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Cardiology Flashcards

1
Q

What does the P wave represent?

A

Atrial depolarisation

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2
Q

How long does atrial depolarisation last?

A

0.08-0.1s

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3
Q

How long does AV node delay last?

A

0.12-0.2s

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4
Q

How long does ventricular depolarisation last?

A

0.06-0.1s

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5
Q

What does the PR interval show?

A

Time taken for atria to depolarise and electrical activation to get through AV node

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6
Q

What does the QRS complex show?

A

Ventricular depolarisation

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7
Q

What does the ST segment show?

A

Interval between ventricular depolarisation and repolarisation

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8
Q

What does the T wave show?

A

Ventricular repolarisation

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9
Q

What occurs during depolarisation?

A

The muscle contracts

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10
Q

What length of time does one small box horizontally on an ECG represent?

A

0.04s/40ms

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11
Q

What length of time does one large box horizontally on an ECG represent?

A

0.2s (5 small boxes per large square)

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12
Q

What voltage does one large box vertically on an ECG represent?

A

0.5mV

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13
Q

What is the S1 heart sound?

A

Mitral and tricuspid valve closure

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14
Q

What is the S2 heart sound?

A

Aortic and pulmonary valve closure

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15
Q

What is the S3 heart sound?

A

NOT NORMAL UNLESS CHILD OR PREGNANCY

Associated with mitral regurgitation and heart failure

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16
Q

What is the S4 heart sound?

A

NOT NORMAL

Blood forced into stiff hypertrophic ventricle

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17
Q

What arteries is atherosclerosis commonly found?

A

LAD
RCA
Circumflex

Peripheral arteries particularly at bifurcations

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18
Q

What are the risk factors for atherosclerosis?

A

Age
Tobacco smoking
High serum cholesterol
Obesity
Hypertension
Family history

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19
Q

What is the best known risk factor for coronary artery disease?

A

Age

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20
Q

Describe the structure of an atherosclerotic plaque

A

Lipid
Necrosic core
Connective tissue
Fibrous cap

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21
Q

What are 2 outcomes of an atherosclerotic plaque?

A

Occlusion of vessel = angina
Rupture = thrombus formation = death

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22
Q

What initiates atherosclerotic formation?

A

Injury to endothelial cells
LDL

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23
Q

Describe the process of inflammation leading to atherosclerotic plaque development

A

Injury -> endothelial dysfunction -> chemoattractants released from endothelium -> leukocyte migration and accumulation intro vessel walls

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24
Q

What are some inflammatory markers found in plaques?

A

IL-1
IL-6
IFN-gamma

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25
Q

What are the 4 stages of atherosclerosis?

A
  1. Fatty streaks
  2. Intermediate lesions
  3. Fibrous plaques/advanced lesions
  4. Plaque rupture/plaque erosion
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26
Q

When does plaque rupture occur?

A

Balance shifted in favour of inflammatory conditions -> cap weakens -> cap ruptures

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27
Q

What are the clinical characteristics/risk factors of plaque rupture?

A

Dyslipidemia
Hypertension
DM
CKD
Winter

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28
Q

What are the outcomes of plaque rupture?

A

Stent
No reflow after PCI
Distal embolisation

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29
Q

What are the clinical characteristics/risk factors of plaque erosion?

A

Smoking
Women
<50
Anterior ischaemia
Summer

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30
Q

What are the outcomes of plaque erosion?

A

Anti-thrombotic
Less micro vascular damage after PCI
Better myocardial perfusion

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31
Q

Define angina

A

Chest pain or discomfort as a result of reversible myocardial ischaemia

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32
Q

What is stable angina?

A

Angina induced by effort and relieved by rest

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33
Q

How is atherosclerosis treated?

A

Percutaneous coronary intervention
-Stent in 90% of people

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34
Q

What are the risk factors of angina?

A

Smoking
Male sex
Sedentary lifestyle
Obesity
Hypertension
DM
Family history
Age

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35
Q

Outline the pathophysiology of angina

A

Atherosclerosis -> lumen narrowing -> ischaemia -> pain (angina)

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36
Q

What are the signs and symptoms of angina?

A

Chest pain
-can radiate to jaw/neck
Breathlessness
No fluid retention
Can have palpitations or syncope

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37
Q

How is stable angina diagnosed?

A

Resting ECG normal may have ST changes
CT Coronary angiography
ECHO ect

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38
Q

What is the gold standard test for stable angina?

A

CT coronary angiography
- shows occluded arteries

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39
Q

What is unstable angina?

A

Angina of recent onset or deterioration of stable angina with symptoms occurring more frequently at rest

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40
Q

What are the 2 sects of ischemic heart disease?

A

Angina
myocardial infarct

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41
Q

What is Levine sign?

A

Fist over chest

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42
Q

What does Levine’s sign indicate?

A

Ischemic heart disease ie. MI or angina

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43
Q

What is prinzmetals angina?

A

Due to coronary vasospasm (not atherogenesis)

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44
Q

When is prinzmetals angina seen?

A

Cocaine users

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45
Q

What does an ECG show in Prinzmetals angina?

A

ST elevation

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46
Q

What are the treatments for stable angina?

A

GTN sublingual spray
Modifying lifestyle
Pharmacological treatments
Revascularisation

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47
Q

What pharmacological treatments can be used to treat angina?

A
  1. GTN spray + verapamil OR beta blockers
    Also: Statin ,Anti platelet therapy, Aspirin

2.beta blocker AND amlodipine
3. Coronary angiography

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48
Q

When are CCBs contraindicated for angina?

A

Heart failure

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49
Q

When are beta blockers contraindicated in angina treatment?

A

Asthma

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50
Q

How does GTN spray alleviate angina?

A

Glycerin trinitrate- potent venodilator and dilates coronary arteries

Dilates systemic veins reducing venous return to right heart reducing preload

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51
Q

What is the main side effect of GTN spray?

A

Profuse headaches

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52
Q

What are 2 forms of revascularisation?

A

Percutaneous coronary intervention (PCI)
Coronary artery bypass graft (CABG)

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53
Q

What is a PCI?

A

Percutaneous coronary intervention

Dilating coronary obstructions by inflation of a balloon within it and inserting a stent

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54
Q

What are the pros and cons of PCI?

A

Pros: less invasive, short recovery
Cons: risk of stent thrombosis

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55
Q

What is a CABG?

A

Coronary artery bypass graft

-LIMA (left internal mammary artery) used to bypass proximal stenosis in LAD

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56
Q

What are the pros and cons of CABG?

A

Pros: good prognosis, good for complex disease
Cons: invasive, long recovery

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57
Q

What are the 4 levels of ischemic heart disease?

A

Stable angina -> unstable angina -> NSTEMI -> STEMI

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58
Q

What are the 3 acute coronary syndromes?

A

Unstable angina
STEMI
NSTEMI

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59
Q

What does STEMI stand for?

A

ST-elevation myocardial infarction

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60
Q

What does NSTEMI stand for?

A

Non-ST-elevation myocardial infarction

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61
Q

Describe the occlusion in unstable angina

A

Partial occlusion of minor coronary artery

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62
Q

Describe the occlusion in NSTEMI

A

Partial occlusion of major coronary artery
OR
Total occlusion of minor coronary artery

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63
Q

Describe the occlusion in STEMI

A

Total occlusion of major coronary artery

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64
Q

Define infarction

A

Necrosis due to obstruction of blood supply to an organ or tissue

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65
Q

Describe the level of infarction in unstable angina

A

No infarction- ischaemia only

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66
Q

Describe the level of infarction in NSTEMI

A

Subendothelial infarction
-area far away from CA occlusion dies

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67
Q

Describe the level of infarction in STEMI

A

Transmural (complete) infarction

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68
Q

How will the ECG appear in unstable angina?

A

Normal
May show ST depression or T wave inversion

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69
Q

How will the ECG appear in NSTEMI?

A

NO Q WAVE
ST depression
T wave inversion

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70
Q

How will the ECG appear in STEMI?

A

ST elevation in local leads
pathological Q waves

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71
Q

How is UA and NSTEMI differentiated?

A

NSTEMI has occluding thrombus -> MC necrosis

RISE IN SERUM TROPONIN OR CK-MB

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72
Q

What is CK-MB?

A

Creatine kinase-MB

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73
Q

When is CK-MB used as opposed to troponin?

A

A few days later- has a longer half life

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74
Q

What are the 5 types of MI?

A

Type 1: spontaneous MI with ischemia due to primary coronary incident (eg dissection)

Type 2: MI secondary to ischemia due to increased O2 demand or decreased supply (eg. Hypertension)

Types 3,4,5: MI due to sudden cardiac death related to PCI and CABG

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75
Q

What are the risk factors of acute cornonary syndrome?

A

Age
Male sex
Family history of IHD
Smoking
Hypertension, DM, HLD
Obesity and sedentary lifestyle

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76
Q

What are the symptoms of UA?

A

Crescendo pattern angina (UA)
Acute central chest pain
New onset angina
Sweating
Nausea and vomiting
Dizziness
Pressure, squeezing and stabbing

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77
Q

What are the investigations carried out for UA?

A

ECG- abnormal in 50%
Chest X ray
Blood test- troponin and CK-MB normal
Angiography to determine state of vessels

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78
Q

How is UA treated?

A

Usually requires hospital admission
ASPIRIN
GTN spray
Anti platelet drugs
Hypertensive and cholesterol drugs
Angioplasty/stent

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79
Q

What are some anti platelet drugs?

A

Aspirin
P2Y12 inhibitors
Glycoprotein IIb/IIIa antagonists

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80
Q

How does aspirin work?

