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Cardiology🫀 Flashcards

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1
Q

What are the thresholds for diagnosis of hypertension?

A

140/90 clinic BP
135/85 ambulatory BP

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2
Q

What is the main cause of hypertension?

A

Essential hypertension - unknown cause

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3
Q

What are the secondary causes of hypertension?

A

ROPED
R - renal failure
O - obesity
P - pre-eclampsia
E - endocrine
D - drugs - NSAIDs, alcohol, steroids, oestrogen

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4
Q

What is the most common cause of secondary hypertension?

A

Renal failure

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5
Q

What are the risks of high blood pressure?

A

Increased risk of:
- Stroke
- IHD
- Heart failure
- Left ventricular hypertrophy
- Hypertensive retinopathy
- Kidney failure
- Vascular dementia

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6
Q

What is stage 1 hypertension?

A

Clinic BP >140/90
Ambulatory BP > 135/85

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7
Q

What is stage 2 hypertension?

A

Clinic BP > 160/100
Ambulatory BP > 150/95

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8
Q

What is stage 3 hypertension?

A

Clinic BP > 180/20

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9
Q

What investigations should all those with a new diagnosis of hypertension have?

A

Urine albumin:creatinine ratio
Urine dipstick
HbA1c
Renal function
Lipids
Fundoscopy
ECG
Calculate Q risk
TFTs - check for secondary causes

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10
Q

What medications are used in the management of hypertension?

A

Under 55:
- 1st line - ACE inhibitor
- 2nd line - ARB

Over 55:
- 1st line - calcium channel blocker

Black or afro-carribean background:
- 1st line - CCB

Type 2 diabetes patients
- 1st line - ACE inhibitor

Alternative medications:
- Beta blockers + potassium sparing diuretics - 4th line
- Thiazide like diuretic - 3rd line

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11
Q

What is malignant hypertension?

A

Hypertension above 180/120 with papilloedema

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12
Q

What is the treatment of malignant hypertension?

A

Same day referral for IV antihypertensives:
- Sodium nitroprusside
- Labetolol
- GTN
- Nicardipine

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13
Q

What lifestyle changes can patients make to manage their hypertension?

A

Stop smoking
Reduce alcohol intake
Reduce caffeine intake
Reducing dietary salt
Diet and exercise

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14
Q

What should be monitored in patients on antihypertensives?

A

Serum electrolytes
Kidney function
Check blood pressure

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15
Q

Which thiazide like diuretic is most commonly used in hypertension?

A

Indapamide

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16
Q

What is heart failure?

A

Impaired heart function, usually of the left ventricle - blood can’t get out to the body

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17
Q

What is the pathophysiology of heart failure?

A

Impaired left ventricular function resulting in blood backing up into the left ventricle and the rest of the heart

The left atrium, pulmonary vein and lungs are increased in volume and pressure

This results in pulmonary oedema

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18
Q

What is a normal ejection fraction?

A

Above 50%

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19
Q

What is ejection fraction?

A

The proportion of blood in the left ventricle that is pumped out of the heart with each contraction

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20
Q

What are the causes of heart failure?

A

Ischaemic heart disease
Valvular heart disease - aortic stenosis
Hypertension
Arrhythmias - AF
Cardiomyopathy

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21
Q

What is the presentation of heart failure?

A

Breathlessness
Cough with frothy pink/white sputum
Orthopnoea
Paroxysmal nocturnal dyspnoea
Peripheral oedema
Fatigue

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22
Q

What signs of heart failure would be seen on examination?

A

Tachypnoea
Tachycardia
Hypertension
Murmurs (if caused by valvulvar heart disease)
3rd heart sound
Bilateral basal crackles
Raised JVP
Peripheral oedema

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23
Q

What investigations are used to diagnose heart failure?

A

ECG
Echocardiogram
BNP
Bloods - LFT, TFT, U&E, FBC, lipids, HbA1c, inflammatory markers
Chest XR

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24
Q

What are the differentials of heart failure?

