Cardiology Flashcards
1
Q
What does the P wave represent?
A
Atrial depolarisation
2
Q
How long does atrial depolarisation last?
A
0.08-0.1s
3
Q
How long does AV node delay last?
A
0.12-0.2s
4
Q
How long does ventricular depolarisation last?
A
0.06-0.1s
5
Q
What does the PR interval show?
A
Time taken for atria to depolarise and electrical activation to get through AV node
6
Q
What does the QRS complex show?
A
Ventricular depolarisation
7
Q
What does the ST segment show?
A
Interval between ventricular depolarisation and repolarisation
8
Q
What does the T wave show?
A
Ventricular repolarisation
9
Q
What occurs during depolarisation?
A
The muscle contracts
10
Q
What length of time does one small box horizontally on an ECG represent?
A
0.04s/40ms
11
Q
What length of time does one large box horizontally on an ECG represent?
A
0.2s (5 small boxes per large square)
12
Q
What voltage does one large box vertically on an ECG represent?
A
0.5mV
13
Q
What is the S1 heart sound?
A
Mitral and tricuspid valve closure
14
Q
What is the S2 heart sound?
A
Aortic and pulmonary valve closure
15
Q
What is the S3 heart sound?
A
NOT NORMAL UNLESS CHILD OR PREGNANCY
Associated with mitral regurgitation and heart failure
16
Q
What is the S4 heart sound?
A
NOT NORMAL
Blood forced into stiff hypertrophic ventricle
17
Q
What arteries is atherosclerosis commonly found?
A
LAD
RCA
Circumflex
Peripheral arteries particularly at bifurcations
18
Q
What are the risk factors for atherosclerosis?
A
Age
Tobacco smoking
High serum cholesterol
Obesity
Hypertension
Family history
19
Q
What is the best known risk factor for coronary artery disease?
A
Age
20
Q
Describe the structure of an atherosclerotic plaque
A
Lipid
Necrosic core
Connective tissue
Fibrous cap
21
Q
What are 2 outcomes of an atherosclerotic plaque?
A
Occlusion of vessel = angina
Rupture = thrombus formation = death
22
Q
What initiates atherosclerotic formation?
A
Injury to endothelial cells
LDL
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
24
Q
What are some inflammatory markers found in plaques?
A
IL-1
IL-6
IFN-gamma
25
What are the 4 stages of atherosclerosis?
1. Fatty streaks
2. Intermediate lesions
3. Fibrous plaques/advanced lesions
4. Plaque rupture/plaque erosion
26
When does plaque rupture occur?
Balance shifted in favour of inflammatory conditions -> cap weakens -> cap ruptures
27
What are the clinical characteristics/risk factors of plaque rupture?
Dyslipidemia
Hypertension
DM
CKD
Winter
28
What are the outcomes of plaque rupture?
Stent
No reflow after PCI
Distal embolisation
29
What are the clinical characteristics/risk factors of plaque erosion?
Smoking
Women
<50
Anterior ischaemia
Summer
30
What are the outcomes of plaque erosion?
Anti-thrombotic
Less micro vascular damage after PCI
Better myocardial perfusion
31
Define angina
Chest pain or discomfort as a result of reversible myocardial ischaemia
32
What is stable angina?
Angina induced by effort and relieved by rest
33
How is atherosclerosis treated?
Percutaneous coronary intervention
-Stent in 90% of people
34
What are the risk factors of angina?
Smoking
Male sex
Sedentary lifestyle
Obesity
Hypertension
DM
Family history
Age
35
Outline the pathophysiology of angina
Atherosclerosis -> lumen narrowing -> ischaemia -> pain (angina)
36
What are the signs and symptoms of angina?
Chest pain
-can radiate to jaw/neck
Breathlessness
No fluid retention
Can have palpitations or syncope
37
How is stable angina diagnosed?
Resting ECG normal may have ST changes
CT Coronary angiography
ECHO ect
38
What is the gold standard test for stable angina?
CT coronary angiography
- shows occluded arteries
39
What is unstable angina?
Angina of recent onset or deterioration of stable angina with symptoms occurring more frequently at rest
40
What are the 2 sects of ischemic heart disease?
Angina
myocardial infarct
41
What is Levine sign?
Fist over chest
42
What does Levine’s sign indicate?
Ischemic heart disease ie. MI or angina
43
What is prinzmetals angina?
Due to coronary vasospasm (not atherogenesis)
44
When is prinzmetals angina seen?
Cocaine users
45
What does an ECG show in Prinzmetals angina?
ST elevation
46
What are the treatments for stable angina?
GTN sublingual spray
Modifying lifestyle
Pharmacological treatments
Revascularisation
47
What pharmacological treatments can be used to treat angina?
1. GTN spray + verapamil OR beta blockers
Also: Statin ,Anti platelet therapy, Aspirin
2.beta blocker AND amlodipine
3. Coronary angiography
48
When are CCBs contraindicated for angina?
Heart failure
49
When are beta blockers contraindicated in angina treatment?
Asthma
50
How does GTN spray alleviate angina?
Glycerin trinitrate- potent venodilator and dilates coronary arteries
Dilates systemic veins reducing venous return to right heart reducing preload
51
What is the main side effect of GTN spray?
Profuse headaches
52
What are 2 forms of revascularisation?
Percutaneous coronary intervention (PCI)
Coronary artery bypass graft (CABG)
53
What is a PCI?
Percutaneous coronary intervention
Dilating coronary obstructions by inflation of a balloon within it and inserting a stent
54
What are the pros and cons of PCI?
Pros: less invasive, short recovery
Cons: risk of stent thrombosis
55
What is a CABG?
Coronary artery bypass graft
-LIMA (left internal mammary artery) used to bypass proximal stenosis in LAD
56
What are the pros and cons of CABG?
Pros: good prognosis, good for complex disease
Cons: invasive, long recovery
57
What are the 4 levels of ischemic heart disease?
Stable angina -> unstable angina -> NSTEMI -> STEMI
58
What are the 3 acute coronary syndromes?
Unstable angina
STEMI
NSTEMI
59
What does STEMI stand for?
ST-elevation myocardial infarction
60
What does NSTEMI stand for?
Non-ST-elevation myocardial infarction
61
Describe the occlusion in unstable angina
Partial occlusion of minor coronary artery
62
Describe the occlusion in NSTEMI
Partial occlusion of major coronary artery
OR
Total occlusion of minor coronary artery
63
Describe the occlusion in STEMI
Total occlusion of major coronary artery
64
Define infarction
Necrosis due to obstruction of blood supply to an organ or tissue
65
Describe the level of infarction in unstable angina
No infarction- ischaemia only
66
Describe the level of infarction in NSTEMI
Subendothelial infarction
-area far away from CA occlusion dies
67
Describe the level of infarction in STEMI
Transmural (complete) infarction
68
How will the ECG appear in unstable angina?
Normal
May show ST depression or T wave inversion
69
How will the ECG appear in NSTEMI?
NO Q WAVE
ST depression
T wave inversion
70
How will the ECG appear in STEMI?
ST elevation in local leads
pathological Q waves
71
How is UA and NSTEMI differentiated?
NSTEMI has occluding thrombus -> MC necrosis
RISE IN SERUM TROPONIN OR CK-MB
72
What is CK-MB?
Creatine kinase-MB
73
When is CK-MB used as opposed to troponin?
A few days later- has a longer half life
74
What are the 5 types of MI?
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
75
What are the risk factors of acute cornonary syndrome?
Age
Male sex
Family history of IHD
Smoking
Hypertension, DM, HLD
Obesity and sedentary lifestyle
76
What are the symptoms of UA?
Crescendo pattern angina (UA)
Acute central chest pain
New onset angina
Sweating
Nausea and vomiting
Dizziness
Pressure, squeezing and stabbing
77
What are the investigations carried out for UA?
ECG- abnormal in 50%
Chest X ray
Blood test- troponin and CK-MB normal
Angiography to determine state of vessels
78
How is UA treated?
Usually requires hospital admission
ASPIRIN
GTN spray
Anti platelet drugs
Hypertensive and cholesterol drugs
Angioplasty/stent
79
What are some anti platelet drugs?
Aspirin
P2Y12 inhibitors
Glycoprotein IIb/IIIa antagonists
80
How does aspirin work?
