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UKMLA Prep > Cardiology 🫀 > Flashcards

Cardiology 🫀 Flashcards

1
Q

What is the definition of loin pain?

A

A common symptom presenting as discomfort in the area between the lower ribs and buttocks on either side of the spine.

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2
Q

What structures are included in the loin region?

A
  • Kidneys
  • Adrenal glands
  • Parts of the colon
  • Musculoskeletal components
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3
Q

What are common causes of loin pain?

A
  • Renal Colic
  • Pyelonephritis
  • Musculoskeletal Pain
  • Radiculopathy
  • Ruptured abdominal aortic aneurysm (AAA)
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4
Q

What is renal colic?

A

Typically caused by kidney stones obstructing the urinary tract.

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5
Q

What are the symptoms of pyelonephritis?

A

Infection of the kidney presenting with fever and systemic symptoms alongside loin pain.

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6
Q

What is the initial management approach for loin pain?

A
  • Detailed history
  • Physical examination
  • Blood tests and urinalysis
  • Imaging studies like ultrasound or CT scan
  • Pain management with analgesics
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7
Q

What is the mortality rate for a ruptured abdominal aortic aneurysm (AAA)?

A

Almost 80%.

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8
Q

What are the features of a ruptured AAA?

A
  • Severe, central abdominal pain radiating to the back
  • Pulsatile, expansile mass in the abdomen
  • Shocked state (hypotension, tachycardia) or collapse
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9
Q

What is the management for a ruptured AAA?

A

Immediate vascular review with a view to emergency surgical repair.

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10
Q

What should be done if a patient is haemodynamically unstable with suspected AAA?

A

Diagnosis is clinical; these patients should be taken straight to theatre.

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11
Q

What are the two classifications of cardiac rhythms during resuscitation?

A
  • ‘Shockable’ rhythms: VF/pulseless VT
  • ‘Non-shockable’ rhythms: asystole/PEA
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12
Q

What is the ratio of chest compressions to ventilation during CPR?

A

30:2.

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13
Q

In the case of VF/pulseless VT, what is the recommended treatment after the third shock?

A

Administer amiodarone 300 mg.

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14
Q

What are the reversible causes of cardiac arrest categorized as the ‘Hs’?

A
  • Hypoxia
  • Hypovolaemia
  • Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia
  • Hypothermia
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15
Q

What are the reversible causes of cardiac arrest categorized as the ‘Ts’?

A
  • Thrombosis (coronary or pulmonary)
  • Tension pneumothorax
  • Tamponade - cardiac
  • Toxins
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16
Q

What are the features of acute coronary syndrome (ACS)?

A
  • Chest pain
  • Dyspnoea
  • Nausea and vomiting
  • Sweating
  • Palpitations
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17
Q

What is aortic dissection?

A

A tear in the tunica intima of the wall of the aorta.

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18
Q

What is the most important risk factor for aortic dissection?

A

Hypertension.

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19
Q

What are the features of aortic dissection?

A
  • Severe and sharp chest/back pain
  • Pain maximal at onset
  • Pulse deficit
  • Variation in systolic blood pressure between arms
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20
Q

What are the two classifications of aortic dissection?

A
  • Stanford classification
  • DeBakey classification
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21
Q

What does the Stanford classification categorize?

A
  • Type A - ascending aorta
  • Type B - descending aorta
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22
Q

What is the characteristic exam feature of myocardial infarction?

A

Heavy, central chest pain that may radiate to the neck and left arm.

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23
Q

What is the typical presentation of a perforated peptic ulcer?

A

Sudden onset of epigastric abdominal pain followed by generalised abdominal pain.

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24
Q

What is Boerhaave’s syndrome?

A

Spontaneous rupture of the oesophagus due to repeated episodes of vomiting.

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25
Q

What is the immediate management for suspected acute coronary syndrome (ACS)?

A
  • Glyceryl trinitrate
  • Aspirin 300mg
  • Perform an ECG as soon as possible
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26
Q

What defines anginal pain according to NICE guidelines?

A
  • Constricting discomfort in the chest or neck, shoulders, jaw, or arms
  • Precipitated by physical exertion
  • Relieved by rest or GTN in about 5 minutes
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27
Q

What is the first line investigation for stable angina?

A

CT coronary angiography.

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28
Q

What are the ECG changes associated with anteroseptal myocardial infarction?

A

V1-V4.

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29
Q

What does MR imaging assess in relation to stress-induced wall motion abnormalities?

A

MR perfusion or MR imaging

This technique helps evaluate myocardial blood flow and wall motion under stress conditions.

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30
Q

Which ECG changes correlate with anteroseptal coronary artery issues?

A

V1-V4

This indicates involvement of the left anterior descending artery.

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31
Q

What ECG leads indicate inferior coronary artery issues?

A

II, III, aVF

This suggests involvement of the right coronary artery.

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32
Q

What are the ECG leads associated with anterolateral coronary artery issues?

A

V1-6, I, aVL

This typically indicates proximal left anterior descending artery involvement.

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33
Q

What changes are seen in the ECG for posterior infarction?

A

ST elevation and Q waves in posterior leads (V7-9)

Usually associated with the left circumflex artery or right coronary artery.

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34
Q

True or False: A new left bundle branch block (LBBB) can indicate acute coronary syndrome.

A

True

It is important to consider this finding in clinical evaluations.

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35
Q

What is myocarditis?

A

Inflammation of the myocardium

It has various underlying causes and should be suspected in younger patients with chest pain.

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36
Q

Name two viral causes of myocarditis.

A
  • Coxsackie B
  • HIV

These viruses are among the common etiologies of myocarditis.

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37
Q

What are two common presentations of myocarditis?

A
  • Chest pain
  • Dyspnoea

Arrhythmias may also be present.

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38
Q

What is a common complication of myocarditis?

A

Dilated cardiomyopathy

This is usually a late complication of myocarditis.

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39
Q

List the three main patterns of presentation in peripheral arterial disease.

A
  • Intermittent claudication
  • Critical limb ischaemia
  • Acute limb-threatening ischaemia

These presentations indicate varying severities of arterial insufficiency.

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40
Q

What are the 6 P’s of acute limb-threatening ischaemia?

A
  • Pale
  • Pulseless
  • Painful
  • Paralysed
  • Paraesthetic
  • ‘Perishing with cold’

These signs help identify serious ischaemia.

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41
Q

What initial investigation is recommended for suspected acute limb-threatening ischaemia?

A

Handheld arterial Doppler examination

This helps assess blood flow in the affected limb.

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42
Q

What factors suggest a thrombus in acute limb-threatening ischaemia?

A
  • Pre-existing claudication with sudden deterioration
  • Reduced or absent pulses in contralateral limb
  • Sudden onset of painful leg (< 24 hours)

These factors help differentiate from embolic causes.

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43
Q

What is the management for acute limb-threatening ischaemia?

A
  • Initial management: ABC approach, analgesia, IV heparin
  • Definitive management: intra-arterial thrombolysis, surgical embolectomy, angioplasty, bypass surgery, amputation

The approach depends on the severity and cause of ischaemia.

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44
Q

What are potential features of pulmonary embolism?

A
  • Chest pain
  • Dyspnoea
  • Haemoptysis
  • Tachycardia
  • Tachypnoea

The presentation can vary widely based on the embolism’s location and size.

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45
Q

What percentage of patients present with the classic triad of pulmonary embolism symptoms?

A

Around 10%

This highlights the variability in presentation.

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46
Q

What are the common clinical signs of pulmonary embolism according to the PIOPED study?

A
  • Tachypnea (96%)
  • Crackles (58%)
  • Tachycardia (44%)
  • Fever (43%)

These signs can help in the diagnosis of pulmonary embolism.

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47
Q

What is the most common acyanotic congenital heart defect?

A

Ventricular septal defect (VSD)

VSD accounts for 30% of acyanotic defects.

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48
Q

What is the most common cyanotic congenital heart defect?

A

Tetralogy of Fallot (TOF)

TOF presents around 1-2 months of age.

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49
Q

What test can differentiate cardiac from non-cardiac causes of cyanosis in infants?

A

Nitrogen washout test (hyperoxia test)

A pO2 of less than 15 kPa indicates cyanotic congenital heart disease.

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50
Q

What is the management for suspected cyanotic congenital heart disease?

A
  • Supportive care
  • Prostaglandin E1 (e.g., alprostadil)

This treatment maintains a patent ductus arteriosus until diagnosis and surgery.

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51
Q

What are the four characteristic features of Tetralogy of Fallot?

A
  • Ventricular septal defect (VSD)
  • Right ventricular hypertrophy
  • Right ventricular outflow tract obstruction (pulmonary stenosis)
  • Overriding aorta

These features define the condition’s anatomical presentation.

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52
Q

What is the management strategy for Tetralogy of Fallot?

A

Surgical repair, beta-blockers for cyanotic episodes

Surgical intervention is often done in two parts.

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53
Q

What are the clinical features of Transposition of the Great Arteries (TGA)?

A
  • Cyanosis
  • Tachypnoea
  • Loud single S2
  • Prominent right ventricular impulse
  • ‘Egg-on-side’ appearance on chest x-ray

These features are indicative of TGA.

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54
Q

What is the management for Transposition of the Great Arteries?

A
  • Maintenance of the ductus arteriosus with prostaglandins
  • Surgical correction

Prostaglandins are used as a temporary measure.

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55
Q

What are the driving restrictions for a patient with hypertension?

A
  • Can drive unless treatment causes unacceptable side effects
  • Group 2 disqualification if BP consistently 180/100 or more

Specific guidelines dictate driving eligibility based on blood pressure management.

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56
Q

What is the required time off driving after CABG?

A

4 weeks

This is a standard recovery period before resuming driving.

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57
Q

What are the alcohol misuse guidelines for driving?

A
  • Persistent alcohol misuse requires licence revocation until 6 months of controlled drinking
  • Alcohol dependency requires 1 year abstinence

These guidelines ensure road safety regarding substance use.

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58
Q

What is the driving restriction for a patient with a first unprovoked seizure?

A

6 months off driving

This applies if there are no relevant structural abnormalities on brain imaging.

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59
Q

What is the driving restriction for patients with established epilepsy?

A

Must be seizure-free for 12 months

After this period, they may qualify for a driving licence.

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60
Q

When can a patient with narcolepsy resume driving?

A

Once satisfactory control of symptoms is achieved

Diagnosis necessitates immediate cessation of driving.

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61
Q

What must patients with chronic neurological disorders inform the DVLA?

A

Complete PK1 form

This is necessary for assessing fitness to drive.

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62
Q

What must be completed by driving licence holders with medical conditions?

A

Complete PK1 form

This form is required to inform the DVLA about the driver’s state of health.

