Cardiology 🫀 Flashcards
What is the definition of loin pain?
A common symptom presenting as discomfort in the area between the lower ribs and buttocks on either side of the spine.
What structures are included in the loin region?
- Kidneys
- Adrenal glands
- Parts of the colon
- Musculoskeletal components
What are common causes of loin pain?
- Renal Colic
- Pyelonephritis
- Musculoskeletal Pain
- Radiculopathy
- Ruptured abdominal aortic aneurysm (AAA)
What is renal colic?
Typically caused by kidney stones obstructing the urinary tract.
What are the symptoms of pyelonephritis?
Infection of the kidney presenting with fever and systemic symptoms alongside loin pain.
What is the initial management approach for loin pain?
- Detailed history
- Physical examination
- Blood tests and urinalysis
- Imaging studies like ultrasound or CT scan
- Pain management with analgesics
What is the mortality rate for a ruptured abdominal aortic aneurysm (AAA)?
Almost 80%.
What are the features of a ruptured AAA?
- Severe, central abdominal pain radiating to the back
- Pulsatile, expansile mass in the abdomen
- Shocked state (hypotension, tachycardia) or collapse
What is the management for a ruptured AAA?
Immediate vascular review with a view to emergency surgical repair.
What should be done if a patient is haemodynamically unstable with suspected AAA?
Diagnosis is clinical; these patients should be taken straight to theatre.
What are the two classifications of cardiac rhythms during resuscitation?
- ‘Shockable’ rhythms: VF/pulseless VT
- ‘Non-shockable’ rhythms: asystole/PEA
What is the ratio of chest compressions to ventilation during CPR?
30:2.
In the case of VF/pulseless VT, what is the recommended treatment after the third shock?
Administer amiodarone 300 mg.
What are the reversible causes of cardiac arrest categorized as the ‘Hs’?
- Hypoxia
- Hypovolaemia
- Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia
- Hypothermia
What are the reversible causes of cardiac arrest categorized as the ‘Ts’?
- Thrombosis (coronary or pulmonary)
- Tension pneumothorax
- Tamponade - cardiac
- Toxins
What are the features of acute coronary syndrome (ACS)?
- Chest pain
- Dyspnoea
- Nausea and vomiting
- Sweating
- Palpitations
What is aortic dissection?
A tear in the tunica intima of the wall of the aorta.
What is the most important risk factor for aortic dissection?
Hypertension.
What are the features of aortic dissection?
- Severe and sharp chest/back pain
- Pain maximal at onset
- Pulse deficit
- Variation in systolic blood pressure between arms
What are the two classifications of aortic dissection?
- Stanford classification
- DeBakey classification
What does the Stanford classification categorize?
- Type A - ascending aorta
- Type B - descending aorta
What is the characteristic exam feature of myocardial infarction?
Heavy, central chest pain that may radiate to the neck and left arm.
What is the typical presentation of a perforated peptic ulcer?
Sudden onset of epigastric abdominal pain followed by generalised abdominal pain.
What is Boerhaave’s syndrome?
Spontaneous rupture of the oesophagus due to repeated episodes of vomiting.
What is the immediate management for suspected acute coronary syndrome (ACS)?
- Glyceryl trinitrate
- Aspirin 300mg
- Perform an ECG as soon as possible
What defines anginal pain according to NICE guidelines?
- Constricting discomfort in the chest or neck, shoulders, jaw, or arms
- Precipitated by physical exertion
- Relieved by rest or GTN in about 5 minutes
What is the first line investigation for stable angina?
CT coronary angiography.
What are the ECG changes associated with anteroseptal myocardial infarction?
V1-V4.
What does MR imaging assess in relation to stress-induced wall motion abnormalities?
MR perfusion or MR imaging
This technique helps evaluate myocardial blood flow and wall motion under stress conditions.
Which ECG changes correlate with anteroseptal coronary artery issues?
V1-V4
This indicates involvement of the left anterior descending artery.
What ECG leads indicate inferior coronary artery issues?
II, III, aVF
This suggests involvement of the right coronary artery.
What are the ECG leads associated with anterolateral coronary artery issues?
V1-6, I, aVL
This typically indicates proximal left anterior descending artery involvement.
What changes are seen in the ECG for posterior infarction?
ST elevation and Q waves in posterior leads (V7-9)
Usually associated with the left circumflex artery or right coronary artery.