A

COPD
Pulmonary fibrosis
Pneumonia
Ageing/physical inactivity

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25
What are the classes of heart failure?
Class 1 - no limitation of activity Class 2 - comfortable at rest but symptomatic with normal activities Class 3 - comfortable at rest but symptomatic with any activity Class 4 - symptomatic at rest
26
What is the first line medical management of heart failure?
ACE inhibitor Beta blocker Aldosterone antagonist (if symptoms are not controlled by A+B) Loop diuretics
27
What is the first line management of acute heart failure?
IV furosemide
28
What are the additional treatments in acute heart failure?
Oxygen Vasodilators - nitrates CPAP
29
What is atrial flutter?
A form of SVT where a short circuit in the heart causes the atria to pump rapidly
30
What heart rate is seen in atrial flutter?
Atrial rate of 300 bpm Ventricular rate of 150 bpm (but can be variable dependent on AV block)
31
What appearance does atrial flutter given on an ECG?
Sawtooth appearance
32
Why can the ventricular rate be variable in atrial flutter?
Dependant on how many impulses from the atria conduct through to the ventricles (a 2:1 ratio would result in 150bpm, a 3:1 ratio would result in 100bpm...)
33
What are the causes of atrial flutter?
COPD Obstructive sleep apnoea Pulmonary emboli Pulmonary hypertension
34
What are the symptoms of atrial flutter?
Palpitations Lightheadedness Syncope Chest pain
35
What is the treatment of atrial flutter in some haemodynamically unstable?
Direct current synchronised cardioversion + amiodarone
36
What is the first line management of atrial flutter in a haemodynamically stable patient?
Beta blocker (bisoprolol) or calcium channel blocker (verapamil or diltiazem)
37
What is the second line management of atrial flutter in a haemodynamically stable patient?
Cardioversion
38
What is the first line management of atrial flutter in a haemodynamically unstable patient?
DC cardioversion +/- amiodarone
39
What is supraventricular tachycardia?
Where abnormal signals from above the ventricles cause tachycardia
40
What is the pathophysiology of supraventricular tachycardia?
The electrical signals in the heart re-enter the atria from the ventricles - the electrical signal then travels down again through the AV node into the ventricles, causing a further ventricular contraction
41
What type of tachycardia is SVT?
Narrow complex tachycardia (QRS complex has a duration of less than 0.12 seconds)
42
What is paroxysmal SVT?
Where SVT reccurs and remits
43
What are the four types of narrow complex tachycardia?
Sinus tachycardia SVT AF Atrial flutter
44
How does SVT appear on ECG?
Appears as a QRS complex, followed by a T wave, followed by another QRS complex There are P waves present, but are buried in the T waves, and therefore cannot be properly seen.
45
What are the three types of SVT?
AV node re-entrant tachycardia AV re-entrant tachycardia Atrial tachycardia
46
What is AV node re-entrant tachycardia?
Most common type of SVT - where electrical signals re-enter atria through AV node
47
What is AV re-entrant tachycardia?
Where the electrical signal re-enters the atria through an accessory pathway (Wolff-Parkinson-White syndrome)
48
What is atrial tachycardia?
Not caused by the signal re-entering the atria, but by an abnormal atrial electrical activity
49
What is the accessory pathway called in Wolff-Parkinson-White syndrome?
Bundle of Kent
50
What are the ECG changes in Wolff-Parkinson-White syndrome?
Short PR interval Wide QRS complex Delta wave (slurred upwards stroke in the QRS complex)
51
What are the stages of acute SVT management?
Stage 1 - vagal manoeuvres Stage 2 - adenosine Stage 3 - verapamil or beta blocker Stage 4 - Synchronised DC cardioversion
52
What are vagal manoeuvres?
Manoeuvres that stimulate the vagus nerve, increasing activity in the parasympathetic nervous system
53
What are examples of vagal manoeuvres?
Blowing hard against resistance Carotid massage (on one side only) - contraindicated in carotid artery stenosis
54
How is adenosine given to patients with SVT?
Given as an IV rapid bolus into a central or lalrge vein - as it only acts for approx. 10 seconds
55
Which patients is adenosine avoided in?
Asthma COPD Heart failure Heart block Hypotension
56
What dose of adenosine is given in SVT?
Initially 6mg then 12mg then 18mg
57
What is the definitive treatment of Wolff-Parkinson-White syndrome?
Radiofrequency ablation of the accessory pathway
58
What is the most important complication of Wolff-Parkinson-White syndrome?
In combination with AF or atrial flutter, the chaotic atrial electrical activity can pass into the ventricles , causing a polymorphic wide complex tachycardia - leading to VF and cardiac arrest
59
What is the management of paroxysmal SVT?
Long term medication - beta blockers, calcium channel blockers, amiodarone Radiofrequency ablation
60
What are the shockable rhythms?
Ventricular tachycardia Ventricular fibrillation
61
What are the non-shockable rhythms?
Pulseless electrical activity Asystole
62
What is narrow complex tachycardia?
A fast heart rate with a QRS complex of less than 0.12 seconds (3 small squares)
63
What is broad complex tachycardia?
A fast heart rate with a QRS duration of more than 0.12 seconds or 3 small squares
64
What are the types of broad complex tachycardia?
Ventricular tachycardia Polymorphic ventricular tachycardia (such as torsades de pointes) AF with bundle branch block SVT with bundle branch block
65
What is the pathophysiology of torsades de pointes?
When QT interval is too long, repolarisation of the heart muscles is prolonged Waiting a long time for repolarisation can cause abnormal spontaneous depolarisation When there are recurrent contractions without normal repolarisation, this is called torsades de pointes
66
What does torsade de pointes look like on ECG?
Ventricular tachycardia, but the QRS complexes get progressively smaller, then larger, then smaller
67
What are the causes of prolonged QT?
Long QT syndrome - inherited Medications Electrolyte imbalances
68
What medications can cause prolonged QT syndrome?
Antipsychotics Citalopram Flecainide Sotalol Amiodarone Macrolides
69