IRREVERSIBLY inhibiting Cox (1+2) and prevents the breakdown of arachidonic acid into prostaglandin H2.
81
How do P2Y12 inhibitors work?
Prevent ADP dependent activation of IIb/IIIa glycoproteins preventing amplification of platelet aggregation
82
What are 2 P2Y12 inhibitors?
Clopidogrel
Prasugrel
83
What are the side effects of P2Y12 inhibitors?
Neutropenia
Thrombocytopenia
Increased risk of bleeding
84
When are glycoprotein IIb/IIIa antagonists used?
IV ONLY
Combination with aspirin and P2Y12 inhibitors in patients undergoing PCI
85
What is an example of a glycoprotein IIb/IIIa antagonist?
Abciximab
Tirofiban
86
What are 4 causes of NSTEMI?
Partial CA obstruction from ruptured plaque
Partial occlusion from stable plaque
CA vasospasm
Coronary arteritis or vasculitis
87
What are the factors affecting the severity of damage in MI?
Duration of ischemia and reperfusion
Extent of atherosclerosis
Degree of occlusion
Diameter of vessel
88
What are the signs and symptoms of MI?
Sudden crushing Chest pain- may radiate to jaw or left arm
Dysponea
Pallor
Diaphoresis
Palpitations
4th heart sound
89
What is dysponea?
Shortness of breath
90
What is diaphoresis?
Excessive sweating
91
What investigation results indicate NSTEMI?
No ST elevation
High troponin
ST depression
T wave inversion
Pathological Q wave
92
How is NSTEMI managed acutely?
MONACA
Morphine
O2 if sats below 94%
Nitrates (GTN spray)
Aspirin 300mg IMMEDIATELY
Clopidogrel or other anticoags
Angiography and revascularisation
93
How is NSTEMI and UA monitored?
GRACE score
94
What is a GRACE score used for?
Mortality risk of patients with ACS from MI
95
What would be done for a patient with a low risk GRACE score?
Monitoring
96
What would be done for a patient with a high risk GRACE score?
Immediate angiography
Consider PCI
97
How is NSTEMI managed post stabilisation?
Dual anti platelet therapy
Beta blockers
ACE-I or CCB
Statin
98
What drugs are commonly used in dual anti platelet therapy?
Aspirin 300mg lowered to 75mg
Clopidogrel 75mg
99
How is STEMI diagnosed?
ST elevation on ECG
Coronary angiograph
Rise in troponin/CK-MB
100
How is STEMI treated acutely?
MONACA
101
How is STEMI treated <12 hours after symptom onset?
PCI or CABG if PCI fails <2 HOURS
Thrombolysis if PCI unavailable in 2 hours
102
How is STEMI treated >12 hours after symptoms onset?
Dual antiplatlet therapy
Angiography and PCI if symptoms persist
103
How is STEMI treated long term?
1st line: dual anti platelet therapy
Beta blocker or CCB
ACE inhibitor or angiotensin 2 receptor antagonist
Statin
104
What are the complications of MI?
DARTH VADER
Death
Arrhythmia
Rupture (septum, ventricles)
Tamponade
Heart failure
Valve disease
Aneurism of ventricle
Dressers syndrome
Embolism
Recurrence/regurgitation
105
What is Dressler syndrome?
Form of secondary pericarditis
106
What is heart failure?
The inability of the heart to deliver blood and O2 at a rate that matches the body’s requirements
107
Is cardiac failure a diagnosis?
No- it is a syndrome
108
What are the causes of heart failure?
IHD-main cause
Cardiomyopathy
Valvular disease
Cor pulmonale
Increased myocardial work; anaemia,obesity, pregnancy
109
What is cor pulmonale?
Right sided heart failure due to disease of lungs or pulmonary vessels
110
What are the risk factors of heart failure?
65<
African descent
Men (lack of oestrogen)
Obesity
Previous MI
111
What are the 4 compensatory changes in cardiac failure?
Changes in preload
Changes in after load
Changes in sympathetic system
RAAS
112
What is decompensation?
Compensatory measures become overwhelmed causing them to become pathophysiological
113
How does heart failure affect preload?
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
114
What is afterload?
Outflow resistance- load or resistance against which the ventricle contracts
115
How does heart failure affect afterload?
1. Increased afterload = increased EDV = decrease in SV = decrease in CO
2. Increase in EDV and ventricle dilation = worse afterload
116
What effects does heart failure have on the sympathetic NS?
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
117
How does heart failure affect the RAAS system?
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
118
What is systolic heart failure?
Inability of the ventricle to contract normally, causing a decrease in CO
119
What are 3 causes of systolic heart failure?
IHD
MI
Cardiomyopathy
120
What is diastolic heart failure?
Inability of the ventricles to relax and fill fully thereby decreasing SV and CO
121
What are 2 causes of diastolic heart failure?
Hypertrophy
Aortic stenosis
122
How does Hypertrophy cause diastolic heart failure?
Chronic hypertension -> increased afterload -> more resistance -> myocytes grow -> Hypertrophy -> less space for blood -> decreased CO
123
How does aortic stenosis cause diastolic heart failure?
Narrowing of vessels -> increased afterload -> decreased CO
124
What is acute heart failure?
New onset or decompensation of chronic heart failure with pulmonary or peripheral oedema without signs of peripheral hypotension
125
What is chronic heart failure?
Develops slowly
Venous congestion common but arterial pressure well maintained for a while
126
What are the signs of left sided heart failure?
Cyanosis
Fatigue
Pulmonary oedema
Bibasal fine crackles
Dyspnoea
Orthopnoea
Prolonged CR
Pink frothy sputum
127
What is orthopnea?
sensation of breathlessness in the recumbent position, relieved by sitting or standing
128
What are the symptoms of right sided heart failure?
Oedema
Raised JVP
Weight gain
Abdominal distension
Anorexia
Pitting oedema
Ascites
129
What is ascites?
Fluid buildup in abdomen
130
What 4 investigations are carried out to diagnose heart failure?
BNP (B-type natriuretic peptide)
Echocardiogram
CXR (chest X ray)
ECG
131
When is BNP secreted?
Secreted by ventricles in response to myocardial wall stress
132
What will BNP be like in patients with heart failure?
Elevated >200
133
Why is echocardiogram used to diagnose heart failure?
Assesses degree of ventricular dysfunction
- Also assesses cardiomyopathy and signs of MI
134
What are the signs of heart failure on CXR?
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
135
What is the gold standard for heart failure diagnosis?
Echocardiogram
136
What lifestyle changes can help treat heart failure?
Avoid large meals
Lose weight
Stop smoking
Exercise
137
What are 5 types of treatments for heart failure?
Lifestyle changes
Drugs
Revascularisation
Surgery to repair damage
Heart transplant in young people
138
What 4 pharmacological interventions can be used to treat heart failure?
Diuretics (decrease preload)
ACE inhibitors or angiotensin receptor blockers
Beta blockers
Digoxin
139
How is heart failure graded?
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
140
What are the complications of heart failure?
Exercise intolerance
Increased stroke risk and thromboembolism
Arrhythmia
Kidney and liver damage
141
Define aneurysm
Permanent dilation of the artery to twice its normal diameter
142
What is a true aneurysm?
Abdominal dilation that involves all layers of the arterial wall
143
What arteries are most affected by true aneurysms?
Abdominal aorta (MC)
Iliac, popliteal, femoral arteries
Thoracic aorta
144
What is a false aneurysm/pseudoaneurysm?
Collection of blood in the adventitia (outer layer) which communicated with the lumen
145
Define abdominal aortic aneurysm
Permanent aortic dilation exceeding 50% where diameter is >3cm
146
Where do AAAs commonly occur?
Infrarenal- below renal arteries
147
What are the risk factors of AAA?
Male sex
Above 60
Family history
Tobacco smoking (BIGGEST RISK)
Atherosclerotic damage
Hypertension
Trauma
148
What are the 3 layers of an artery?
Intima
Media
Adventitia
149
Outline the pathophysiology of AAA
Degradation of elastic lamellar causing leukocyte infiltration causing proteolysis and smooth muscle cell loss
150
What are the signs and symptoms of unruptured AAA?