True or False: A new left bundle branch block (LBBB) can indicate acute coronary syndrome.
True
It is important to consider this finding in clinical evaluations.
What is myocarditis?
Inflammation of the myocardium
It has various underlying causes and should be suspected in younger patients with chest pain.
Name two viral causes of myocarditis.
- Coxsackie B
- HIV
These viruses are among the common etiologies of myocarditis.
What are two common presentations of myocarditis?
- Chest pain
- Dyspnoea
Arrhythmias may also be present.
What is a common complication of myocarditis?
Dilated cardiomyopathy
This is usually a late complication of myocarditis.
List the three main patterns of presentation in peripheral arterial disease.
- Intermittent claudication
- Critical limb ischaemia
- Acute limb-threatening ischaemia
These presentations indicate varying severities of arterial insufficiency.
What are the 6 P’s of acute limb-threatening ischaemia?
- Pale
- Pulseless
- Painful
- Paralysed
- Paraesthetic
- ‘Perishing with cold’
These signs help identify serious ischaemia.
What initial investigation is recommended for suspected acute limb-threatening ischaemia?
Handheld arterial Doppler examination
This helps assess blood flow in the affected limb.
What factors suggest a thrombus in acute limb-threatening ischaemia?
- 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.
What is the management for acute limb-threatening ischaemia?
- 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.
What are potential features of pulmonary embolism?
- Chest pain
- Dyspnoea
- Haemoptysis
- Tachycardia
- Tachypnoea
The presentation can vary widely based on the embolism’s location and size.
What percentage of patients present with the classic triad of pulmonary embolism symptoms?
Around 10%
This highlights the variability in presentation.
What are the common clinical signs of pulmonary embolism according to the PIOPED study?
- Tachypnea (96%)
- Crackles (58%)
- Tachycardia (44%)
- Fever (43%)
These signs can help in the diagnosis of pulmonary embolism.
What is the most common acyanotic congenital heart defect?
Ventricular septal defect (VSD)
VSD accounts for 30% of acyanotic defects.
What is the most common cyanotic congenital heart defect?
Tetralogy of Fallot (TOF)
TOF presents around 1-2 months of age.
What test can differentiate cardiac from non-cardiac causes of cyanosis in infants?
Nitrogen washout test (hyperoxia test)
A pO2 of less than 15 kPa indicates cyanotic congenital heart disease.
What is the management for suspected cyanotic congenital heart disease?
- Supportive care
- Prostaglandin E1 (e.g., alprostadil)
This treatment maintains a patent ductus arteriosus until diagnosis and surgery.
What are the four characteristic features of Tetralogy of Fallot?
- Ventricular septal defect (VSD)
- Right ventricular hypertrophy
- Right ventricular outflow tract obstruction (pulmonary stenosis)
- Overriding aorta
These features define the condition’s anatomical presentation.
What is the management strategy for Tetralogy of Fallot?
Surgical repair, beta-blockers for cyanotic episodes
Surgical intervention is often done in two parts.
What are the clinical features of Transposition of the Great Arteries (TGA)?
- Cyanosis
- Tachypnoea
- Loud single S2
- Prominent right ventricular impulse
- ‘Egg-on-side’ appearance on chest x-ray
These features are indicative of TGA.
What is the management for Transposition of the Great Arteries?
- Maintenance of the ductus arteriosus with prostaglandins
- Surgical correction
Prostaglandins are used as a temporary measure.
What are the driving restrictions for a patient with hypertension?
- 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.
What is the required time off driving after CABG?
4 weeks
This is a standard recovery period before resuming driving.
What are the alcohol misuse guidelines for driving?
- 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.
What is the driving restriction for a patient with a first unprovoked seizure?
6 months off driving
This applies if there are no relevant structural abnormalities on brain imaging.
What is the driving restriction for patients with established epilepsy?
Must be seizure-free for 12 months
After this period, they may qualify for a driving licence.
When can a patient with narcolepsy resume driving?
Once satisfactory control of symptoms is achieved
Diagnosis necessitates immediate cessation of driving.
What must patients with chronic neurological disorders inform the DVLA?
Complete PK1 form
This is necessary for assessing fitness to drive.
What must be completed by driving licence holders with medical conditions?
Complete PK1 form
This form is required to inform the DVLA about the driver’s state of health.
When can a driving licence be reconsidered after surgery for a benign meningioma?
6 months after surgery if remains seizure free
What are the rules for driving with severe anxiety or depression?