What electrolyte imbalances can cause prolonged QT?
Hypokalaemia Hypomagnesaemia Hypocalcaemia
70
What is the acute management of torsades de pointes?
IV magnesium (even if normal serum magnesium) Debrillation if VT occurs
71
What is the management of prolonged QT?
Stop and avoid medications that cause prolonged QT Correct electrolyte disturbances Beta blockers Pacemaker or implantable cardioverter defibrillator
72
What are ventricular ectopics?
Premature ventricular beats caused by random electrical discharges outside the atria
73
What is the appearance of a ventricular ecoptic on ECG?
An isolated, random, abnormal broad QRS complex on an otherwise normal ECG
74
What is bigeminy?
When every other beat is a ventricular ectopic
75
What is first degree heart block?
Delayed conduction through the AV node - Causes a consistently long PR interval
76
What are the types of second degree heart block?
Mobitz type 1 Mobitz type 2
77
What is mobitz type 1 heart block?
Conduction through the AV node takes progressively longer until it fails - Progressively longer PR intervals until one QRS complex is dropped
78
What is mobitz type 2 heart block?
There is usually a set ratio of P waves to QRS complexes
79
What is third degree heart block?
Complete heart block - There is no association between the P waves and QRS complexes
80
What is the management of a broad complex tachycardia in a stable patient?
First line - IV amiodarone
81
What is the management of broad complex tachycardia in a haemodynamically unstable patients?
DC cardioversion
82
What is pericarditis?
Inflammation of the pericardium
83
What is a pericardial effusion?
Buildup of fluid in the potential space of the pericardial cavity
84
What is cardiac tamponade?
Where the pericardial effusion is large enough to raise the intrapericardial pressure, putting pressure on the heart, and reducing its function
85
How does cardiac tamponade reduce function?
It causes reduced filling during diastole which in turn causes a reduced cardiac output during systole
86
What are the two key presenting features of pericarditis?
Chest pain Low grade fever
87
What type of chest pain is seen in pericarditis?
Pleuritic (worse with inspiration) Sharp Central Worse on lying down Relieved on sitting forwards
88
What are the causes of pericarditis?
Idiopathic Infection Autoimmune and inflammatory conditions Injury to pericardium Uraemia Cancer Medications
89
What viruses can cause pericarditis?
Coxsackie B Echovirus CMV Herpes HIV
90
What bacteria can cause pericarditis?
Staphylococcus Pneumococcus Streptococcus Haemophilus M. tuberculosis
91
What types of cancer can casue pericarditis?
Lung cancer Breast cancer Hodgkin lymphoma
92
What drugs can cause pericarditis?
Methotrexate Isoniazid Chemotherapies Methyldopa Phenytoin Penicillins
93
What is the first line investigation for pericarditis? What does it show?
ECG - PR depression - Saddle shaped ST elevation
94
What bloods would be taken in suspected pericarditis?
CRP and ESR Serial troponins (rule out MI) Viral serology - help determine cause
95
What imaging may be used to aid diagnosis of pericarditis?
Echocardiogram Angiogram Cardiac MRI
96
What is the first line management of viral pericarditis?
NSAIDs Restriction of exercise
97
What are the second and third line treatments of viral pericarditis?
2nd line - colchicine 3rd line - corticosteroids
98
What is the treatment of bacterial pericarditis?
IV antibiotics Pericardiocentesis if purulent exudate is present
99
What is the treatment of non-infective pericarditis?
Corticosteroids
100
What are the causes of cardiac tamponade?
Pericarditis Malignancies Systemic inflammatory infections Myocardial rupture after MI
101
What are the features of cardiac tamponade?
Beck's triad Kussmaul's sign Pulsus paradoxus Dyspnoea Fatigue
102
What is pulses paradoxus?
A decrease in systolic BP of more than 10, during inspiration
103
What are the differentials of cardiac tamponade?
Acute heart failure Pulmonary embolism Constrictive pericarditis
104
What is the most useful investigation in cardiac tamponade?
Echocardiogram
105
What is the definitive management of cardiac tamponade?
Pericardiocentesis
106
What is Kussmaul's sign?
A paradoxical rise in JVP during inspiration
107
What is Beck's triad?
Raised JVP Hypotension Muffled heart sounds
108
What ejection fraction is considered normal?
50%
109
What are the causes of chronic heart failure?
Ischaemic heart disease Valvular heart disease - aortic stenosis Hypertension Arrhythmias - AF Cardiomyopathy
110
What are the key symptoms of heart failure?
Breathlessness Peripheral oedema Orthopnoea Cough - pink/white frothy sputum Fatigue Paroxysmal nocturnal dyspnoea
111
What are the signs of heart failure on examination?
Tachycardia Tachypnoea Hypertension Murmurs 3rd heart sound on auscultation Raised JVP Bilateral basal crackles Peripheral oedema
112
What is paroxysmal nocturnal dyspnoea?
The experience of patients waking up in the night with a severe attack of breathlessness, cough and wheeze
113
What are the main investigations for diagnosis of heart failure?
NT-proBNP ECG Echocardiogram
114
What other investigations may be performed in the diagnosis of heart failure?
Bloods - anaemia, renal function, thyroid function, liver function, lipids, diabetes CXR - to exclude lung pathology
115
What is the NYHA classification of heart failure?
Class 1 - no limitation on activity Class 2 - comfortable at rest, symptomatic with normal activities Class 3 - comfortable at rest, symptomatic with any activity Class 4 - symptomatic at rest
116
How quick should heart failure patients be referred to cardiology?
If BNP between 400 and 2000 - referral and echo within 6 weeks If BNP > 2000 - referral and echo within 2 weeks
117
What vaccines should heart failure patients be given?
Pneumococcal vaccine Flu vaccine annually Covid vaccine annually
118
What is the pharmacological management of heart failure?
ABAL - ACE inhibitor - Beta blocker - Aldosterone antagonist (if symptoms are not controlled) - Loop diuretics
119
When is an aldosterone antagonist used in heart failure?
When ejection fraction is less than 50%, and symptoms are not adequately controlled with an ACE inhibitor and a beta blocker
120
