Cardiology Flashcards
1
Q
Define mitral regurgitation
A
Backflow through the mitral valve during systole
2
Q
Causes of mitral regurgiation
A
- Functional (LV dilitation)
- Infective endocarditis
- Rheumatic fever
- Annualar calcification (elderly)
- Mitral valve prolapse
3
Q
Symptoms of mitral regurgitation
A
- Dyspnoea
- Fatigue
- Palpitations
- Symptoms of causative factor (e.g. fever)
4
Q
Signs of mitral regurgitation
A
- AF
- Displaced hyperdynamic apex
- Pansystolic murmur at the apex radiating to the axilia
5
Q
Tests for mitral regurgitation
A
- ECG (AF, LVH)
- CXR (Big LA and LV, Mitral valve calcification, Pulmonary oedema)
- Transoesophageal echo (diagnostic)
6
Q
Why use a transoesphogeal echocardiogram with mitral regurgitation
A
Assess LV function and MR severity and aetiology
7
Q
Causes of mitral stenosis
A
- Rheumatic fever
- Congenital
- Prosthetic valve
8
Q
When do symptoms and signs of mitral stenosis appear?
A
When the mitral valve orifice area is less than 2cm squared
(usually 4-6cm squared)
9
Q
How does mitral stenosis present?
A
Pulmonary hypertension causes:
* Dyspnoea
* Haemoptysis
* Chronic bronchitis picture
Pressure from large left atrium on local structures causes:
* Hoarseness (recurrent laryngeal nerve)
* Dysphagia (oesophagus)
* Bronchial obstruction
Also:
* Fatigure
* Palpitations
* Chest pain
* Systemic emboli
10
Q
Signs of mitral stenosis
A
- Malar flush on cheeks (due to ↓CO)
- AF (often due to enlarged LA)
- Rumbling mid-diastolic murmur
- Non-displaced apex beat
11
Q
Tests for mitral stenosis
A
- ECG (AF, P-mitrale, RVH)
- CXR (LA enlargement, pulmonary oedema, mitral valave calcification)
- Transopesophageal echocardiogram (diagnostic)
12
Q
Causes of aortic stenosis
A
- Senile calcification (most common)
- Congenital (bicuspid aortic valve)
- Rheumatic heart disease
13
Q
Presentation of aortic stenosis
A
(Think about elderly person with chest pain, exertional dyspnoea or syncope)
Classic triad:
* Angina
* Syncope
* Heart failure
Other:
* Dyspnoea
* Dizziness
* Faints
* Systemic emboli (if IE)
* Sudden death
14
Q
Signs of aortic stenosis
A
- Slow rising pulse with narrow pulse pressure (feel for diminished and delayed carotid upstroke -* parvus et tardus*)
- Non-displaced apex beat (heaving)
- Ejection systolic murmur (radiates to carotids)
15
Q
Tests for aortic stenosis
A
- ECG (LVH with strain pattern, P-mitrale, LBBB or complete AV block (calcified ring))
- CXR (LVH, calcified aortic valve, post stenotic dilitation of ascending aortic)
- Echo (diagnostic)
- Doppler echo (estimate gradient across valves)
16
Q
Differential diagnosis for aortic stenosis
A
- Hypertrophic cardiomyopathy
- Aortic sclerosis
17
Q
Causes of aortic regurgitation (acute and chronic)
A
Acute:
* Infective endocarditis
* Ascending aortic dissection
* Chest trauma
Chronic:
* Congenital
* Connective tissue disorders (Marfan’s, Ehlers-Danlos syndrome)
* Rheumatic fever
18
Q
Symptoms of aortic regurgitation
A
- Exertional dyspnoea
- Orthopnoea
- Palpitations
- Angina
- Syncope
19
Q
Signs of aortic regurgitation
A
- Collapsing pulse
- Wide pulse pressure
- Displaced hyperdynamic beat
- High-pitched early diastolic murmur
20
Q
Tests for aortic regurgitation
A
- ECG (LVH)
- CXR (Cardiomegaly, dilated descending aorta, pulmonary oedema)
- Echo (diagnostic)
21
Q
What are cardiac natriuretic peptides? Name them from the artia and ventricles
A
Natriuretic peptides = released from the stretching of atria or ventriculaar muscles/raised atrial or ventricular pressures → causes sodium + water excretion
* Atrial natriuretic peptide → from the atria
- B (brain) natriuretic peptide → from the ventricles
22
Q
What are the main effects of cardiac natriuretic peptides?
A
- increase renal excretion of sodium (natriuresis) and water (diuresis)
- relax vascular smooth muscle (except efferent arterioles of renal glomeruli)
- increase vascular permeability
- inhibit release/actions of → aldosterone, ANG2, endothelin, ADH
23
Q
What are the effects of nitrates?
A
- Arterial + venous dilation
- Reducing both preload (venous) and afterload (arteries)
- Lower blood pressure
24
Q
When are nitrates used?
A
- IHD → angina
- Heart failure
25
What are the classes of anti-arrhythmic drugs and give an example for each?
* Sodium channel blockers → flecainide, lidocaine
* Beta adrenceptor antagonists → propanolol (non-selective), metoprolol (Beta-1 selective)
* Prolong the action potential → amiodarone
* Calcium channel blockers → verapamil
26
What is digoxin used for?
Used in **AF** to reduce ventricular response rate OR **severe heart failure** (becuase its positively inotropic)
27
What does digoxin cause?
* Bradycardia
* Slowing AV conduction (vagal tone)
* Increased ectopic activity
* Increased force of contraction
28
What are the side effects of digoxin?
* Nausea
* Vomiting
* Diarrhoea
* Confusion
29
Which SGLT2 inhibitor (used in diabetes) has a positive effect on heart failure?
Dapagliflozin
30
What are 3 types of acute coronary syndrome?
* Unstable angina
* STEMI
* NSTEMI
31
What is ACS usually caused by?
* A **thrombus** from an **atherosclerotic** **plaque** blocking a **coronary artery**
* Formed mainly of **platelets** → **antiplatelets** (**aspirin**, **clopidogrel**, **ticagrelor**)
32
The RCA curves around the right side + under the heart to supply which regions of the heart?
