
* Drugs - citalopram, amiodarone, macrolides
178
What is torsades de pointes
*Polymorphic ventricular tachycardia in patients with prolonged QT
* Stops spontaneously or progresses into ventricular fibrillation
179
ECG characteristics of torsades de pointes
Rapid irregular QRS complexes which twist around baseline
180
Describe first degree heart block
* Occurs when there is delayed AV conduction through the AV node
* Every p wave results in a QRS complex
* PR interval prolonged (>200ms)
181
3 causes of first degree heart block
* Hypokalaemia
* Inferior MI
* drugs - BB, CCB, digoxin (block AV conduction)
182
How is first degree heart block managed
Usually asymptomatic and doesn't require treatment
183
What are the 2 types of 2nd degree heart block
Mobitz I and II
184
Describe Mobitz I
This is when PR intervals become progressively longer until a p wave is not followed by a QRS complex (dropped)
185
Cause of Mobitz I
AV blocking drugs
Inferior MI
186
How is 2nd degree heart block
managed
No treatment unless very symptomatic (e.g. fainting) then pacemaker
187
Describe Mobitz II
Constant long PR intervals and a random p wave not followed by a QRS complex
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Causes of Mobitz II
* Anterior MI
* Rheumatic fever
* Mitral valve surgery
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Describe third degree heart block
Complete heart block
* atria and ventricles beat independently from each other
* no observable relationship between p waves and QRS complexes
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Causes of third degree heart block
* structural HD
* MI
* Endocarditis
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Treatment for third degree heart block
Permanent pacemaker and IV atropine
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What are ventricular ectopics
Premature ventricular beats caused by random electrical discharges from outside the atria
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Causes of right bundle branch block (RBBB)
* PE
* IHD
*Cor pulmonale
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Describe the ECG presentation of RBBB
MaRRoW:
M: tall late R wave in V1
W: Wide, slurred S wave in V6
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Explain the pathophys of RBBB
* RB no longer conducts
* Ventricles don't contract at same time
* LV contracts first then activates RV
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Causes of LBBB
* IHD
* Aortic valve disease
* Cardiomyopathy
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Describe the ECG presentation of LBBB
WiLLiaM:
W: Deep S wave in V1
M: tall late R wave in V6
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Explain the pathophys of LBBB
RV contracts first then activates LV
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Define cardiomyopathy
A group of diseases of the myocardium that cause muscular/ conduction defects
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What are the 3 types of cardiomyopathy
Hypertrophic
Dilated
Restricted
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Define dilated cardiomyopathy
MC cardiomyopathy
* dilation of all 4 chambers on the heart
* Contracts poorly due to thin muscle
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Causes of dilated cardiomyopathy
* IHD
* Alcohol
* Genetic
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Signs and symptoms of dilated cardiomyopathy
* shortness of breath
* HF - pulm oedema
* systolic murmur
* Increase pulse, decrease bp
* AF
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Investigations for dilated cardiomyopathy
* ECHO - dilated ventricles
* ECG - tachycardia, T wave changes
* Bloods: elevated brain natriuretic peptide
* CXR - cardiac enlargement
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Treatment for dilated cardiomyopathy
Treat the underlying cause if possible
* BB
* ACEi
* Diuretics if oedema
* Anticoagulation due to increased risk of thromboembolism
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What is hypertrophic cardiomyopathy
Ventricular hypertrophy that causes obstruction of the outflow tract
Mostly LVH
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Causes of hypertrophic cardiomyopathy
Genetic - autosomal dominant
Sporadic
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Signs and symptoms of hypertrophic cardiomyopathy
* Sudden death (mc cause of sudden death in young people)
* Palpitations
* Dyspnoea
* ejection-systolic murmur - quieter on squatting, louder of valsalva manoeuvre
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Explain the pathophysiology of hypertrophic cardiomyopathy
Gene mutation for sarcomere protein:
* thick non compliant heart = impaired diastolic filling
* reduced CO
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Describe the diagnosis of hypertrophic cardiomyopathy
* ECG - T wave inversion, deep Q waves