What is stable angina?
Constricting chest pain, only during exertion
121
What is unstable angina?
Constricting chest pain, that can occur both during exertion, and at rest
122
What initial investigations should be performed in a patient with suspected angina?
ECG FBC - anaemia U&Es LFTs TFTs Lipid profile HbA1c
123
What further investigations can be performed to confirm angina?
Cardiac stress testing CT coronary angiography Invasive coronary angiography
124
What immediate relief can be given to treat angina?
GTN spray
125
How is GTN spray taken?
Take GTN when symptoms start Can take second and third doses at intervals of 5 minutes Call an ambulance if symptoms do not resolve after third dose
126
What is the first line management for long term relief of angina?
Beta blockers (bisoprolol) or calcium channel blockers (diltiazem or verapamil)
127
Which patients should diltiazem and verapamil be avoided in?
Heart failure with reduced ejection fraction
128
What medicines are prescribed for secondary prevention of ACS?
4 As - Aspirin - Atorvastatin 80mg OD - ACE inhibitor - Already on a beta blocker
129
What is the second line management for long term relief of angina?
If using beta blockers: - Add dihydropyridine calcium channel blocker (e.g amlodipine)
130
What does ACS encompass?
Unstable angina NSTEMI STEMI
131
What is the process of atherosclerotic plaue formation?
- Accumulation of LDL cholesterol in inner layers of blood vessels - Leukocytes adhere to the endothelium and enter the intima, where they combine with lipids to become foam cells - Artery remodelling, calcification and foam cells cause plaques to form - Rupture of a plaque causes platelet activation, thrombus formation and coronary artery occlusion
132
What is a type 1 MI?
MI due to artheromatous plaque formation
133
What is a type 2 MI?
MI due to hypoxia (increased oxygen demand or decreased supply)
134
What ECG changes can be seen in unstable angina?
Can be normal ST depression T wave inversion
135
What ECG changes can be seen in NSTEMI?
May be normal ST depression T wave inversion
136
What are the non-modifiable risk factors for ACS?
Age Male Family history South Asian or Afro-Carribean ethnicity
137
What are the modifiable risk factors for ACS?
Smoking Diabetes Hypertension Hyperlipidaemia Obesity Sedentary lifestyle Recreational drug use
138
What is the presentation of ACS?
Central, crushing chest pain Radiation to left arm or neck Shortness of breath Sweating Nausea and vomiting Palpitations Anxiety
139
What are the primary investigations for ACS?
ECG Troponin - troponin is measured at baseline and 4 hours
140
What are alternative causes of raised troponin?
CKD Sepsis Myocarditis Aortic dissection Pulmonary embolism
141
Where does the left coronary artery correspond to on ECG?
I, aVL, V3-V6
142
Where does the LAD correspond to on ECG?
V1-V4
143
Where does the circumflex artery correspond to on ECG?
I, aVL, V5-V6
144
Where does the right coronary artery correspond to on ECG?
II, III, aVF
145
Where does the circumflex artery supply?
Left atrium Posterior aspect of left ventricle
146
Where does the LAD supply?
Anterior aspect of left ventricle Anterior aspect of septum
147
Where does the right coronary artery supply?
Right atium Right ventricle Inferior aspect of left ventricle Posterior septal area
148
What ECG changes can be seen in a STEMI?
ST segment elevation New left bundle branch block
149
What other investigations may be useful in the diagnosis of ACS?
FBC, U&E, LFT, lipids, glucose CXR to exclude other causes of chest pain Echocardiogram once stable
150
What is the initial mangement of ACS?
Oxygen if sats < 94 Morphine GTN Aspirin 300mg
151
What is the GRACE score?
A score that gives the 6 month probability of death after an NSTEMI - Patients with above 3% are considered for early angiography with PCI
152
What is the diagnostic investigation for ACS?
Coronary angiography
153
What is the management of STEMI within 120 minutes?
PCI
154
What is the management of STEMI after 120 minutes?
Thrombolysis with alteplase/tenecteplase Unfractionated heparin
155
What are the early complications of ACS?
Post-MI pericarditis Ventricular fibrillation (cardiac arrest) Cardiogenic shock Mitral regurgitation (secondary to papillary muscle rupture) Left ventricular wall rupture
156
What are the late complications of ACS?
Dressler's syndrome - presents similar to post-MI pericarditis Heart failure Left ventricular aneurysm
157
What is the presentation of Dressler's syndrome?
Pleuritic chest pain Low-grade fever Pericardial rub on auscultation
158
What is the management of Dressler's syndrome?
NSAIDs Prednisolone in severe cases
159
What is the presentation of left ventricular aneurysm post-MI?
Persistent ST elevation and left ventricular failure
160
What is seen on ECG in a posterior STEMI?
ST depression in leads V1-V3 Tall R waves in leads V1-V3 Upright T waves in V1-V3 Inverted T wave in lead aVR
161
What is the secondary prevention offered after an MI?
Dual antiplatelet therapy (aspirin + another agent) ACE inhibitor Beta-blocker Statin
162
What are the second antiplatelets of choice after MI?
Post MI (medically managed) - ticagrelor Post PCI - prasugrel or ticagrelor
163
What is an abdominal aortic aneurysm?
Dilation of the abdominal aorta, with a diameter of more than 3cm
164
Where does a AAA most commonly form?
Below the level of the renal arteries - called an infra-renal anerysm
165
What are the risk factors for AAA?
Increasing age Male gender Smoking Hypertension Connective tissues disorders - Elhers Danlos and Marfan syndrome Family history
166
Who is offered screening for AAA?
All men in England are offered a screening ultrasound at age 65 to detect asymptomatic AAA
167
What is the presentation of AAA?
Most cases are asymptomatic Symptoms can include: - Flank, back or abdominal pain - Pulsating abdominal sensation
168
What is the initial investigation for diagnosis of a AAA?
Abdominal ultrasound
169
What other investigations may be considered in diagnosis of AAA?
FBC - leaking AAA can cause anaemia U&Es CRP/ESR Group and save and crossmatch CT angiogram - more detailed anatomical information
170
How often should identified AAA be rescanned?