Often asymptomatic and picked up on X-ray ect
Back, abdomen and groin pain
Pulsatile abdo swelling
151
What diameter indicates high risk of AAA rupture?
>5.5cm
152
What are the symptoms of AAA rupture?
Sudden abdo pain
Pronounced abdo swelling
Collapse
Tachycardia
Sudden death
153
What are the differential diagnoses of AAA?
Acute pancreatitis (would be non pulsatile)
GI bleed
MSK pain
perforated ulcer
Appendicitis
154
How is AAA diagnosed?
Abdominal ultrasound
Screening
155
How is unruptured AAA treated?
<5.5 are monitored
Treat lifestyle factors
Strict BP control
Elective surgery or EVAR (stent)
156
How is ruptured AAA treated?
ABCDE and fluids
AAA graft surgery and clamp
SURGICAL EMERGENCY
157
What does TAA stand for?
Thoracic abdominal aneurysm
158
What are the causes of TAA?
Genetic link
Marfans syndrome
Ehlers danlos syndrome
Loeys-dietz syndrome
Weightlifting
Cocaine and amphetamine use
Infection
159
Outline the pathophysiology of TAA
Inflammation, proteolysis and reduced survival of smooth muscles in aorta wall
160
What are the signs and symptoms of TAA?
Mostly asymptomatic
Pain in chest, neck, upper back
Aortic regurgitation
Collapse, shock and death
Tamponade
161
How is TAA diagnosed?
Aortography to assess position of branches
TOE (Transoesophageal echocardiography)
CT or MRI
162
How is TAA treated?
Immediate surgery for rupture
Surgery for symptomatic TAA
BP control
Treat underlying cause
163
Define aortic dissection
Tear in intima resulting in blood dissecting through media and separating layers
164
What is the most common emergency affecting the aorta?
Aortic dissection
165
What is the most common medical emergency?
STEMI
166
What are the risk factors of aortic dissection?
hypertension- MOST COMMON
Male sex
Increased age
Congenital tissue disorders
Trauma
Smoking
167
What are the 3 classifications of aortic dissection?
Acute: <2 weeks
Subacute: 2-8 weeks
Chronic: 8< weeks
168
What are the 5 causes of aortic dissection?
Inherited
Degenerative
Atherosclerotic
Inflammatory
Trauma. (Eg. RTA)
169
Outline the pathophysiology of aortic dissection
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
170
What are the 2 directions of false lumen growth in aortic dissection?
Anterograde: towards bifurcations
Retrograde: towards aortic root
171
What are the 2 most common sites of intimal tears in aortic dissection?
2-3cm from aortic valve
Distal to left subclavian in descending aorta
172
Describe the 2 Stanford classifications of aortic dissection
A: ascending aorta and aortic arch (70%)
B: descending aorta (30%)
173
What are the signs and symptoms of aortic dissection?
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
174
What are the differential diagnoses of aortic dissection?
MI
MSK pain
Pericarditis
Acute coronary syndrome
Cholecystitis
175
How is aortic dissection diagnosed?
GS: CT angiogram
TOE (echo)
CXR shows >8cm widened mediastinum
176
What are 4 treatments for aortic dissection?
Antihypertensives (IV GTN)
Analgesia
Surgery
Stents
177
What are the complications of aortic dissection?
Death due to rupture (80% mortality)
Tamponade
Limb ischemia
Pre renal AKI
Ischemic stroke
178
What is an arrhythmia?
Abnormality in cardiac rhythm
179
What is one of the 10 rules of ECGs (involving the PR interval)?
Should be 120-200 miliseconds (3-5 small squares)
180
What is one of the 10 rules of ECGs (involving QRS complex width)?
Width of QRS complex should be no longer than 110ms (<3 little squares)
181
What is one of the 10 rules of ECGs (involving QRS in leads 1 and 2)
It should be dominantly upright
182
What is one of the 10 rules of ECGs (involving QRS and T waves)?
Should be in the same direction in the limb lead
183
What is one of the 10 rules of ECGs (in the AVR lead)?
All waves are negative
184
What is one of the 10 rules of ECGs (involving the R and S waves)?
R wave must grow from V1 to V4
S wave must grow from V1 to V3 and disappear in V6
185
What is one of the 10 rules of ECGs (involving ST segment)?
Should start isoelectric except in V1 and V2 where it should be elevated
186
What is one of the 10 rules of ECGs (involving P waves)?
P waves should be upright in 1,2 and V2 to V6
187
What is one of the 10 rules of ECGs (involving Q wave)?
There should be no/small (0.04s) in width in 1,2, and V2 to V6
188
What are the 2 main types of arrhythmia?
Bradycardia
Tachycardia
189
Define bradycardia
Slow hear rate (<60bpm in day and <50bpm at night)
190
Define tachycardia
Fast heart rate (>100bpm)
191
What are the 2 subdivisions of tachycardia?
Supraventricular tachycardias
Ventricular tachycardias
192
Where do supraventricular tachycardias arise from?
Atrium or AV junction
193
Where do ventricular tachycardias come from?
Ventricles
194
How does the nervous system induce tachycardia?
Reduced parasympathetic tone
Increased sympathetic tone
195
How does the nervous system induce bradycardia?
Increased parasympathetic tone
Decreased sympathetic tone
196
What are the 4 types of supraventricular tachycardia?
Atrial fibrillation
Atrial flutter
AVRT (Wolff-Parkinson White Syndrome)
AVNRT
197
What is the most common sustained cardiac arrhythmia?
Atrial fibrillation
198
Define atrial fibrillation
Uncoordinated irregular atrial rhythm of 300-600bpm
-uncoordinated atrial activation and ineffective atrial contraction
199
Outline the epidemiology of atrial fibrillation
More common in men
5-15% of over 75s
200
What are the 5 classifications of atrial fibrillation?
Acute: onset <48 hours
Paroxysmal: self limiting- stops spontaneously within 7 days
Recurrent: 2 or more episodes
Persistent: >7 days
Permanent
201
What are the causes of atrial fibrillation?
Idiopathic
Inflammation, increased pressure, fibrosis ect
Hypertension (MC)
Heart failure (MC)
CHD
VHD
Surgery
Alcohol
202
What are the risk factors of atrial fibrillation?
Age
Diabetes
Hypertension
CAD
Obesity
Structural defects
203
Outline the pathophysiology of atrial fibrillation
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
204
What are the symptoms of atrial fibrillation?
Highly variable
Palpitations
Irregular pulse
Dysponea and chest pain
Fatigue
205
How is atrial fibrillation diagnosed on an ECG?
Absent P waves
Irregular and rapid QRS
206
How is atrial fibrillation treated acutely?
1. Cardioversion
2. Ventricular rate control
-CCB
-BB
-digoxin
- anti-arrhythmic
207
What is an example of a CCB used to treat arrhythmias?
Verapamil
208
What is an example of a beta blocker?
Bisoprolol
209
What is an example of an anti-arrhythmic?
Amiodarone
210
How is cardioversion achieved?
DC shock (defibrillator)
- low weight heparin given
If fails give IV anti arrhythmic
211
What are 2 examples of molecular low weight heparins?
Enoxaparin
Dalteparin
212
What are the 2 methods of controlling atrial fibrillation?
Rate control (1st line)
Rhythm control
213
When is rhythm control used over rate control in atrial fibrillation?
RANCH
Reversible
Ablation
New onset
Clinical judgment ie. Rate control doesnt work
Heart failure caused by AF
214
What are 4 methods of controlling rate in atrial fibrillation?
1. Beta blocker / AV node slowing CCB (Dilitiazem)
2. Verapamil
3. 2nd line: digoxin the amiodarone
215
How is rhythm control achieved in atrial fibrillation?
Cardioversion
- flecainide if no defects
- amiodarone if defects (huge Side effects so use with old people)
+ electrical Cardioversion
216
What anticoagulants are used to treat atrial fibrillation?
DOACs
Eg Apixaban or Rivaroxaban
217
How do DOACs work?
Directly inhibit factors of the coagulation cascade eg factor Xa and IIa
218
How does warfarin work?
Vitamin K antagonist
219
How is CHA2DS2-VASc score calculated?
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)
220
What CHA2DS2-VASc indicates a need for anticoagulation?
1+ for men
2+ for women
221
What are 3 examples of NOACs/DOACs?