* Right atrium
* Right ventricle
* Inferior aspect of left ventricle
* Posterior septal area
33
The LCA becomes what two cornary arteries?
* Circumflex artery
* Left anterior descending (LAD)
34
The circumflex artery curves around the top, left and back of the heart and to supply which regions of the heart?
* Left atrium
* Posterior aspect of the left ventricle
35
The LAD coronary artery travels down the middle of the heart to supply which regions of the heart?
* Anterior aspect of the left ventricle
* Anterior aspect of the septum
36
What group of patients are at risk of silent MIs?
Diabtetics
37
How does ACS usually present?
* Central, constricting chest pain
* Pain radiating to jaws or arms
* N + V
* Sweating + clamminess
* A feeling of impending doom
* SOB
* Palpitations
| Symptoms should continue at rest for more than 15 minutes.
38
ECG changes of a STEMI (2)
* ST elevation
* New LBBB
39
ECG changes in a NSTEMI (2)
* ST depression
* T wave inversion
40
What do pathological Q waves suggest on an ECG?
* **Deep infarction** - involving full thickness of the heart muscle (**transmural**)
* Typically appear 6 or more hours after onset of symptoms
41
Name the heart areas supplied by the LCA, RCA, LAD, Cx
* LCA - Anterolateral
* LAD - anterior
* Cx - Lateral
* RCA - Inferior
42
What is a troponin associated with?
Myocardial ischaemia
(They are released from ischaemic muscle tissue)
43
Troponin results are used to diagnose which ACS?
NSTEMI
(STEMI just used ECG + clinical presentation)
44
Troponin is a non-specific marker, apart form ACS, when can it also rise?
* Chronic kidney disease
* Sepsis
* Myocarditis
* Aortic dissection
* Pulmonary embolism
45
A high troponin or rising troponin indicates what?
NSTEMI
46
Apart from ECG and troponin levels, what other investigations can be performed for acute coronary syndromes?
* **Baseline bloods**, including FBC, U&E, LFT, lipids and glucose
* **Chest x-ray** to investigate for pulmonary oedema and other causes of chest pain
* **Echocardiogram** once stable to assess the functional damage to the heart, specifically the **left ventricular function**
47
A patient with acute constricting central chest pain requires what tests to diagnose which ACS?
* ECG
* Troponin
48
What is the diagnostic criteria for a STEMI?
* ST elevation
* New LBBB
49
What is the diagnostic criteria for an NSTEMI?
* Raised troponin
* ST depression
* T wave inversion
50
Diagnostic criteria for unstable angina
* Normal troponin
* Normal ECG or ST depression/T wave inversion
51
If a patient presents with central constricting chest pain and their troponin and ECG return normal, what are the possible diagnoses?
* Unstable angina
* Other - Musculoskeletal chest pain
52
What is the mneumonic for the inital management for a patient presenting with ACS symptoms?
CPAIN
* C - Call for an ambulance
* P - Perform an**12-lead** ECG
* A - Aspirin (300mg)
* I - IV morphine for pain if required (with an antiemetic e.g. metoclopramide)
* N - Nitrate (GTN)
53
What is the management for a STEMI?
* Within 2 hours: Percutaneous Coronary Intervention (**PCI**) (angiography + angioplasty)
* After 2 hours: **Thrombolysis** (fibrinolytic agent - **streptokinase**, atleplase)
54
What is the management for a NSTEMI?
BATMAN
* B - Beta-blockers (if not contrindicated)
* A- Aspirin (300mg stat dose) - chewed pref.
* T - Ticagrelor (180mg stat dose) (clopidogrel if high bleeding risk)
* M - Morphine (titrated for pain)
* A - Antithrombin therapy (fondaparinux)
* N - Nitrate (GTN)
| Give oxygen only if their saturation drops (less than 95% in someone wit
55
What does the GRACE score indicate?
Gives a **6 month** probability of **death** after having an NSTEMI
56
A patient having an NSTEMI has a 4% on the GRACE score, what risk are they considered to have and what management is then considered?
* Medium to high risk
* Considered for early angiography with PCI (within 72 hours)
57
What is the ongoing management for ACS (after intial)?
* **Echocardiogram** once stable to assess the functional damage to the heart, specifically the left ventricular function
* **Cardiac rehabilitation**
* **Secondary prevention**
58
What are the medications involved in the **seondary prevention** for ACS?
The 6As
* **Aspirin** (75mg OD)
* Another **Antiplatelet** (ticagrelor, clopidogrel)
* **Atorvastatin**
* **ACEi** (ramipril)
* **Atenolol** (or another beta blocker - usually bisoprolol)
* **Aldosterone antagonist** (for those with clinical heart failure (eplerenone)
59
What electrolyte imbalance can ACEis and aldosterone antagonists cause?
Hyperkalaemia
(closely monitor renal function)
60
What are the complications of a myocardial infarction? (mneumonic)
DREAD
D - Death
R - Rupture of the heart septum or papillary muscles
E - oEdema (heart failure)
A - Arrhythmia or aneurysm
D - Dressler's syndrome
61
What is Dressler's syndrome?
A post-myocardial infarction syndrome → **Pericarditis**
62
How does Dressler's syndrome present?
* Usually occurs 2-3 weeks after an acute myocardial infarction
* Pleuritic chest pain
* Low-grade fever
* Pericardial rub on auscultation
(A pericardial rub is a rubbing, scratching sound that occurs alongside the heart sounds)
63
What is a complication of Dressler's syndrome?
* Pericardial effusion
* Pericardial tamponade (rarely) (pericardial fluid constricts the heart + inhibits its function)
64
Diagnostic criteria for Dressler's syndrome
* ECG (global ST elevation + T wave inversion)
* Echocardiogram (pericardial effusion)
* Raised inflammatory markers (CRP + ESR)
65
Management of Dressler's syndrome
* NSAIDs: aspirin, ibuprofen
* Severe cases: Prednisolone
* Pericardiocentesis: Remove fluid from heart - if there is a significant pericardial effusion
66
What is a STEMI?
- Develop a **complete occlusion of a MAJOR coronary artery**
previously affected by atherosclerosis
- This causes **full thickness damage of heart muscle** (**transmural**)
67
What is an NSTEMI?