Must not drive and must notify the DVLA
What should a person with acute psychotic disorder do regarding driving?
Must not drive during acute illness and must notify the DVLA
Can individuals with mild cognitive impairment drive?
May drive and need not inform the DVLA
What is required for individuals with monocular vision?
Must notify DVLA and may drive if acuity and visual field is normal in the remaining eye
What are common features of acute coronary syndrome (ACS)?
- Chest pain
- Dyspnoea
- Nausea and vomiting
- Sweating
- Palpitations
What are the causes of myocarditis?
- Viral: coxsackie B, HIV
- Bacteria: diphtheria, clostridia
- Autoimmune
- Drugs: doxorubicin
What are the investigations for myocarditis?
- Bloods
- ECG
- Cardiac enzymes
- ↑ inflammatory markers
What defines pulmonary arterial hypertension (PAH)?
Resting mean pulmonary artery pressure of >= 20 mmHg
What is the classical presentation of pulmonary arterial hypertension (PAH)?
Progressive exertional dyspnoea
What management is central to pulmonary arterial hypertension (PAH)?
Acute vasodilator testing
What are the potential features of pulmonary embolism?
- Chest pain
- Dyspnoea
- Haemoptysis
- Tachycardia
- Tachypnoea
What is erectile dysfunction (ED)?
Persistent inability to attain and maintain an erection sufficient for satisfactory sexual performance
What are the risk factors for erectile dysfunction (ED)?
- Cardiovascular disease risk factors
- Alcohol use
- Drugs: SSRIs, beta-blockers
What is the first-line treatment for erectile dysfunction (ED)?
PDE-5 inhibitors (e.g., sildenafil)
What are the contraindications for PDE-5 inhibitors?
- Patients taking nitrates
- Hypotension
- Recent stroke or myocardial infarction
What are the side effects of sildenafil?
- Visual disturbances
- Flushing
- Headache
- Priapism
What are the major criteria for diagnosing infective endocarditis?
- Positive blood cultures
- Evidence of endocardial involvement
What are the minor criteria for diagnosing infective endocarditis?
- Fever > 38ºC
- Vascular phenomena
- Immunological phenomena
What is aortic dissection?
A tear in the tunica intima of the wall of the aorta
What are common features of aortic dissection?
- Severe and sharp chest/back pain
- Pulse deficit
- Variation in systolic blood pressure between arms
What are the classifications of aortic dissection?
- Stanford classification: Type A and Type B
- DeBakey classification: Type I, II, III
What are the ECG changes associated with some patients experiencing ST-segment elevation?
ST-segment elevation may be seen in the inferior leads in a minority of patients
What are the two types of Stanford classification for aortic dissection?
- Type A - ascending aorta, 2/3 of cases
- Type B - descending aorta, distal to left subclavian origin, 1/3 of cases
What are the three types of DeBakey classification for aortic dissection?
- 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
What is the typical presentation of chronic kidney disease?
Usually asymptomatic, diagnosed following abnormal urea and electrolyte results
List possible features of late-stage chronic kidney disease.
- Oedema (e.g. ankle swelling, weight gain)
- Polyuria
- Lethargy
- Pruritus (secondary to uraemia)
- Anorexia (may result in weight loss)
- Insomnia
- Nausea and vomiting
- Hypertension
What does coarctation of the aorta describe?
A congenital narrowing of the descending aorta
What are common associations with coarctation of the aorta?
- Turner’s syndrome
- Bicuspid aortic valve
- Berry aneurysms
- Neurofibromatosis
What symptoms may present in infancy and adulthood due to coarctation of the aorta?
- Infancy: heart failure
- Adult: hypertension, radio-femoral delay, mid systolic murmur, apical click, notching of inferior border of ribs
What defines hypertension?
Chronically raised blood pressure, typically without symptoms unless very high
What is considered ‘normal’ blood pressure?
Between 90/60 mmHg and 140/90 mmHg
How does NICE define hypertension in terms of blood pressure readings?
- Clinic reading persistently above >= 140/90 mmHg
- 24-hour blood pressure average reading >= 135/85 mmHg
What are the two categories of hypertension?
- Primary (essential) hypertension
- Secondary hypertension
List some causes of secondary hypertension.
- 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)
What symptoms may occur in severely elevated hypertension (> 200/120 mmHg)?
- Headaches
- Visual disturbance
- Seizures
What tests are typically performed following a diagnosis of hypertension?