Dabigatran
Apixaban
Edoxaban
222
How is HASBLED score calculated?
Hypertension (1)
Abnormal liver/ kidney function (1/2)
Stroke(1)
Bleeding (1)
Labile INR (1)
Elderly >65 (1)
Drug or alcohol abuse (1/2)
223
What HASBLED score indicates that anti coagulation is not advisable?
3+
224
What are the complications of atrial fibrillation?
Heart failure
Ischemic stroke
225
Define atrial flutter
Organised atrial rhythm with an atrial rate of 250-350BPM
226
Where is atrial flutter most common?
Right atrium
227
What are the causes of atrial flutter?
Idiopathic (1/3)
Structural defects
Anti arrhythmics for AF
Lung issues (eg COPD)
Alcohol intoxication
228
What are the risk factors for atrial flutter?
Atrial fibrillation
229
What are the clinical presentations of atrial flutter?
Palpitations
Breathlessness
Dizziness
Chest pain
Syncope
Fatigue
230
What are the signs of atrial flutter on an ECG?
Sawtooth pattern (F waves) between QRS complex
Regular rhythm
Narrow QRS
231
How is atrial flutter treated?
Cardioversion (acute)
Rhythm/rate control with anticoagulant and BB
Basically the same as AF
232
When are SVTs usually seen?
Young people with little to no structural defects
12-30 years old
AVN essential component
233
What does AVRT stand for?
Atrioventricular re-entrant tachycardia
234
What is the most common type of AVRT?
Wolff-Parkinson White Syndrome
235
Define AVRT
Accessory pathway/ abnormal connection exists in the heart, and this can bypass the AV node
236
What is the accessory pathway known as in WPW (wolf Parkinson white)?
Bundle of Kent
237
What occurs in WPW?
normal AV conduction and also an accessory pathway
Atrium -> ventricle too quickly- PRE EXCITATION
238
What are 3 ways that AVRT is reflected on an ECG?
Delta waves (notch at beginning of QRS complex)
Wide QRS complex
Short PR interval
239
What are the symptoms of AVRT?
WPW can be asymptomatic
Severe dizziness
Syncope
Palpitations
Dysponea
240
How are patients with unstable AVRT characterised?
Hypotension
Pulmonary oedema
241
How is unstable AVRT treated?
Emergency Cardioversion
242
What is cardioversion?
Medical procedure using quick low energy shocks to restore heart rhythm
243
How is stable AVRT treated (1st line)?
Vagal manoeuvres
- Valsalva manoeuvre (1st line)
- Carotid massage
- Breath-holding
244
How is stable AVRT treated if 1st line doesnt work?
IV adenosine
DC cardioversion
245
What does IV adenosine do?
Causes complete heart block for a very short period of time- can terminate AVRT and AVNRT very well
246
How is complex AVRT treated?
Catheter ablation of accessory pathway
247
What does AVNRT stand for?
Atrioventricular nodal re-entrant tachycardia
248
What brings on symptoms of AVNRT?
Exertion
Emotional stress
Coffee and tea
Alcohol
249
What are the 2 pathways within the AV node in AVNRT?
1. slow conduction pathway
2. fast conduction pathway
250
What are the 4 clinical presentations of AVNRT?
Rapid regular palpitations that start abruptly and end suddenly
Chest pain and Dysponea
Jugular pulsations
Polyuria
251
How is AVNRT diagnosed on ECG?
SVT appearance
P waves not visible or seen immediately before or after QRS complex
252
How is AVNRT treated?
Same as AVRT
253
What are 3 types of ventricular tachycardias?
Ventricular ectopic -> ventricular fibrillation
Prolonged QT syndrome
Torsades de pointes
254
Define ventricular ectopic
Premature ventricular contraction
255
When does ventricular ectopic occur?
Most common post MI arrhythmia
Can occur in healthy people too
256
What are the presentations of ventricular ectopics?
Usually asymptomatic
Extra, missed or heavy beats
Irregular pulse due to premature beats
Faint or dizzy
Can cause ventricular fibrillation
257
How is ventricular ectopic treated?
Beta blockers if symptomatic
258
What does ventricular ectopic look like on an ECG?
Widened QRS complex
Compensatory pause
259
Define ventricular fibrillation?
Very rapid and irregular ventricular with no mechanical effect (ie. No CO)
260
What are the symptoms of ventricular fibrillation?
Patient is pulseless
Unconscious
No respiration
CARDIAC ARREST
261
How does ventricular fibrillation show on an ECG?
Shapeless
Rapid oscillations
No organised complexes
262
What is the usual cause of ventricular fibrillation?
Ventricular ectopic beat
263
What is the treatment for ventricular fibrillation?
ONLY electrical defibrillation
264
How is risk of sudden death reduced in ventricular fibrillation?
Implantable cardioverter defibrillation
265
Define long QT syndrome
Ventricular repolarisation (QT interval) is greatly prolonged
480ms+
266
What are 2 congenital causes of long QT syndrome?
Jervell-Lange-Nielse syndrome (recessive)
Romano-Ward syndrome (dominant)
267
What does Jervell-Lange-Nielsen syndrome cause?
Mutation in cardiac potassium and sodium channel genes
268
What are acquired causes of long QT syndrome?
Hypokalaemia
Hypocalcaemia
Drugs
Bradycardia
DM
269
What are 2 drugs that can cause long QT syndrome?
Amiodarone
Tricyclic antidepressants (eg. Amitriptyline)
270
What are 3 clinical presentations of long QT syndrome?
Syncope
Palpitations
May degenerate into ventricular fibrillation
271
How is long QT syndrome treated?
Treat underlying cause
If acquired (CI for congenital) give IV isoprenaline
- non selective beta adrenoreceptor agonist
272
What is Torsades de Pointes?
Polymorphic ventricular tachycardia in patients with prolonged QT
273
What does Toursades do Pointes look like on an ECG?
Irregular QRS complex
-Kind of looks like arctic monkeys album cover
274
How does heparin work?
Binds to Antithrombin and makes it more potent
275
What is an AV block?
Block in the AV node or His bundle
276
What is a bundle branch block?
Block lower than the AV node and His bundle
277
What are the 3 forms of AV block?
First degree
Second degree
Third degree
278
Define first degree AV block
Prolongation of electrical conduction through av node causing prolonged PR interval
>0.22 seconds/200ms
No missed beats
279
What are the causes of first degree AV block?
Increased vagaries tone eg athlete
Hyperkalaemia
Myocarditis
Inferior MI
AVN blocking drugs
280
What is the treatment for first degree AV block?
Asymptomatic- no treatment
281
How does first degree AV block appear on an ECG?
Long PR interval
-delayed gap on ECG paper
282
What are the 2 types of 2nd degree AV block?
Mobitz I block
Mobitz II block
283
What is the other name for Mobitz I block?
Wenckebach block phenomenon
284
What is Mobitz I block?
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
What are the causes of Mobitz I block?
AVN blocking drugs
Inferior MI
Fit athletes vagal toning
286
What are 3 AVN blocking drugs?
Beta blockers
CCB
Digoxin
287
How is Mobitz I block treated?
Stop underlying cause
- Usually asymptomatic so its fine
288
What is Mobitz II block?
PR interval consistently prolonged and QRS randomly dropped (not usually occurring)
289
What Mobitz block occurs when His-Purkinje system is blocked?
Mobitz II
290
What Mobitz block occurs when AVN or His bundle is blocked?
Mobitz I block
291
What are the causes of Mobitz II block?
Anterior MI
Mitral valve surgery
SLE and Lyme disease
Rheumatic fever
292
What are 3 symptoms of Mobitz I block?
Light headlines
Dizziness
Syncope
293
What are 3 symptoms of Mobitz II block?
SOB
Postural hypotension
CP
294
How is Mobitz II block treated?
Pacemaker should be inserted due to risk of complete AV block
295
What is the main complication of Mobitz II block?
Sudden complete AV block
296
What is 3rd degree AV block?
Complete AV block when atrial activity fails to conduct to the ventricles - atria and ventricles beat independently
297
How does 3rd degree AV block appear on an ECG?
P waves are completely independent from QRS complex
- Biiiiiggggg gaps
298
What are 4 causes of 3rd degree AV block?