* Occurs by developing a **complete occlusion of a MINOR** or a **partial occlusion of a major coronary artery** previously affected by atherosclerosis
* This causes** partial thickness damage of heart muscle**
68
Very brief pathology of an MI
Plaque rupture 🡪 development of thrombosis 🡪 total occlusion of coronary artery 🡪 myocardial cell death
69
Describe the pain associated with ACS
* Longer than 20 mins
* Not relieved by GTN spray
* Pain may radiate to left arm, neck and/or jaw
* **Occurs at rest**
70
Differential diagnosis for chest pain
- Cardiac – ACS, Aortic dissection, pericarditis, myocarditis
- Respiratory – PE, pneumonia, pleurisy, lung cancer
- MSK – rib fracture, chest trauma, costochondritis (inflammation of the cartilage between the ribs and sternum)
- GORD
- Oesophageal spasm
- Anxiety/panic attacks
71
What is unstable angina also called and why?
**Crescendo** Angina
(Crescendo pattern of pain → gets worse and worse more readily)
72
What is unstable (crescendo) angina)
An acute coronary syndrome (ACS) that is defined by the absence of biochemical evidence of myocardial damage
73
Signs and symptoms of ACS (separately)
Signs:
* Pallor
* Increased pulse + reduced BP
* Reduced 4th heart sound
* Tachy/bradycardia
* Peripherial oedema
Symptoms:
* Central, crushing chest pain (elephant sitting on it)
* Pleuritic chest pain
* N + V
* Dyspnoea
* Fatigue
* SOB
* Palpitations
74
Name two P2Y12 inhibitors (antiplatelet therapy)
* Ticagrelor
* Clopidogrel
75
Managment of unstable angina
* Aspirin 300 mg (chewed or dispersed in water)
* Sublingual glyceryl trinitrate (GTN)
* Morphine + anti-emetic (metoclopramide)
* Clopidogrel
| Like NSTEMI (this answer is just shorter than BATMAN)
76
Name some risk factor modifications for ACS
* Smoking cessation
* Lose weight
* Healthy diet
* Exercise
77
Complications of unstable angina
**Complications – DARTH VADER**
- Death
- Arrhythmias
- Ruptured septum
- Tamponade
- HF
- Valve disease
- Aneurysm of ventricle
- Dressler’s syndrome – pericarditis and pericardial effusion after 2-12 weeks
- Embolism
- Reoccurrence of ACS
78
Define angina
- Narrowing of the coronary arteries → reduced blood flow to myocardium
- During times of high demand such as exercise there is insufficient supply of blood to meet demand.
- This causes symptoms the symptoms of angina, typically constricting chest pain with or without radiation to jaw or arms.
79
What is the difference between stable and unstable angina?
* Stable angina = always relieved **glyceryl trinitrate (GTN)** or rest
* Unstable angina = symptoms come on randomly whilst at rest (an ACS)
80
Sx of stable angina
1) chest pressure or squeezing lasting several minutes
2) provoked by exercise or emotional stress,
3) relieved by rest or glyceryl trinitrate
81
Ix for angina
* 12-lead resting ECG (normal)
* FBC (anaemia)
* HbA1c + fasting glucose (diabetes)
* U&Es (required before starting an ACE inhibitor and other medications)
* LFTs (required before starting statins)
* Lipid profile
* **Cardiac stress testing** - patient exercise whilst on ECG (or echo, MRI)
82
What is the gold-standard for determining coronary artery disease? E.g. angina
CT coronary angiography (with contrast)
83
What are the three aims of medical management for stable angina? Example of each
* **Symptomatic treatment** → **GTN** spray (headaches, dizziness)
* **Long-term symptomatic relief** → beta blocker (**bisprolol**) + calcium channel blocker (**verapamil**)
* **Secondary prevention** (of CVD) → 4 As (**A**spirin 75mg, **A**torvastatin, **A**CEi, **A**lready on a beta blocker for symptomatic relief)
84
What are the surgical procedures offered to patients with severe stable angina and where treatements do not control symptoms?
* PCI (percutaneous coronary intervention)
* CABG (coronary artery bypass graft)
85
What is stable angina also called?
Angina Pectoris
86
Define preload
Amount of blood in the left ventricle before contraction
87
Define afterload
Stress on the ventricular wall during systole
88
What is heart failure with reduced ejection fraction (HFrEF)?
* Systolic HF
* Inability of the ventricle to contract normally ('pump dysfunction') → reduced CO
* Ejection fraction <40%
* Causes: Cardiomyopathy, IHD, MI
89
What is heart failure with preserved ejection fraction (HFpEF)?
* Diastolic HF
* Inability of the ventricle to relax + fill normall → causing increased filling pressures ('filling dysfunction)
* Ejection fraction >50%
* Causes: Constrictive pericarditis, restrictive cardiomyopathy, obesity
90
What is the minimum diameter for an AAA?
3cm dilated abdominal aorta
91
Rx and causes of an AAA
* **ATHEROSCLEROSIS**
* Inflammation
* Increased age
* Hypertension
* Existing CVD
92
Brief pathology of AAA
* Degradation of tunica media + adventitia → vessel dilation
* Most importnat risk factor = atherosclerosis
* 99% true aneurysms
* Most occur below renal arteries (AA lacks vasa vasorum → more susceptible to ischaemia)
93
Most AAAs are what?
Asymptomatic
94
What is the triad of 50% of AAAs?
* Flank, back and (non-specific) back pain
* Hypotension
* Pulsatile abdominal mass
| Most AAAs are asymptomatic
95
First line and gold-standard Ix for an AAA
* First line: **Aortic ultrasound**, FBC, blood cultures
* Gold standard: CT angiogram (more detailed picture)
96
Management of AAA
* Surveillance
* Surgical repair: endovascular aneurysm repair (EVAR)
97
Where do aortic dissections most commonly affect?
Ascending aortic and aortic arch
98
What system is used to classify aortic dissections?
Stanford system
* Type A: ascending aorta
* Type B: descending aorta
99
What is an aortic dissection?
* Separation in the aortic wall intima
* → causing blood flow into a new false channel composed of the inner + outer layers of the media.