- Urea and electrolytes
- HbA1c
- Lipids
- ECG
- Urine dipstick
What are the main aspects of managing hypertension?
- Drug therapy using antihypertensives
- Modification of risk factors
- Monitoring for complications
What is the mechanism of action of ACE inhibitors?
Inhibit the conversion of angiotensin I to angiotensin II
What are common side effects of ACE inhibitors?
- Cough
- Angioedema
- Hyperkalaemia
What is the first-line treatment for younger patients (< 55 years old) with hypertension?
ACE inhibitors
What are the common side effects of calcium channel blockers?
- Flushing
- Ankle swelling
- Headache
What is the role of thiazide-type diuretics in hypertension management?
Inhibit sodium absorption at the beginning of the distal convoluted tubule
What is the recommended daily salt intake for hypertension management?
Less than 6g/day, ideally 3g/day
What recommendation did NICE make regarding ambulatory blood pressure monitoring (ABPM)?
It is now recommended for the diagnosis of hypertension
What is the criteria for Stage 1 hypertension according to NICE?
Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
What should be done if a patient’s blood pressure is >= 180/120 mmHg?
Admit for specialist assessment if signs of retinal haemorrhage, life-threatening symptoms, or suspected phaeochromocytoma are present
What is the protocol for home blood pressure monitoring (HBPM)?
- 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
What is the updated NICE guideline regarding antihypertensive drug treatment for adults under 60 with stage 1 hypertension?
Consider treatment in addition to lifestyle advice for those with a 10-year risk below 10%
What should be checked in patients with resistant hypertension before adding a fourth drug?
- Confirm elevated clinic BP with ABPM or HBPM
- Assess for postural hypotension
- Discuss adherence
What is the first step in treatment for patients < 55 years old?
ACE inhibitor or Angiotensin receptor blocker
What defines step 4 treatment in hypertension management?
Resistant hypertension, consider adding a 4th drug or seeking specialist advice
What is defined as resistant hypertension according to NICE?
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.
What should be added if potassium levels are less than 4.5 mmol/l?
Low-dose spironolactone
What should be added if potassium levels are greater than 4.5 mmol/l?
An alpha- or beta-blocker
What blood pressure targets does NICE recommend for patients under 80 years?
140/90 mmHg for clinic BP and 135/85 mmHg for ABPM/HBPM
What percentage of patients diagnosed with hypertension have primary hyperaldosteronism?
5-10%
List some conditions that may increase blood pressure due to renal disease.
- Glomerulonephritis
- Pyelonephritis
- Adult polycystic kidney disease
- Renal artery stenosis
Name endocrine disorders that may result in increased blood pressure.
- Phaeochromocytoma
- Cushing’s syndrome
- Liddle’s syndrome
- Congenital adrenal hyperplasia (11-beta hydroxylase deficiency)
- Acromegaly
What are some drug causes of secondary hypertension?
- Steroids
- Monoamine oxidase inhibitors
- Combined oral contraceptive pill
- NSAIDs
- Leflunomide
What is pre-eclampsia?
Emergence of high blood pressure during pregnancy that may precede eclampsia and other complications
What are the classic triad symptoms of pre-eclampsia?
- New-onset hypertension
- Proteinuria
- Oedema
What is the formal definition of pre-eclampsia?
New-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following: proteinuria, other organ involvement
What are potential consequences of pre-eclampsia?
- Eclampsia
- Altered mental status
- Blindness
- Stroke
- Clonus
- Severe headaches
- Fetal complications
- Cardiac failure
List high-risk factors for pre-eclampsia.
- Hypertensive disease in a previous pregnancy
- Chronic kidney disease
- Autoimmune disease
- Type 1 or type 2 diabetes
- Chronic hypertension
What should women with high-risk factors do to reduce the risk of hypertensive disorders in pregnancy?
Take aspirin 75-150mg daily from 12 weeks gestation until birth
What are the three main patterns of presentation in peripheral arterial disease?
- Intermittent claudication
- Critical limb ischaemia
- Acute limb-threatening ischaemia
Describe intermittent claudication.
Aching or burning in the leg muscles following walking, usually relieved within minutes of stopping
What does an ankle brachial pressure index (ABPI) of <0.3 indicate?
Impending limb ischaemia
What is mitral regurgitation (MR)?
Occurs when blood leaks back through the mitral valve on systole
What are common risk factors for mitral regurgitation?