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63
Q

When can a driving licence be reconsidered after surgery for a benign meningioma?

A

6 months after surgery if remains seizure free

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64
Q

What are the rules for driving with severe anxiety or depression?

A

Must not drive and must notify the DVLA

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65
Q

What should a person with acute psychotic disorder do regarding driving?

A

Must not drive during acute illness and must notify the DVLA

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66
Q

Can individuals with mild cognitive impairment drive?

A

May drive and need not inform the DVLA

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67
Q

What is required for individuals with monocular vision?

A

Must notify DVLA and may drive if acuity and visual field is normal in the remaining eye

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68
Q

What are common features of acute coronary syndrome (ACS)?

A
  • Chest pain
  • Dyspnoea
  • Nausea and vomiting
  • Sweating
  • Palpitations
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69
Q

What are the causes of myocarditis?

A
  • Viral: coxsackie B, HIV
  • Bacteria: diphtheria, clostridia
  • Autoimmune
  • Drugs: doxorubicin
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70
Q

What are the investigations for myocarditis?

A
  • Bloods
  • ECG
  • Cardiac enzymes
  • ↑ inflammatory markers
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71
Q

What defines pulmonary arterial hypertension (PAH)?

A

Resting mean pulmonary artery pressure of >= 20 mmHg

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72
Q

What is the classical presentation of pulmonary arterial hypertension (PAH)?

A

Progressive exertional dyspnoea

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73
Q

What management is central to pulmonary arterial hypertension (PAH)?

A

Acute vasodilator testing

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74
Q

What are the potential features of pulmonary embolism?

A
  • Chest pain
  • Dyspnoea
  • Haemoptysis
  • Tachycardia
  • Tachypnoea
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75
Q

What is erectile dysfunction (ED)?

A

Persistent inability to attain and maintain an erection sufficient for satisfactory sexual performance

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76
Q

What are the risk factors for erectile dysfunction (ED)?

A
  • Cardiovascular disease risk factors
  • Alcohol use
  • Drugs: SSRIs, beta-blockers
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77
Q

What is the first-line treatment for erectile dysfunction (ED)?

A

PDE-5 inhibitors (e.g., sildenafil)

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78
Q

What are the contraindications for PDE-5 inhibitors?

A
  • Patients taking nitrates
  • Hypotension
  • Recent stroke or myocardial infarction
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79
Q

What are the side effects of sildenafil?

A
  • Visual disturbances
  • Flushing
  • Headache
  • Priapism
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80
Q

What are the major criteria for diagnosing infective endocarditis?

A
  • Positive blood cultures
  • Evidence of endocardial involvement
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81
Q

What are the minor criteria for diagnosing infective endocarditis?

A
  • Fever > 38ºC
  • Vascular phenomena
  • Immunological phenomena
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82
Q

What is aortic dissection?

A

A tear in the tunica intima of the wall of the aorta

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83
Q

What are common features of aortic dissection?

A
  • Severe and sharp chest/back pain
  • Pulse deficit
  • Variation in systolic blood pressure between arms
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84
Q

What are the classifications of aortic dissection?

A
  • Stanford classification: Type A and Type B
  • DeBakey classification: Type I, II, III
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85
Q

What are the ECG changes associated with some patients experiencing ST-segment elevation?

A

ST-segment elevation may be seen in the inferior leads in a minority of patients

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86
Q

What are the two types of Stanford classification for aortic dissection?

A
  • Type A - ascending aorta, 2/3 of cases
  • Type B - descending aorta, distal to left subclavian origin, 1/3 of cases
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87
Q

What are the three types of DeBakey classification for aortic dissection?

A
  • Type I - originates in ascending aorta, propagates to aortic arch and beyond distally
  • Type II - originates in and is confined to the ascending aorta
  • Type III - originates in descending aorta, rarely extends proximally but extends distally
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88
Q

What is the typical presentation of chronic kidney disease?

A

Usually asymptomatic, diagnosed following abnormal urea and electrolyte results

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89
Q

List possible features of late-stage chronic kidney disease.

A
  • Oedema (e.g. ankle swelling, weight gain)
  • Polyuria
  • Lethargy
  • Pruritus (secondary to uraemia)
  • Anorexia (may result in weight loss)
  • Insomnia
  • Nausea and vomiting
  • Hypertension
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90
Q

What does coarctation of the aorta describe?

A

A congenital narrowing of the descending aorta

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91
Q

What are common associations with coarctation of the aorta?

A
  • Turner’s syndrome
  • Bicuspid aortic valve
  • Berry aneurysms
  • Neurofibromatosis
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92
Q

What symptoms may present in infancy and adulthood due to coarctation of the aorta?

A
  • Infancy: heart failure
  • Adult: hypertension, radio-femoral delay, mid systolic murmur, apical click, notching of inferior border of ribs
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93
Q

What defines hypertension?

A

Chronically raised blood pressure, typically without symptoms unless very high

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94
Q

What is considered ‘normal’ blood pressure?

A

Between 90/60 mmHg and 140/90 mmHg

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95
Q

How does NICE define hypertension in terms of blood pressure readings?

A
  • Clinic reading persistently above >= 140/90 mmHg
  • 24-hour blood pressure average reading >= 135/85 mmHg
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96
Q

What are the two categories of hypertension?

A
  • Primary (essential) hypertension
  • Secondary hypertension
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97
Q

List some causes of secondary hypertension.

A
  • Renal disease (e.g. glomerulonephritis, renal artery stenosis)
  • Endocrine disorders (e.g. primary hyperaldosteronism, Cushing’s syndrome)
  • Other causes (e.g. glucocorticoids, pregnancy, coarctation of the aorta)
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98
Q

What symptoms may occur in severely elevated hypertension (> 200/120 mmHg)?

A
  • Headaches
  • Visual disturbance
  • Seizures
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99
Q

What tests are typically performed following a diagnosis of hypertension?

A
  • Urea and electrolytes
  • HbA1c
  • Lipids
  • ECG
  • Urine dipstick
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100
Q

What are the main aspects of managing hypertension?

A
  • Drug therapy using antihypertensives
  • Modification of risk factors
  • Monitoring for complications
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101
Q

What is the mechanism of action of ACE inhibitors?

A

Inhibit the conversion of angiotensin I to angiotensin II

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102
Q

What are common side effects of ACE inhibitors?

A
  • Cough
  • Angioedema
  • Hyperkalaemia
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103
Q

What is the first-line treatment for younger patients (< 55 years old) with hypertension?

A

ACE inhibitors

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104
Q

What are the common side effects of calcium channel blockers?

A
  • Flushing
  • Ankle swelling
  • Headache
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105
Q

What is the role of thiazide-type diuretics in hypertension management?

A

Inhibit sodium absorption at the beginning of the distal convoluted tubule

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106
Q

What is the recommended daily salt intake for hypertension management?

A

Less than 6g/day, ideally 3g/day

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107
Q

What recommendation did NICE make regarding ambulatory blood pressure monitoring (ABPM)?

A

It is now recommended for the diagnosis of hypertension

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108
Q

What is the criteria for Stage 1 hypertension according to NICE?

A

Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg

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109
Q

What should be done if a patient’s blood pressure is >= 180/120 mmHg?

A

Admit for specialist assessment if signs of retinal haemorrhage, life-threatening symptoms, or suspected phaeochromocytoma are present

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110
Q

What is the protocol for home blood pressure monitoring (HBPM)?

A
  • Two consecutive measurements at least 1 minute apart
  • Record twice daily for at least 4 days
  • Discard first day’s measurements and average the rest
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111
Q

What is the updated NICE guideline regarding antihypertensive drug treatment for adults under 60 with stage 1 hypertension?

A

Consider treatment in addition to lifestyle advice for those with a 10-year risk below 10%

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112
Q

What should be checked in patients with resistant hypertension before adding a fourth drug?

A
  • Confirm elevated clinic BP with ABPM or HBPM
  • Assess for postural hypotension
  • Discuss adherence
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113
Q

What is the first step in treatment for patients < 55 years old?

A

ACE inhibitor or Angiotensin receptor blocker

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114
Q

What defines step 4 treatment in hypertension management?

A

Resistant hypertension, consider adding a 4th drug or seeking specialist advice

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115
Q

What is defined as resistant hypertension according to NICE?

A

Step 4 treatment involves adding a 4th drug or seeking specialist advice

Confirm elevated clinic BP with ABPM or HBPM, assess for postural hypotension, and discuss adherence.

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116
Q

What should be added if potassium levels are less than 4.5 mmol/l?

A

Low-dose spironolactone

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117
Q

What should be added if potassium levels are greater than 4.5 mmol/l?

A

An alpha- or beta-blocker

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118
Q

What blood pressure targets does NICE recommend for patients under 80 years?

A

140/90 mmHg for clinic BP and 135/85 mmHg for ABPM/HBPM

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119
Q

What percentage of patients diagnosed with hypertension have primary hyperaldosteronism?

A

5-10%

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120
Q

List some conditions that may increase blood pressure due to renal disease.

A
  • Glomerulonephritis
  • Pyelonephritis
  • Adult polycystic kidney disease
  • Renal artery stenosis
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121
Q

Name endocrine disorders that may result in increased blood pressure.

A
  • Phaeochromocytoma
  • Cushing’s syndrome
  • Liddle’s syndrome
  • Congenital adrenal hyperplasia (11-beta hydroxylase deficiency)
  • Acromegaly
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122
Q

What are some drug causes of secondary hypertension?

A
  • Steroids
  • Monoamine oxidase inhibitors
  • Combined oral contraceptive pill
  • NSAIDs
  • Leflunomide
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123
Q

What is pre-eclampsia?

A

Emergence of high blood pressure during pregnancy that may precede eclampsia and other complications

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124
Q

What are the classic triad symptoms of pre-eclampsia?

A
  • New-onset hypertension
  • Proteinuria
  • Oedema
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125
Q

What is the formal definition of pre-eclampsia?

A

New-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following: proteinuria, other organ involvement

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126
Q

What are potential consequences of pre-eclampsia?

A
  • Eclampsia
  • Altered mental status
  • Blindness
  • Stroke
  • Clonus
  • Severe headaches
  • Fetal complications
  • Cardiac failure
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127
Q

List high-risk factors for pre-eclampsia.

A
  • Hypertensive disease in a previous pregnancy
  • Chronic kidney disease
  • Autoimmune disease
  • Type 1 or type 2 diabetes
  • Chronic hypertension
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128
Q

What should women with high-risk factors do to reduce the risk of hypertensive disorders in pregnancy?

A

Take aspirin 75-150mg daily from 12 weeks gestation until birth

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129
Q

What are the three main patterns of presentation in peripheral arterial disease?

A
  • Intermittent claudication
  • Critical limb ischaemia
  • Acute limb-threatening ischaemia
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130
Q

Describe intermittent claudication.