Structural heart disease
IHD
Hypertension
Endocarditis or Lyme disease
299
How is 3rd degree AV block treated?
Permanent pacemaker
IV atropine
300
Does the blocked bundle depolarise sooner or later in BBB?
Later
Eg. LBBB will be right then left
301
What are the causes of RBBB?
PE
IHD
Ventricular or atrial septum defect
302
How does RBBB appear on ECG?
MaRRoW
- QRS looks like M in lead V1
- QRS looks like W in V5 and V6
303
What effect does RBBB have on heart sounds?
Splitting of second heart sound
304
What are the causes of LBBB?
ALWAYS pathological
IHD
AVD
305
What does LBBB look like on ECG?
WiLLiaM
QRS looks like a W in V1 and V2
QRS looks like an M in V4-V6
- also abnormal Q waves
306
What effect does LBBB have on heart sounds?
Reverse splitting of second HS
307
What are the symptoms of BBB?
Usually asymptomatic
Syncope
HF
308
What is normal BP?
120/80
309
What is hypotension?
90/60
310
What is stage 1 hypertension at home?
≥ 135/85
311
What is stage 1 hypertension in clinic?
≥ 140/90
312
What is stage 2 hypertension at home?
≥ 150/95
313
What is stage 2 hypertension in clinic?
≥ 160/100
314
What is stage 3 hypertension (severe)?
≥ 180/110
315
Define hypertension
Abnormally high blood pressure
316
What are the 2 classifications of hypertension?
Essential (primary/idiopathic): cause is unknown
Secondary hypertension: other causes
317
What is the most common classification of hypertension?
Essential
318
What are the causes of essential hypertension?
Primary cause unknown
Multifactoral causes:
Genes
Excessive NS activity
Na/K transport issues
High salt intake
RAAS abnormalities
319
What are the causes of secondary hypertension?
ROPE
Renal disease
Obesity
Pregnancy
Endocrine
320
What is aorta coarctation?
Birth defect causing narrowing of the aorta
321
What are some renal causes of hypertension?
CKD (MC of 2ndary)
Chronic glomerulonephritis
Diabetes can cause CKD (MC)
322
What are 3 endocrine causes of hypertension?
1. Cushings (corticosteroids->vasoconstriction)
2. Conn’s (aldosterone -> higher blood volume)
3. Phaeochromocytoma (catecholamines -> vasoconstriction, inc. contractility)
323
What are 3 drugs associated with hypertension?
Corticosteroids
Erythropoietin
Alcohol, cocaine ect
324
What are the risk factors of hypertension?
Age
Race (black)
Family history
Overweight and sedentary
Smoking and alcohol
Stress
325
What are the effects of hypertension on the cardiovascular system?
Accelerates atherosclerosis
Thickening of arteries
Risk factor for IDH
326
What effect can hypertension have on the NS?
Intracerebral haemorrhage
327
What are the symptoms of hypertension?
Usually asymptomatic
Can have pulsatile headaches
328
What is malignant hypertension?
Nothing to do with cancer!
Raised DBP (>120) and renal disease
329
When does malignant hypertension occur?
Previously fit individuals
Black males
30-40s
330
What are the consequences of hypertension?
Cardiac failure (LV Hypertrophy)
Blurred vision due to papillodema
Haematuria and renal failure
Headaches and cerebral haemmorage
331
How is hypertension diagnosed?
Reading 140/90
Look for FUBE:
Fundoscopy (retinopathy)
Urinalysis albumin: creatine ratio
Bloods (creatine, eGFR, glucose)
ECG
332
What are the lifestyle factors that can be altered in hypertension?
Change diet: fruit and veg and low fat
Exercise
Reduce alcohol
Lose weight
Less salt
Stop smoking
333
What is the ACD pathway?
First line drugs for hypertension treatment
A- ACE- inhibitor / Angiotensin receptor blocker (ARB)
C- Calcium channel blocker (CCB)
D- Diuretics
334
What are 2 examples of ACE inhibitors?
Ramipril
Enalapril
335
What are 2 examples of ARBs?
Candesartan
Losartan
336
When are ACE-inhibitors contraindicated?
Pregnancy
CKD
Angioedema
337
What are 2 CCBs?
Amlodipine
Nifedipine
338
What is an example of a thiazide diuretic?
Bendroflumethiazide
339
What is an example of a loop diruretic?
Furosemide
340
Are thiazide or loop diuretics more potent?
Loop
341
What is given when ACE inhibitors are contraindicated?
Angiotensin receptor blocker (ARB)
342
When is an ACE inhibitor given to hypertensives?
DMT2
<55
343
When is a CCB given to hypertensives?
≥55
Afro Caribbean
344
What is the first line treatment for hypertension?
ACE inhibitor or CCB
345
What is the second line treatment for hypertension?
ACE-I + CCB
346
What is the 3rd line treatment for hypertension?
ACE-I + CCB + thiazide like diuretic or thiazide
347
What is the 4th line treatment for hypertension?
ACE-I + CCB + TLD +
K+ <4.5 = spironolactone (diuretic)
K+ >4.5 = BB
348
What are the complications of hypertension?
Retinopathy
Neuropathy
AF
HF
IHD
CVD
349
What are 2 types of venous thromboemboli?
Deep vein thrombosis
Pulmonary embolism
350
Define deep vein thrombosis
Formation of a thrombus in a deep vein (usually leg) which partially or completely obstructs blood flow
351
What is the most common site of DVT?
Below the calf
- Less concerning
352
What is the most concerning location of DVT?
Above the calf
353
What are the risk factors of DVT?
Cancer
HF
>60
Male
Thrombophilia
History of DVT
354
What are temporary factors increasing the risk of DVT?
Immobility
Trauma
Hormone treatment
Pregnancy
Dehydration
355
What are the symptoms of DVT?
Unilateral localised pain and swelling
Tenderness
Swelling, discolouration, warmth
Vein dissenting
356
What WELL score indicates DVT?
First line test
>2
357
What investigation is carried out for DVT if WELLS score is low?
D dimer test
358
What do D dimer test results indicate?
Positive: treat for DVT and have ultrasound
Negative: do not treat + stop anticoags
359
What is the diagnosis test for DVT?
doppler ultrasound compression
- Thrombus will prevent compression
360
How is DVT differentiated from cellulitis?
Blood test shows leukocytosis
361
What is the first line treatment for DVT?
Apixaban or rivaroxaban
DOAC factor Xa inhibitor
362
What are the second line treatments for DVT?
LWMH
Warfarin
Stockings
Thrombectomy (massive)
363
What are the complications of DVT?
PE
Recurrent DVT
364
Define pulmonary embolism
Embolus (usually from DVT) are lodged in and obstruct the pulmonary arterial system
365
How can PE cause cor pulmonale?
Causes increased PVR
RV is then strained
Causes RV Hypertrophy
366
What are the symptoms of PE?
Sudden pleuritic chest pain
Tachycardia
Evidence of DVT
Dysponea with haemoptysis
367
What WELLS score indicates PE?
>4
368
How is PE differentiated from pneumothorax ect?
CXR will be normal in PE
369
How is PE seen on ECG?
Sinus tachycardia
S1 Q1 TIII
T wave inversion
New RBBB
370
What test is conducted if WELLS score is >4?
CTPA (CT scan pulmonary angiogram)
371
What is the GS diagnostic for PE?
CT- pulmonary angiogram
372
What is the 1st line test for PE?
WELLS score
373
What is the 1st line treatment for PE?
DOACS
- Apixaban or rivaroxaban
374
What is the treatment for a large PE?
Thrombolysis- clot buster
Surgical thrombo-embolectomy
375
How long should anticoagulation be carried on after PE?
3-6 months (provoked/unprovoked)
376
What are 2 types of peripheral vascular disease?
Peripheral arterial disease (PAD)
Peripheral venous disease (PVD)
377
What is peripheral arterial disease?
Narrowing of arteries usually due to atherosclerosis
378
What are the risk factors for peripheral vascular disease?
Smoking
Hypertension
Diabetes
Hypercholesterolaemia
379
Outline the aetiology of peripheral arterial disease/PVD
Atherosclerosis
- Embolisation
- Thrombosis (MC)
Inflammatory
Vasospasm
Trauma
380
What are the signs and symptoms of acute ischemia?