* ECHO - ventricular hypertrophy
* Genetic testing
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Treatment of hypertrophic cardiomyopathy
CBB - Verapamil
Amiodarone - anti-arrythmic
BB - atenolol
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What is restrictive cardiomyopathy
Scar tissue replaces the normal heart muscle and the ventricles become rigid so don't contract properly
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Causes of restrictive cardiomyopathy
* Granulomatous disease: Amyloidosis, Sarcoidosis
* Idiopathic
* Post MI fibrosis
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Signs and symptoms of restrictive cardiomyopathy
* Dyspnoea
* Oedema
* 3rd & 4th heart sounds
* Ascites
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Investigations for restrictive cardiomyopathy
* Cardiac catheterisation (definitive)
* ECHO
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Treatment for restrictive cardiomyopathy
Poor prognosis (1y)
No treatment, can consider transplant
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What is the most common cardiomyopathy in young people
Hypertrophic cardiomyopathy
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Define rheumatic fever
Systemic infection from a group A beta-haemolytic streptococci
Common in developing countries
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Explain the pathophysiology of rheumatic fever
Antibody from cell wall cross-reacts with valve tissue which can cause permanent damage to the valves through auto-antibody mediated destruction
* mostly affects MV and typically thickens leaflets = mitral stenosis
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Signs and symptoms of rheumatic fever
* New pansystolic murmur
* Erythema marginatum - red rash with raised edges and pale centre
* Chorea - jerky movements
* Arthritis
221
Describe the investigation and diagnosis of rheumatic fever
Jones criteria - recent strep infection and:
* 2 major (arthritis, chorea) criteria
or
* 1 major (new murmur) and 2 minor (arthralgia, fever ) criteria
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Treatment for rheumatic fever
* IV Benzylpenicillin then phenoxymethylpenicillin for 10 days
* Haloperidol/ diazepam for chorea
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What is deep vein thrombosis
thrombus in deep vein of leg
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Describe the different types of DVT and their severity
Below calf:
* minor veins (e.g. ant & post tibial)
* Less concerning and more common
Thigh:
* major veins (e.g. superficial femoral); occlusion may impede distal flow
* Life threatening
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What is pulmonary embolism
This is usually due to DVT embolising and lodging in the pulmonary artery circulation
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Risk factors for venous thromboembolism (DVT and PE)
Venous stasis:
* long flights, recent surgery
Hypercoagulability:
* pregnancy, malignancy, obesity
Endothelial injury:
* Trauma/surgery, smoking
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Presentation of PE
* Pleuritic chest pain
* Dyspnoea (+/- blood)
* Tachycardia
* Hypotensive
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Presentation of DVT
* Unilateral swollen calf - typically warm and oedematous
* Leg turns blue
229
Investigations for PE
* Wells score (>4)
* D-dimer - size of clot
* CT pulmonary angiogram (GS) - specific
* ECG - tachycardia, new RBBB, T wave inversion of ant and inf leads
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Investigations for DVT
* Wells score (>1)
* D-dimer
* Duplex ultrasound (GS)
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Treatment for massive PE
Thrombolysis - injecting fibrinolytic medication (eg. alteplase)
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Treatment for non-massive PE and DVT
* Anticoagulants - DOAC (Apixaban/ rivaroxaban
* LMWH if above contraindicated
* DVT: compression stockings
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What is a differential diagnosis of DVT
Cellulitis
* Skin infection (strep.pyogenes)
* Leukocytosis on blood test
• US to differentiate
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What is a differential diagnosis of DVT
Cellulitis
* Skin infection (strep.pyogenes)
* Leukocytosis on blood test
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Differential diagnosis of PE
Pleural effusion, Pneumothorax and pneumonia all have pleuritic chest pain
* CXR - normal in PE. Diagnostic in others
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Describe an atrial septal defect
(inc Sx, Dx & Tx)
* Shunting of blood from left to right atria
* May report dizziness and palpitations
* Found on ECHO
* Most close spontaneously otherwise surgical
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Describe a complication of atrial septal defect