3-4.4cm - rescan every 12 months 4.5-5.4cm - rescan every 3 months >5.5cm - refer within 2 weeks to vascular surgery
171
What are the indications for elective repair of aneurysm?
Symptomatic aneurysm Diameter growing more than 1cm per year Diameter above 5.5cm
172
What are the surgical management options for AAA?
Open repair via laparotomy Endovascular aneurysm repair (EVAR) via femoral arteries
173
What is the presentation of a ruptured AAA?
Severe abdominal pain Pain radiating to the back Haemodynamic instability Pulsatile and expansile abdominal mass Collapse Loss of consciousness
174
Where is a thoracic aortic aneurysm most commonly found?
Ascending aorta
175
What is the presentation of a thoracic aortic aneurysm?
Chest or back pain Cough SOB - tracheal compression Stridor Hiccups - phrenic nerve compression Dysphagia - oesophageal compression Hoarse voice - recurrent laryngeal nerve compression
176
What are the imaging options for a thoracic aortic aneurysm?
CT angiogram MRI angiogram Echo
177
What are the complications of a thoracic aortic aneurysm?
Aortic dissection Ruptured aneurysm Aortic regurgitation
178
What are the pathophysiology of aortic stenosis?
Most cases are due to calcification and fibrosis of the aortic valve Congenital biscuspid valve is the most common cause of aortic stenosis in younger patients Rheumatic heart disease
179
What are the symptoms associated with aortic stenosis?
Exertional dyspnoea Chest pain Exertional syncope Fatigue
180
What murmur may be heard in aortic stenosis?
Ejection-systolic high pitched murmur over aortic area Radiates to carotids Enhanced on expiration Thrill over aortic area
181
What are the other features of aortic stenosis?
Narrow pulse pressure Slow rising pulse Soft/absent S2 S4 Left ventricular hypertrophy
182
What are the primary causes of aortic regurgitation?
Chronic rheumatic fever Infective carditis SLE associated endocarditis Bicuspid aortic valve
183
What are the secondary causes of aortic regurgitation?
Idiopathic aortic root dilatation Aortic root aneurysms Aortic root dilatation from connective tissue disorders Aortic dissection Syphilitic aortitis
184
What are the symptoms of aortic regurgitation?
Exertional dyspnoea Fatigue Palpitations Orthopnoea Paroxsymal nocturnal dyspnoea
185
What murmur will be heard in aortic regurgitation?
Early diastolic murmur/rumbling murmur heard at the apex Heard loudest during end expiration Heard loudest with patient leaning forwards
186
What features of aortic regurgitation may be seen on examination?
Wide pulse pressure Collapsing pulse
187
What investigations are useful in the diagnosis of aortic valve disease?
ECG - evaluate for left ventricular hypertrophy TTE - used to confirm diagnosis CXR BNP
188
What are the indications for valve replacement in aortic stenosis?
Severe aortic stenosis and symptomatic Severe aortic stenosis, asymptomatic, and one of: - Evidence of heart failure - Symptoms on exercise testing
189
What is the management of mild to moderate aortic regurgitation?
Lifestyle modifications ACE-inhibitors - ramipril Beta blockers - bisoprolol
190
What is the management of severe aortic valve disease?
Loop diuretics - manage HF associated with aortic regurgitation Aortic valve repair or replacement
191
What are the complications of aortic regurgitation?
Left ventricular dysfunction Heart failure AF Sudden cardiac death
192
What are the risk factors for infective endocarditis?
IVDU Structural heart pathology CKD Immunocompromised History of infective endocarditis
193
What structural pathologies are associated with infective endocarditis?
Valvular heart disease Congenital heart disease Hypertrophic cardiomyopathy Prosthetic heart valves Implantable cardiac devices
194
Which valve is most commonly affected by IE?
Mitral valve
195
Which valve is most commonly affected by IE associated with IVDU?
Tricuspid valve
196
What are the bacterial causes of IE?
Staphylococcus aureus - most common Staphylococcus epidermidis - associated with indwelling lines and prosthetic valves Streptococcus viridans - associated with poor dental hygeine Enterococcus
197
What are the symptoms of IE?
Fever Headache SOB Night sweats Fatigue Weight loss Muscle aches
198
What are the key examination findings in IE?
New heart murmur Splinter haemorrhages Petechiae Janeway lesions Osler's nodes Roth spots Splenomegaly Finger clubbing
199
What investigations are required for a diagnosis of infective endocarditis?
Three blood cultures - Separated by 6 hours - Taken from different sites - Ideally taken before starting antibiotic therapy Echocardiogram (TTE is first line)
200
What investigations are useful in infective endocarditis?
Inflammatory markers - raised CRP, raised WCC CXR - exclude other causes of dyspnoea 12 lead ECG
201
What are the Duke criteria?
Requires one major plus three minor criteria or five minor criteria Major criteria: - Persistently positive blood cultures - Specific imaging findings Minor criteria: - Predisposition - Fever - Vascular phenomena - Immunological phenomena - Microbiological phenomena
202
What is the first line management of infective endocarditis when the affective organism is unknown?
IV antibiotics - amoxicillin and gentamicin - 4 weeks for native heart valves - 6 weeks for prosthetic heart valves
203
What is the second line management of infective endocarditis?
Surgery to remove infected tissue and repair or replace affected valves
204
What are the complications of infective endocarditis?
Congestive heart failure Septic embolisation Valvular rupture Glomerulonephritis
205
What is the first line treatment for native valve S. aureus endocarditis?
Flucloxacillin
206
What is the second line treatment for native valve S. aureus endocarditis?
Vancomycin + rifampicin
207
What is the management of prosthetic valve S. aureus IE?
Flucloxacillin + rifampicin + gentamicin
208
What is the first line management of strep viridans IE?
Benzylpenicillin
209
What is the second line management of strep viridans IE?
Vancomycin + gentamicin
210
What is atrial fibrillation?
Where the electrical activity of the atria becomes disorganised, leading to fibrillation of the atria, and an irregularly irregular pulse
211
What is the pathophysiology of AF?