100
Causes and Rx of aortic dissection
* Bicuspid aortic valve (BAV)
* Coarctation of aorta
* Hypertension
* Marfan syndrome
* Ehlers-Danlos syndrome
101
What is the pain associated with an aortic dissection?
* **Sudden onset, severe 'ripping' or 'tearing' chest pain**
* Anterior chest pain → ascending aorta is affected
- Back pain → descending aorta is affected.
- The pain may change location (***migrate***) over time.
102
Signs and symptoms of an aortic dissection
Signs:
* Hypertension → hypotension
* **Differences in BP between arms (more than 20 mmHg)**
* Radial pulse deficit in one arm
Symptoms:
* **Severe chest AND abdominal pain**
* Collapse (syncope) - red flag
103
First line Ix (+ gold standard) for aortic dissection
* **CT angiogram** (initial Ix to confirm the diagnosis)
* ECG + CXR (exclude MI)
* High-sensitivity troponin, FBC, CRP, blood gas
104
Differentials for aortic dissection
- Acute coronary syndrome
- Pericarditis
- **Aortic aneurysm (Aortic dissection = chest + abdominal pain)**
- Musculoskeletal pain
- Pulmonary embolus
105
First line treatment for an aortic dissection
* Beta-blockers (metoprolol IV) → BP + HR control
* Thoracic endovaascular aortic repair (TEVAR)
* IV morphine
106
Complications of aortic dissection
* MI
* Stroke
* Death
107
A man aged around 60 with a background of hypertension, presenting with a sudden onset tearing chest pain. Possible diagnosis and risk factors?
* Aortic dissection
* Ehlers-Danlos and Marfan's syndrome
108
What ECG change is seen in first-degree heart block?
* **PR interval prolongation (>0.2s)**
* Delayed conduction athrough the AV node
* (Every P wave followed by a QRS complex)
| Asymptomatic therefore no Tx
109
What is second-degree heart block? And what are the two types?
* Some atrial impulses = do not make it through the AV node to the ventricles
* Some P waves are not followed by QRS complexes
* Mobitz type 1 (Wenkebach phenomenom)
* Mobitz type 2
110
What is Mobitz type 1 and how does it present on an ECG?
* Conduction through AV node takes progressively longer until it fails and resets, cycle restarts
* **Increasing PR interval until a P wave is not followed by a QRS complex**
* The PR interval then returns to normal, cycle repeats itself
111
What is Mobitz type 2 and how does it present on an ECG?
* Intermittent failure of conduction through the AV node - with an absence of QRS complezes following P waves
* **Usually a set ratio of P waves to QRS complexes** (e.g. 3 P waves to each QRS complex (3:1 block))
* **PR interval = remains normal**
* **Risk of asystole** with Mobitz type 2
112
What is third-degree heart block and how does it present on an ECG?
* Complete heart block
* **No relationship between the P waves and the QRS complexes**
* **Significant risk of asystole**
113
What drugs can cause first and second degree heart block?
* Beta-blockers
* Calcium channel blockers
* Digoxin
114
What are the Sx of 1st degree heart block?
Asymptomatic
115
What are the Sx of the 2nd degree heart blocks?
* Mobitz type 1: Syncope
* Mobitz type 2: Syncope, chest pain, SOB
116
Treatment for 2nd degree heart block
Pacemaker
117
What can cause third degree heart block?
* Acute MI
* HTN
* Structural heart disease
118
Treatment of third degree heart block
* IV atropine
* Permanent pacemaker
119
What are the causes of second degree heart block?
* Drugs (verapamil, calcium channel blockers, digoxin)
* Inferior MI
* Rheumatic fever
120
What is bundle branch block (BBB)?
Block of Bundle of His
121
What are the causes of right BBB?
* Underlying lung pathology (pulmonary emboli, COPD)
* Ischaemic heart disease
* Congential heart disease (ASD)
122
In RBBB, what happens to the ventricular contraction?
RV contraction is later than LV
123
What does RBBB look like on an ECG?
* MaRRoW (V1 and V6)
* QRS >120ms (3 small squares)
* Wide, slurred S wave in V6 (lateral leads)
124
What causes LBBB?
* Ischaemic heart disease
* Valvular heart disease
125
What does LBBB look like on an ECG?
* WiLLiaM
* QRS duration > 120ms (3 small squares)
* Prolonged R wave (>60 ms) in V5-V6 leads
126
What BP is considered normotensive and what is high?
Hypertension:
* Above 140/90 in clinic
OR
* 135/85 with ambulatory or home readings
Normotensive:
* Less than 140/90 mmHg
127
What is malignant hypertension?
Rapid rise in BP leading to vascular damage
128
What are the symptoms of malignant hypertension?
* Headache
* Visual disturbance
129
What are the causes of secondary hypertension?
ROPED:
* R - Renal disease e.g. renal artery stenosis (most common)
* O - Obesity
* P - Pregnancy-induced hypertension pr Pre-eclampsia
* E - Endocrine (Hyperaldosterone, Conn's syndrome)
* D - Drugs (alcohol, steroids, NSAIDs, oestrogen)
130
What BP is considered malignant hypertension? And other signs?
* Systolic > 180 mmHg
* Diastolic > 120 mmHg
* With **retinal haemorrhages** or **papilloedema** (require **FUNDOSCOPY**)
131
What are some complications of malignant hypertension?
- Hypertensive emergencies e.g. acute kidney injury, HF and encephalopathy
- Cardiac failure - with left ventricular hypertrophy + dilatation
- Blurred vision - due to papilloedema with retinal haemorrhages
- Severe headache + cerebral haemorrhage
132
What is the treatment for malignant hypertension?
Sodium nitroprusside IV
Glyceryl trinitrate (GTN)
133
What Ix can you perform to assess end-organ damage as a result of hypertension?
* Fundoscopy (hypertnesive retinopathy)
* ECG + echocardiogram (cardiac abnormalities)
* Bloods (HbA1c, renal function (eGFR), lipids)
* Urine albumin:creatinine ratio (for proteinuria)
* Urinalysis (haematuria)
134
Define white coat effect
More than a 20/10 mmHg difference in blood pressure between clinic and ambulatory or home readings
135
General management style for hypertension
* Establish a diagnosis
* Investigate for potential causes + end-organ damage
* Advise on lifestyle
136
When do you use angiotensin receptor blockers instead of ACEi
* Patient is black, African or African-Caribbean descent
* Patient does not tolerate ACEis (commonly due to **dry cough**)
137
When is medical management offered for hypertension?