A

Aching or burning in the leg muscles following walking, usually relieved within minutes of stopping

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131
Q

What does an ankle brachial pressure index (ABPI) of <0.3 indicate?

A

Impending limb ischaemia

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132
Q

What is mitral regurgitation (MR)?

A

Occurs when blood leaks back through the mitral valve on systole

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133
Q

What are common risk factors for mitral regurgitation?

A
  • Female sex
  • Lower body mass
  • Age
  • Renal dysfunction
  • Prior myocardial infarction
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134
Q

What is a common cause of mitral regurgitation following a myocardial infarction?

A

Damage to the papillary muscles or chordae tendinae

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135
Q

What are the symptoms of mitral regurgitation?

A
  • Fatigue
  • Shortness of breath
  • Oedema
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136
Q

What type of murmur is associated with mitral regurgitation?

A

Pansystolic murmur described as ‘blowing’

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137
Q

What are the management options for severe mitral regurgitation?

A
  • Medical management
  • Surgery (repair or replacement)
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138
Q

What is mitral stenosis?

A

Obstruction of blood flow across the mitral valve from the left atrium to the left ventricle

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139
Q

What are common features of mitral stenosis?

A
  • Dyspnoea
  • Haemoptysis
  • Mid-late diastolic murmur
  • Loud S1
  • Atrial fibrillation
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140
Q

What is the normal cross-sectional area of the mitral valve?

A

4-6 sq cm

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141
Q

What is the first-line treatment for patients with mitral stenosis and atrial fibrillation?

A

Anticoagulation with warfarin

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142
Q

What percentage of the population is affected by mitral valve prolapse?

A

5-10%

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143
Q

What are some associations with mitral valve prolapse?

A
  • Congenital heart disease
  • Cardiomyopathy
  • Marfan’s syndrome
  • Ehlers-Danlos syndrome
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144
Q

What are the two main options for valve replacement?

A
  • Biological (bioprosthetic) valves
  • Mechanical valves
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145
Q

What is a major disadvantage of biological (bioprosthetic) valves?

A

Structural deterioration and calcification over time

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146
Q

What is the target INR for aortic mechanical valves?

A

3.0

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147
Q

What is the target INR for mitral mechanical valves?

A

3.5

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148
Q

True or False: Antibiotics are recommended for prophylaxis of endocarditis for common procedures such as dental work.

A

False

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149
Q

What causes the first heart sound (S1)?

A

Closure of the mitral and tricuspid valves

S1 may be soft in long PR or mitral regurgitation and loud in mitral stenosis.

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150
Q

What causes the second heart sound (S2)?

A

Closure of the aortic and pulmonary valves

S2 may be soft in aortic stenosis and splitting during inspiration is normal.

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151
Q

What is the third heart sound (S3) associated with?

A

Diastolic filling of the ventricle

Considered normal if < 30 years old; may persist in women up to 50 years old.

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152
Q

What conditions can S3 be heard in?

A
  • Left ventricular failure
  • Constrictive pericarditis
  • Mitral regurgitation

S3 may be referred to as a pericardial knock in constrictive pericarditis.

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153
Q

What is the fourth heart sound (S4) caused by?

A

Atrial contraction against a stiff ventricle

S4 coincides with the P wave on ECG and may be heard in aortic stenosis, HOCM, and hypertension.

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154
Q

Where is the pulmonary valve best auscultated?

A

Left second intercostal space, at the upper sternal border

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155
Q

Where is the aortic valve best auscultated?

A

Right second intercostal space, at the upper sternal border

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156
Q

Where is the mitral valve best auscultated?

A

Left fifth intercostal space, just medial to mid clavicular line

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157
Q

Where is the tricuspid valve best auscultated?

A

Left fourth intercostal space, at the lower left sternal border

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158
Q

What causes a loud S2?

A
  • Hypertension (systemic or pulmonary)
  • Hyperdynamic states
  • Atrial septal defect without pulmonary hypertension
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159
Q

What causes a soft S2?

A

Aortic stenosis

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160
Q

What is the cause of a fixed split S2?

A

Atrial septal defect

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161
Q

What causes a widely split S2?

A
  • Deep inspiration
  • RBBB
  • Pulmonary stenosis
  • Severe mitral regurgitation
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162
Q

What causes a reversed (paradoxical) split S2?

A
  • LBBB
  • Severe aortic stenosis
  • Right ventricular pacing
  • WPW type B
  • Patent ductus arteriosus
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163
Q

What are the characteristics of an innocent ejection murmur?

A
  • Soft-blowing murmur in the pulmonary area or short buzzing murmur in the aortic area
  • May vary with posture
  • Localized with no radiation
  • No diastolic component
  • No thrill
  • No added sounds
  • Asymptomatic child
  • No other abnormality
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164
Q

What is an ejection systolic murmur associated with?

A
  • Aortic stenosis
  • Hypertrophic obstructive cardiomyopathy
  • Pulmonary stenosis
  • Atrial septal defect
  • Tetralogy of Fallot
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165
Q

What characterizes a holosystolic (pansystolic) murmur?

A

Mitral/tricuspid regurgitation, high-pitched and ‘blowing’ in character

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166
Q

What is the typical presentation of acute coronary syndrome (ACS)?

A
  • Chest pain (classically on the left side)
  • Dyspnoea
  • Nausea and vomiting
  • Sweating
  • Palpitations
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167
Q

What are the features of acute pericarditis?

A
  • Chest pain (often pleuritic, relieved by sitting forwards)
  • Non-productive cough
  • Dyspnoea
  • Flu-like symptoms
  • Pericardial rub
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168
Q

What ECG changes are associated with pericarditis?

A
  • Global ST elevation
  • PR depression
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169
Q

What is the management for acute pericarditis?

A
  • Outpatient management for most patients
  • Inpatient management for high-risk features
  • NSAIDs and colchicine for viral pericarditis
  • Avoid strenuous physical activity until symptom resolution
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170
Q

What are common features of pulmonary embolism?

A
  • Chest pain (typically pleuritic)
  • Dyspnoea
  • Haemoptysis
  • Tachycardia
  • Tachypnoea
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171
Q

What are the common clinical signs of pulmonary embolism according to the PIOPED study?

A
  • Tachypnea (96%)
  • Crackles (58%)
  • Tachycardia (44%)
  • Fever (43%)
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172
Q

What is the primary cause of venous leg ulcers?

A

Venous hypertension due to chronic venous insufficiency

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173
Q

What are the features of venous insufficiency?

A
  • Oedema
  • Brown pigmentation
  • Lipodermatosclerosis
  • Eczema
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174
Q

What is the Waterlow score used for?

A

To screen for patients at risk of developing pressure ulcers

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175
Q

What is defined as a transient loss of consciousness due to global cerebral hypoperfusion?

A

Syncope

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176
Q

What is the most common cause of syncope?

A

Reflex syncope, particularly vasovagal syncope

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177
Q

What is the typical duration of vasovagal syncope?

A

Less than 1-2 minutes

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178
Q

What are the classifications of syncope according to the European Society of Cardiology?

A
  • Reflex syncope (neurally mediated)
  • Orthostatic syncope
  • Cardiac syncope
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179
Q

What is the typical management for pressure ulcers?

A
  • Maintain a moist wound environment
  • Use hydrocolloid dressings and hydrogels
  • Consider referral to tissue viability nurse
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180
Q

What is Marjolin’s ulcer?

A

Squamous cell carcinoma occurring at sites of chronic inflammation

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181
Q

What is considered diagnostic for a symptomatic fall in blood pressure?

A

A symptomatic fall in systolic BP > 20 mmHg or diastolic BP > 10 mmHg or decrease in systolic BP < 90 mmHg

This indicates potential underlying issues requiring further evaluation.

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182
Q

What is the first test recommended for all patients experiencing sudden visual loss?

A

ECG for all patients

This helps assess cardiac causes of symptoms.

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183
Q

What additional tests may be needed for patients with sudden visual loss?

A

Other tests depend on clinical features

Typical features with a normal ECG may not require further investigations.

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184
Q

What does the term transient monocular visual loss (TMVL) refer to?

A

A sudden, transient loss of vision that lasts less than 24 hours

This condition is alarming for patients and may indicate serious issues.

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185
Q

What are the most common causes of sudden painless loss of vision?

A
  • Ischaemic/vascular causes
  • Vitreous haemorrhage
  • Retinal detachment
  • Retinal migraine

Ischaemic causes may include thrombosis, embolism, and temporal arteritis.

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186
Q

What does ‘amaurosis fugax’ refer to?

A

Ischaemic/vascular causes of transient monocular visual loss

It is associated with various vascular issues affecting vision.

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187
Q

What is a common treatment for transient ischaemic attack (TIA) related to sudden vision loss?

A

Aspirin 300mg

This treatment is used to prevent further vascular events.

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188
Q

What visual defect is often described as ‘curtain coming down’?

A

Altitudinal field defects

This description is common in cases of ischaemic optic neuropathy.

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189
Q

What are the common causes of central retinal vein occlusion?

A
  • Glaucoma
  • Polycythaemia
  • Hypertension

The incidence of this condition increases with age.

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190
Q

What are the features of central retinal artery occlusion?

A
  • Afferent pupillary defect
  • ‘Cherry red’ spot on a pale retina

This condition is often caused by thromboembolism or arteritis.

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191
Q

What conditions can lead to vitreous haemorrhage?

A
  • Diabetes
  • Bleeding disorders
  • Anticoagulants

Symptoms may include sudden visual loss and dark spots.

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192
Q

What are the features of retinal detachment?

A
  • Dense shadow that starts peripherally and progresses towards central vision
  • A veil or curtain over the field of vision
  • Straight lines appear curved
  • Central visual loss

It may follow vitreous detachment, which includes flashes of light or floaters.

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193
Q

Fill in the blank: The features of posterior vitreous detachment include _______.

A

Flashes of light (photopsia) in the peripheral field of vision

Floaters are often seen on the temporal side of central vision.

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194
Q

What differentiates retinal detachment from vitreous haemorrhage?

A
  • Retinal detachment: dense shadow, veil, central visual loss
  • Vitreous haemorrhage: large bleeds cause sudden visual loss, moderate bleeds may cause numerous dark spots

These distinctions are crucial for proper diagnosis and management.

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195
Q

What does acute coronary syndrome (ACS) encompass?

A

ACS includes ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina.

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196
Q

What is ischaemic heart disease synonymous with?

A

Ischaemic heart disease is synonymous with coronary heart disease and coronary artery disease.

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197
Q

What are the two main problems caused by the gradual buildup of fatty plaques in coronary arteries?

A
  • Gradual narrowing leading to angina
  • Risk of sudden plaque rupture causing occlusion
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198
Q

List three unmodifiable risk factors for developing ischaemic heart disease.