A

IRREVERSIBLY inhibiting Cox (1+2) and prevents the breakdown of arachidonic acid into prostaglandin H2.

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81
Q

How do P2Y12 inhibitors work?

A

Prevent ADP dependent activation of IIb/IIIa glycoproteins preventing amplification of platelet aggregation

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82
Q

What are 2 P2Y12 inhibitors?

A

Clopidogrel
Prasugrel

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83
Q

What are the side effects of P2Y12 inhibitors?

A

Neutropenia
Thrombocytopenia
Increased risk of bleeding

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84
Q

When are glycoprotein IIb/IIIa antagonists used?

A

IV ONLY
Combination with aspirin and P2Y12 inhibitors in patients undergoing PCI

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85
Q

What is an example of a glycoprotein IIb/IIIa antagonist?

A

Abciximab
Tirofiban

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86
Q

What are 4 causes of NSTEMI?

A

Partial CA obstruction from ruptured plaque
Partial occlusion from stable plaque
CA vasospasm
Coronary arteritis or vasculitis

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87
Q

What are the factors affecting the severity of damage in MI?

A

Duration of ischemia and reperfusion
Extent of atherosclerosis
Degree of occlusion
Diameter of vessel

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88
Q

What are the signs and symptoms of MI?

A

Sudden crushing Chest pain- may radiate to jaw or left arm
Dysponea
Pallor
Diaphoresis
Palpitations
4th heart sound

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89
Q

What is dysponea?

A

Shortness of breath

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90
Q

What is diaphoresis?

A

Excessive sweating

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91
Q

What investigation results indicate NSTEMI?

A

No ST elevation
High troponin
ST depression
T wave inversion
Pathological Q wave

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92
Q

How is NSTEMI managed acutely?

A

MONACA

Morphine
O2 if sats below 94%
Nitrates (GTN spray)
Aspirin 300mg IMMEDIATELY
Clopidogrel or other anticoags
Angiography and revascularisation

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93
Q

How is NSTEMI and UA monitored?

A

GRACE score

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94
Q

What is a GRACE score used for?

A

Mortality risk of patients with ACS from MI

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95
Q

What would be done for a patient with a low risk GRACE score?

A

Monitoring

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96
Q

What would be done for a patient with a high risk GRACE score?

A

Immediate angiography
Consider PCI

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97
Q

How is NSTEMI managed post stabilisation?

A

Dual anti platelet therapy
Beta blockers
ACE-I or CCB
Statin

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98
Q

What drugs are commonly used in dual anti platelet therapy?

A

Aspirin 300mg lowered to 75mg
Clopidogrel 75mg

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99
Q

How is STEMI diagnosed?

A

ST elevation on ECG
Coronary angiograph
Rise in troponin/CK-MB

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100
Q

How is STEMI treated acutely?

A

MONACA

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101
Q

How is STEMI treated <12 hours after symptom onset?

A

PCI or CABG if PCI fails <2 HOURS
Thrombolysis if PCI unavailable in 2 hours

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102
Q

How is STEMI treated >12 hours after symptoms onset?

A

Dual antiplatlet therapy
Angiography and PCI if symptoms persist

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103
Q

How is STEMI treated long term?

A

1st line: dual anti platelet therapy
Beta blocker or CCB
ACE inhibitor or angiotensin 2 receptor antagonist
Statin

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104
Q

What are the complications of MI?

A

DARTH VADER

Death
Arrhythmia
Rupture (septum, ventricles)
Tamponade
Heart failure
Valve disease
Aneurism of ventricle
Dressers syndrome
Embolism
Recurrence/regurgitation

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105
Q

What is Dressler syndrome?

A

Form of secondary pericarditis

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106
Q

What is heart failure?

A

The inability of the heart to deliver blood and O2 at a rate that matches the body’s requirements

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107
Q

Is cardiac failure a diagnosis?

A

No- it is a syndrome

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108
Q

What are the causes of heart failure?

A

IHD-main cause
Cardiomyopathy
Valvular disease
Cor pulmonale
Increased myocardial work; anaemia,obesity, pregnancy

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109
Q

What is cor pulmonale?

A

Right sided heart failure due to disease of lungs or pulmonary vessels

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110
Q

What are the risk factors of heart failure?

A

65<
African descent
Men (lack of oestrogen)
Obesity
Previous MI

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111
Q

What are the 4 compensatory changes in cardiac failure?

A

Changes in preload
Changes in after load
Changes in sympathetic system
RAAS

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112
Q

What is decompensation?

A

Compensatory measures become overwhelmed causing them to become pathophysiological

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113
Q

How does heart failure affect preload?

A
  1. Cause a reduction in SV and an increase in ESV
  2. Increased preload (due to higher ESV) stretches myocardium = increased force of contraction
  3. After failure progresses, the myocardium doesnt contract as much so CO may DECREASE
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114
Q

What is afterload?

A

Outflow resistance- load or resistance against which the ventricle contracts

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115
Q

How does heart failure affect afterload?

A
  1. Increased afterload = increased EDV = decrease in SV = decrease in CO
  2. Increase in EDV and ventricle dilation = worse afterload
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116
Q

What effects does heart failure have on the sympathetic NS?

A
  1. Baroreceptors detect a drop in arterial pressure or rise in venous pressure and stimulate SNS activation
  2. Increased intropy = increased SV = increased HR= increased CO
  3. Chronic activation = downregulation = CO stops increasing
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117
Q

How does heart failure affect the RAAS system?

A
  1. Reduced CO = decreased renal perfusion = RAAS activated
  2. angiotensin -> angiotensin I -> angiotensin II -> aldosterone release
  3. Increased Na+ absorption and ADH release
  4. Increased blood volume -> increased BP ->increased stretching of heart
  5. Increased intropy = increased SV
  6. Prolonged failure leads to decreased SV and CO
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118
Q

What is systolic heart failure?

A

Inability of the ventricle to contract normally, causing a decrease in CO

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119
Q

What are 3 causes of systolic heart failure?

A

IHD
MI
Cardiomyopathy

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120
Q

What is diastolic heart failure?

A

Inability of the ventricles to relax and fill fully thereby decreasing SV and CO

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121
Q

What are 2 causes of diastolic heart failure?

A

Hypertrophy
Aortic stenosis

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122
Q

How does Hypertrophy cause diastolic heart failure?

A

Chronic hypertension -> increased afterload -> more resistance -> myocytes grow -> Hypertrophy -> less space for blood -> decreased CO

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123
Q

How does aortic stenosis cause diastolic heart failure?

A

Narrowing of vessels -> increased afterload -> decreased CO

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124
Q

What is acute heart failure?

A

New onset or decompensation of chronic heart failure with pulmonary or peripheral oedema without signs of peripheral hypotension

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125
Q

What is chronic heart failure?

A

Develops slowly
Venous congestion common but arterial pressure well maintained for a while

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126
Q

What are the signs of left sided heart failure?

A

Cyanosis
Fatigue
Pulmonary oedema
Bibasal fine crackles
Dyspnoea
Orthopnoea
Prolonged CR
Pink frothy sputum

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127
Q

What is orthopnea?

A

sensation of breathlessness in the recumbent position, relieved by sitting or standing

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128
Q

What are the symptoms of right sided heart failure?

A

Oedema
Raised JVP
Weight gain
Abdominal distension
Anorexia
Pitting oedema
Ascites

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129
Q

What is ascites?

A

Fluid buildup in abdomen

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130
Q

What 4 investigations are carried out to diagnose heart failure?

A

BNP (B-type natriuretic peptide)
Echocardiogram
CXR (chest X ray)
ECG

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131
Q

When is BNP secreted?

A

Secreted by ventricles in response to myocardial wall stress

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132
Q

What will BNP be like in patients with heart failure?

A

Elevated >200

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133
Q

Why is echocardiogram used to diagnose heart failure?

A

Assesses degree of ventricular dysfunction
- Also assesses cardiomyopathy and signs of MI

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134
Q

What are the signs of heart failure on CXR?

A

ABCDEF

A- alveolar oedema
B- Kerley B lines caused by interstitial oedema
C- cardiomegaly
D- upper lobe blood Diversion
E- pleural Effusions
F- Fluid in horizontal fissure

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135
Q

What is the gold standard for heart failure diagnosis?

A

Echocardiogram

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136
Q

What lifestyle changes can help treat heart failure?

A

Avoid large meals
Lose weight
Stop smoking
Exercise

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137
Q

What are 5 types of treatments for heart failure?

A

Lifestyle changes
Drugs
Revascularisation
Surgery to repair damage
Heart transplant in young people

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138
Q

What 4 pharmacological interventions can be used to treat heart failure?

A

Diuretics (decrease preload)
ACE inhibitors or angiotensin receptor blockers
Beta blockers
Digoxin

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139
Q

How is heart failure graded?

A

New York classification:
Grade 1) no function limitation
Grade 2) slight limit- symptoms not at rest
Grade 3) marked limit- symptoms not at rest
Grade 4) severe limit - may have symptoms at rest

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140
Q

What are the complications of heart failure?

A

Exercise intolerance
Increased stroke risk and thromboembolism
Arrhythmia
Kidney and liver damage

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141
Q

Define aneurysm

A

Permanent dilation of the artery to twice its normal diameter

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142
Q

What is a true aneurysm?

A

Abdominal dilation that involves all layers of the arterial wall

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143
Q

What arteries are most affected by true aneurysms?

A

Abdominal aorta (MC)
Iliac, popliteal, femoral arteries
Thoracic aorta

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144
Q

What is a false aneurysm/pseudoaneurysm?