* All patients with **stage 2 hypertension**
* Patients under 80 with stage 1 hypertensopm - that also have a QRISK score pf 10% or more, renal disease, diabetes, CVD, end-organ damage
138
What are some complications of hypertension?
* **Left ventricular hypertrophy**
* Ischaemic heart disease (**angina** and acute coronary syndrome)
* Cerebrovascular accident (**stroke** or intracranial haemorrhage)
* Vascular disease (peripheral arterial disease, aortic dissection and aortic aneurysms)
* **Hypertensive retinopathy**
* **Hypertensive nephropathy**
* Vascular dementia
* **Heart failure**
139
What are the clinic readings and ambulatory/home readings for stage 1, 2, 3 hypertension?
Clinic:
* Stage1: Above 140/90
* Stage 2: Above 160/100
* Stage 3: Above 180/120
Home:
* Stage 1: Above 135/85
* Stage 2: Above 150/95
140
What does the Wells Score predict?
Wells score = predicts the risk of a patient presenting woth symptoms having a DVT or PE
141
What is the driving force in thrombosis formation in the arterial and venous circulation?
* Arterial circulation → platelets (high-pressure)
* Venous circulation → fibrin (low pressure)
142
Causes of arterial thrombosis
* ATHEROSCLEROSIS
- Hypercholesterolaemia
- Hypertension
- Smoking
- Plaque deposition → rupture → thrombosis
* Inflammatory
* Infective
* Trauma
143
How might an arterial thrombosis present?
* MI
* CVA
* Peripheral cardiovascular diease
144
Treatment of coronary arterial thrombosis
* Aspirin (300mg), other antiplatelets (inhibits platelet function)
* LMWH or Fondaparinux
* Thrombolytic therapy → streptokinase (tissue plasminogen activator) - generates plasmin + degrades fibrin
* Reperfusion → catheter-directed treatments + stents
145
What is the treatment for a cerebral arterial thrombosis?
* Aspirin, other antiplatelets
* Thrombolysis (streptokinase)
* Reperfusion
146
Why is the use of heparin avoided in cerebral arterial thrombosis?
* Risk of haemorrhage → catastrophic complications
* Acute cerebral occlusion = treated less aggressively
147
What are the components of Virchow's triad?
* **Hypercoagulability** (preggo, antiphospholipid syndrome, sepsis)
* **Endothelial injury** (smoking, trauma)
* **Venous stasis** (immobility - long flights, after surgery)
148
What is the underlying pathology of arterial and venous thrombosis formation?
* Arterial → atherosclerosis + rupture of plaque
* Venous → Virchow's triad (+ underlying coagulation disorders)
149
Name an underlying condition that increases coagulability, increasing chances of a venous thrombosis
Antiphospolipid syndrome
150
Basic treatment for arterial and venous thrombosis
* Arterial → anti-platelets (aspirin)
* Venous → anti-coagulation
- Heparin (IV or S/C) + oral agents
- Coagulation cascade → fibrin at the end
151
Portal hypertension can increase the risk of what CVD event?
Thrombosis
152
What are the long-term effects of damage to the venous circulation?
Post-thrombotic limb:
* Long-term leg swelling
* Venous circulation
153
What do you monitor and what level does it need to be at when using unfractionated heparin?
Activated partial thrombin time (APTT)
Needs to be **twice** as normal
154
How is unfractionated heparin given and why?
* Continuous infusion
* Very short-life (4 hours)
155
Why is low molecular weight heparin used instead of unfractionated heparin?
* Longer half-life (12 hours)
* Don't need to monitor them
* Given subcutaneously (weight-adjusted)
* Less risk of heparin-induced thrombocytopaenia (HIT)
156
How does warfarin work and what needs to be monitored?
* Warfarin = orally active
* Prevents the synthesis of factors 2,7,9,2 (1972)
* 36 hours half-life
* Warfarin = anatgonist of vitamin K
* Warfarin = prolongs the prothrombin time
* International normalised ratio (INR) - derived from the prothrombin time
- Usual target range: 2-3
157
What does NOAC/DOAC mean?
* New Oral Anticoagulant Drugs
* Direct-acting Oral Anticoagulant Drugs
158
What do DOACs act on and do they need to monitored?
* Directly acting on factor 2 or 10 (II or X)
* No blood tests/monitoring needed
159
Why and which conditions are DOACs used?
* DOACs = used to extend thromboprophylaxis
* AF and DVT/PE
160
Contraindications forDOACs
* Pregnancy
* Metal heart valves (use heparin instead)
161
What does fondaparinux inhibit?
Xa inhibitor
162
Name some anti-platelets
* Aspirin
P2Y12 inhibitors:
* Clopidogrel
* Ticagrelor
163
Rx for DVT
* Surgery
* Immobility
* OC pill, pregnancy, HRT
* Long haul flights
* Inherited thrombophilia
* THINK VIRCHOW'S TRIAD
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Sign and symptoms of a DVT
Symptoms:
* Leg pain
* Tenderness
Signs:
* Calf or leg swelling
* Warmth
* Discolouration
* Unilateral (almost always)
* Dilated superficial veins
165
Why does DVT lead to ischaemia?
- All of the small veins are thrombosed
- Increased compartment pressures
- Causes compression of the arterioles → causes ischaemia
166
Give an example of LWMH
Dalteparin
167
What are the Ix for a DVT?
* **D-Dimer** level (sensitive - but not specific) - not diagnostic
* **Doppler ultrasound** (with **compression**) = diagnostic
Other:
* CT or MR venogram - catheter venogram
168
What investigation can diagnose a pulmonary embolism?
* D-Dimer
* CT pulmonary angiogram (CTPA)
169
What is the first line treatment you should use immediately for a DVT or PE?
Apixaban
170
What are the signs and symptoms of a pulmonary embolism?
* Sudden onset pleuritic chest pain
* Dyspnoea
Signs:
* Tachycardic
* Hypotensive
* Raised JVP
* Ankle oedema
171
What are the Wells score for a PE and DVT?