Electrical activity from the SA node is disorganised, causing the contraction of the atria to become uncoordinated, rapid and irregular These signals pass through to the ventricles causing irregularly irregular ventricular contraction
212
What are the common causes of AF?
PIRATES - Pulmonary - PE and COPD - Ischaemic heart disease - Rheumatic heart disease - Anaemia, alcohol, advancing age - Thyroid disease (hyperthyroidism) - Electrolyte disturbance - Sepsis and sleep apnoea
213
What is the presentation of AF?
May be asymptomatic Palpitations SOB Dizziness or syncope Chest pain Irregularly irregular pulse
214
What are the differentials for an irregularly irregular pulse?
Atrial fibrillation Ventricular ectopics
215
What is the first line investigation (and findings) in AF?
ECG - Absent P waves - Narrow QRS complexes - Irregularly irregular ventricular rhythm
216
What other investigations can be useful in the diagnosis of AF?
Serum electrolytes TFTs - hyperthyroidism as secondary cause CXR - if suspicion of heart failure TTE - consider if there is suspicion of underlying structural or functional heart disease
217
What are the adverse features of AF?
Shock Syncope MI Heart failure
218
What is paroxysmal AF?
Episodes of AF that reoccur and spontaneously resolve back to sinus rhythm
219
What additional investigations are useful in paroxysmal AF?
24 hour ambulatory ECG Cardiac event recorder (for 1-2 weeks)
220
What is management of AF in a haemodynamically unstable patient?
Emergency electrical synchronised DC cardioversion
221
What is the management of new AF < 48 hours in a stable patient ?
Rate control or Rhythm control (immediate cardioversion) - electrical or pharmacological
222
What are the options for rate control in AF?
First line - beta blocker (bisoprolol) Calcium channel blocker - verapamil or diltiazem (not in HF) Digoxin - first line in patients with HF
223
What are the options for rhythm control?
Immediate cardioversion - Pharmacological - flecainide or amiodarone - Electrical - DC cardioversion Delayed cardioversion
224
What is the management of AF > 48 hours or unknown onset?
Offer rate control and anticoagulation for 3 weeks - Offer rhythm control (DC cardioversion) if rate control is unsuccessful
225
What is the management of paroxsymal AF?
If infrequent episodes and no structural heart disease: - Flecainide when they have symptoms
226
When is ablation for atrial fibrillation indicated?
When drug treatment has failed to control symptoms, or is unsuitable
227
What are the options for ablation in AF?
Left atrial ablation - catheter through the femoral vein under general anaethetic to ablate abnormal pathways AV node ablation and permenant pacemaker - destroys connection between atria and ventricles - a permenant pacemaker is required to control ventricular contraction
228
What are the complications of AF?
Stroke MI Heart failure
229
What are the first line anticoagulants in AF?
DOACs
230
What is the second line anticoagulant in AF?
Warfarin
231
What is aortic dissection?
A break or tear in the inner lining of the aorta, allowing blood to flow between the layers of the wall of the aorta
232
What layers of the aorta does blood flow between in aortic dissection?
Between the intima and media layers of the aorta
233
What is the stanford system of classification for aortic dissection?
Type A - affects the ascending aorta, before the brachiocephalic artery Type B - affects the descending aorta, after the left subclavian artery
234
What is the DeBakey system of classification for aortic dissection?
Type I - begins in the ascending aorta, and involved at the least the aortic arch Type II - isolated to the ascending aorta Type IIIa - begins in the descending aorta, and involves only the section above the diaphragm Type IIIb - begins in the descending aorta, and involves the aorta below the diaphragm
235
What are the risk factors for aortic dissection?
Biscuspid aortic valve Coarctation of the aorta Aortic valve replacement Coronary bypass graft Ehlers-Danlos syndrome Marfan's syndrome HTN
236
What is the presentation of aortic dissection?
Ripping or tearing chest pain Syncope Radio-radial or radio-femoral delay Difference in blood pressure between two arms Hypertension
237
What investigations are performed in suspected aortic dissection?
ECG FBC U&Es Group and save, and crossmatch CXR
238
What is the gold standard investigation for diagnosis of aortic dissection?
Contrast-enhanced CT angiogram
239
What is the management of aortic dissection?
IV labetalol if BP is 100-120 (high pressures are associated with extension of the dissection) Urgent surgical repair - Open surgery with replacement of ascending aorta for type A - Thoracic endovascular aortic repair for type B
240
What are the complications of aortic dissection?
MI Stroke Paraplegia Cardiac tamponade Aortic valve regurgitation Death
241
What is a DVT?
Formation of a blood clot in the deep veins of the leg or pelvis
242
What is Virchow's triad?
Hypercoagulability Venous stasis Endothelial damage
243
What are the risk factors for DVT?
Age Immobility Trauma Thrombophilia Polycythemia Malignancy Smoking Pregnancy Drugs - COCP, HRT, tamoxifen
244
What are the clinical features of DVT?
Unilateral calf or leg swelling Dilated superficial veins Calf tenderness Oedema Redness to the leg
245
What is the Wells score for DVT?
Each criterion scores 1 point: - Active cancer - Bedridden or recent major surgery - Calf swelling > 3cm compared to other leg - Superficial veins present - Entire leg swollen - Tenderness along veins - Pitting oedema of the affected leg - Immobility of affected leg - Previous DVT -2 points for alternative diagnosis likely
246
What are the first line investigations for DVT?
Wells score > 2 - Duplex ultrasound of leg Wells score < 1 - D-dimer - perform an ultrasound if raised
247
What are the possible causes of a raised D dimer?
Pneumonia Malignancy Heart failure Surgery Pregnancy
248
What is the initial management of a DVT?
First line - Offer apixaban or rivaroxaban Second line - LMWH for 5 days, followed by dabigatran or edoxaban, or LMWH and warfarin for 5 days, and then warfarin alone
249
How long should anticoagulation be continued for in patients with a DVT?