A

Collection of blood in the adventitia (outer layer) which communicated with the lumen

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145
Q

Define abdominal aortic aneurysm

A

Permanent aortic dilation exceeding 50% where diameter is >3cm

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146
Q

Where do AAAs commonly occur?

A

Infrarenal- below renal arteries

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147
Q

What are the risk factors of AAA?

A

Male sex
Above 60
Family history
Tobacco smoking (BIGGEST RISK)
Atherosclerotic damage
Hypertension
Trauma

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148
Q

What are the 3 layers of an artery?

A

Intima
Media
Adventitia

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149
Q

Outline the pathophysiology of AAA

A

Degradation of elastic lamellar causing leukocyte infiltration causing proteolysis and smooth muscle cell loss

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150
Q

What are the signs and symptoms of unruptured AAA?

A

Often asymptomatic and picked up on X-ray ect
Back, abdomen and groin pain
Pulsatile abdo swelling

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151
Q

What diameter indicates high risk of AAA rupture?

A

> 5.5cm

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152
Q

What are the symptoms of AAA rupture?

A

Sudden abdo pain
Pronounced abdo swelling
Collapse
Tachycardia
Sudden death

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153
Q

What are the differential diagnoses of AAA?

A

Acute pancreatitis (would be non pulsatile)
GI bleed
MSK pain
perforated ulcer
Appendicitis

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154
Q

How is AAA diagnosed?

A

Abdominal ultrasound
Screening

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155
Q

How is unruptured AAA treated?

A

<5.5 are monitored
Treat lifestyle factors
Strict BP control
Elective surgery or EVAR (stent)

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156
Q

How is ruptured AAA treated?

A

ABCDE and fluids
AAA graft surgery and clamp

SURGICAL EMERGENCY

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157
Q

What does TAA stand for?

A

Thoracic abdominal aneurysm

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158
Q

What are the causes of TAA?

A

Genetic link
Marfans syndrome
Ehlers danlos syndrome
Loeys-dietz syndrome
Weightlifting
Cocaine and amphetamine use
Infection

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159
Q

Outline the pathophysiology of TAA

A

Inflammation, proteolysis and reduced survival of smooth muscles in aorta wall

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160
Q

What are the signs and symptoms of TAA?

A

Mostly asymptomatic
Pain in chest, neck, upper back
Aortic regurgitation
Collapse, shock and death
Tamponade

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161
Q

How is TAA diagnosed?

A

Aortography to assess position of branches
TOE (Transoesophageal echocardiography)
CT or MRI

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162
Q

How is TAA treated?

A

Immediate surgery for rupture
Surgery for symptomatic TAA
BP control
Treat underlying cause

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163
Q

Define aortic dissection

A

Tear in intima resulting in blood dissecting through media and separating layers

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164
Q

What is the most common emergency affecting the aorta?

A

Aortic dissection

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165
Q

What is the most common medical emergency?

A

STEMI

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166
Q

What are the risk factors of aortic dissection?

A

hypertension- MOST COMMON
Male sex
Increased age
Congenital tissue disorders
Trauma
Smoking

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167
Q

What are the 3 classifications of aortic dissection?

A

Acute: <2 weeks
Subacute: 2-8 weeks
Chronic: 8< weeks

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168
Q

What are the 5 causes of aortic dissection?

A

Inherited
Degenerative
Atherosclerotic
Inflammatory
Trauma. (Eg. RTA)

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169
Q

Outline the pathophysiology of aortic dissection

A
  1. Tear in intima
  2. Blood enters aortic wall and forms haematoma
  3. Separates intima from adventitia -> false lumen
  4. False lumen extends
  5. Tear occurs
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170
Q

What are the 2 directions of false lumen growth in aortic dissection?

A

Anterograde: towards bifurcations
Retrograde: towards aortic root

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171
Q

What are the 2 most common sites of intimal tears in aortic dissection?

A

2-3cm from aortic valve
Distal to left subclavian in descending aorta

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172
Q

Describe the 2 Stanford classifications of aortic dissection

A

A: ascending aorta and aortic arch (70%)
B: descending aorta (30%)

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173
Q

What are the signs and symptoms of aortic dissection?

A

Sudden and severe chest pain radiating to back and down arms
“Tearing” pain
Pain maximal since onset (unlike MI)
Uneven arm pulses
Lack of distal pulse

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174
Q

What are the differential diagnoses of aortic dissection?

A

MI
MSK pain
Pericarditis
Acute coronary syndrome
Cholecystitis

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175
Q

How is aortic dissection diagnosed?

A

GS: CT angiogram
TOE (echo)
CXR shows >8cm widened mediastinum

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176
Q

What are 4 treatments for aortic dissection?

A

Antihypertensives (IV GTN)
Analgesia
Surgery
Stents

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177
Q

What are the complications of aortic dissection?

A

Death due to rupture (80% mortality)
Tamponade
Limb ischemia
Pre renal AKI
Ischemic stroke

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178
Q

What is an arrhythmia?

A

Abnormality in cardiac rhythm

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179
Q

What is one of the 10 rules of ECGs (involving the PR interval)?

A

Should be 120-200 miliseconds (3-5 small squares)

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180
Q

What is one of the 10 rules of ECGs (involving QRS complex width)?

A

Width of QRS complex should be no longer than 110ms (<3 little squares)

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181
Q

What is one of the 10 rules of ECGs (involving QRS in leads 1 and 2)

A

It should be dominantly upright

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182
Q

What is one of the 10 rules of ECGs (involving QRS and T waves)?

A

Should be in the same direction in the limb lead

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183
Q

What is one of the 10 rules of ECGs (in the AVR lead)?

A

All waves are negative

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184
Q

What is one of the 10 rules of ECGs (involving the R and S waves)?

A

R wave must grow from V1 to V4
S wave must grow from V1 to V3 and disappear in V6

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185
Q

What is one of the 10 rules of ECGs (involving ST segment)?

A

Should start isoelectric except in V1 and V2 where it should be elevated

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186
Q

What is one of the 10 rules of ECGs (involving P waves)?

A

P waves should be upright in 1,2 and V2 to V6

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187
Q

What is one of the 10 rules of ECGs (involving Q wave)?

A

There should be no/small (0.04s) in width in 1,2, and V2 to V6

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188
Q

What are the 2 main types of arrhythmia?

A

Bradycardia
Tachycardia

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189
Q

Define bradycardia

A

Slow hear rate (<60bpm in day and <50bpm at night)

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190
Q

Define tachycardia

A

Fast heart rate (>100bpm)

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191
Q

What are the 2 subdivisions of tachycardia?

A

Supraventricular tachycardias
Ventricular tachycardias

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192
Q

Where do supraventricular tachycardias arise from?

A

Atrium or AV junction

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193
Q

Where do ventricular tachycardias come from?

A

Ventricles

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194
Q

How does the nervous system induce tachycardia?

A

Reduced parasympathetic tone
Increased sympathetic tone

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195
Q

How does the nervous system induce bradycardia?

A

Increased parasympathetic tone
Decreased sympathetic tone

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196
Q

What are the 4 types of supraventricular tachycardia?

A

Atrial fibrillation
Atrial flutter
AVRT (Wolff-Parkinson White Syndrome)
AVNRT

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197
Q

What is the most common sustained cardiac arrhythmia?

A

Atrial fibrillation

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198
Q

Define atrial fibrillation

A

Uncoordinated irregular atrial rhythm of 300-600bpm

-uncoordinated atrial activation and ineffective atrial contraction

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199
Q

Outline the epidemiology of atrial fibrillation

A

More common in men
5-15% of over 75s

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200
Q

What are the 5 classifications of atrial fibrillation?

A

Acute: onset <48 hours
Paroxysmal: self limiting- stops spontaneously within 7 days
Recurrent: 2 or more episodes
Persistent: >7 days
Permanent

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201
Q

What are the causes of atrial fibrillation?

A

Idiopathic
Inflammation, increased pressure, fibrosis ect
Hypertension (MC)
Heart failure (MC)
CHD
VHD
Surgery
Alcohol

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202
Q

What are the risk factors of atrial fibrillation?

A

Age
Diabetes
Hypertension
CAD
Obesity
Structural defects

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203
Q

Outline the pathophysiology of atrial fibrillation

A
  1. Uncoordinated activity = atrial spasm
  2. AV node responds intermittently so irregular ventricular rhythm
  3. Ventricules cant empty -> decreased CO and increased risk of thromboembolic events
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204
Q

What are the symptoms of atrial fibrillation?

A

Highly variable

Palpitations
Irregular pulse
Dysponea and chest pain
Fatigue

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205
Q

How is atrial fibrillation diagnosed on an ECG?

A

Absent P waves
Irregular and rapid QRS

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206
Q

How is atrial fibrillation treated acutely?

A
  1. Cardioversion
  2. Ventricular rate control
    -CCB
    -BB
    -digoxin
    • anti-arrhythmic
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207
Q

What is an example of a CCB used to treat arrhythmias?

A

Verapamil

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208
Q

What is an example of a beta blocker?

A

Bisoprolol

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209
Q

What is an example of an anti-arrhythmic?

A

Amiodarone

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210
Q

How is cardioversion achieved?

A

DC shock (defibrillator)
- low weight heparin given
If fails give IV anti arrhythmic

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211
Q

What are 2 examples of molecular low weight heparins?

A

Enoxaparin
Dalteparin

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212
Q

What are the 2 methods of controlling atrial fibrillation?