A
  • Increasing age
  • Male gender
  • Family history
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199
Q

List four modifiable risk factors for developing ischaemic heart disease.

A
  • Smoking
  • Diabetes mellitus
  • Hypertension
  • Hypercholesterolaemia
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200
Q

What triggers initial endothelial dysfunction in ischaemic heart disease?

A
  • Smoking
  • Hypertension
  • Hyperglycaemia
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201
Q

What is the role of macrophages in the development of atherosclerosis?

A

Monocytes migrate from the blood, differentiate into macrophages, phagocytose oxidized LDL, and turn into foam cells.

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202
Q

What are the classic symptoms of acute coronary syndrome (ACS)?

A
  • Chest pain
  • Dyspnoea
  • Sweating
  • Nausea and vomiting
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203
Q

What is the most common feature of ACS?

A

Chest pain.

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204
Q

What are the two most important investigations in assessing a patient with chest pain?

A
  • ECG
  • Cardiac markers (e.g., troponin)
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205
Q

What does the acronym MONA stand for in ACS management?

A
  • Morphine
  • Oxygen
  • Nitrates
  • Aspirin
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206
Q

What is the priority of management for patients presenting with STEMI?

A

Revascularise the blocked vessel.

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207
Q

What is the first step in managing a confirmed STEMI?

A

Assess eligibility for coronary reperfusion therapy.

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208
Q

What are the two types of coronary reperfusion therapy for STEMI?

A
  • Percutaneous coronary intervention (PCI)
  • Fibrinolysis
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209
Q

Fill in the blank: In NSTEMI, a risk stratification tool called _______ is used.

A

[GRACE]

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210
Q

What is the minimum lifelong drug therapy for patients who have had an ACS?

A
  • Aspirin
  • Second antiplatelet (if appropriate)
  • Beta-blocker
  • ACE inhibitor
  • Statin
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211
Q

What ECG changes are associated with an anterior myocardial infarction?

A

ST elevation in leads V1-V4.

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212
Q

True or False: Oxygen should be given to all patients with ACS.

213
Q

What should be considered if a patient’s ECG shows persistent ST elevation after fibrinolysis?

A

Transfer for PCI.

214
Q

What is the significance of new left bundle branch block (LBBB) in STEMI criteria?

A

LBBB should be considered new unless there is evidence otherwise.

215
Q

What is the role of dual antiplatelet therapy prior to PCI?

A

It combines aspirin with another antiplatelet drug.

216
Q

What is the GRACE tool used for?

A

Risk assessment in NSTEMI/unstable angina.

217
Q

What does the acronym GRACE stand for in the context of risk assessment?

A

[Global Registry of Acute Coronary Events]

218
Q

What are the ECG criteria for determining STEMI?

A
  • Clinical symptoms of ACS
  • Persistent ST elevation in ≥ 2 contiguous leads
219
Q

What is the most widely used tool for risk assessment in acute coronary events?

A

Acute Coronary Events (GRACE)

220
Q

Which factors are taken into account when calculating the GRACE score?

A
  • age
  • heart rate
  • blood pressure
  • cardiac (Killip class) and renal function (serum creatinine)
  • cardiac arrest on presentation
  • ECG findings
  • troponin levels
221
Q

What are the risk stratifications based on predicted 6-month mortality?

A
  • 1.5% or below - Lowest
  • > 1.5% to 3.0% - Low
  • > 3.0% to 6.0% - Intermediate
  • > 6.0% to 9.0% - High
  • over 9.0% - Highest
222
Q

Which patients with NSTEMI/unstable angina should have coronary angiography immediately?

A

Patients who are clinically unstable (e.g. hypotensive)

223
Q

When should coronary angiography be performed for patients with a GRACE score?

A

Within 72 hours for patients with a GRACE score > 3%

224
Q

What is the recommended drug therapy for patients undergoing percutaneous coronary intervention (PCI)?

A
  • unfractionated heparin
  • dual antiplatelet therapy (aspirin + another drug)
  • prasugrel or ticagrelor if not taking an oral anticoagulant
  • clopidogrel if taking an oral anticoagulant
225
Q

What is the treatment for patients with NSTEMI/unstable angina at high risk of bleeding?

A

Clopidogrel

226
Q

What are poor prognostic factors in patients with acute coronary syndrome?

A
  • age
  • development (or history) of heart failure
  • peripheral vascular disease
  • reduced systolic blood pressure
  • Killip class
  • initial serum creatinine concentration
  • elevated initial cardiac markers
  • cardiac arrest on admission
  • ST segment deviation
227
Q

What does the Killip class system stratify?

A

Risk post myocardial infarction

228
Q

What is the 30-day mortality for Killip class I?

229
Q

What is the most common cause of death following a myocardial infarction?

A

Cardiac arrest due to ventricular fibrillation

230
Q

What is cardiogenic shock?

A

A condition where ejection fraction decreases due to a large part of the ventricular myocardium being damaged in an infarction

231
Q

What are common arrhythmias following a myocardial infarction?

A
  • Ventricular fibrillation
  • Ventricular tachycardia
  • Atrioventricular block
232
Q

What is Dressler’s syndrome?

A

An autoimmune reaction occurring 2-6 weeks after a myocardial infarction characterized by fever, pleuritic pain, pericardial effusion, and raised ESR

233
Q

What are the key drugs recommended for all patients following a myocardial infarction according to NICE guidelines?

A
  • dual antiplatelet therapy
  • ACE inhibitor
  • beta-blocker
  • statin
234
Q

What is the recommended lifestyle change regarding diet for patients post-myocardial infarction?

A

Advise a Mediterranean style diet, switch butter and cheese for plant oil based products

235
Q

What is the management for a ruptured abdominal aortic aneurysm (AAA)?

A

Surgical emergency - immediate vascular review and emergency surgical repair

236
Q

What is the interpretation for an aorta width of < 3 cm during AAA screening?

A

Normal - No further action

237
Q

What is the most important risk factor for aortic dissection?

A

Hypertension

238
Q

What are the features of acute limb-threatening ischaemia?

A
  • pale
  • pulseless
  • painful
  • paralysed
  • paraesthetic
  • ‘perishing with cold’
239
Q

What does an ankle-brachial pressure index (ABPI) of < 0.5 suggest?

A

Critical limb ischaemia

240
Q

What classification is used for aortic dissection?

A

Stanford classification

241
Q

What are the two types in the Stanford classification of aortic dissection?

A
  • Type A - ascending aorta
  • Type B - descending aorta
242
Q

What is the main characteristic of type A aortic dissection in the Stanford classification?

A

Ascending aorta, 2/3 of cases

243
Q

How does type B aortic dissection differ in the Stanford classification?

A

Descending aorta, distal to left subclavian origin, 1/3 of cases

244
Q

In the DeBakey classification, what is the origin of type I aortic dissection?

A

Originates in ascending aorta, propagates to at least the aortic arch and possibly beyond it distally

245
Q

What defines type II aortic dissection in the DeBakey classification?

A

Originates in and is confined to the ascending aorta

246
Q

What is the characteristic of type III aortic dissection in the DeBakey classification?

A

Originates in descending aorta, rarely extends proximally but will extend distally

247
Q

What key finding in diagnosing aortic dissection is identified on CT angiography?

A

A false lumen

248
Q

What is the initial management for type A aortic dissection?

A

Surgical management with blood pressure control to a target systolic of 100-120 mmHg

249
Q

What is the preferred management for type B aortic dissection?

A

Conservative management, bed rest, reduce blood pressure IV labetalol

250
Q

Name a complication associated with backward tear in aortic dissection.

A

Aortic incompetence/regurgitation

251
Q

Which murmur is characteristic of aortic regurgitation?

A

Early diastolic murmur

252
Q

What is the most common cause of chronic aortic regurgitation in the developing world?

A

Rheumatic fever

253
Q

What are the causes of aortic regurgitation due to valve disease? List at least three.

A
  • Rheumatic fever
  • Calcific valve disease
  • Bicuspid aortic valve
254
Q

What is Quincke’s sign?

A

Nailbed pulsation associated with aortic regurgitation

255
Q

What is the management for symptomatic patients with severe aortic regurgitation?

256
Q

What are the clinical features of symptomatic aortic stenosis? List at least three.

A
  • Chest pain
  • Dyspnoea
  • Syncope / presyncope
257
Q

What is the most common cause of aortic stenosis in older patients?

A

Degenerative calcification

258
Q

What is the treatment of choice for symptomatic aortic stenosis?

A

Valve replacement

259
Q

What is the key characteristic of aortic regurgitation’s murmur during examination?

A

Intensity of the murmur is increased by the handgrip manoeuvre

260
Q

What are the options for aortic valve replacement (AVR)? List at least two.

A
  • Surgical AVR
  • Transcatheter AVR (TAVR)
261
Q

What is the major disadvantage of biological (bioprosthetic) valves?

A

Structural deterioration and calcification over time

262
Q

What is the target INR for patients with mechanical mitral valves?

263
Q

True or False: Long-term anticoagulation is usually needed for patients with biological valves.

264
Q

What is a common complication associated with aortic stenosis?

A

Aortic regurgitation

265
Q

Fill in the blank: Aortic regurgitation is the leaking of the _______ valve of the heart.

266
Q

What is the most common valves that need replacing?

A
  • Aortic valve
  • Mitral valve
267
Q

What is the management for asymptomatic patients with severe aortic regurgitation?

A

Medical management of any associated heart failure

268
Q

What is a transient ischaemic attack (TIA)?

A

A brief period of neurological deficit due to a vascular cause, typically lasting less than an hour.

Patients often refer to TIAs as ‘mini-strokes’.

269
Q

What was the original definition of a TIA?

A

A sudden onset of a focal neurologic symptom and/or sign lasting less than 24 hours, caused by a transient decrease in blood flow.

270
Q

What is the new definition of a TIA?

A

A transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction.

271
Q

List possible clinical features of a TIA. (7)

A
  • Unilateral weakness or sensory loss
  • Aphasia or dysarthria
  • Ataxia, vertigo, or loss of balance
  • Visual problems
  • Sudden transient loss of vision in one eye (amaurosis fugax)
  • Diplopia
  • Homonymous hemianopia
272
Q

What should patients with suspected TIA receive immediately?

A

Aspirin 300 mg unless contraindicated.

273
Q

What is the ABCD2 prognostic score used for?

A

It was used to risk stratify patients presenting with a suspected TIA, but is no longer recommended due to poor performance.

274
Q

What imaging should be performed for patients with suspected TIA?

A

MRI is preferred to determine the territory of ischaemia or detect alternative pathologies.

275
Q

What is the recommended management for patients who have had a TIA?