3 months
250
What is the initial management of DVT in renal impairment?
LMWH or Unfractioned heparin or LWMH or UFH and warfarin for 5 days, and then warfarin alone
251
How long should anticoagulation for DVT be continued in cancer patients?
3 to 6 months
252
What is post-thrombotic syndrome?
A chronic condition that develops weeks to months after a DVT, due to venous hypertension
253
What is the presentation of post-thrombotic syndrome?
Painful, heavy calves Pruritus Swelling Varicose veins Venous ulceration
254
What is hypertrophic obstructive cardiomyopathy?
The left ventricle becomes hypertrophic, which also affects the septum of the heart, ad causes left ventricular outflow tract obstruction
255
What is the inheritance of HOCM?
Autosomal dominant
256
What is the presentation of HOCM?
Most patients are asymptomatic Shortness of breath Fatigue Dizziness Syncope Chest pain Palpitations
257
What is HOCM associated with an increased risk of?
Heart failure MI Arrhythmias Sudden cardiac death
258
What are the examination findings in HOCM?
Ejection systolic murmur Fourth heart sound Thrill at lower left sternal border
259
What initial investigations are performed in HOCM?
ECG - left ventricular hypertrophy CXR - normal
260
What investigations are diagnostic of HOCM?
Echocardiogram Cardiac MRI
261
What is the management of HOCM?
ABCDE A - amiodarone B - beta blockers (or verapamil) C - cardioverter defibrillator D - dual chamber pacemaker E - endocarditis prophylaxis
262
What is dilated cardiomyopathy?
A dilated heart, leading to systolic dysfunction
263
What are the causes of dilated cardiomyopathy?
Idiopathic - most common Myocarditis Ischaemic heart disease Hypertension Iatrogenic Substance abuse Inherited
264
What is restrictive cardiomyopathy?
Where the heart becomes rigid and stiff, leading to impaired ventricular filling during diastole
265
What is peripheral arterial disease?
Narrowing of the arteries supplying the limbs, reducing blood supply to these areas
266
What is intermittent claudication
A symptom of ischaemia in a limb, that occurs during exertion and is relieved by rest
267
What is critical limb ischaemia?
The end-stage of peripheral arterial disease, where there is an inadequate supply of blood to a limb, causing dysfunction at rest
268
What are the risk factors for peripheral arterial disease?
Smoking - biggest risk factor Diabetes Advancing age Male Hypercholesterolaemia Hypertension CKD
269
What are the stages of peripheral vascular disease?
1 - asymptomatic 2 - intermittent claudication 3 - critical limb ischaemia 4 - tissue loss
270
Where are the common sites of claudication and where would they cause pain?
Common iliac - unilateral buttock Common femoral - unilateral thigh Superficial femoral - unilateral calf
271
What is the presentation of acute limb ischaemia?
6Ps - Pain - Pallor - Pulseless - Paralysis - Paraesthesia - Perishing cold
272
What is Leriche syndrome?
Occlusion in the distal aorta or proximal common iliac artery causing: - Thigh/buttock claudication - Absent femoral pulses - Erectile dysfunction
273
What are the first line investigations for peripheral vascular disease?
Duplex ultrasound ABPI
274
What is the interpretation of ABPI results?
0.9-1.3 - normal 0.6-0.9 - mild peripheral arterial disease 0.3-0.6 - moderate to severe peripheral arterial disease <0.3 - severe disease to critical ischaemia
275
What are the signs of arterial disease on inspection?
Skin pallor Cyanosis Muscle wasting Hair loss Ulcers Poor wound healing Gangrene
276
What is Buerger's test?
The legs are held at an angle of 45 degrees for 1-2 minutes, looking for pallor The legs are then hung over the side of the bed with the patient sat up. In arterial disease: - The legs will go blue initially - Legs will then turn dark red (rubor) after a short time
277
What is the appearance of arterial ulcers?
Smaller than venous ulcers Deeper than venous ulcers Well defined borders Punched out appearance Occur peripherally Reduced bleeding Painful
278
What is the appearance of venous ulcers?
Occur after minor injury to the leg Larger than arterial ulcers More superficial than arterial ulcers Irregular, gently sloping borders Affect the gaiter area of the leg (mid calf down to ankle) Less painful than venous ulcers
279
What is the non-pharmacological management of intermittent claudication?
Lifestyle changes Exercise training
280
What is the medical management of intermittent claudication?
Atorvastatin 80mg daily Clopidogrel 75mg daily Treat other comorbidities - HTN, diabetes
281
What is the surgical management of intermittent claudication?
Endovascular angioplasty and stenting Endarterectomy Bypass surgery
282
What is the management of critical limb ischaemia?
Urgent revascularisation: - Endovascular angioplasty and stenting - Endarterectomy - Bypass surgery - Amputation of limb as last resort
283
What is the management of acute limb ischaemia?
Endovascular thrombolysis Endovascular thrombectomy Surgical thrombectomy Endarterectomy Bypass surgery Amputation
284
What are the complications of peripheral arterial disease?
Critical limb ischaemia and acute limb ischaemia Ulceration and gangrene Infection and poor tissue healing Amputation
285
What is the cause of arterial leg ulcers?
Insufficient blood supply to the skin due to peripheral arterial disease
286
What is the cause of venous leg ulcers?
Due to the pooling of blood and waste products in the skin secondary to venous insufficiency
287
What is the management of arterial ulcers?
Treat peripheral arterial disease
288
What is the management of venous ulcers?
Compression therapy - 4 layer compression banding Wound care: - Cleaning the wound - Debridement - Dressing the wound Antibiotics to treat infection Analgesia
289
What is the second line management of venous leg ulcers?
Skin grafting - If they fail to heal after 12 weeks or if larger than 10cm2
290
What is atherosclerosis?
A combination of fatty deposits (atheromas) in the artery walls, and sclerosis of the vessel walls
291
How does atherosclerosis cause ischaemia?
Plaque rupture creates a thrombus that can block a distal vessel and cause ischaemia
292