A

Rate control (1st line)
Rhythm control

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213
Q

When is rhythm control used over rate control in atrial fibrillation?

A

RANCH

Reversible
Ablation
New onset
Clinical judgment ie. Rate control doesnt work
Heart failure caused by AF

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214
Q

What are 4 methods of controlling rate in atrial fibrillation?

A
  1. Beta blocker / AV node slowing CCB (Dilitiazem)
  2. Verapamil
  3. 2nd line: digoxin the amiodarone
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215
Q

How is rhythm control achieved in atrial fibrillation?

A

Cardioversion
- flecainide if no defects
- amiodarone if defects (huge Side effects so use with old people)
+ electrical Cardioversion

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216
Q

What anticoagulants are used to treat atrial fibrillation?

A

DOACs

Eg Apixaban or Rivaroxaban

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217
Q

How do DOACs work?

A

Directly inhibit factors of the coagulation cascade eg factor Xa and IIa

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218
Q

How does warfarin work?

A

Vitamin K antagonist

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219
Q

How is CHA2DS2-VASc score calculated?

A

Congestive heart failure (1)
Hypertension (1)
Age greater or=75 (2)
DM (1)
Stroke/TIA/TE (2)
Vascular disease (1)
Age 65-74 (1)
Female Sex (1)

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220
Q

What CHA2DS2-VASc indicates a need for anticoagulation?

A

1+ for men
2+ for women

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221
Q

What are 3 examples of NOACs/DOACs?

A

Dabigatran
Apixaban
Edoxaban

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222
Q

How is HASBLED score calculated?

A

Hypertension (1)
Abnormal liver/ kidney function (1/2)
Stroke(1)
Bleeding (1)
Labile INR (1)
Elderly >65 (1)
Drug or alcohol abuse (1/2)

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223
Q

What HASBLED score indicates that anti coagulation is not advisable?

A

3+

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224
Q

What are the complications of atrial fibrillation?

A

Heart failure
Ischemic stroke

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225
Q

Define atrial flutter

A

Organised atrial rhythm with an atrial rate of 250-350BPM

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226
Q

Where is atrial flutter most common?

A

Right atrium

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227
Q

What are the causes of atrial flutter?

A

Idiopathic (1/3)
Structural defects
Anti arrhythmics for AF
Lung issues (eg COPD)
Alcohol intoxication

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228
Q

What are the risk factors for atrial flutter?

A

Atrial fibrillation

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229
Q

What are the clinical presentations of atrial flutter?

A

Palpitations
Breathlessness
Dizziness
Chest pain
Syncope
Fatigue

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230
Q

What are the signs of atrial flutter on an ECG?

A

Sawtooth pattern (F waves) between QRS complex
Regular rhythm
Narrow QRS

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231
Q

How is atrial flutter treated?

A

Cardioversion (acute)
Rhythm/rate control with anticoagulant and BB

Basically the same as AF

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232
Q

When are SVTs usually seen?

A

Young people with little to no structural defects
12-30 years old
AVN essential component

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233
Q

What does AVRT stand for?

A

Atrioventricular re-entrant tachycardia

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234
Q

What is the most common type of AVRT?

A

Wolff-Parkinson White Syndrome

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235
Q

Define AVRT

A

Accessory pathway/ abnormal connection exists in the heart, and this can bypass the AV node

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236
Q

What is the accessory pathway known as in WPW (wolf Parkinson white)?

A

Bundle of Kent

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237
Q

What occurs in WPW?

A

normal AV conduction and also an accessory pathway

Atrium -> ventricle too quickly- PRE EXCITATION

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238
Q

What are 3 ways that AVRT is reflected on an ECG?

A

Delta waves (notch at beginning of QRS complex)
Wide QRS complex
Short PR interval

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239
Q

What are the symptoms of AVRT?

A

WPW can be asymptomatic
Severe dizziness
Syncope
Palpitations
Dysponea

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240
Q

How are patients with unstable AVRT characterised?

A

Hypotension
Pulmonary oedema

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241
Q

How is unstable AVRT treated?

A

Emergency Cardioversion

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242
Q

What is cardioversion?

A

Medical procedure using quick low energy shocks to restore heart rhythm

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243
Q

How is stable AVRT treated (1st line)?

A

Vagal manoeuvres

  • Valsalva manoeuvre (1st line)
  • Carotid massage
  • Breath-holding
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244
Q

How is stable AVRT treated if 1st line doesnt work?

A

IV adenosine
DC cardioversion

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245
Q

What does IV adenosine do?

A

Causes complete heart block for a very short period of time- can terminate AVRT and AVNRT very well

246
Q

How is complex AVRT treated?

A

Catheter ablation of accessory pathway

247
Q

What does AVNRT stand for?

A

Atrioventricular nodal re-entrant tachycardia

248
Q

What brings on symptoms of AVNRT?

A

Exertion
Emotional stress
Coffee and tea
Alcohol

249
Q

What are the 2 pathways within the AV node in AVNRT?

A
  1. slow conduction pathway
  2. fast conduction pathway
250
Q

What are the 4 clinical presentations of AVNRT?

A

Rapid regular palpitations that start abruptly and end suddenly
Chest pain and Dysponea
Jugular pulsations
Polyuria

251
Q

How is AVNRT diagnosed on ECG?

A

SVT appearance
P waves not visible or seen immediately before or after QRS complex

252
Q

How is AVNRT treated?

A

Same as AVRT

253
Q

What are 3 types of ventricular tachycardias?

A

Ventricular ectopic -> ventricular fibrillation
Prolonged QT syndrome
Torsades de pointes

254
Q

Define ventricular ectopic

A

Premature ventricular contraction

255
Q

When does ventricular ectopic occur?

A

Most common post MI arrhythmia
Can occur in healthy people too

256
Q

What are the presentations of ventricular ectopics?

A

Usually asymptomatic
Extra, missed or heavy beats
Irregular pulse due to premature beats
Faint or dizzy
Can cause ventricular fibrillation

257
Q

How is ventricular ectopic treated?

A

Beta blockers if symptomatic

258
Q

What does ventricular ectopic look like on an ECG?

A

Widened QRS complex
Compensatory pause

259
Q

Define ventricular fibrillation?

A

Very rapid and irregular ventricular with no mechanical effect (ie. No CO)

260
Q

What are the symptoms of ventricular fibrillation?

A

Patient is pulseless
Unconscious
No respiration
CARDIAC ARREST

261
Q

How does ventricular fibrillation show on an ECG?

A

Shapeless
Rapid oscillations
No organised complexes

262
Q

What is the usual cause of ventricular fibrillation?

A

Ventricular ectopic beat

263
Q

What is the treatment for ventricular fibrillation?

A

ONLY electrical defibrillation

264
Q

How is risk of sudden death reduced in ventricular fibrillation?

A

Implantable cardioverter defibrillation

265
Q

Define long QT syndrome

A

Ventricular repolarisation (QT interval) is greatly prolonged
480ms+

266
Q

What are 2 congenital causes of long QT syndrome?

A

Jervell-Lange-Nielse syndrome (recessive)
Romano-Ward syndrome (dominant)

267
Q

What does Jervell-Lange-Nielsen syndrome cause?

A

Mutation in cardiac potassium and sodium channel genes

268
Q

What are acquired causes of long QT syndrome?

A

Hypokalaemia
Hypocalcaemia
Drugs
Bradycardia
DM

269
Q

What are 2 drugs that can cause long QT syndrome?

A

Amiodarone
Tricyclic antidepressants (eg. Amitriptyline)

270
Q

What are 3 clinical presentations of long QT syndrome?

A

Syncope
Palpitations
May degenerate into ventricular fibrillation

271
Q

How is long QT syndrome treated?

A

Treat underlying cause
If acquired (CI for congenital) give IV isoprenaline
- non selective beta adrenoreceptor agonist

272
Q

What is Torsades de Pointes?

A

Polymorphic ventricular tachycardia in patients with prolonged QT

273
Q

What does Toursades do Pointes look like on an ECG?

A

Irregular QRS complex
-Kind of looks like arctic monkeys album cover

274
Q

How does heparin work?

A

Binds to Antithrombin and makes it more potent

275
Q

What is an AV block?

A

Block in the AV node or His bundle

276
Q

What is a bundle branch block?

A

Block lower than the AV node and His bundle

277
Q

What are the 3 forms of AV block?

A

First degree
Second degree
Third degree

278
Q

Define first degree AV block

A

Prolongation of electrical conduction through av node causing prolonged PR interval
>0.22 seconds/200ms

No missed beats

279
Q

What are the causes of first degree AV block?

A

Increased vagaries tone eg athlete
Hyperkalaemia
Myocarditis
Inferior MI
AVN blocking drugs

280
Q

What is the treatment for first degree AV block?

A

Asymptomatic- no treatment

281
Q

How does first degree AV block appear on an ECG?

A

Long PR interval

-delayed gap on ECG paper

282
Q

What are the 2 types of 2nd degree AV block?

A

Mobitz I block
Mobitz II block

283
Q

What is the other name for Mobitz I block?

A

Wenckebach block phenomenon

284
Q

What is Mobitz I block?

A

Progressively longer PR interval until P wave “drops” and is not followed by QRS complex

PR interval before blocked P wave is longer than the PR interval after the blocked P wave

285
Q

What are the causes of Mobitz I block?

A

AVN blocking drugs
Inferior MI
Fit athletes vagal toning

286
Q

What are 3 AVN blocking drugs?

A

Beta blockers
CCB
Digoxin

287
Q

How is Mobitz I block treated?