Eisenmenger's syndrome
Pul htn causes reversal of shunt from right to left resulting in deoxygenated blood in the systemic circulation
238
Describe ventricular septal defect
(inc Sx, Dx & Tx)
* Blood shunts from LV to RV
* small VSD = asymptomatic
* Large VSD = Exercise intolerance, harsh pansystolic murmur
* Dx - Found on ECHO
* Tx - spontaneous closure or surgical
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What is a patent ductus arteriosus
When the ductus arteriosus fails to close after birth
Blood shunts from the aorta to the pulm trunk
240
Describe the Sx, Dx, Tx and Cx of a patent ductus arteriosus
* Sx - failure to thrive, machine like continuous murmur, dyspnoea
* Dx - ECHO
* Tx - prostaglandin inhibitors may induce closure or surgery
* Comp - Eisenmenger's
241
4 defects found tetralogy of fallot
* Large Ventral septal defect
* Overriding aorta (misplaced)
* RV hypertrophy
* RV outflow obstruction (Pulm stenosis)
242
Sign of tetralogy of fallot
Cyanosis due to deoxygenated blood being shunted systemically
243
Investigation and treatment of tetralogy of fallot
* CXR - boot shaped heart
* Tx- surgical repair within 2y of life
244
What is coarctation of aorta
* Aorta narrow at/just distal to ductus arteriosus
* Blood is diverted through aortic arch branches = increased perfusion to upper body vs lower
245
Sx, Dx and Tx of coarctation of aorta
* Sx - upper body HTN, leg cramps, cold feet
* Dx - CXR (dilated intercostal vessels), CT angiogram
* Tx - surgery or stenting
246
What chromosomal condition is aortic coarctation a common Cx of
Turner syndrome - 45 XO, female has a single X chromosome
Sx - short stature, webbed neck, primary amenorrhoea
247
What makes shock a medical emergency
It is life threatening due to acute circulation failure
This leads to hypoxia and risk of organ dysfunction
248
What causes hypovolaemic shock
* blood loss - trauma, GI bleed
* Fluid loss - dehydration
249
Presentation of hypovolaemic shock
* Hypotension
* Tachycardia
* Clammy pale skin
* Confusion
250
Treatment for hypovolaemic shock
* ABCDE
* IV fluids
251
Causes anaphylactic shock
* Due to type 1 hypersensitivity
* histamine release causes excess vasodilation and bronchoconstriction
252
Presentation of anaphylactic shock
* Hypotension
* Tachycardia
* Puffy face
* Flushed cheeks
253
Treatment for anaphylactic shock
*ABCDE
* IM adrenaline
254
Causes of septic shock
Due to uncontrolled bacterial infection in blood
255
Presentation of septic shock
* Fever
* Tachycardia
* warm peripheries
* decreased urine output
256
Treatment of septic shock
* ABCDE
* Broad spectrum antibiotics
257
Causes of cardiogenic shock
* heart pump failure
* MI
* Cardiac tamponade
258
Treatment of cardiogenic shock
* ABCDE
* treat underlying cause
259
Causes of neurogenic shock
spinal cord trauma - disrupted SNS but intact PSNS
260
Presentation of neurogenic shock
* Hypotension
* Bradycardia
* Confused
261
Treatment for neurogenic shock
* ABCDE
* IV atropine
262
What are the 4 key organs at risk of failure from shock
Kidney
Lung
Heart
Brain
263
What is syncope
Term used to describe temporarily losing consciousness due to disruption of blood flow to the brain
Aka fainting
264
What causes primary syncope
Primary (simple fainting)
* extended standing in warm environment
* missed meal
* sudden surprise, pain
265
What causes secondary syncope
Secondary (underlying problem)
* hypoglycaemia
* anaemia
* anaphylaxis
Valvular heart disease
266
Signs and symptoms of syncope
Hot
Sweaty
Dizzy
Blurry/dark vision
Headache
267
Describe the investigation of syncope
* ECG - assess for arrhythmia and long QT syndrome
* ECHO - structural HD
* Bloods - FBC (anaemia), BG (diabetes), Electrolytes (arrhythmias)
268
How is syncope managed
* underlying pathology needs to be managed by appropriate specialist
* simple fainting usually resolves itself by adulthood
* reassurance and simple advice - avoid dehydration and skipping meals
269
Which valve disease causes left ventricular dilatation
Aortic regurgitation
270
Describe the CHA2DS2-VASc score
Tool used for assessing whether patient with AF should have anticoagulants
* Congestive HF
* HTN
* A2 - Age >75
* Diabetes
* S2 - Stroke
* Vascular disease
* Age (65-74)
* Sex (female)
271
3 types of CCB with examples
* Dihydropyridines - e.g. amlodipine, nifedipine
* Phenylalkylamines - e.g. verapamil
* Benzothiazepines - e.g. diltiazem
272
MOA of amlodipine
Preferentially affect vascular smooth muscle
Peripheral arterial vasodilators
273
MOA of verapamil
* Main effects on heart
* Negatively chronotropic (rate), negatively inotropic (force)
274
SE of CCB due to vasodilatation
* Flushing
* Headache
* Oedema
* Palpitations
275
SE of CCB due to negatively chronotropic effects
* Bradycardia
* Atrioventricular block
276
SE of verapamil
Constipation
277
SEs of BB
Fatigue
Headache
Bradycardia
Hypotension
Erectile dysfunction