6 Ps
Paralysis
Pain
Pallor
Pulse deficit
Parasthesia
Perishing cold
381
What are the symptoms of PVD?
Walking impairment
Pain in buttocks and thighs relieved at rest
Pale, cold leg
Hair loss
Ulcers
Poorly healing wounds
Weak or absent pulses
382
What sign indicates PVD?
Buegers angle: if pallor occurs when limb is raised >20 degrees indicates severe ischemia
383
How is PVD diagnosed?
1. ABPI- ankle brachial pressure index
Duplex arterial USS
384
How is PVD treated?
Clopidogrel
Statin
Naftidrofuryl oxalate (vasodilator)
385
How is chronic PVD treated?
Revascularisation surgery
Small = PCI
Large = bypass
Necrotic = amputation
386
How is acute limb ischemia treated?
Emergency revascularisation in 4-6 hours
Fogarty catheter
Irreversible = amputation
387
What are the complications of PVD?
Acute limb ischemia
Reperfusion injury
Amputation
Rhabdomyolosis (proteins and electrolytes from damaged muscle released into blood)
388
Define pericarditis
Inflammation of the pericardium
389
What are the 2 types of pericarditis?
Fibrinous (dry)
Effusive: serous and /haemorrhagic exudate
390
What is the main type of pericarditis?
Wet Exudative
391
What are the causes of pericarditis?
Coxsackie virus (MC)
Idiopathic
TB/bacteria
Dressler’s syndrome
Urinaemia
Malignancy
392
Who is mainly affected by pericarditis?
Males 20-50y
393
Outline the pathophysiology of pericarditis
Inflammed layers rub against each other -> more inflammation
Constrictive pericarditis impedes normal diastolic filling
394
What are the signs and symptoms of pericarditis?
CP radiating to trapezius ridge, neck and shoulders
Relieved by sitting forward, exacerbated by lying flat
Pericardial friction rub
Sharp pleuritic pain
395
What are the 4 diagnostic tests for pericarditis?
Needs 2/4 of
CP
Friction rub
ECG changes
Pericardial effusion
396
What changes can be seen on an ECG when pericarditis is present?
Concave saddle ST elevation
PR depression
397
What imaging tests may be used to diagnose pericarditis?
CXR shows “water bottle heart”
Echo
398
How is pericarditis treated?
Usually self limiting
Treat cause eg antibiotics
NSAIDs and rest
399
How is serious pericarditis managed?
Colchicine (anti inflammatory)
Corticosteroids
400
What are the complications of pericarditis?
Tamponade
Pericardial effusion
Restrictive pericarditis - inhibits normal heart filling
Myocarditis
401
Define pericardial effusion
Collection of fluid in the potential space of the serous pericardial sac (>50ml)
402
Define cardiac tamponade
Accumulation of pericardial fluid raising intrapericardial pressure causing poor ventricular fillling and a fall in CO
403
What is the most common cause of pericardial effusion?
Pericarditis
404
What are 4 symptoms of pericardial effusion?
Pulsus paradoxus
Kaussmauls sign
Ewarts sign
Dysponea and tachycardia
405
What is pulsus paradoxus?
Loss of peripheral pulse when inspiring
406
What is Kaussmauls sign?
Increased vein distension during inspiration
Increased RA pressure
407
What is Ewarts sign?
Dullness to percussion in left lower lung field
408
What are the 3 signs of cardiac tamponade?
Becks triad
Hypotension
Jugular venous distension (JVD)
Muffled heart sounds
409
How are cardiac tamponade and pericardial effusion diagnosed?
ECG: low voltage QRS complexes
CXR: large globular heart
Pericardiocentesis- drain and test fluid
410
How is pericardial effusion differentiated from cardiac tamponade?
CT has late diastolic collapse of RA in tamponade
411
How is pericardial effusion treated?
Treat underlying cause
NSAIDs
Colchicine
Usually resolves spontaneous
412
How is cardiac tamponade treated?
Urgent pericardiocentesis
413
What is pericardiocentesis?
Catheter is used to drain excess fluid from the pericardial sac
414
Define endocarditis
Infection of the endocardium or vascular endothelium of the heart
415
Where does infective endocarditis occur on the heart?
Valves with congenital or acquired defects
Normal valves (viral)
Prosthetic valves and pacemakers
416
Who is most commonly affected by infective endocarditis?
IV drug users
Males
Elderly
Congenital heart disease
Poor oral hygiene
417
What are 3 causes of endocarditis?
Staph aureus (MC)
Strep Viridans
S. Bovis
418
What bacteria related to poor dental hygiene can cause infective endocarditis?
Strep Viridans
419
Where does IE usually affect IV drug users?
Tricuspid valve
Right side
420
What is the most common cause of IE?
Staph aureus
421
Outline the pathophysiology of IE
1.Damaged endocardium promotes platelet and fibrin deposition
2. Organisms adhere and grow -> infected vegetation
3. Typically around valves so causes regurgitation
422
What are the signs of IE?
New valve lesion or regurgitation murmur
Sepsis
Haematuria, renal infarction ect
Clubbing
Embolism of vegetation
423
What are the symptoms of IE?
Fever
Night sweats
Headaches
Malaise
Confusion
424
What are the clinical manifestations of IE?
Splinter haemmorages on nail beds
Embolitic skin lesions (black spots)
Olster nodes
Janeway lesions
Roth spots
Petechiae
425
What are olser lesions?
Tender nodules in digits
426
What are janeway lesions?
Painful haemmorages and nodules in digits
427
What are Roth spots?
Retinal haemmorages with white or clear centres
428
What are petechiae?
Red/purple spots caused by bleeds in the skin
429
How is IE diagnosed using Dukes criteria?
2 major
1 major 2/3 minor
5 minor
430
What are the 2 major categories of Dukes criteria?
2 or more positive cultures
Echo (TOE) shows vegetations
431
What are the 5 minor sign on Dukes criteria?
Immunological signs
IVDU or predisposition
Septic emboli
1 positive blood test
Pyrexia
432
How does IE appear on a blood test?
CRP and ESR raised
Neutrophilia
433
How is IE treated by surgery?
Removing valve and replacing with prosthetic
Remove large vegetations
Remove infected devices
434
What are the complications of IE?
HF
Aortic root abscess
Septic emboli and sepsis
435
Are most murmurs diastolic or systolic?
Systolic
436
What are the 2 main systolic murmurs?
ASMR
AS: aortic stenosis
MR: mitral regurgitation
437
What are the 2 diastolic murmurs?
ARMS
AR: aortic regurgitation
MS: mitral stenosis
438
What are 2 other systolic murmurs?
Mitral valve prolapse
Tricuspid regurgitation
439
How are heart murmurs best heard?
RILE
Right side = inspiration
Left side = expiration
440
What valves are on the right?
Pulmonary valve
Tricuspid valve
441
What valves are on the left?
Aortic valve
Mitral valve
442
Define aortic stenosis
Narrowing of the aortic valve resulting in obstruction to left ventricular stroke volume
443
When do symptoms of aortic stenosis appear?
When lumen is 1/4 of its normal size (normal is 3-4cm)
444
Outline the pathophysiology of aortic stenosis
Narrowing -> decreased SV -> increased afterload -> increased LV pressure -> LVH -> increased O2 demand -> ischemia
445
What are 3 causes of aortic stenosis?
Aging calcification
Congenital bicuspid aortic valve
Rheumatic heart disease (rare)
446
What are the symptoms of aortic stenosis?
SAD:
Syncope
Angina
Dysponea+ HF
447
What is the murmur like in aortic stenosis?
**Ejection systolic murmur-crescendo-decrescendo radiating to carotids**
448
How is aortic stenosis diagnosed?
Echo: left ventricular size and function
ECG: LVH
CXR: LVH or calcified aortic valve
449
How is aortic stenosis treated?
Surgery if symptomatic
- surgical aortic valve replacement
- if at risk: TAVI (transcutaneous aortic valve implantation)
450
Define aortic regurgitation
Leakage of blood into LV from the aorta during diastole due to ineffective coaptation of the aortic cusps
451
What are 4 causes of aortic regurgitation?
Congenital bicuspid aortic valve (BAV)
Rheumatic fever
IE
Connective tissue disorders
452
Describe the pathophysiology of aortic regurgitation
Low CO -> LVH -> HF -> decreased CA supply
453
What are the general symptoms of aortic regurgitation?