A

Stop underlying cause
- Usually asymptomatic so its fine

288
Q

What is Mobitz II block?

A

PR interval consistently prolonged and QRS randomly dropped (not usually occurring)

289
Q

What Mobitz block occurs when His-Purkinje system is blocked?

290
Q

What Mobitz block occurs when AVN or His bundle is blocked?

A

Mobitz I block

291
Q

What are the causes of Mobitz II block?

A

Anterior MI
Mitral valve surgery
SLE and Lyme disease
Rheumatic fever

292
Q

What are 3 symptoms of Mobitz I block?

A

Light headlines
Dizziness
Syncope

293
Q

What are 3 symptoms of Mobitz II block?

A

SOB
Postural hypotension
CP

294
Q

How is Mobitz II block treated?

A

Pacemaker should be inserted due to risk of complete AV block

295
Q

What is the main complication of Mobitz II block?

A

Sudden complete AV block

296
Q

What is 3rd degree AV block?

A

Complete AV block when atrial activity fails to conduct to the ventricles - atria and ventricles beat independently

297
Q

How does 3rd degree AV block appear on an ECG?

A

P waves are completely independent from QRS complex

  • Biiiiiggggg gaps
298
Q

What are 4 causes of 3rd degree AV block?

A

Structural heart disease
IHD
Hypertension
Endocarditis or Lyme disease

299
Q

How is 3rd degree AV block treated?

A

Permanent pacemaker
IV atropine

300
Q

Does the blocked bundle depolarise sooner or later in BBB?

A

Later
Eg. LBBB will be right then left

301
Q

What are the causes of RBBB?

A

PE
IHD
Ventricular or atrial septum defect

302
Q

How does RBBB appear on ECG?

A

MaRRoW

  • QRS looks like M in lead V1
  • QRS looks like W in V5 and V6
303
Q

What effect does RBBB have on heart sounds?

A

Splitting of second heart sound

304
Q

What are the causes of LBBB?

A

ALWAYS pathological
IHD
AVD

305
Q

What does LBBB look like on ECG?

A

WiLLiaM

QRS looks like a W in V1 and V2
QRS looks like an M in V4-V6

  • also abnormal Q waves
306
Q

What effect does LBBB have on heart sounds?

A

Reverse splitting of second HS

307
Q

What are the symptoms of BBB?

A

Usually asymptomatic
Syncope
HF

308
Q

What is normal BP?

309
Q

What is hypotension?

310
Q

What is stage 1 hypertension at home?

A

≥ 135/85

311
Q

What is stage 1 hypertension in clinic?

A

≥ 140/90

312
Q

What is stage 2 hypertension at home?

A

≥ 150/95

313
Q

What is stage 2 hypertension in clinic?

A

≥ 160/100

314
Q

What is stage 3 hypertension (severe)?

A

≥ 180/110

315
Q

Define hypertension

A

Abnormally high blood pressure

316
Q

What are the 2 classifications of hypertension?

A

Essential (primary/idiopathic): cause is unknown
Secondary hypertension: other causes

317
Q

What is the most common classification of hypertension?

318
Q

What are the causes of essential hypertension?

A

Primary cause unknown

Multifactoral causes:
Genes
Excessive NS activity
Na/K transport issues
High salt intake
RAAS abnormalities

319
Q

What are the causes of secondary hypertension?

A

ROPE

Renal disease
Obesity
Pregnancy
Endocrine

320
Q

What is aorta coarctation?

A

Birth defect causing narrowing of the aorta

321
Q

What are some renal causes of hypertension?

A

CKD (MC of 2ndary)
Chronic glomerulonephritis

Diabetes can cause CKD (MC)

322
Q

What are 3 endocrine causes of hypertension?

A
  1. Cushings (corticosteroids->vasoconstriction)
  2. Conn’s (aldosterone -> higher blood volume)
  3. Phaeochromocytoma (catecholamines -> vasoconstriction, inc. contractility)
323
Q

What are 3 drugs associated with hypertension?

A

Corticosteroids
Erythropoietin
Alcohol, cocaine ect

324
Q

What are the risk factors of hypertension?

A

Age
Race (black)
Family history
Overweight and sedentary
Smoking and alcohol
Stress

325
Q

What are the effects of hypertension on the cardiovascular system?

A

Accelerates atherosclerosis
Thickening of arteries
Risk factor for IDH

326
Q

What effect can hypertension have on the NS?

A

Intracerebral haemorrhage

327
Q

What are the symptoms of hypertension?

A

Usually asymptomatic
Can have pulsatile headaches

328
Q

What is malignant hypertension?

A

Nothing to do with cancer!

Raised DBP (>120) and renal disease

329
Q

When does malignant hypertension occur?

A

Previously fit individuals
Black males
30-40s

330
Q

What are the consequences of hypertension?

A

Cardiac failure (LV Hypertrophy)
Blurred vision due to papillodema
Haematuria and renal failure
Headaches and cerebral haemmorage

331
Q

How is hypertension diagnosed?

A

Reading 140/90

Look for FUBE:

Fundoscopy (retinopathy)
Urinalysis albumin: creatine ratio
Bloods (creatine, eGFR, glucose)
ECG

332
Q

What are the lifestyle factors that can be altered in hypertension?

A

Change diet: fruit and veg and low fat
Exercise
Reduce alcohol
Lose weight
Less salt
Stop smoking

333
Q

What is the ACD pathway?

A

First line drugs for hypertension treatment

A- ACE- inhibitor / Angiotensin receptor blocker (ARB)
C- Calcium channel blocker (CCB)
D- Diuretics

334
Q

What are 2 examples of ACE inhibitors?

A

Ramipril
Enalapril

335
Q

What are 2 examples of ARBs?

A

Candesartan
Losartan

336
Q

When are ACE-inhibitors contraindicated?

A

Pregnancy
CKD
Angioedema

337
Q

What are 2 CCBs?

A

Amlodipine
Nifedipine

338
Q

What is an example of a thiazide diuretic?

A

Bendroflumethiazide

339
Q

What is an example of a loop diruretic?

A

Furosemide

340
Q

Are thiazide or loop diuretics more potent?

341
Q

What is given when ACE inhibitors are contraindicated?

A

Angiotensin receptor blocker (ARB)

342
Q

When is an ACE inhibitor given to hypertensives?

343
Q

When is a CCB given to hypertensives?

A

≥55
Afro Caribbean

344
Q

What is the first line treatment for hypertension?

A

ACE inhibitor or CCB

345
Q

What is the second line treatment for hypertension?

A

ACE-I + CCB

346
Q

What is the 3rd line treatment for hypertension?

A

ACE-I + CCB + thiazide like diuretic or thiazide

347
Q

What is the 4th line treatment for hypertension?

A

ACE-I + CCB + TLD +

K+ <4.5 = spironolactone (diuretic)
K+ >4.5 = BB

348
Q

What are the complications of hypertension?

A

Retinopathy
Neuropathy
AF
HF
IHD
CVD

349
Q

What are 2 types of venous thromboemboli?

A

Deep vein thrombosis
Pulmonary embolism

350
Q

Define deep vein thrombosis

A

Formation of a thrombus in a deep vein (usually leg) which partially or completely obstructs blood flow

351
Q

What is the most common site of DVT?

A

Below the calf
- Less concerning

352
Q

What is the most concerning location of DVT?

A

Above the calf

353
Q

What are the risk factors of DVT?

A

Cancer
HF
>60
Male
Thrombophilia
History of DVT

354
Q

What are temporary factors increasing the risk of DVT?

A

Immobility
Trauma
Hormone treatment
Pregnancy
Dehydration

355
Q

What are the symptoms of DVT?

A

Unilateral localised pain and swelling
Tenderness
Swelling, discolouration, warmth
Vein dissenting

356
Q

What WELL score indicates DVT?

A

First line test

> 2

357
Q

What investigation is carried out for DVT if WELLS score is low?

A

D dimer test

358
Q

What do D dimer test results indicate?

A

Positive: treat for DVT and have ultrasound
Negative: do not treat + stop anticoags

359
Q

What is the diagnosis test for DVT?

A

doppler ultrasound compression
- Thrombus will prevent compression

360
Q

How is DVT differentiated from cellulitis?

A

Blood test shows leukocytosis

361
Q

What is the first line treatment for DVT?

A

Apixaban or rivaroxaban

DOAC factor Xa inhibitor

362
Q

What are the second line treatments for DVT?

A

LWMH
Warfarin
Stockings
Thrombectomy (massive)

363
Q

What are the complications of DVT?

A

PE
Recurrent DVT

364
Q

Define pulmonary embolism

A

Embolus (usually from DVT) are lodged in and obstruct the pulmonary arterial system

365
Q

How can PE cause cor pulmonale?

A

Causes increased PVR
RV is then strained
Causes RV Hypertrophy

366
Q

What are the symptoms of PE?

A

Sudden pleuritic chest pain
Tachycardia
Evidence of DVT
Dysponea with haemoptysis

367
Q

What WELLS score indicates PE?

368
Q

How is PE differentiated from pneumothorax ect?

A

CXR will be normal in PE

369
Q

How is PE seen on ECG?

A

Sinus tachycardia
S1 Q1 TIII
T wave inversion
New RBBB

370
Q

What test is conducted if WELLS score is >4?

A

CTPA (CT scan pulmonary angiogram)

371
Q

What is the GS diagnostic for PE?

A

CT- pulmonary angiogram

372
Q

What is the 1st line test for PE?

A

WELLS score

373
Q

What is the 1st line treatment for PE?