A
  • Immediate antithrombotic therapy
  • Antiplatelet therapy
  • Lipid modification with high-intensity statin
  • Carotid imaging if indicated
276
Q

What is the aim of statin therapy in TIA management?

A

To reduce non-HDL cholesterol by more than 40%.

277
Q

What is the difference between ischaemic and haemorrhagic strokes?

A
  • Ischaemic: ‘Blockage’ in the blood vessel stops blood flow.
  • Haemorrhagic: Blood vessel ‘bursts’ leading to reduction in blood flow.
278
Q

What are the two main types of strokes?

A
  • Ischaemic
  • Haemorrhagic
279
Q

What are common risk factors for strokes?

A
  • Age
  • Hypertension
  • Smoking
  • Hyperlipidaemia
  • Diabetes mellitus
280
Q

What symptoms might suggest a stroke?

A
  • Motor weakness
  • Speech problems (dysphasia)
  • Visual field defects (homonymous hemianopia)
  • Balance problems
281
Q

What is the FAST campaign used for?

A

To raise awareness of stroke symptoms: Face, Arms, Speech, Time.

282
Q

What is the purpose of emergency neuroimaging in suspected stroke cases?

A

To classify the stroke as either ischaemic or haemorrhagic and determine eligibility for thrombolytic therapy.

283
Q

What should be given to ischaemic stroke patients once haemorrhagic stroke has been excluded?

A

Aspirin 300 mg as soon as possible.

284
Q

What are the subtypes of ischaemic strokes?

A
  • Thrombotic stroke
  • Embolic stroke
285
Q

What is a lacunar stroke?

A

A type of stroke that presents with either isolated hemiparesis, hemisensory loss, or hemiparesis with limb ataxia.

286
Q

What is the Oxford Stroke Classification?

A

A classification system that categorizes strokes based on initial symptoms.

287
Q

What defines a total anterior circulation infarct (TACI)?

A

Involves middle and anterior cerebral arteries with all three Oxford Stroke Classification criteria present.

288
Q

What are the associated effects of an anterior cerebral artery lesion?

A

Contralateral hemiparesis and sensory loss, lower extremity > upper.

289
Q

True or False: The symptoms of a TIA typically last longer than 24 hours.

290
Q

Fill in the blank: The essential problem in ischaemic strokes is a ‘________’ in the blood vessel that stops blood flow.

291
Q

What should be done if a patient presents with a suspected TIA more than 7 days ago?

A

They should be seen by a stroke specialist clinician as soon as possible within 7 days.

292
Q

What is the management approach for haemorrhagic stroke?

A

Supportive management, stopping anticoagulants and antithrombotic medications

Anticoagulation should be reversed quickly to minimize further bleeding.

293
Q

What is the FAST screening tool used for?

A

To identify symptoms of stroke with a positive predictive value of 78%

FAST stands for Face, Arms, Speech, Time.

294
Q

What is the ROSIER score?

A

A validated tool for assessing stroke risk in medical professionals

Recommended by the Royal College of Physicians.

295
Q

What should be excluded first when using the ROSIER score?

A

Hypoglycaemia

296
Q

What is the first line radiological investigation for suspected stroke?

A

Non-contrast CT head scan

297
Q

What indicates a stroke in the ROSIER score?

A

A score of > 0

298
Q

What are the key signs of acute ischaemic stroke on a CT scan?

A

Areas of low density, hyperdense artery sign

These changes may take time to develop.

299
Q

What are the typical findings for acute haemorrhagic stroke on a CT scan?

A

Areas of hyperdense material (blood) surrounded by low density (oedema)

300
Q

What should be maintained within normal limits in stroke management?

A

Blood glucose, hydration, oxygen saturation, temperature

301
Q

What is the recommended initial treatment for a patient with an acute ischaemic stroke?

A

Aspirin 300mg if haemorrhagic stroke has been excluded

302
Q

What is the time frame for administering thrombolysis after stroke onset?

A

Within 4.5 hours

303
Q

What are the absolute contraindications to thrombolysis? (10)

A
  • Previous intracranial haemorrhage
  • Seizure at onset
  • Intracranial neoplasm
  • Suspected subarachnoid haemorrhage
  • Recent stroke or traumatic brain injury
  • Recent lumbar puncture
  • Recent gastrointestinal haemorrhage
  • Active bleeding
  • Oesophageal varices
  • Uncontrolled hypertension >200/120mmHg
304
Q

What is mechanical thrombectomy used for?

A

Treatment for patients with acute ischaemic stroke

305
Q

What are the recommendations for secondary prevention after an ischaemic stroke?

A
  • Clopidogrel recommended ahead of aspirin + MR dipyridamole
  • Aspirin only if clopidogrel is contraindicated
306
Q

What is the Oxford Stroke Classification used for?

A

Classifying strokes based on initial symptoms

307
Q

What are the criteria for Total Anterior Circulation Infarcts (TACI)?

A

All three criteria:
* Unilateral hemiparesis/sensory loss
* Homonymous hemianopia
* Higher cognitive dysfunction (e.g., dysphasia)

308
Q

What are common clinical signs of pulmonary embolism?

A
  • Tachypnea (96%)
  • Crackles (58%)
  • Tachycardia (44%)
  • Fever (43%)
309
Q

What is the PERC rule used for?

A

To rule out pulmonary embolism when the pre-test probability is low

310
Q

What is the 2-level PE Wells score used for?

A

To assess the probability of pulmonary embolism

311
Q

What is the initial recommended lung-imaging modality for non-massive PE?

A

CTPA (Computed Tomography Pulmonary Angiography)

312
Q

What should be done if a PE is ‘likely’ according to the Wells score?

A

Arrange an immediate CTPA and consider interim therapeutic anticoagulation

313
Q

What is the recommended action if a PE is ‘unlikely’ according to the Wells score?

A

Arrange a D-dimer test

314
Q

What are the potential features of pulmonary embolism?

A
  • Chest pain (typically pleuritic)
  • Dyspnoea
  • Haemoptysis
  • Tachycardia
  • Tachypnoea
315
Q

What is the recommended initial lung-imaging modality for non-massive PE?

A

CTPA

CTPA provides speed, ease of performance out-of-hours, and can offer alternative diagnoses.

316
Q

What should be done if the CTPA is negative for pulmonary embolism?

A

Patients do not need further investigations or treatment for PE.

317
Q

Under what circumstances may V/Q scanning be used initially?

A

If appropriate facilities exist, chest x-ray is normal, and no significant symptomatic concurrent cardiopulmonary disease.

318
Q

What is the sensitivity and specificity of D-dimers?

A

Sensitivity = 95-98%, poor specificity.

319
Q

What should be considered for patients over 50 years regarding D-dimer levels?

A

Age-adjusted D-dimer levels.

320
Q

What classic ECG changes are seen in PE?

A

S1Q3T3 pattern: large S wave in lead I, large Q wave in lead III, inverted T wave in lead III.

321
Q

What percentage of patients exhibit the classic ECG changes associated with PE?

A

No more than 20%.

322
Q

What are the possible findings of a chest x-ray in PE?

A

Typically normal; possible findings include wedge-shaped opacification.

323
Q

What is the sensitivity and specificity of V/Q scans?

A

Sensitivity around 75%, specificity 97%.

324
Q

What other conditions can cause mismatch in V/Q scans? (4)

A
  • Old pulmonary embolisms
  • AV malformations
  • Vasculitis
  • Previous radiotherapy
325
Q

What is the cornerstone of VTE management?

A

Anticoagulant therapy.

326
Q

What is the first-line treatment for most people with VTE according to NICE 2020 guidelines?

A

Direct oral anticoagulants (DOACs).

327
Q

What is the recommended treatment for patients with active cancer and VTE?

A

DOACs, as opposed to low-molecular weight heparin.

328
Q

What tool does NICE recommend for determining the suitability of outpatient treatment for low-risk PE patients?

A

Validated risk stratification tool.

329
Q

What is the Pulmonary Embolism Severity Index (PESI) score used for?

A

To assess suitability for outpatient treatment in PE.

330
Q

What is the recommendation for the length of anticoagulation therapy?

A

At least 3 months.

331
Q

What factors determine the continuation of anticoagulation treatment after the initial 3 months?

A

Whether the VTE was provoked or unprovoked.

332
Q

What is the ORBIT score used for?

A

To assess the risk of bleeding.

333
Q

What is the first-line treatment for massive PE with circulatory failure?

A

Thrombolysis.

334
Q

What is pulmonary arterial hypertension (PAH) defined as?

A

Resting mean pulmonary artery pressure of >= 20 mmHg.

335
Q

What are the classical features of pulmonary arterial hypertension?

A
  • Progressive exertional dyspnoea
  • Exertional syncope
  • Exertional chest pain
  • Peripheral oedema
  • Cyanosis
336
Q

What management strategies are used for PAH based on acute vasodilator testing results?

A

Positive response: oral calcium channel blockers
Negative response: prostacyclin analogues, endothelin receptor antagonists, phosphodiesterase inhibitors.

337
Q

What are the WHO classifications of pulmonary hypertension?

A
  • Group 1: PAH
  • Group 2: Pulmonary hypertension with left heart disease
  • Group 3: Pulmonary hypertension secondary to lung disease/hypoxia
  • Group 4: Pulmonary hypertension due to thromboembolic disease
  • Group 5: Miscellaneous conditions
338
Q

What is the primary treatment for severe PAD or critical limb ischaemia?

A
  • Endovascular revascularization
  • Surgical revascularization
339
Q

What drugs are licensed for use in peripheral arterial disease (PAD)?

A
  • Naftidrofuryl oxalate
  • Cilostazol
340
Q

What is acute pericarditis characterized by?

A

Inflammation of the pericardial sac lasting less than 4-6 weeks.

341
Q

What are common symptoms of acute pericarditis?

A
  • Chest pain
  • Non-productive cough
  • Dyspnoea
  • Flu-like symptoms
342
Q

What is the most specific ECG marker for pericarditis?

A

PR depression.

343
Q

What is the management for most patients with acute pericarditis?

A

Outpatient management; treat underlying causes.

344
Q

What percentage of patients may have an elevated troponin indicating possible myopericarditis?

A

30%

Elevated troponin levels can indicate myopericarditis among other cardiac conditions.

345
Q

How should patients with high-risk features like fever > 38°C or elevated troponin be managed?

A

Managed as an inpatient

High-risk features necessitate closer monitoring and treatment.

346
Q

What is the first-line treatment for patients with acute idiopathic or viral pericarditis?

A

A combination of NSAIDs and colchicine

This treatment is effective until symptom resolution and normalization of inflammatory markers.

347
Q

What are the classical features of cardiac tamponade known as Beck’s triad?

A
  • Hypotension
  • Raised JVP
  • Muffled heart sounds

These features indicate the presence of cardiac tamponade.