Exertional dysponea
Palpitations
Angina
Syncope
Wide pulse pressure
454
What are the signs of aortic regurgitation on auscultation?
Displaced apex beat
**Early diastolic blowing murmur**
Austin flint murmur
Collapsing water hammer pulse
455
What are 4 signs of aortic regurgitation?
Wide pulse pressure
Corrigans pulse
De Mussets sign
Quinckes sign
456
What is Corrigan’s pulse?
Collapsing pulse appearing and reappearing at carotids
457
What is De Mussets sign?
Head nodding at each heartbeat
458
What is Quincke’s sign?
Capillary pulsation at nail beds
459
How does aortic regurgitation appear on CXR?
Enlarged cardiac silhouette
Aortic root enlargement
460
What is the gold standard diagnosis for valve disease?
Echocardiogram
461
How does aortic regurgitation appear on ECG?
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
How is aortic regurgitation treated?
consider IE prophylaxis
Vasodilators (eg. ACE inhibitors)
Surgery if symptomatic or worsening
- valve replacement
463
Define mitral stenosis
Narrowing mitral valve that prevents the LA from pushing blood to the LV normally during diastole
464
What are 3 causes of mitral stenosis?
MC: Rheumatic fever
IE
Mitral valve calcification
465
When do symptoms of mitral stenosis appear?
>2cm
Decades after rheumatic fever
466
What are the symptoms of mitral stenosis?
Haemoptysis
Malar cheek flush
Right HF
467
What is malar flush?
Bilateral pink/bluish patches on cheeks due to vasoconstriction
468
What heart sounds indicate mitral stenosis?
**low pitched mid diastolic murmur loudest at apex with snapping**
Loud opening S1 snap
Short s2 opening snap
469
How will mitral stenosis appear on ECG?
AF
LA enlargement
470
How may mitral stenosis appear on CXR?
LA enlargement
Pulmonary congestion
471
How is mitral stenosis treated?
Rate control: BB, CCB, digoxin
Diuretic
Surgery:
- Percutaneous mitral balloon valvotomy
-PCI/open surgeyr
472
Define mitral regurgitation
Backflow of blood from LV to LA during systole
473
How many people have mild mitral regurgitation?
80%
474
What is the MC cause of mitral regurgitation?
Myxomatous degeneration (MVP)
475
What are the risk factors for mitral regurgitation?
Female
Low BMI
Increasing age
Renal dysfunction
Prior MI
476
What are the symptoms of mitral regurgitation?
Exertion dysponea
HF
Fatigue
Palpitations
477
How is mitral regurgitation heard on auscultation?
**Pansystolic blowing murmur radiating to axilla**
RV heave
Soft S1
478
Does the volume of a MR murmur correlate with severity?
No
479
How is mitral regurgitation seen on ECG?
LA enlargement
AF
480
How does mitral regurgitation appear on CXR?
LA enlargement
Central pulmonary arterial enlargement
481
How is mitral regurgitation treated?
Rate control: BB, CCB, Digoxin
Diuretics
Anticoagulant for AF
Surgery: replacement or repair
482
When is surgery recommended for mitral regurgitation?
Symptoms at rest or exercise
Ejection fraction <60%
New onset AF
483
What would a pan systolic blowing murmur radiating to axilla with quiet S1 indicate?
Mitral regurgitation
484
What would a murmur ejection systolic crescendo descrecendo radiating to carotids indicate?
Aortic stenosis
485
What would an early diastolic blowing murmur indicate?
Aortic regurgitation
486
What would a low pitched mid diastolic murmur loudest at apex with snapping indicate?
Mitral stenosis
487
Define shock
Acute circulatory failure causing hypoperfusion, meaning there is inadequate materials for respiration throughout the body, leading to hypoxia
488
What would severe nocturnal pain in left toes alleviated by gravity perfusion indicate?
Critical ischemia
489
What type of ischemia is related to MI?
Acute ischemia
490
What would the diagnosis be for loss of right sided body use and fast irregular pulse?
Acute ischemia.
491
What would a non-healing non-traumatic painful ulcer on the big toe indicate?
Critical ischemia
492
What are 5 types of shock?
NCASH
Neurogenic
Cardiogenic
Anaphylactic
Septic
Hypovolemic
493
What are the signs of shock?
Capillary refill time >3 seconds!
Skin is cold, pale, sweaty
Reduced pulse pressure
Reduced urine output
Confusion, weakness, collapse and coma
494
What are the effects of shock?
Can cause prolonged hypotension -> organ failure after recovery from acute event
495
What causes hypovolemic shock?
Blood loss eg trauma
Fluid loss eg. Dehydration
496
What are 4 symptoms of hypovolemic shock?
Clammy skin
Confusion
Hypotension
Tachycardia
497
How is hypovolemic shock treated?
ABC
Give O2
IV fluids
498
What causes septic shock?
Uncontrolled bacterial infection
499
What are 3 symptoms of septic shock?
Pyrexia
Warm peripheral \s
Tachycardia
500
How is septic shock treated?
ABCDE
Broad spec antibiotics
501
What causes cardiogenic shock?
Heart pump failure
- MI
- Tamponade
- PE
502
What are 3 symptoms of cardiogenic shock?
Signs of HF
Increased JVP
Weak threads pulse
503
How is cardiogenic shock treated?
ABCDE
Treat underlying cause
Oxygen and fluids
504
What causes anaphylactic shock?
IgE mediated type 1 hypersensitivity reaction and massive histamine release causing vasodilation and bronchconstriction
505
What are 3 symptoms of anaphylactic shock?
Hypotension and tachycardia
Puffy face
Warm peripheries
506
How is anaphylactic shock treated?
ABCDE
IM adrenaline (500 micrograms)
507
What causes neurogenic shock?
Spinal cord trauma eg RTA
Essentially SNS is disrupted but PSNS is intact
508
What are 3 symptoms of neurogenic shock?
Hypotension
Bradycardia
Warm dry skin
509
How is neurogenic shock treated?
ABCDE
IV atropine
510
What are 4 organs most at risk of failure from shock?
Kidneys
Lungs
Heart
Brain
511
What are cardiomyopathies?
Diseases of the myocardium
512
What are 4 types of cardiomyopathies?
Hypertrophic
Dilated
Restrictive
Arrythmogenic right ventricular
513
What is the most common cause of cardiomyopathic death in young people?
Hypertrophy
514
What is the most common cardiomyopathy?
Dilated cardiomyopathy
515
What are 3 causes of hypertrophic cardiomyopathy?
Autodom inherited mutation of sarcomere
Exercise
Aortic stenosis
516
Outline the pathophysiology of HCM
Thick non-compliant heart -> impaired filling -> decreased CO and SV
517
What are the symptoms of HCM?
Sudden death
CP
Palpitations
SOB
Syncope
518
What are 3 ways of diagnosing HCM?
ECG has T wave inversion and deep Q waves
Echo (GS)
Genetic testing
519
How is HCM treated?
BB
CCB
Amiodarone
520
What is dilated cardiomyopathy?
Dilated thin cardiac walls which contract poorly
521
What are 3 causes of dilated cardiomyopathy?
Autodom cytoskeleton mutation
IHD
Alcohol
522
What are 4 symptoms of dilated cardiomyopathy?
SOB
HF
AF
Thromboemboli
523
How is dilated cardiomyopathy diagnosed?
CXR shows enlargement
ECG arrhythmia ect
Echo
524
How is dilated cardiomyopathy treated?
Treat AF and HF
525
What is restrictive cardiomyopathy?
Rigid fibrotic myocardium that fills and contracts poorly
526
What are 3 causes of restrictive cardiomyopathy?
Granulomatous disease (eg. Sarcoidosis)
Idiopathic
Post MI fibrotic
527
What are the symptoms of restrictive cardiomyopathy?
Dysponea and fatigue
Oedema and congestive HF
3rd and 4th heart sounds
528
What is the definitive diagnosis for restrictive cardiomyopathy?
Cardiac catheterisation
529
How is restrictive cardiomyopathy treated?
Only transplant
Most die within a year
530
What is arrythmogenic right ventricular cardiomyopathy?