PE: More than 4
DVT: More than 1
172
Ix for a pulmonary embolsim
* D-Dimer (raised)
* CT pulmonary angiogram (CTPA) = diagnostic
* ECG (sinus tachycardia)
173
Management for a massive PE and not massive PE (most common)
* Massive PE: Thrombolysis → alteplase
* Not massie PE: Apixaban
174
What is the immediate first line management for DVT?
* Apixaban (DOAC (anticoagulant))
175
What is a differential diagnosis for a DVT?
Cellulitis
* (Skin infection, staphylococcus aureus + streptococcus pyogenes)
* Will show LEUKOCYTOSIS
176
What are the 2 shockable rhythms?
* Ventricular tachycardia
* Ventricular fibrillation
177
What are the 2 non-shockable rhythms?
* **Pulseless electrical activity** (all electrical activity except VF/VT, including sinus rhythm without a pulse)
* **Asystole** (no significant electrical activity)
178
What is narrow complex tachycardia?
* Fast HR (tachycardia)
* QRS complex less than 0.12s (2 small squares)
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What is broad complex tachycardia?
* Fast HR (tachycardia)
* QRS comple = more than 0.12 seconds (3 small squares)
180
Name the 4 supraventricular tachycardias
* Atrial fibrillation
* Atrial flutter
* AVRT (Wolff-Parkinson White Syndrome)
* AVNRT
181
Name the ventricular tachycardias
182
Name the 3 ventricular tachycardias
* Ventricular ectopics
* Prolonged QT syndrome
* Torsades de Pointes
183
How is atrial fibrillation described?
* Irregularly irregular atrial firing rhythm
* HR = 300-600 bpm → HR = 120-180 bpm
184
What are the causes of atrial fibrillation? mneumonic
Mrs SMITH:
* S - Sepsis
* M - Mitral valve pathology (stenosis or regurgitation)
* I - Ischaemic heart disease
* T - Thyrotoxicosis
* H - Hypertension/Heart failure
185
Describe the pathology of atrial fibrillation
- Disorganised electrical activity in SA node → lack of coordinated atrial electrical activity = leads to irregular conduction of electrical impulses to the ventricles - results:
- Irregularly irregular ventricular contractions
- Tachycardia
- HF - due to poor filling of the ventricles - during systole
- Risk of stroke
- Atrial action 300-600/minute
- Only a proportion of the impulses conducted to the ventricles → due to the refractory period of AVN
- HR 120-180 bpm
186
Why is AF associated with an increased risk of stroke?
Tendency of blood to collect in the atria → forms blood clots → emboli → occlude cerebral arteries → ischaemic stroke
187
What is the appearance of AF on an ECG?
* No P waves
* Irregularly irregular ventricular rhythm
* Narrow QRS complex tachycardia
* (Absence of isoelectric baseline)
188
What are the types of AF?
* Paroxysaml AF (episodic, resolve back to sinus rhythm)
* Persistent (longer than 7 days)
* Permanent (sinus rhythm unrestorable)
189
Signs and symptoms of AF
* Asymptomatic
* Palpitations
* Fatigue
* Dyspnoea and/or chest pain
* Heart failure
* Other conditions: Thromboemboli ('ischaemic stroke'), stroke, thyrotoxicosis, sepsis
190
What are the two aims of AF management?
* **Rate** or rhythm control
- Rate control = unless contraindicated
* **Anticoagulation**
- To prevent stroke
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# REALLY USEFUL CARD
What is the most common form of treatment for AF?
| If stuck on exam
* Beta-blocker (bisoprolol)
* DOAC (apixaban)
192
What does rate control in AF aim to do?
* Get the HR below 100 bpm
* Extending the time during dystole for the ventricles to fill with blood
193
What are the contraindications for rate control in AF?
* A **reversible cause** of AF
* **New onset AF** (within 48 hours)
* **Heart failure** (caused by AF)
* **Symptoms** (despite being effectively rate controlled)
194
What is the first line for rate control in AF (and others as alternative)
* **Beta-blockers (atenolol)**
* Calcium channel blockers - not in HF
* Digoxin (only in sedentary patients)
195
What is the aim of rhythm control in AF? What is it achieved through?
* Return the patinet to normal sinus rhythm
* Achieved through:
- Cardioversion
- Long-term rhythm control (medications)
196
What are the two typoes of cardioversion used in AF? Which one is first line?
* Pharmacological (first line)
- Flecanide
- Amiodarone (for structural heart disease)
* Electrical
- Sedation or general anaesthetic
- **Cardiac defibrillator** (attempt to restore sinus rhythm)
197
What are the 3 options for long term rhythm control in AF? Which one is first line?
* **Beta blocker (first line)**
* Dronedarone (scond line)
* **Amiodarone** (patients with HF or left ventricular dysfunction)
198
What medication is used in paroxysmal atrial fibrillation? And what is the term given?
* Flecanide
* 'Pill-in-pocket' approach
* Paroxysmal AF = infrequent episodes without structural heart defects
199
What is the risk of flecanide use in paroxysmal AF?
Converting AF into atrial flutter (with 1:1 AV conduction to the ventricles)
200
Should patients with paroxysmal AF be anticoagulated?
Yes
Based on their CHA2DS2-VASc score
201
In AF where rate and rhythm control is inadequate, what is the two next options for treatment?
* Left atrial ablation (radiofrequency ablation)
* Atrioventricular node ablation + permanent pacemaker
202
What is the first and second line treatment for anticoagulation in AF?
* **First line: DOACs (direct-acting oral anticoagulants)**
* Second line: Warfarin (if DOACs are contraindicated)
203
What are the most common indications for DOACs?
* **Stroke prevention** in patients with **AF**
* **Treatment** of **DVT** and **PE**
* **Prophylaxis** of **venous thromboembolism (DVTs and PEs)** after a knee or hip replacement
204
Why are some antibiotics contraindicated in warfarin use?
Wafarin = affected by CYP450
205
Advanatages of DOACs
- No monitoring required
- No major interaction problems
- Equal or slightly better than warfarin at preventing strokes in AF
- Equal or slightly less risk of bleeding than warfarin
206
What is the CHA2DS2VASc Score used for?