348
Q

What is a characteristic feature of cardiac tamponade in relation to JVP?

A

Absent Y descent

This is due to limited right ventricular filling.

349
Q

What is a common mnemonic to remember the absent Y descent in cardiac tamponade?

A

TAMponade = TAMpaX

This mnemonic helps recall the features of cardiac tamponade.

350
Q

What is the management for cardiac tamponade?

A

Urgent pericardiocentesis

This procedure helps relieve pressure on the heart.

351
Q

Which infectious cause is particularly associated with constrictive pericarditis?

A

Tuberculosis (TB)

TB is a significant cause of constrictive pericarditis in certain populations.

352
Q

What are common causes of pericardial effusion?

A
  • Infectious pericarditis (viral, tuberculosis)
  • Uraemia
  • Idiopathic
  • Post-myocardial infarction
  • Malignancy
  • Heart failure
  • Nephrotic syndrome
  • Hypothyroidism
  • Trauma

Various conditions can lead to the accumulation of fluid in the pericardial space.

353
Q

What typically characterizes myocarditis?

A

Inflammation of the myocardium

Myocarditis can have various underlying causes, including infections.

354
Q

What are the common symptoms of mitral regurgitation (MR)?

A
  • Fatigue
  • Shortness of breath
  • Oedema

Symptoms arise when the left ventricle fails to compensate for the regurgitation.

355
Q

What is the most common valve disease after aortic stenosis?

A

Mitral regurgitation (MR)

MR is prevalent and can affect heart efficiency.

356
Q

What are the risk factors for developing mitral regurgitation?

A
  • Female sex
  • Lower body mass
  • Age
  • Renal dysfunction
  • Prior myocardial infarction
  • Prior mitral stenosis or valve prolapse
  • Collagen disorders (e.g., Marfan’s Syndrome)

Various factors can increase the likelihood of MR.

357
Q

What is the typical auscultation finding in mitral regurgitation?

A

A pansystolic ‘blowing’ murmur

This murmur is best heard at the apex and may radiate to the axilla.

358
Q

What is the management for symptomatic patients with mitral stenosis?

A
  • Percutaneous mitral balloon valvotomy
  • Mitral valve surgery (commissurotomy or valve replacement)

These interventions are considered for symptomatic relief.

359
Q

What is the primary cause of mitral stenosis?

A

Rheumatic fever

This condition is the most common cause, particularly in developing countries.

360
Q

What is the management for patients with mitral valve prolapse?

A

Typically no treatment unless complications arise

Most patients with mitral valve prolapse are asymptomatic.

361
Q

What are the two main types of heart valve replacements?

A
  • Biological (bioprosthetic) valves
  • Mechanical valves

Each type has its own advantages and risks.

362
Q

What is the target INR for patients with mechanical mitral valves?

A

3.5

This target helps minimize thromboembolic risks.

363
Q

What is the investigation of choice for diagnosing acute mesenteric ischaemia?

A

CT scan

CT is crucial for identifying vascular occlusions.

364
Q

What are common features of bowel ischaemia?

A
  • Abdominal pain
  • Rectal bleeding
  • Diarrhoea
  • Fever

These symptoms can vary based on the type of ischaemia.

365
Q

What is a common predisposing factor for mesenteric ischaemia?

A

Atrial fibrillation

Atrial fibrillation increases the risk of embolic events leading to mesenteric ischaemia.

366
Q

What are the cardiovascular disease risk factors?

A

Smoking, hypertension, diabetes

367
Q

What condition is sometimes seen in young patients following cocaine use?

A

Ischaemic colitis

368
Q

What is a common feature of acute mesenteric ischaemia?

A

Sudden onset abdominal pain

369
Q

What clinical signs are associated with acute mesenteric ischaemia?

A
  • Rectal bleeding
  • Diarrhoea
  • Fever
  • Elevated white blood cell count
  • Lactic acidosis
370
Q

What is the investigation of choice for diagnosing mesenteric ischaemia?

371
Q

What typically causes acute mesenteric ischaemia?

A

Embolism resulting in occlusion of an artery supplying the small bowel

372
Q

What is the management approach for acute mesenteric ischaemia?

A

Urgent surgery is usually required

373
Q

What is chronic mesenteric ischaemia often referred to as?

A

‘Intestinal angina’

374
Q

What does ischaemic colitis describe?

A

Acute but transient compromise in blood flow to the large bowel

375
Q

In which areas is ischaemic colitis more likely to occur?

A

‘Watershed’ areas such as the splenic flexure

376
Q

What radiological feature may be seen in ischaemic colitis on an abdominal x-ray?

A

‘Thumbprinting’

377
Q

What is the initial management for ischaemic colitis?

A

Supportive care

378
Q

What are the three main conditions associated with ischaemia to the lower gastrointestinal tract?

A
  • Acute mesenteric ischaemia
  • Chronic mesenteric ischaemia
  • Ischaemic colitis
379
Q

What is the strongest risk factor for developing infective endocarditis?

A

A previous episode of endocarditis

380
Q

Which heart valve is most commonly affected in infective endocarditis?

A

Mitral valve

381
Q

What is the most common cause of infective endocarditis?

A

Staphylococcus aureus

382
Q

What type of bacteria was historically the most common cause of infective endocarditis?

A

Streptococcus viridans

383
Q

What is a common association of Streptococcus bovis?

A

Colorectal cancer

384
Q

What are the major criteria for diagnosing infective endocarditis?

A
  • Positive blood cultures
  • Evidence of endocardial involvement on echocardiogram
385
Q

What are some minor criteria for diagnosing infective endocarditis?

A
  • Predisposing heart condition
  • Fever > 38ºC
  • Vascular phenomena
  • Immunological phenomena
386
Q

Which organism is associated with a 30% mortality rate in infective endocarditis?

A

Staphylococci

387
Q

What is the first-line treatment for haemochromatosis?

A

Venesection

388
Q

What is the typical iron study profile in a patient with haemochromatosis?

A
  • Transferrin saturation > 55% in men or > 50% in women
  • Raised ferritin
  • Low TIBC
389
Q

What condition is characterized by the death of body tissue due to lack of blood supply?

390
Q

What is the appearance of dry gangrene?

A

Dry, shrivelled, and blackened tissue

391
Q

What distinguishes wet gangrene from dry gangrene?

A

Swollen, moist, and blistered tissue with a foul odour

392
Q

What is gas gangrene caused by?

A

Infection with Clostridium bacteria

393
Q

What is a severe condition characterized by rapid tissue necrosis and infection?

A

Necrotising fasciitis

394
Q

What is gas gangrene?

A

Infection caused by Clostridium bacteria, producing gas and toxins.

Gas gangrene, also known as Clostridial myonecrosis, can lead to severe complications and requires urgent medical intervention.

395
Q

What are the key symptoms of gas gangrene?

A

Severe pain, swelling, crepitus, systemic symptoms like tachycardia, hypotension, and shock.

Crepitus is the crackling sound produced by gas in the tissues.

396
Q

What is necrotising fasciitis?

A

A severe form of gangrene involving the fascia and subcutaneous tissues, often caused by mixed bacterial infections.

Common bacteria include Streptococcus pyogenes and Staphylococcus aureus.

397
Q

What are the symptoms of necrotising fasciitis?

A

Intense pain disproportionate to visible signs, rapid progression of erythema, swelling, tissue necrosis, and systemic signs of sepsis.

Symptoms of sepsis may include fever, tachycardia, and hypotension.

398
Q

What are the key management strategies for gangrene?

A

Urgent intervention, surgical intervention, antibiotic therapy, supportive care, hyperbaric oxygen therapy.

These strategies focus on controlling infection, restoring blood supply, and removing necrotic tissue.

399
Q

What does surgical intervention for gangrene involve?

A

Debridement, amputation, revascularisation.

Debridement is the surgical removal of necrotic tissue to prevent infection spread.

400
Q

What is the purpose of antibiotic therapy in managing gangrene?

A

To control infection with empirical broad-spectrum antibiotics followed by targeted therapy.

High-dose penicillin and clindamycin are often recommended for gas gangrene.

401
Q

Fill in the blank: The surgical removal of necrotic tissue is called _______.

A

debridement

402
Q

True or False: Hyperbaric oxygen therapy is used to enhance oxygen delivery to ischaemic tissues in some cases of gas gangrene.

403
Q

What are some systemic symptoms that may require supportive care in gangrene management?

A

Fluid resuscitation, pain control, nutritional support, monitoring of comorbid conditions.

Comorbid conditions may include diabetes and cardiovascular disease.

404
Q

What are the potential outcomes of untreated gas gangrene?

A

Rapid progression to systemic sepsis and high mortality.

Timely medical intervention is crucial to prevent these severe outcomes.

405
Q

What are angiotensin-converting enzyme (ACE) inhibitors primarily used for?

A

First-line treatment in younger patients with hypertension and extensively used to treat heart failure

ACE inhibitors are also used to treat diabetic nephropathy and have a role in the secondary prevention of ischemic heart disease.

406
Q

How do ACE inhibitors work?

A

Inhibit the conversion of angiotensin I to angiotensin II, leading to vasodilation and reduced blood pressure

This also results in decreased stimulation for aldosterone release, reducing sodium and water retention.

407
Q

What are common side effects of ACE inhibitors?

A
  • Cough
  • Angioedema
  • Hyperkalaemia
  • First-dose hypotension

Cough occurs in around 15% of patients and may occur up to a year after starting treatment.

408
Q

In which patients should ACE inhibitors be avoided?

A
  • Pregnancy and breastfeeding
  • Renovascular disease
  • Aortic stenosis
  • Hereditary or idiopathic angioedema
  • Potassium >= 5.0 mmol/L

Specialist advice should be sought in patients with elevated potassium levels.

409
Q

What is the role of calcium channel blockers?

A

Primarily used in the management of cardiovascular disease

They affect myocardial cells, the conduction system, and vascular smooth muscle.

410
Q

What are the side effects of Verapamil?

A
  • Heart failure
  • Constipation
  • Hypotension
  • Bradycardia
  • Flushing

It is highly negatively inotropic and should not be given with beta-blockers.

411
Q

What is the definition of hypertension according to NICE?

A

A clinic reading persistently above >= 140/90 mmHg, or a 24-hour blood pressure average reading >= 135/85 mmHg

Normal blood pressure ranges from 90/60 mmHg to 140/90 mmHg.

412
Q

What are some common causes of secondary hypertension?

A
  • Renal parenchymal disease
  • Renal vascular disease
  • Coarctation of the aorta
  • Phaeochromocytoma
  • Congenital adrenal hyperplasia

Essential hypertension becomes more common as children age.

413
Q

What should be checked to assess for end-organ damage in hypertension?