A

DOACS
- Apixaban or rivaroxaban

374
Q

What is the treatment for a large PE?

A

Thrombolysis- clot buster
Surgical thrombo-embolectomy

375
Q

How long should anticoagulation be carried on after PE?

A

3-6 months (provoked/unprovoked)

376
Q

What are 2 types of peripheral vascular disease?

A

Peripheral arterial disease (PAD)
Peripheral venous disease (PVD)

377
Q

What is peripheral arterial disease?

A

Narrowing of arteries usually due to atherosclerosis

378
Q

What are the risk factors for peripheral vascular disease?

A

Smoking
Hypertension
Diabetes
Hypercholesterolaemia

379
Q

Outline the aetiology of peripheral arterial disease/PVD

A

Atherosclerosis
- Embolisation
- Thrombosis (MC)
Inflammatory
Vasospasm
Trauma

380
Q

What are the signs and symptoms of acute ischemia?

A

6 Ps

Paralysis
Pain
Pallor
Pulse deficit
Parasthesia
Perishing cold

381
Q

What are the symptoms of PVD?

A

Walking impairment
Pain in buttocks and thighs relieved at rest
Pale, cold leg
Hair loss
Ulcers
Poorly healing wounds
Weak or absent pulses

382
Q

What sign indicates PVD?

A

Buegers angle: if pallor occurs when limb is raised >20 degrees indicates severe ischemia

383
Q

How is PVD diagnosed?

A
  1. ABPI- ankle brachial pressure index
    Duplex arterial USS
384
Q

How is PVD treated?

A

Clopidogrel
Statin
Naftidrofuryl oxalate (vasodilator)

385
Q

How is chronic PVD treated?

A

Revascularisation surgery

Small = PCI
Large = bypass
Necrotic = amputation

386
Q

How is acute limb ischemia treated?

A

Emergency revascularisation in 4-6 hours
Fogarty catheter
Irreversible = amputation

387
Q

What are the complications of PVD?

A

Acute limb ischemia
Reperfusion injury
Amputation
Rhabdomyolosis (proteins and electrolytes from damaged muscle released into blood)

388
Q

Define pericarditis

A

Inflammation of the pericardium

389
Q

What are the 2 types of pericarditis?

A

Fibrinous (dry)
Effusive: serous and /haemorrhagic exudate

390
Q

What is the main type of pericarditis?

A

Wet Exudative

391
Q

What are the causes of pericarditis?

A

Coxsackie virus (MC)
Idiopathic
TB/bacteria
Dressler’s syndrome
Urinaemia
Malignancy

392
Q

Who is mainly affected by pericarditis?

A

Males 20-50y

393
Q

Outline the pathophysiology of pericarditis

A

Inflammed layers rub against each other -> more inflammation
Constrictive pericarditis impedes normal diastolic filling

394
Q

What are the signs and symptoms of pericarditis?

A

CP radiating to trapezius ridge, neck and shoulders
Relieved by sitting forward, exacerbated by lying flat
Pericardial friction rub
Sharp pleuritic pain

395
Q

What are the 4 diagnostic tests for pericarditis?

A

Needs 2/4 of

CP
Friction rub
ECG changes
Pericardial effusion

396
Q

What changes can be seen on an ECG when pericarditis is present?

A

Concave saddle ST elevation
PR depression

397
Q

What imaging tests may be used to diagnose pericarditis?

A

CXR shows “water bottle heart”
Echo

398
Q

How is pericarditis treated?

A

Usually self limiting

Treat cause eg antibiotics
NSAIDs and rest

399
Q

How is serious pericarditis managed?

A

Colchicine (anti inflammatory)
Corticosteroids

400
Q

What are the complications of pericarditis?

A

Tamponade
Pericardial effusion
Restrictive pericarditis - inhibits normal heart filling
Myocarditis

401
Q

Define pericardial effusion

A

Collection of fluid in the potential space of the serous pericardial sac (>50ml)

402
Q

Define cardiac tamponade

A

Accumulation of pericardial fluid raising intrapericardial pressure causing poor ventricular fillling and a fall in CO

403
Q

What is the most common cause of pericardial effusion?

A

Pericarditis

404
Q

What are 4 symptoms of pericardial effusion?

A

Pulsus paradoxus
Kaussmauls sign
Ewarts sign
Dysponea and tachycardia

405
Q

What is pulsus paradoxus?

A

Loss of peripheral pulse when inspiring

406
Q

What is Kaussmauls sign?

A

Increased vein distension during inspiration
Increased RA pressure

407
Q

What is Ewarts sign?

A

Dullness to percussion in left lower lung field

408
Q

What are the 3 signs of cardiac tamponade?

A

Becks triad

Hypotension
Jugular venous distension (JVD)
Muffled heart sounds

409
Q

How are cardiac tamponade and pericardial effusion diagnosed?

A

ECG: low voltage QRS complexes
CXR: large globular heart
Pericardiocentesis- drain and test fluid

410
Q

How is pericardial effusion differentiated from cardiac tamponade?

A

CT has late diastolic collapse of RA in tamponade

411
Q

How is pericardial effusion treated?

A

Treat underlying cause
NSAIDs
Colchicine
Usually resolves spontaneous

412
Q

How is cardiac tamponade treated?

A

Urgent pericardiocentesis

413
Q

What is pericardiocentesis?

A

Catheter is used to drain excess fluid from the pericardial sac

414
Q

Define endocarditis

A

Infection of the endocardium or vascular endothelium of the heart

415
Q

Where does infective endocarditis occur on the heart?

A

Valves with congenital or acquired defects
Normal valves (viral)
Prosthetic valves and pacemakers

416
Q

Who is most commonly affected by infective endocarditis?

A

IV drug users
Males
Elderly
Congenital heart disease
Poor oral hygiene

417
Q

What are 3 causes of endocarditis?

A

Staph aureus (MC)
Strep Viridans
S. Bovis

418
Q

What bacteria related to poor dental hygiene can cause infective endocarditis?

A

Strep Viridans

419
Q

Where does IE usually affect IV drug users?

A

Tricuspid valve
Right side

420
Q

What is the most common cause of IE?

A

Staph aureus

421
Q

Outline the pathophysiology of IE

A

1.Damaged endocardium promotes platelet and fibrin deposition
2. Organisms adhere and grow -> infected vegetation
3. Typically around valves so causes regurgitation

422
Q

What are the signs of IE?

A

New valve lesion or regurgitation murmur
Sepsis
Haematuria, renal infarction ect
Clubbing
Embolism of vegetation

423
Q

What are the symptoms of IE?

A

Fever
Night sweats
Headaches
Malaise
Confusion

424
Q

What are the clinical manifestations of IE?

A

Splinter haemmorages on nail beds
Embolitic skin lesions (black spots)
Olster nodes
Janeway lesions
Roth spots
Petechiae

425
Q

What are olser lesions?

A

Tender nodules in digits

426
Q

What are janeway lesions?

A

Painful haemmorages and nodules in digits

427
Q

What are Roth spots?

A

Retinal haemmorages with white or clear centres

428
Q

What are petechiae?

A

Red/purple spots caused by bleeds in the skin

429
Q

How is IE diagnosed using Dukes criteria?

A

2 major
1 major 2/3 minor
5 minor

430
Q

What are the 2 major categories of Dukes criteria?

A

2 or more positive cultures
Echo (TOE) shows vegetations

431
Q

What are the 5 minor sign on Dukes criteria?

A

Immunological signs
IVDU or predisposition
Septic emboli
1 positive blood test
Pyrexia

432
Q

How does IE appear on a blood test?

A

CRP and ESR raised
Neutrophilia

433
Q

How is IE treated by surgery?

A

Removing valve and replacing with prosthetic
Remove large vegetations
Remove infected devices

434
Q

What are the complications of IE?

A

HF
Aortic root abscess
Septic emboli and sepsis

435
Q

Are most murmurs diastolic or systolic?

436
Q

What are the 2 main systolic murmurs?

A

ASMR

AS: aortic stenosis
MR: mitral regurgitation

437
Q

What are the 2 diastolic murmurs?

A

ARMS

AR: aortic regurgitation
MS: mitral stenosis

438
Q

What are 2 other systolic murmurs?

A

Mitral valve prolapse
Tricuspid regurgitation

439
Q

How are heart murmurs best heard?

A

RILE

Right side = inspiration
Left side = expiration

440
Q

What valves are on the right?

A

Pulmonary valve
Tricuspid valve

441
Q

What valves are on the left?

A

Aortic valve
Mitral valve

442
Q

Define aortic stenosis

A

Narrowing of the aortic valve resulting in obstruction to left ventricular stroke volume

443
Q

When do symptoms of aortic stenosis appear?

A

When lumen is 1/4 of its normal size (normal is 3-4cm)

444
Q

Outline the pathophysiology of aortic stenosis

A

Narrowing -> decreased SV -> increased afterload -> increased LV pressure -> LVH -> increased O2 demand -> ischemia

445
Q

What are 3 causes of aortic stenosis?

A

Aging calcification
Congenital bicuspid aortic valve
Rheumatic heart disease (rare)

446
Q

What are the symptoms of aortic stenosis?

A

SAD:

Syncope
Angina
Dysponea+ HF

447
Q

What is the murmur like in aortic stenosis?

A

Ejection systolic murmur-crescendo-decrescendo radiating to carotids

448
Q

How is aortic stenosis diagnosed?

A

Echo: left ventricular size and function
ECG: LVH
CXR: LVH or calcified aortic valve

449
Q

How is aortic stenosis treated?