Progressive genetic cardiomyopathy characterised by progressive fatty and fibrous replacement of right ventricular myocardium
531
Outline the pathophysiology of ARVC
Desmosome mutation -> RV replaced by fat and fibrous tissue -> myocytes die and replaced by fat
532
What are 3 symptoms of ARVH?
Arrhythmia
Syncope
Right HF
533
How is ARVC diagnosed?
ECG can show T wave inversion
ECHO can show RV dilation
Genetic testing (GS)
534
How is ARVC treated?
BB for arrhythmia (not serious)
Amiodarone for bad arrhythmias
Transplant if really bad
535
Define rheumatic fever
Systemic response to beta haemolytic group A strep 2-4 weeks post infection
Usually pharyngitis
536
Outline the pathology of rheumatic fever
M protein reaches heart valves -> antibodies crosslink -> autoimmune mediated destruction -> inflammation
537
What valve is usually affected by rheumatic fever?
Mitral valve
- Mitral stenosis
538
What do Aschoff bodies on histology indicate?
Rheumatic fever
539
What are 4 symptoms of rheumatic fever?
New murmur
Sydenham’s chorea
Arthritis
Erythema nodosum
540
What is Sydenham’s chorea?
Uncontrolled jerky movements
541
What is erythema nodosum?
Tender red bumps on bilateral shins
542
How is rheumatic fever diagnosed using jones criteria?
Recent strep
2 major OR 1 major and 2 minors
543
How is rheumatic fever treated?
Antibiotics: benzylpenicillin and then phenoxypenicillin
544
How is Sydenham’s chorea treated?
Haloperidol
545
What is the most common form of cyanotic congenital heart disease?
Tetralogy of fallout
546
What are the 4 characteristics of tetralogy of fallot?
1. Large ventricular septal defect (VSD)
2. Overriding aorta
3. RV outflow obstruction
4. RV hypertrophy
547
Outline the pathophysiology of TOF
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
What are the signs and symptoms of TOF?
Central cyanosis
Low birthweight and growth
Excretion dysponea
Delayed puberty
Systolic murmur
549
How is TOF diagnosed?
ECHO
CXR: boot shaped heart
550
How is TOF treated?
Full surgical treatment within 2 years of life
Often later need pulmonary regurgitation surgery late
551
Define coarctation of the aorta
Narrowing of aorta at or just distal to the insertion of ductus arteriosus (just after the arch)
552
What are the effects of coarctation of the aorta?
Excessive blood flow through carotids and subclavians into systemic vascular shunts to supply the lower parts of the body, perfusing them more
553
What are 3 conditions associated with coarctation of the aorta?
Turner syndrome
Berry aneurysm
Patent ductus arteriosus
554
What are the clinical presentations of coarctation of the aorta?
Can be asymptomatic and sudden death
Right arm hypertension
Bruits on scapula
Discrepancy in BP in upper and lower limbs
555
How is coarctation of the aorta diagnosed?
ECG: LVH
CT: can demonstrate the coarctation and quantity flow
CXR: dilated aorta at site of coarctation and “notched ribs”
556
How is coarctation of the aorta treated?
Surgery
Balloon dilation
Stenting
557
What is the most common congential heart disease?
Bicuspid aortic valve
558
Define bicuspid aortic valve
Aortic valve should have 3 cusps but in BAV it has 2
559
What is the main complication of BAV?
Valves degenerate quicker than normal valves and become regurgitant quicker
560
Why does BAV require surgery?
Can turn into aortic stenosis so will need a valve replacement
561
Are atrial septal defects (ASD) more common in men or women?
Women
562
What is the other name for atrial septum defects?
Probe patent foramen ovale
563
Where does the blood shunt in ASD?
Left to right
So not cyanotic
564
What are the effects of untreated ASD?
Right heart overload -> dilation -> hypertrophy
Arrhythmia
Eisenmenger syndrome
Flow murmur ect
565
What are the symptoms of ASD?
Dysponea
Exercise intolerance
Atrial rhythms
Split second heart sound
566
What is Eisenmengers syndrome?
Pulmonary hypertension causes shunting to shift from right-> left so blue blood shunted systemically
567
How is ASD diagnosed?
CXR: large P.arteries and large heart
ECG: RBBB
echo: Hypertrophy and dilation of R side of heart
568
How is ASD treated?
Surgical closure
Percutaneous keyhole surgery
569
Define ventricular septal defect (VSD)
Abnormal connection between the 2 ventricles
570
Define atrial septum defect (ASD)
Abnormal connection between the 2 atria
571
Outline the pathophysiology of VSD
Higher pressure in LV than RV
Shunt L-> R
Non cyanotic
572
What are the symptoms of a large VSD?
Pulmonary HTN -> eisenmengers
Small breathless skinny baby
Inc respiration and tachycardia
Murmur
573
What are the symptoms of a small VSD?
Large systemic murmur
Thrill (buzzing sensation)
Well grown
Normal HR and size
574
How are large VSD diagnosed?
CXR: Large heart
Echo
575
How are VSD treated?
Some spontaneously close!
Surgical closure
Can be left alone if small
Prophylactic antibiotics (endocarditis)
Furosemide, Ramipril ect
576
Define atrioventricular septal defect (AVSD)
A giant hole in AV septum
Involves mitral an tricuspid valves and there is effectively just one big malformed leaky valve
577
What is most associated with AVSD?
Down’s syndrome
578
What are the symptoms of a complete AVSD?
Breathless as neonate
Poor weight gain and feeding
Torrential pulmonary flow -> Eisenmenger’s syndrome
579
What are the symptoms of a partial AVSD?
Similar to ASD or VSD eg dysponea, exercise intolerance ect
580
How is AVSD treated?
Hard to treat surgically!
Pulmonary retry banding if large defect in infancy to reduce Eisenmengers
Partial defect could be left alone
581
Is BAV more common in males or females?
Males
582
Does patent ductus arteriosus affect males or females more?
Females
583
Define patent ductus arteriosus
Ductus arteriosus fails to close after birth
584
What I the function of ductus arteriosus in foetal life?
Allows flow to shunt from PA to aorta
585
When may patent ductus arteriosus occur?
Premature
Maternal rubella
586
What are the effects of patent ductus arteriosus?
Abnormal L->R shunt
Pulmonary hypertension occurs -> right side HF
Increased risk of IE
587
What are the symptoms of patent ductus arteriosus?
Continuous machinery murmurs
Bounding pulse
Eisenmengers
588
How is patent ductus arteriosus diagnosed?
CXR: large shunt = aorta and PA are more prominent
ECG: LA abnormality and LV Hypertrophy
589
How is patent ductus arteriosus treated?
Prostaglandin inhibitor can stimulate duct closure
Venous = AV loop
Closed surgically
590
What is an example of a prostaglandin inhibitor?
Indometacin
591
What does a boot shaped heart on CXR indicate?
Tetralogy of Fallot
592
what are 2 differential diagnoses of DVT?
cellulitis
acute ischemia
593
what are dihydropyridine CCBs used to treat?
hypertension
594
what are non-dihydropyridine CCBs used to treat?
arrhythmia
595
What does high levels of BNP indicate?
Heart failure
596
What are the cardinal signs of HF?
Sob
Ankle swelling
Fatigue
597
When does venous congestion and pulmonary hypoperfusion occur?
Right sided HF
598
When does pulmonary congestion and systemic hypoperfusion occur?
Left sided HF
599
How is BBB treated?
Pacemaker if symptomatic
600
What is a thiazide like diuretic?
Indapamide
601
Define acute limb ischemia
sudden decrease in limb perfusion that threatens viability of limb
602
Define constrictive pericarditis
Scarring and loss of elasticity preventing normal heart filling
603
What is the first line test for endocarditis?
Transthoracic echo
604
Define shock
Inadequate perfusion of key organs
605
What prophylactic drug is given to patients with an increased risk of VTE development?
LMWH eg. dalteparin
606
What would ST elevation in leads 2,3 and AVF indicate?
Inferior MI
607
What would St elevation in leads V1-V4 indicate?
Anterior MI
608
What would ST elevation in leads V5-6 indicate?
Left sided MI
609
What region of the heart does RCA supply?
Inferior
610
What region of the heart does LAD supply?
Anterior
611
What area of the heart does LCx suppply?
Left