A
  • Fundoscopy for hypertensive retinopathy
  • Urine dipstick for renal disease
  • ECG for left ventricular hypertrophy or ischemic heart disease

These assessments help ensure complications are not present.

414
Q

What is the recommended method for diagnosing hypertension?

A

Use 24-hour blood pressure monitoring or home blood pressure monitoring

This helps avoid white coat hypertension and provides a more accurate assessment.

415
Q

What is the significance of using 24-hour blood pressure monitoring?

A

It correlates better with clinical outcomes and helps prevent overdiagnosis of hypertension

ABPM is a more accurate predictor of cardiovascular events than clinic readings.

416
Q

What are the criteria for Stage 1 hypertension?

A

Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg

This classification is important for treatment decisions.

417
Q

What is the procedure for ambulatory blood pressure monitoring (ABPM)?

A

At least 2 measurements per hour during the person’s usual waking hours, using the average value of at least 14 measurements

If ABPM is not tolerated, HBPM should be offered.

418
Q

What are the acceptable changes in creatinine and potassium after starting ACE inhibitors?

A

Increase in serum creatinine up to 30% from baseline and increase in potassium up to 5.5 mmol/L

Significant renal impairment may occur with undiagnosed bilateral renal artery stenosis.

419
Q

Fill in the blank: ACE inhibitors are activated by _______ metabolism in the liver.

420
Q

What are the common drugs used to treat hypertension?

A
  • Angiotensin-converting enzyme (ACE) inhibitors
  • Calcium channel blockers
  • Thiazide-type diuretics
  • Angiotensin II receptor blockers (A2RB)

Drug therapy follows established NICE guidelines for hypertension management.

421
Q

What is the threshold for treating stage 1 hypertension in patients under 80 years according to NICE guidelines?

A

Lowered from 20% to 10%

This change was made in 2019 to include patients with a 10-year cardiovascular risk below 10%.

422
Q

At what blood pressure measurements is stage 1 hypertension classified?

A

Clinic BP >= 140/90 mmHg and ABPM/HBPM average BP >= 135/85 mmHg

423
Q

What drug treatment is recommended for patients with stage 2 hypertension?

A

Offer drug treatment regardless of age

424
Q

What lifestyle advice is recommended for managing hypertension?

A
  • Low salt diet (aim for < 6g/day)
  • Reduce caffeine intake
  • Stop smoking
  • Drink less alcohol
  • Eat a balanced diet rich in fruits and vegetables
  • Exercise more
  • Lose weight
425
Q

What is the blood pressure classification for stage 2 hypertension?

A

Clinic BP >= 160/100 mmHg and ABPM/HBPM average BP >= 150/95 mmHg

426
Q

What are the first-line treatments for patients under 55 years or with type 2 diabetes mellitus?

A

ACE inhibitor or Angiotensin receptor blocker (ACE-i or ARB)

427
Q

What is a common cause of secondary hypertension?

A

Primary hyperaldosteronism, including Conn’s syndrome

428
Q

What are the features of primary hyperaldosteronism?

A
  • Hypertension
  • Hypokalaemia
  • Metabolic alkalosis
429
Q

What is the first-line investigation for suspected primary hyperaldosteronism?

A

Plasma aldosterone/renin ratio

430
Q

What management is recommended for adrenal adenoma?

A

Surgery (laparoscopic adrenalectomy)

431
Q

What are common adverse effects of thiazide diuretics?

A
  • Dehydration
  • Postural hypotension
  • Hypokalaemia
  • Hyponatraemia
  • Hypercalcaemia
  • Gout
  • Impaired glucose tolerance
  • Impotence
432
Q

What is the cornerstone of VTE management?

A

Anticoagulant therapy

433
Q

What anticoagulants are now recommended as first-line treatment for most people with VTE?

A

Direct oral anticoagulants (DOACs) such as apixaban or rivaroxaban

434
Q

What is the two-level DVT Wells score used for?

A

To assess the probability of DVT based on clinical features

435
Q

What should be done if a DVT is ‘likely’ according to the Wells score?

A

A proximal leg vein ultrasound scan should be carried out within 4 hours

436
Q

What should be done if a DVT is ‘unlikely’ according to the Wells score?

A

Perform a D-dimer test

437
Q

What is the recommended length of anticoagulation for a provoked VTE?

A

Typically stopped after 3 months

438
Q

What is the recommended length of anticoagulation for an unprovoked VTE?

A

Typically continued for up to 6 months

439
Q

What are the clinical features of DVT?

A
  • Lower limb pain (often calf pain)
  • Tenderness along the deep veins
  • Swelling
  • Erythema
  • Pitting oedema
  • Distension of superficial veins
440
Q

What is the primary underlying cause of arterial ulcers?

A

Atherosclerosis

441
Q

What is the management for bilateral adrenocortical hyperplasia?

A

Aldosterone antagonist e.g. spironolactone

442
Q

What recent change did NICE make regarding the use of DOACs for patients with active cancer?

A

DOACs are now recommended instead of low-molecular weight heparin

443
Q

What should be assessed before step 4 treatment for resistant hypertension?

A
  • Confirm elevated clinic BP with ABPM or HBPM
  • Assess for postural hypotension
  • Discuss adherence
444
Q

What are arterial ulcers also known as?

A

Ischemic ulcers

Arterial ulcers are chronic wounds caused by insufficient blood supply, typically from peripheral arterial disease (PAD).

445
Q

What is the primary underlying cause of arterial ulcers?

A

Atherosclerosis

Atherosclerosis leads to the narrowing and hardening of arteries, resulting in reduced blood flow.

446
Q

List some clinical features of arterial ulcers.

A
  • Small, round appearance
  • Well-defined edges
  • Pale, dry, or necrotic ulcer base
  • Severe pain, especially at night
  • Shiny, thin, hairless surrounding skin
  • Diminished or absent peripheral pulses
  • Coolness of the affected limb
447
Q

What does an Ankle-Brachial Pressure Index (ABPI) of less than 0.9 indicate?

A

Peripheral arterial disease (PAD)

ABPI is a non-invasive test measuring blood pressure ratios in the ankle and arm.

448
Q

What are the key management strategies for arterial ulcers?

A
  • Risk factor modification
  • Optimisation of blood flow
  • Wound care
  • Infection control
449
Q

True or False: Chest compressions in CPR are given at a ratio of 30:2.

A

True

This is the recommended compression to ventilation ratio during CPR.

450
Q

What should be done if IV access cannot be achieved during cardiac arrest?

A

Use intraosseous route (IO)

Delivery of drugs via tracheal tube is no longer recommended.

451
Q

What are the ‘Hs’ in the reversible causes of cardiac arrest?

A
  • Hypoxia
  • Hypovolaemia
  • Hyperkalaemia
  • Hypokalaemia
  • Hypoglycaemia
  • Hypocalcaemia
  • Acidaemia
  • Hypothermia
452
Q

Name one of the major changes in the 2015 Resuscitation Council guidelines for paediatric basic life support.

A

Compression:ventilation ratio changed to 30:2 for lay rescuers

For two or more rescuers, the ratio is 15:2.

453
Q

What features of pulmonary oedema can be seen on a chest x-ray?

A
  • Interstitial oedema
  • Bat’s wing appearance
  • Upper lobe diversion
  • Kerley B lines
  • Pleural effusion
  • Cardiomegaly
454
Q

What is the first-line blood test for diagnosing heart failure according to NICE guidelines?

A

N-terminal pro-B-type natriuretic peptide (NT-proBNP)

This test is now recommended for all patients regardless of previous myocardial infarction.

455
Q

What are the normal levels of BNP and NT-proBNP?

A
  • BNP: < 100 pg/ml (29 pmol/litre)
  • NT-proBNP: < 400 pg/ml (47 pmol/litre)
456
Q

What is the first-line therapy for all patients with heart failure?

A

ACE-inhibitor and beta-blocker

Clinical judgement is used to determine which one to start first.

457
Q

Fill in the blank: The standard second-line treatment for heart failure is an _______.

A

Aldosterone antagonist

Examples include spironolactone and eplerenone.

458
Q

What criteria must be met for ivabradine to be initiated?

A

Sinus rhythm > 75/min and a left ventricular fraction < 35%

Ivabradine is used in heart failure treatment.

459
Q

What does the New York Heart Association (NYHA) Class II indicate?

A

Mild symptoms with slight limitation of physical activity

Comfortable at rest but ordinary activity results in fatigue, palpitations, or dyspnoea.

460
Q

What is acute heart failure (AHF)?

A

A life-threatening emergency with sudden onset or worsening symptoms of heart failure

AHF may occur with or without a pre-existing history of heart failure.

461
Q

What are common precipitating causes of acute heart failure?

A
  • Acute coronary syndrome
  • Hypertensive crisis
  • Acute arrhythmia
  • Valvular disease
462
Q

What is the diagnostic workup for patients with AHF?

A
  • Blood tests
  • Chest X-ray
  • Echocardiogram
  • B-type natriuretic peptide
463
Q

What is the purpose of tests in heart failure diagnosis?

A

To look for any underlying abnormality such as anaemia, abnormal electrolytes or infection.

464
Q

What findings can be seen in a Chest X-ray for heart failure?

A

Pulmonary venous congestion, interstitial oedema and cardiomegaly.

465
Q

When is an Echocardiogram recommended?

A

For patients with new-onset heart failure and for known heart failure patients with suspected change in cardiac function.

466
Q

What do raised levels of B-type natriuretic peptide indicate?

A

Myocardial damage and support the diagnosis of heart failure.

467
Q

What are the recommended treatments for all patients with heart failure?

A

IV loop diuretics, e.g., furosemide or bumetanide.

468
Q

What is the recommended oxygen saturation level for patients with heart failure?

469
Q

What is a major contraindication for using nitrates in heart failure treatment?

A

Hypotension.

470
Q

True or False: Opiates should be routinely offered to people with acute heart failure.

471
Q

What should be done for patients with severe left ventricular dysfunction and cardiogenic shock?

A

Consider inotropic agents, e.g., dobutamine.

472
Q

How is heart failure defined?

A

A clinical syndrome where the heart is unable to pump enough blood to meet the metabolic needs of the body.

473
Q

What are the two classifications of heart failure by ejection fraction?

A
  • Heart failure with reduced ejection fraction (HF-rEF) * Heart failure with preserved ejection fraction (HF-pEF)
474
Q

What is the typical left ventricular ejection fraction (LVEF) for HF-rEF?

A

< 35 to 40%.

475
Q

What is the difference between systolic and diastolic dysfunction?

A

Systolic dysfunction is impaired myocardial contraction during systole, while diastolic dysfunction is impaired ventricular filling during diastole.

476
Q

What are some causes of systolic dysfunction?