A

Surgery if symptomatic

  • surgical aortic valve replacement
  • if at risk: TAVI (transcutaneous aortic valve implantation)
450
Q

Define aortic regurgitation

A

Leakage of blood into LV from the aorta during diastole due to ineffective coaptation of the aortic cusps

451
Q

What are 4 causes of aortic regurgitation?

A

Congenital bicuspid aortic valve (BAV)
Rheumatic fever
IE
Connective tissue disorders

452
Q

Describe the pathophysiology of aortic regurgitation

A

Low CO -> LVH -> HF -> decreased CA supply

453
Q

What are the general symptoms of aortic regurgitation?

A

Exertional dysponea
Palpitations
Angina
Syncope
Wide pulse pressure

454
Q

What are the signs of aortic regurgitation on auscultation?

A

Displaced apex beat
Early diastolic blowing murmur
Austin flint murmur
Collapsing water hammer pulse

455
Q

What are 4 signs of aortic regurgitation?

A

Wide pulse pressure
Corrigans pulse
De Mussets sign
Quinckes sign

456
Q

What is Corrigan’s pulse?

A

Collapsing pulse appearing and reappearing at carotids

457
Q

What is De Mussets sign?

A

Head nodding at each heartbeat

458
Q

What is Quincke’s sign?

A

Capillary pulsation at nail beds

459
Q

How does aortic regurgitation appear on CXR?

A

Enlarged cardiac silhouette
Aortic root enlargement

460
Q

What is the gold standard diagnosis for valve disease?

A

Echocardiogram

461
Q

How does aortic regurgitation appear on ECG?

A

Signs of LV Hypertrophy

tall R waves
deeply inverted T waves in the left-sided chest leads
deep S waves in the right-sided leads

462
Q

How is aortic regurgitation treated?

A

consider IE prophylaxis
Vasodilators (eg. ACE inhibitors)
Surgery if symptomatic or worsening
- valve replacement

463
Q

Define mitral stenosis

A

Narrowing mitral valve that prevents the LA from pushing blood to the LV normally during diastole

464
Q

What are 3 causes of mitral stenosis?

A

MC: Rheumatic fever
IE
Mitral valve calcification

465
Q

When do symptoms of mitral stenosis appear?

A

> 2cm
Decades after rheumatic fever

466
Q

What are the symptoms of mitral stenosis?

A

Haemoptysis
Malar cheek flush
Right HF

467
Q

What is malar flush?

A

Bilateral pink/bluish patches on cheeks due to vasoconstriction

468
Q

What heart sounds indicate mitral stenosis?

A

low pitched mid diastolic murmur loudest at apex with snapping
Loud opening S1 snap
Short s2 opening snap

469
Q

How will mitral stenosis appear on ECG?

A

AF
LA enlargement

470
Q

How may mitral stenosis appear on CXR?

A

LA enlargement
Pulmonary congestion

471
Q

How is mitral stenosis treated?

A

Rate control: BB, CCB, digoxin
Diuretic

Surgery:
- Percutaneous mitral balloon valvotomy
-PCI/open surgeyr

472
Q

Define mitral regurgitation

A

Backflow of blood from LV to LA during systole

473
Q

How many people have mild mitral regurgitation?

474
Q

What is the MC cause of mitral regurgitation?

A

Myxomatous degeneration (MVP)

475
Q

What are the risk factors for mitral regurgitation?

A

Female
Low BMI
Increasing age
Renal dysfunction
Prior MI

476
Q

What are the symptoms of mitral regurgitation?

A

Exertion dysponea
HF
Fatigue
Palpitations

477
Q

How is mitral regurgitation heard on auscultation?

A

Pansystolic blowing murmur radiating to axilla
RV heave
Soft S1

478
Q

Does the volume of a MR murmur correlate with severity?

479
Q

How is mitral regurgitation seen on ECG?

A

LA enlargement
AF

480
Q

How does mitral regurgitation appear on CXR?

A

LA enlargement
Central pulmonary arterial enlargement

481
Q

How is mitral regurgitation treated?

A

Rate control: BB, CCB, Digoxin
Diuretics
Anticoagulant for AF

Surgery: replacement or repair

482
Q

When is surgery recommended for mitral regurgitation?

A

Symptoms at rest or exercise
Ejection fraction <60%
New onset AF

483
Q

What would a pan systolic blowing murmur radiating to axilla with quiet S1 indicate?

A

Mitral regurgitation

484
Q

What would a murmur ejection systolic crescendo descrecendo radiating to carotids indicate?

A

Aortic stenosis

485
Q

What would an early diastolic blowing murmur indicate?

A

Aortic regurgitation

486
Q

What would a low pitched mid diastolic murmur loudest at apex with snapping indicate?

A

Mitral stenosis

487
Q

Define shock

A

Acute circulatory failure causing hypoperfusion, meaning there is inadequate materials for respiration throughout the body, leading to hypoxia

488
Q

What would severe nocturnal pain in left toes alleviated by gravity perfusion indicate?

A

Critical ischemia

489
Q

What type of ischemia is related to MI?

A

Acute ischemia

490
Q

What would the diagnosis be for loss of right sided body use and fast irregular pulse?

A

Acute ischemia.

491
Q

What would a non-healing non-traumatic painful ulcer on the big toe indicate?

A

Critical ischemia

492
Q

What are 5 types of shock?

A

NCASH

Neurogenic
Cardiogenic
Anaphylactic
Septic
Hypovolemic

493
Q

What are the signs of shock?

A

Capillary refill time >3 seconds!
Skin is cold, pale, sweaty
Reduced pulse pressure
Reduced urine output
Confusion, weakness, collapse and coma

494
Q

What are the effects of shock?

A

Can cause prolonged hypotension -> organ failure after recovery from acute event

495
Q

What causes hypovolemic shock?

A

Blood loss eg trauma
Fluid loss eg. Dehydration

496
Q

What are 4 symptoms of hypovolemic shock?

A

Clammy skin
Confusion
Hypotension
Tachycardia

497
Q

How is hypovolemic shock treated?

A

ABC
Give O2
IV fluids

498
Q

What causes septic shock?

A

Uncontrolled bacterial infection

499
Q

What are 3 symptoms of septic shock?

A

Pyrexia
Warm peripheral \s
Tachycardia

500
Q

How is septic shock treated?

A

ABCDE
Broad spec antibiotics

501
Q

What causes cardiogenic shock?

A

Heart pump failure

  • MI
  • Tamponade
  • PE
502
Q

What are 3 symptoms of cardiogenic shock?

A

Signs of HF
Increased JVP
Weak threads pulse

503
Q

How is cardiogenic shock treated?

A

ABCDE
Treat underlying cause
Oxygen and fluids

504
Q

What causes anaphylactic shock?

A

IgE mediated type 1 hypersensitivity reaction and massive histamine release causing vasodilation and bronchconstriction

505
Q

What are 3 symptoms of anaphylactic shock?

A

Hypotension and tachycardia
Puffy face
Warm peripheries

506
Q

How is anaphylactic shock treated?

A

ABCDE
IM adrenaline (500 micrograms)

507
Q

What causes neurogenic shock?

A

Spinal cord trauma eg RTA

Essentially SNS is disrupted but PSNS is intact

508
Q

What are 3 symptoms of neurogenic shock?

A

Hypotension
Bradycardia
Warm dry skin

509
Q

How is neurogenic shock treated?

A

ABCDE
IV atropine

510
Q

What are 4 organs most at risk of failure from shock?

A

Kidneys
Lungs
Heart
Brain

511
Q

What are cardiomyopathies?

A

Diseases of the myocardium

512
Q

What are 4 types of cardiomyopathies?

A

Hypertrophic
Dilated
Restrictive
Arrythmogenic right ventricular

513
Q

What is the most common cause of cardiomyopathic death in young people?

A

Hypertrophy

514
Q

What is the most common cardiomyopathy?

A

Dilated cardiomyopathy

515
Q

What are 3 causes of hypertrophic cardiomyopathy?

A

Autodom inherited mutation of sarcomere
Exercise
Aortic stenosis

516
Q

Outline the pathophysiology of HCM

A

Thick non-compliant heart -> impaired filling -> decreased CO and SV

517
Q

What are the symptoms of HCM?

A

Sudden death
CP
Palpitations
SOB
Syncope

518
Q

What are 3 ways of diagnosing HCM?

A

ECG has T wave inversion and deep Q waves
Echo (GS)
Genetic testing

519
Q

How is HCM treated?

A

BB
CCB
Amiodarone

520
Q

What is dilated cardiomyopathy?

A

Dilated thin cardiac walls which contract poorly

521
Q

What are 3 causes of dilated cardiomyopathy?

A

Autodom cytoskeleton mutation
IHD
Alcohol

522
Q

What are 4 symptoms of dilated cardiomyopathy?

A

SOB
HF
AF
Thromboemboli

523
Q

How is dilated cardiomyopathy diagnosed?

A

CXR shows enlargement
ECG arrhythmia ect
Echo

524
Q

How is dilated cardiomyopathy treated?

A

Treat AF and HF

525
Q

What is restrictive cardiomyopathy?

A

Rigid fibrotic myocardium that fills and contracts poorly

526
Q

What are 3 causes of restrictive cardiomyopathy?

A

Granulomatous disease (eg. Sarcoidosis)
Idiopathic
Post MI fibrotic

527
Q

What are the symptoms of restrictive cardiomyopathy?

A

Dysponea and fatigue
Oedema and congestive HF
3rd and 4th heart sounds

528
Q

What is the definitive diagnosis for restrictive cardiomyopathy?