Assessing whether an AF patient should be started on anticoagulation
**Estimating risk of stroke**
(No role for aspirin in preventing stroke)
207
What are the categories of CHA2DS2VASc?
* Score 0 = negligible risk of stroke
* Score 1 = 1.3%/y risk of stroke
* Score 2 or more: >2.2% (high risk)
* **SCORE 2 or MORE = ANTICOAGULATION**
208
What does CHA2DS2VASc standard for?
* C - Congestive heart failure (LV systolic dysfunction)
* H - Hypertension
* A2 - Age (75 and above)
* D - Diabetes
* S2 - Prior Stroke or TIA or thromboembolism
* V - Vascular disease (peripheral artery disease, MI)
* A - Age 65-74 years
* Sc - Sex category (female = 1 point)
209
What is ORBIT Tool or HAS-BLED used for?
Assess patient's risk of major bleeding whilst on anticoagulation
210
What does HAS-BLED and ORBIT scan for? What score requires regular reviews?
**HAS-BLED Score of 3** and aboves = requires regular reviews
HAS-BLED:
* **H** – **H**ypertension
- **A** – **A**bnormal renal and liver function
- **S** – **S**troke
- **B** – **B**leeding
- **L** – **L**abile INRs (whilst on warfarin)
- **E** – **E**lderly
- **D** – **D**rugs or alcohol
ORBIT Tool:
O – Older age (age 75 or above)
R – Renal impairment (GFR less than 60)
B – Bleeding previously (history of gastrointestinal or intracranial bleeding)
I – Iron (low haemoglobin or haematocrit)
T – Taking antiplatelet medication
211
What are some complications of atrial fibrillation?
* Embolic events - stroke
* Heart failure
* Cardiomyopathy
212
Difference between AF and ventricular ectopics
(Both are irregularly irregular pulse)
Just do an ECG:
- Ventricular ectopics
- Disappear when the HR gets over a certain threshold
- Regular HR during exercise = suggests a diagnoses of ventricular ectopics
213
Define atrial flutter
* Irregular organised atrial firing (atrial rate = approx. 300 bpm)
* Atrial flutter = 're-entrant rhythm' in ether atrium
- This is where the electrical signal re-circulates in a self-perpetuating loop - due to an extra electrical pathway.
* Less common + less severe than AF
214
What is the appearance of atrial flutter on an ECG?
* F wave 'Sawtooth appearance'
* Narrow complex tachycardia
* Often with a 2:1 conduction (2 paves for every QRS complex)
215
Sx for atrial flutter
* Palpitations
* Chest pain
* Syncope
* Fatigue
216
Causes of atrial flutter
* Idiopathic
* HTN
* Percarditis
* Obesity
217
What is the treatment for atrial flutter?
* **Rate/rhythm control → beta-blockers or cardioversion**
- IV amiodarone (restore rhythm)
- Beta-blocker (suppress further arrhythmias)
* **DOACs** for anticoagulation (based on CHA2DS2VASc score)
* **Radiofrequncy ablation **
218
What is the other name of atrioventricular re-entry tachycardia (AVNT)?
Wolff-Parkinson White Syndrome
Pre-excitation syndrome
219
What is AVRT (Wolff-Parkinson-White syndrome)?
* Additional accessory pathy (**Bundle of Kent**)
* Allows electrical activity to pass between the atria and ventricles - bypasssing the AV node
* **Excites the ventricles earlier → get delta waves**
220
Sx for AVRT (Wolff-Parkinson-Wgite syndrome)
* Palpitations
* Chest pain
* Dyspnoea
* Syncope
221
What dos AVRT (Wolf-Parkinson-White) look like on an ECG?
* Shortened PR interval <0.12s
* Slurred DELTA waves
* Wide QRS >0.12s
| Early depolarisation of part of the ventricle
222
First, second line and definitive management for AVRT (Wolf-Parkinson-White Syndrome)
* First line: Carotid massage or valsalva manoeuvre
* Second line: IV adenosine
* Third: IV Verapamil or a beta blocker
* Fourth: Synchronised DC cardioversion
* ?Definitive management: Radiofrequency ablation of Bundle of Kent
223
Biggest complication of Wolff-Parkinson-White
Prone to developing ventricular fibrillation
224
How does adenosine work?
* Slows the cardiac conduction (primarily through the AV node)
* It interrupts the AV node or accessory pathyway during SVT and 'resets' it to sinus rhythm
225
When is adenosine avoided?
* Asthma
* COPD
* Heart failure
* Heart block
* Severe hypotension
* Potential atrial arrhythmia with underlying pre-excitation
226
What is atrioventricular nodaal re-entrant tachycardia?
* Re-entry point is back through the atrioventricular node
227
Supraventricular tachycardia (SVT) causes what type of tachycardia?
Narrow complex tachycardia
228
What is the most common type of SVT?
AVNRT
Commonest cause of palpitations in patients with structurally normal hearts
229
What are the signs and symptoms of AVNRT?
* Typically paroxysmal
* Occur spontaneously or w/ triggers: Exertion, caffeine, alcohol, beta-agonists (salbutamol)
* Presyncope or syncope
* Regular rapid palpitations (abrupt onset + sudden termination)
* Neck pulsation (JV pulsations)
* Chest pain + SOB
* Polyuria (due to the release of ANP in response to increased atrial pressure during tachycardia)
230
What are the EGG changes seen in AVNRT?
* **Regular tachycardia** (140-280 bpm)
* **P waves not visible** OR immediately before or after the QRS complex
* **Narrow QRS complexes <120 ms**
231
What is the treatment of AVRT and AVNRT?
* Vagal maoeuvres (carotid massage or valsalva maneouvres)
* IV adenosine
* IV verapamil or beta-blocker
232
What is the long term management for paroxysaml SVT?
* beta blockers
* Calcium channel blockers
* Amioderone
233
What is acute left ventricular failure?
An acute event results in the left ventricle being unable to move blood efficiency through the left side of the heart into the **systemic circulation**
234
SV x HR = ?
Cardiac output
235
Why does pulmonary oedema occur in left ventricular heart failure?
* As the blood can't flow efficiently through the left side of the heart → **backlog of blood** in the **left atrium, pulmonary veins + lungs**
* The high pressure in these areas → leak fluid → **pulmonary oedema**
236
What Sx does pulmonary oedema cause?