A
  • Ischaemic heart disease * Dilated cardiomyopathy * Myocarditis * Arrhythmias * Hypertrophic obstructive cardiomyopathy * Restrictive cardiomyopathy * Cardiac tamponade * Constrictive pericarditis
477
Q

How is heart failure classified by time?

A

Acute or chronic.

478
Q

What typically causes acute heart failure?

A

Acute exacerbation of chronic heart failure.

479
Q

What are the consequences of left ventricular failure?

A
  • Pulmonary oedema * Dyspnoea * Orthopnoea * Paroxysmal nocturnal dyspnoea * Bibasal fine crackles
480
Q

What are the consequences of right ventricular failure?

A
  • Peripheral oedema * Ankle/sacral oedema * Raised jugular venous pressure * Hepatomegaly * Weight gain due to fluid retention * Anorexia (‘cardiac cachexia’)
481
Q

What characterizes high-output heart failure?

A

A ‘normal’ heart unable to pump enough blood to meet the metabolic needs of the body.

482
Q

What are some causes of high-output heart failure?

A
  • Anaemia * Arteriovenous malformation * Paget’s disease * Pregnancy * Thyrotoxicosis * Thiamine deficiency (wet Beri-Beri)
483
Q

What is atrial fibrillation (AF)?

A

The most common sustained cardiac arrhythmia, present in around 5% of patients over 70-75 years and 10% of patients aged 80-85 years.

Uncontrolled AF can lead to symptomatic palpitations and inefficient cardiac function, with a significant risk of stroke.

484
Q

How is atrial fibrillation classified?

A

AF may be classified as:
* First detected episode
* Paroxysmal AF
* Persistent AF
* Permanent AF

Paroxysmal AF lasts less than 7 days, persistent AF lasts more than 7 days, and permanent AF is continuous and cannot be cardioverted.

485
Q

What are the common symptoms of atrial fibrillation?

A

Symptoms include:
* Palpitations
* Dyspnoea
* Chest pain

Many cases are asymptomatic and found incidentally.

486
Q

What is a key sign of atrial fibrillation?

A

An irregularly irregular pulse.

This sign can also be present in other conditions, so an ECG is essential for diagnosis.

487
Q

What is essential for diagnosing atrial fibrillation?

A

An ECG is essential to make the diagnosis.

Other conditions can cause an irregular pulse, such as ventricular ectopics or sinus arrhythmia.

488
Q

What are the two key parts of managing patients with atrial fibrillation?

A
  1. Rate/rhythm control
  2. Reducing stroke risk
489
Q

What are the two main strategies for managing the arrhythmia in atrial fibrillation?

A

Strategies include:
* Rate control
* Rhythm control

Rate control involves accepting an irregular pulse while slowing the rate; rhythm control aims to restore and maintain normal sinus rhythm.

490
Q

What is the first-line treatment for rate control in atrial fibrillation?

A

A beta-blocker or a rate-limiting calcium channel blocker (e.g., diltiazem).

If one drug does not adequately control the rate, combination therapy may be used.

491
Q

What should be considered before attempting cardioversion in patients with atrial fibrillation?

A

Patients must either have had a short duration of symptoms (less than 48 hours) or be anticoagulated prior to attempting cardioversion.

This is to mitigate the risk of embolism leading to stroke.

492
Q

What scoring system is used to assess stroke risk in atrial fibrillation?

A

CHA2DS2-VASc score.

This score helps determine the need for anticoagulation.

493
Q

List the points associated with the CHA2DS2-VASc score.

A

Risk factors and points:
* C: Congestive heart failure - 1
* H: Hypertension - 1
* A2: Age >= 75 years - 2, Age 65-74 years - 1
* D: Diabetes - 1
* S2: Prior Stroke, TIA, or thromboembolism - 2
* V: Vascular disease - 1
* S: Sex (female) - 1

494
Q

What is the recommended anticoagulation strategy based on the CHA2DS2-VASc score?

A

Score:
* 0: No treatment
* 1: Males: Consider anticoagulation; Females: No treatment
* 2 or more: Offer anticoagulation.

495
Q

What anticoagulants are recommended by NICE for atrial fibrillation?

A

Recommended DOACs include:
* Apixaban
* Dabigatran
* Edoxaban
* Rivaroxaban

Warfarin is now a second-line treatment.

496
Q

What is the ORBIT scoring system used for?

A

To assess bleeding risk in patients requiring anticoagulation.

This system helps evaluate the risk/benefit profile of starting anticoagulation.

497
Q

What variables are included in the ORBIT score?

A

Variables and points:
* Haemoglobin <130 g/L (males) or <120 g/L (females) - 2
* Age > 74 years - 1
* Bleeding history - 2
* Renal impairment - 1
* Treatment with antiplatelet agents - 1

498
Q

What are the two scenarios where cardioversion may be used in atrial fibrillation?

A
  1. Electrical cardioversion as an emergency if the patient is haemodynamically unstable
  2. Elective electrical or pharmacological cardioversion where rhythm control is preferred.
499
Q

What is the recommended approach for cardioversion if AF onset is less than 48 hours?

A

Patients should be heparinised and may be cardioverted using:
* Electrical cardioversion
* Pharmacological cardioversion (e.g., amiodarone, flecainide)

Anticoagulation is unnecessary if AF duration is confirmed as less than 48 hours.

500
Q

What should be done if AF has lasted more than 48 hours before cardioversion?

A

Anticoagulation should be given for at least 3 weeks prior to cardioversion.

Alternatively, a transoesophageal echo (TOE) can be performed to exclude a left atrial appendage thrombus.

501
Q

What is the significance of the R wave in electrical cardioversion?

A

Electrical cardioversion is synchronised to the R wave to prevent shocks during vulnerable cardiac repolarisation periods.

502
Q

What is the traditional anticoagulant of choice?

A

Warfarin

Warfarin requires regular monitoring, unlike newer alternatives.

503
Q

What are Non-Vitamin K Antagonist Oral Anticoagulants (NOACs)?

A

Alternatives to warfarin that do not require regular monitoring

NOACs are more convenient for patients.

504
Q

What are the two options for managing heart rate in atrial fibrillation?

A
  • Restore normal sinus rhythm
  • Slow the heart rate down

The latter reduces the adverse consequences of persistent tachycardia.

505
Q

What is the primary management strategy for atrial fibrillation?

A

Rhythm control strategy

This is often preferred as patients may revert back to AF after cardioversion.

506
Q

Which medications are first-line for controlling heart rate in atrial fibrillation?

A
  • Beta-blockers
  • Calcium channel blockers
  • Digoxin (second line)

Digoxin is not preferred for patients with high physical activity.

507
Q

List agents with proven efficacy in the pharmacological cardioversion of atrial fibrillation. (6)

A
  • Amiodarone
  • Flecainide (if no structural heart disease)
  • Quinidine
  • Dofetilide
  • Ibutilide
  • Propafenone

Some agents are less commonly used in the UK.

508
Q

What should be excluded before starting anticoagulation or antiplatelet therapy after a stroke or TIA?

A

Haemorrhage

This is crucial to prevent complications from anticoagulation.

509
Q

When should anticoagulation for atrial fibrillation start after a TIA?

A

Immediately once imaging has excluded haemorrhage

This is vital for stroke prevention.

510
Q

What is the recommended timing for starting anticoagulation after an acute stroke?

A

After 2 weeks in the absence of haemorrhage

Antiplatelet therapy should be given in the intervening period.

511
Q

What is the first-line treatment strategy for patients with atrial fibrillation?

A

Rate control

Except in specific cases such as reversible causes or new-onset AF.

512
Q

What are the three types of heart block?

A
  • First-degree heart block
  • Second-degree heart block
  • Third-degree heart block

Each type has distinct characteristics in PR interval and symptoms.

513
Q

What is the first-line treatment for bradycardia with adverse signs?

A

Atropine (500mcg IV)

If there’s an unsatisfactory response, higher doses or transcutaneous pacing may be used.

514
Q

What is Torsades de Pointes?

A

A form of polymorphic ventricular tachycardia associated with a long QT interval

It may deteriorate into ventricular fibrillation.

515
Q

What are the causes of a prolonged QT interval?

A
  • Congenital syndromes
  • Antiarrhythmics
  • Electrolyte imbalances
  • Myocarditis
  • Hypothermia
  • Subarachnoid haemorrhage

These factors can lead to serious cardiac events.

516
Q

What is the management for ventricular tachycardia (VT) with adverse signs?

A

Immediate cardioversion

If no adverse signs, antiarrhythmics may be used.

517
Q

What should be done if drug therapy fails in managing VT?

A
  • Electrophysiological study (EPS)
  • Implantable cardioverter-defibrillator (ICD)

Particularly indicated in patients with impaired left ventricular function.

518
Q

What is the significance of CHA2DS2-VASc score in anticoagulation therapy?

A
  • Score = 0: 2 months anticoagulation recommended
  • Score > 1: long-term anticoagulation recommended

This score helps assess stroke risk in atrial fibrillation patients.

519
Q

What ECG finding is characteristic of atrial flutter?

A

‘Sawtooth’ appearance of flutter waves

The atrial rate is often around 300/min.

520
Q

What is the recommended approach for catheter ablation in atrial fibrillation?

A

For patients who have not responded to or wish to avoid antiarrhythmic medication

The aim is to ablate faulty electrical pathways.

521
Q

In a peri-arrest situation, what is assumed to be the origin of the condition?

A

Ventricular

The assumption is based on guidelines from the resuscitation council.

522
Q

What adverse signs indicate immediate cardioversion is needed?

A

Systolic BP < 90 mmHg, chest pain, heart failure, syncope

These signs suggest significant hemodynamic instability.

523
Q

What may be used in the absence of adverse signs before considering electrical cardioversion?

A

Antiarrhythmics

If antiarrhythmics fail, synchronized DC shocks may be required.

524
Q

Which drug is ideally administered through a central line?

A

Amiodarone

This method ensures better delivery and reduces complications.

525
Q

Which drug should be used with caution in severe left ventricular impairment?

A

Lidocaine

Caution is necessary due to potential adverse effects on heart function.

526
Q

Which drug is contraindicated in ventricular tachycardia (VT)?

A

Verapamil

Verapamil can worsen VT by causing further hemodynamic instability.

527
Q

What are the next steps if drug therapy fails?

A

Electrophysiological study (EPS), implantable cardioverter-defibrillator (ICD)

ICDs are particularly indicated in patients with significantly impaired left ventricular function.

528
Q

Fill in the blank: If a patient has adverse signs, _______ is indicated.

A

immediate cardioversion

This is crucial for stabilizing the patient.

529
Q

True or False: Procainamide is a drug that can be used in the treatment of VT.

A

True

Procainamide is an antiarrhythmic that may be used in certain situations.

UKMLA Prep (48 decks)

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