A

Cardiac catheterisation

529
Q

How is restrictive cardiomyopathy treated?

A

Only transplant

Most die within a year

530
Q

What is arrythmogenic right ventricular cardiomyopathy?

A

Progressive genetic cardiomyopathy characterised by progressive fatty and fibrous replacement of right ventricular myocardium

531
Q

Outline the pathophysiology of ARVC

A

Desmosome mutation -> RV replaced by fat and fibrous tissue -> myocytes die and replaced by fat

532
Q

What are 3 symptoms of ARVH?

A

Arrhythmia
Syncope
Right HF

533
Q

How is ARVC diagnosed?

A

ECG can show T wave inversion
ECHO can show RV dilation
Genetic testing (GS)

534
Q

How is ARVC treated?

A

BB for arrhythmia (not serious)
Amiodarone for bad arrhythmias
Transplant if really bad

535
Q

Define rheumatic fever

A

Systemic response to beta haemolytic group A strep 2-4 weeks post infection

Usually pharyngitis

536
Q

Outline the pathology of rheumatic fever

A

M protein reaches heart valves -> antibodies crosslink -> autoimmune mediated destruction -> inflammation

537
Q

What valve is usually affected by rheumatic fever?

A

Mitral valve
- Mitral stenosis

538
Q

What do Aschoff bodies on histology indicate?

A

Rheumatic fever

539
Q

What are 4 symptoms of rheumatic fever?

A

New murmur
Sydenham’s chorea
Arthritis
Erythema nodosum

540
Q

What is Sydenham’s chorea?

A

Uncontrolled jerky movements

541
Q

What is erythema nodosum?

A

Tender red bumps on bilateral shins

542
Q

How is rheumatic fever diagnosed using jones criteria?

A

Recent strep

2 major OR 1 major and 2 minors

543
Q

How is rheumatic fever treated?

A

Antibiotics: benzylpenicillin and then phenoxypenicillin

544
Q

How is Sydenham’s chorea treated?

A

Haloperidol

545
Q

What is the most common form of cyanotic congenital heart disease?

A

Tetralogy of fallout

546
Q

What are the 4 characteristics of tetralogy of fallot?

A
  1. Large ventricular septal defect (VSD)
  2. Overriding aorta
  3. RV outflow obstruction
  4. RV hypertrophy
547
Q

Outline the pathophysiology of TOF

A

Stenosis of RV causes high RV pressure
Blue blood passes from RV to LV due to septum defect
Blue blood shunted around body = CYANOTIC

548
Q

What are the signs and symptoms of TOF?

A

Central cyanosis
Low birthweight and growth
Excretion dysponea
Delayed puberty
Systolic murmur

549
Q

How is TOF diagnosed?

A

ECHO
CXR: boot shaped heart

550
Q

How is TOF treated?

A

Full surgical treatment within 2 years of life
Often later need pulmonary regurgitation surgery late

551
Q

Define coarctation of the aorta

A

Narrowing of aorta at or just distal to the insertion of ductus arteriosus (just after the arch)

552
Q

What are the effects of coarctation of the aorta?

A

Excessive blood flow through carotids and subclavians into systemic vascular shunts to supply the lower parts of the body, perfusing them more

553
Q

What are 3 conditions associated with coarctation of the aorta?

A

Turner syndrome
Berry aneurysm
Patent ductus arteriosus

554
Q

What are the clinical presentations of coarctation of the aorta?

A

Can be asymptomatic and sudden death
Right arm hypertension
Bruits on scapula
Discrepancy in BP in upper and lower limbs

555
Q

How is coarctation of the aorta diagnosed?

A

ECG: LVH
CT: can demonstrate the coarctation and quantity flow
CXR: dilated aorta at site of coarctation and “notched ribs”

556
Q

How is coarctation of the aorta treated?

A

Surgery

Balloon dilation
Stenting

557
Q

What is the most common congential heart disease?

A

Bicuspid aortic valve

558
Q

Define bicuspid aortic valve

A

Aortic valve should have 3 cusps but in BAV it has 2

559
Q

What is the main complication of BAV?

A

Valves degenerate quicker than normal valves and become regurgitant quicker

560
Q

Why does BAV require surgery?

A

Can turn into aortic stenosis so will need a valve replacement

561
Q

Are atrial septal defects (ASD) more common in men or women?

562
Q

What is the other name for atrial septum defects?

A

Probe patent foramen ovale

563
Q

Where does the blood shunt in ASD?

A

Left to right

So not cyanotic

564
Q

What are the effects of untreated ASD?

A

Right heart overload -> dilation -> hypertrophy

Arrhythmia
Eisenmenger syndrome
Flow murmur ect

565
Q

What are the symptoms of ASD?

A

Dysponea
Exercise intolerance
Atrial rhythms
Split second heart sound

566
Q

What is Eisenmengers syndrome?

A

Pulmonary hypertension causes shunting to shift from right-> left so blue blood shunted systemically

567
Q

How is ASD diagnosed?

A

CXR: large P.arteries and large heart
ECG: RBBB
echo: Hypertrophy and dilation of R side of heart

568
Q

How is ASD treated?

A

Surgical closure
Percutaneous keyhole surgery

569
Q

Define ventricular septal defect (VSD)

A

Abnormal connection between the 2 ventricles

570
Q

Define atrial septum defect (ASD)

A

Abnormal connection between the 2 atria

571
Q

Outline the pathophysiology of VSD

A

Higher pressure in LV than RV
Shunt L-> R
Non cyanotic

572
Q

What are the symptoms of a large VSD?

A

Pulmonary HTN -> eisenmengers
Small breathless skinny baby
Inc respiration and tachycardia
Murmur

573
Q

What are the symptoms of a small VSD?

A

Large systemic murmur
Thrill (buzzing sensation)
Well grown
Normal HR and size

574
Q

How are large VSD diagnosed?

A

CXR: Large heart
Echo

575
Q

How are VSD treated?

A

Some spontaneously close!
Surgical closure
Can be left alone if small
Prophylactic antibiotics (endocarditis)
Furosemide, Ramipril ect

576
Q

Define atrioventricular septal defect (AVSD)

A

A giant hole in AV septum

Involves mitral an tricuspid valves and there is effectively just one big malformed leaky valve

577
Q

What is most associated with AVSD?

A

Down’s syndrome

578
Q

What are the symptoms of a complete AVSD?

A

Breathless as neonate
Poor weight gain and feeding
Torrential pulmonary flow -> Eisenmenger’s syndrome

579
Q

What are the symptoms of a partial AVSD?

A

Similar to ASD or VSD eg dysponea, exercise intolerance ect

580
Q

How is AVSD treated?

A

Hard to treat surgically!
Pulmonary retry banding if large defect in infancy to reduce Eisenmengers
Partial defect could be left alone

581
Q

Is BAV more common in males or females?

582
Q

Does patent ductus arteriosus affect males or females more?

583
Q

Define patent ductus arteriosus

A

Ductus arteriosus fails to close after birth

584
Q

What I the function of ductus arteriosus in foetal life?

A

Allows flow to shunt from PA to aorta

585
Q

When may patent ductus arteriosus occur?

A

Premature
Maternal rubella

586
Q

What are the effects of patent ductus arteriosus?

A

Abnormal L->R shunt
Pulmonary hypertension occurs -> right side HF
Increased risk of IE

587
Q

What are the symptoms of patent ductus arteriosus?

A

Continuous machinery murmurs
Bounding pulse
Eisenmengers

588
Q

How is patent ductus arteriosus diagnosed?

A

CXR: large shunt = aorta and PA are more prominent
ECG: LA abnormality and LV Hypertrophy

589
Q

How is patent ductus arteriosus treated?

A

Prostaglandin inhibitor can stimulate duct closure
Venous = AV loop
Closed surgically

590
Q

What is an example of a prostaglandin inhibitor?

A

Indometacin

591
Q

What does a boot shaped heart on CXR indicate?

A

Tetralogy of Fallot

592
Q

what are 2 differential diagnoses of DVT?

A

cellulitis
acute ischemia

593
Q

what are dihydropyridine CCBs used to treat?

A

hypertension

594
Q

what are non-dihydropyridine CCBs used to treat?

A

arrhythmia

595
Q

What does high levels of BNP indicate?

A

Heart failure

596
Q

What are the cardinal signs of HF?

A

Sob
Ankle swelling
Fatigue

597
Q

When does venous congestion and pulmonary hypoperfusion occur?

A

Right sided HF

598
Q

When does pulmonary congestion and systemic hypoperfusion occur?

A

Left sided HF

599
Q

How is BBB treated?

A

Pacemaker if symptomatic

600
Q

What is a thiazide like diuretic?

A

Indapamide

601
Q

Define acute limb ischemia

A

sudden decrease in limb perfusion that threatens viability of limb

602
Q

Define constrictive pericarditis

A

Scarring and loss of elasticity preventing normal heart filling

603
Q

What is the first line test for endocarditis?

A

Transthoracic echo

604
Q

Define shock

A

Inadequate perfusion of key organs

605
Q

What prophylactic drug is given to patients with an increased risk of VTE development?

A

LMWH eg. dalteparin

606
Q

What would ST elevation in leads 2,3 and AVF indicate?

A

Inferior MI

607
Q

What would St elevation in leads V1-V4 indicate?

A

Anterior MI

608
Q

What would ST elevation in leads V5-6 indicate?

A

Left sided MI

609
Q

What region of the heart does RCA supply?

610
Q

What region of the heart does LAD supply?

611
Q

What area of the heart does LCx suppply?

Phase 2a Annabel (12 decks)

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