What are the non-modifiable risk factors for cardiovascular disease?
Older age Family history Male
293
What are the modifiable risk factors for cardiovascular disease?
Hypercholesterolaemia Smoking Alcohol excess Poor diet Sedentary lifestyle Obesity Poor sleep Stress
294
What co-morbidities increase the risk of cardiovascular disease?
Diabetes HTN CKD Inflammatory conditions e.g rheumatoid Atypical antipsychotic medications
295
What are the end results of cardiovascular disease?
Angina MI TIA Stroke Peripheral arterial disease Chronic mesenteric ischaemia
296
What diet advice is recommended for prevention of cardiovascular disease?
Total fat less than 30% of total calories Low saturated fat Reduced sugar intake Wholegrain foods 5 portions of fruit and veg a day 2 portions of fish a week 4 portions of legumes, seeds and nuts a week
297
What exercise advice is recommended for prevention of cardiovascular disease?
150 minutes of moderate intensity exercise a week or 75 minutes of vigorous intensity exercise a week Strength training activities at least 2 days a week
298
What score is used to assess risk in patients with CVD?
QRISK3
299
How should patients with a high QRISK score be managed?
Patients with a score of >10% should be offered atorvastatin 20mg daily
300
What are the side effects of statins?
Myopathy Rhabdomyolysis Type 2 diabetes Haemorrhagic strokes
301
What type of antibiotics do statins interact with?
Macrolides - clarithromycin, erythromycin
302
What medications are used in the secondary prevention of CVD?
4 As - Antiplatelet - Atorvastatin 80mg - Atenolol - ACE inhibitor
303
What is familial hypercholesterolaemia?
An autosomal dominant disorder that causes very high cholesterol levels
304
305
What is myocarditis?
Inflammation of the myocardium that commonly occurs following a viral inection
306
What is the most common cause of myocarditis?
Cocksackie B virus
307
What are the common causes of myocarditis?
Viral infections: - Cocksackie B virus - COVID-19 - Adenovirus - EBV Bacterial infections: - Diphtheria - Clostridia - Neisseria gonorrhoea Autoimmune - Kawasaki disease - Scleroderma, SLE, sarcoid and systemic vasculitidies Drug reaction - Antipsychotics - Mesalazine
308
What is the clinical presentation of myocarditis?
Chest pain - sharp/stabbing Shortness of breath Palpitations Lightheadedness Syncope Fever and viral prodrome
309
What are the signs of myocarditis on examination?
Dull heart sounds If myopericarditis - pericardial rub may be heard In fulminant myocarditis - may have signs of heart failure
310
What are the differentials of myocarditis?
ACS Pericarditis Pulmonary embolism
311
What investigations are performed in the diagnosis of myocarditis?
ECG - non specific ST segment and T wave changes Troponin - raised Inflammatory markers Viral serology Echocardiogram Cardiac MRI
312
What is the gold standard investigation for myocarditis?
Endomyocardial biopsy - histopathology shows infiltration of inflammatory cells into the myocardium and myocardial necrosis
313
What is the management of myocarditis?
Supportive/addressing the underlying cause - Patients with severe myocarditis may require ITU support and vasopressors - Patients with viral acute myocarditis may benefit from corticosteroids
314
What are the complications of myocarditis?
Heart failure Arrhythmias Dilated cardiomyopathy
315
What signs in bradycardia indicate the need for immediate treatment?
Shock Syncope Myocardial ischaemia Heart failure
316
What is the first line management of bradycardia?
500mcg IV atropine
317
What is the second line management of bradycardia?
Continue giving atropine, up to a maximum of 3mg
318
What is the third line management of bradycardia?
Transcutaneous pacing Isoprenaline/adrenaline infusion
319
What is the fourth line management of bradycardia?
Transvenous pacing
320
What is a third heart sound?
Rapid ventricular filling causes the chords in the ventricle to pull, and then twang (like a guitar)
321
What can S3 indicate?
Heart failure (but can be normal in young people)
322
When is the third heart sound heard?
Just after the second heart sound
323
When is the fourth heart sound heard?
Just before the first heart sound
324
What does a fourth heart sound indicate?
Stiff/ hypertrophic ventricles
325
What are we hearing with the fourth heart sound?
Turbulent flow into the ventricle, caused by the filling of a non-compliant ventricle
326
What types of valvular pathologies cause hypertrophy of the heart?
Stenosis - Mitral stenosis causes left atrial hypertrophy - Aortic stenosis causes left ventricular hypertrophy
327
What types of valvular pathologies cause heart dilatation?
Regurgitation - Mitral regurgitation causes left atrial dilatation - Aortic regurgitation causes left ventricular regurgitation
328
What are the causes of mitral stenosis?
Rheumatic fever Endocarditis
329
What murmur is heard in mitral stenosis?
Mid-diastolic, low pitched rumbling
330
What else is heard in mitral stenosis?
Loud S1 - hypertrophied valve is loud to shut
331
What face sign is associated with mitral stenosis?
Malar flush
332
What arrhythmia is mitral stenosis associated with?
Atrial fibrillation
333
What type of murmur is heard in mitral regurgitation
Pan-systolic with high pitched whistling
334
What condition is mitral regurgitation associated with?
Congestive cardiac failure
335
Where does mitral regurgitation radiate to?
Axilla
336
What are the causes of mitral regurgitation?
Idiopathic weakening of valve Ischaemic heart disease Endocarditis Rheumatic heart disease Connective tissue disorders
337
What is the most common valvular disease?
Aortic stenosis
338
What kind of murmur is heard in aortic stenosis?
Ejection systolic murmur - High pitched - Crescendo-decrescendo
339
Where does aortic stenosis radiate?
Carotids
340
What other features are present in aortic stenosis?
Slow rising pulse Narrow pulse pressure
341
What are the causes of aortic stenosis?
Idiopathic age related calcification Rheumatic heart disease
342
What type of murmur does aortic regurgitation cause?
Early diastolic murmur
343
What type of pulse is associated with aortic regurgitation?
Collapsing pulse

Finals 🩺 (28 decks)

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