* Interferes with gas exchange in lungs
* SOB + reduced oxygen saturation
237
Causes of left ventricular heart failure
* IHD
* Hypertension
* Cardiomyopathy
* Aortic stenosis
238
Symptoms of left ventricular heart failure
* (Acute) SOB → Exacerbated by lying flat + improves sitting up
OPEN:
* Orthopnoea (SOB when lying down)
* Paroxysmal nocturnal dyspnoea
* Extertional dyspnoea
* Nocturnal cough (pink, frothy sputum)
239
What are the causes of pericarditis and give an example of each?
* Viral (Coxsackie viruses)
* Bacterial (TB)
* Fungal (immunocompromised patient)
* Non-infectious:
- Autoimmune (RA)
- Dressler's syndrome (post-MI)
- Neoplastic
240
A patient presents with sharp pleuritic chest pain and radiates to left shoulder tip. It is relieved by sitting forwards. Possible diagnosis?
Pericarditis
241
Signs and symptoms of pericarditis
Signs:
* Pericardial friction rub (scratching sound) heard by ausculation
* Raised JVP
Symptoms:
* Central chest: Pleuritic, worse on lying down and breathing in
* Dyspnoea
* Fever
* Hiccups (phenic involvement)
242
What is the first line and diagnostic Ix for pericarditis? What does it show?
ECG:
* Concave (saddle-shaped) ST segment elevation (global ST elevation)
* PR depression
* PeRicardiTiS
243
Apart from an ECG what other tests can you perform for pericarditis?
* CXR: 'water bottle' heart (cardiomegaly) , bacterial (pneumonia)
* Bloods: Raised ESR (autoimmune), FBC - raised WBC (infective)
244
What are differential diagnoses for pericarditis?
* Angina
* MI - rule out pleuritic pain, and pericardial rub ioon auscultation
* Pneumonia, GI reflux, peritonitis
* Aortic dissection
245
What treatment do you give for pericarditis? Viral + idiopathic, bacterial, Autoimmune
* Viral + idiopathic = NSAIDs (aspirin) + PPI + Colchicine
* Bacterial = Antibiotics (RIPE for TB)
* Autoimmune = Prednisolone
246
What is colchicine used for?
In pericarditis
Inhibits migration of neutrophils to site of inflamaation
(Reduces risk of occurrence)
247
What are 3 complications for pericarditis?
* Pericardial effusion
* Cardiac tamponade
* Chronic constrictive pericarditis
248
What is a pericardial effusion and a cardiac tamponade?
* Pericardial effussion = collection of fluid within the pericardial sac
* Cardiac tamponade = when a large volume compromises ventricular filling - impacting circulation
249
What are the signs and symptoms of a cardiac tamponade?
* Becks triad: Hypotension; Raised JVP; Muffled heart sounds
* Pulsus paradoxus (A fall in BP of more than 10mmHg on inspiration)
* High pulse - but low BP
Kussmaul's sign = rise in JVP + increased neck distension during inspiration
250
What is Beck's triad and what does it indicate?
* Hypotension
* Muffled heart sounds
* Raised JVP
251
Ix for cardiac tamponade and pericardial effusion
* CXR → Large globular heart
* ECG → Low-voltage QRS complexes + sinus tachycardia
*** Echocardiogram → echo-free zone surrounding the heart**
252
Management for a cardiac tamponade
* Pericardiocentesis
- Drain the fluid → relieving the pressure on the heart
- Send fluid for culture → Ziehl-Nielsen stain and cytology
253
What is infective endocarditis?
- Infection of the endocardium (including valves, chordae tendineae, septal defect sites, pacemaker leads, surgical patches) - typically affects valves
- Endocardium becomes inflamed secondary to infection
- A really bad infection, plus showers of infectious material around your bloodstream, and/or damaging the heart valves to cause heart failure.
254
Rx for infective endocarditis
* Male
* Prosthetic heart valves or cardiac devices
* Congenital HD
* Poor dental hygeine
* IV drug use
* Immunosuppression
* Rheumatic heart disease
255
Which valves are most commonly affected in IE, in the general population and IVDUs?
* Typical: mitral valve
* IVDUs: Tricuspid valve
256
What are the two most common bacteria to cause IE?
* Staph aureus (IVDU, T2DM, surgery)
* Srep viridans (poor dental hygeine)
257
Describe Strep Viridans and what cardiac condition it causes
* Infective endocarditis
* Gram +ve
* Alpha-haemolytic, optochin resistant strp
* Assocaited with poor dental hygeine
258
Describe the pathology of IE
* Abnormal/damaged endocardium have increased platelet deposition
* Bacteria adheres → causes vegetations
* Typically around valves
* Causes **regurgitation** → therefore aortic + mitral insufficiency → increased risk of heart failure
259
What are the symptoms and signs of infective endocarditis?
Symptoms:
* vague; fever, non-specific
Signs: (JOS PR)
* **Janeway lesions** (painless spots on hands)
* **Olser nodes** (finger nodules)
* **Splinter haemorrhages** (finger nail-bed)
* **Petechiae**
* **Roth spots** (retinal haemorrhages)
Septic emboli (MI, stroke, PVD)
260
What is the gold standard Ix for IE?
Transoesophageal echocardiogram (TOE ECHO)
261
First line Ix for IE
* Transthoracic echo (TTE) - 60% sensitive - but not invasive
* Blood cultures (3 sites over 24 hours)
* ESR/CRP (raised) + neutrophillia
* ECG (Prolonged PR intervals)
262
What is the Duke Criteria used for? What makes a diagnosis?
Diagnosis of infective endocarditis (IE)
Definite IE = 2 major or 1 major + 3 minor
Major criteria (pathogen grown in blood culture, TOE Echo shows vegetation)
263
Treatment for IE (both bacteria)
IV antibiotics/antimicrobials for approx. 6 weeks
* Staphylcoccus aureus → vancomycin + rifampicin (if MRSA)
* Streptococcus viridans → benzylpenicillin + gentamycin
Surgery → remove valve if incompetent + replace with prosthetic
264
Complications of IE
* Acute heart failure
* Systemic embolisation (including stroke)
* Acute kidney injury
* SEPSIS