- Female sex
- Lower body mass
- Age
- Renal dysfunction
- Prior myocardial infarction
What is a common cause of mitral regurgitation following a myocardial infarction?
Damage to the papillary muscles or chordae tendinae
What are the symptoms of mitral regurgitation?
- Fatigue
- Shortness of breath
- Oedema
What type of murmur is associated with mitral regurgitation?
Pansystolic murmur described as ‘blowing’
What are the management options for severe mitral regurgitation?
- Medical management
- Surgery (repair or replacement)
What is mitral stenosis?
Obstruction of blood flow across the mitral valve from the left atrium to the left ventricle
What are common features of mitral stenosis?
- Dyspnoea
- Haemoptysis
- Mid-late diastolic murmur
- Loud S1
- Atrial fibrillation
What is the normal cross-sectional area of the mitral valve?
4-6 sq cm
What is the first-line treatment for patients with mitral stenosis and atrial fibrillation?
Anticoagulation with warfarin
What percentage of the population is affected by mitral valve prolapse?
5-10%
What are some associations with mitral valve prolapse?
- Congenital heart disease
- Cardiomyopathy
- Marfan’s syndrome
- Ehlers-Danlos syndrome
What are the two main options for valve replacement?
- Biological (bioprosthetic) valves
- Mechanical valves
What is a major disadvantage of biological (bioprosthetic) valves?
Structural deterioration and calcification over time
What is the target INR for aortic mechanical valves?
3.0
What is the target INR for mitral mechanical valves?
3.5
True or False: Antibiotics are recommended for prophylaxis of endocarditis for common procedures such as dental work.
False
What causes the first heart sound (S1)?
Closure of the mitral and tricuspid valves
S1 may be soft in long PR or mitral regurgitation and loud in mitral stenosis.
What causes the second heart sound (S2)?
Closure of the aortic and pulmonary valves
S2 may be soft in aortic stenosis and splitting during inspiration is normal.
What is the third heart sound (S3) associated with?
Diastolic filling of the ventricle
Considered normal if < 30 years old; may persist in women up to 50 years old.
What conditions can S3 be heard in?
- Left ventricular failure
- Constrictive pericarditis
- Mitral regurgitation
S3 may be referred to as a pericardial knock in constrictive pericarditis.
What is the fourth heart sound (S4) caused by?
Atrial contraction against a stiff ventricle
S4 coincides with the P wave on ECG and may be heard in aortic stenosis, HOCM, and hypertension.
Where is the pulmonary valve best auscultated?
Left second intercostal space, at the upper sternal border
Where is the aortic valve best auscultated?
Right second intercostal space, at the upper sternal border
Where is the mitral valve best auscultated?
Left fifth intercostal space, just medial to mid clavicular line
Where is the tricuspid valve best auscultated?
Left fourth intercostal space, at the lower left sternal border
What causes a loud S2?
- Hypertension (systemic or pulmonary)
- Hyperdynamic states
- Atrial septal defect without pulmonary hypertension
What causes a soft S2?
Aortic stenosis
What is the cause of a fixed split S2?
Atrial septal defect
What causes a widely split S2?
- Deep inspiration
- RBBB
- Pulmonary stenosis
- Severe mitral regurgitation
What causes a reversed (paradoxical) split S2?
- LBBB
- Severe aortic stenosis
- Right ventricular pacing
- WPW type B
- Patent ductus arteriosus
What are the characteristics of an innocent ejection murmur?
- 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
What is an ejection systolic murmur associated with?
- Aortic stenosis
- Hypertrophic obstructive cardiomyopathy
- Pulmonary stenosis
- Atrial septal defect
- Tetralogy of Fallot
What characterizes a holosystolic (pansystolic) murmur?
Mitral/tricuspid regurgitation, high-pitched and ‘blowing’ in character
What is the typical presentation of acute coronary syndrome (ACS)?
- Chest pain (classically on the left side)
- Dyspnoea
- Nausea and vomiting
- Sweating
- Palpitations
What are the features of acute pericarditis?
- Chest pain (often pleuritic, relieved by sitting forwards)
- Non-productive cough
- Dyspnoea
- Flu-like symptoms
- Pericardial rub
What ECG changes are associated with pericarditis?
- Global ST elevation
- PR depression
What is the management for acute pericarditis?
- Outpatient management for most patients
- Inpatient management for high-risk features
- NSAIDs and colchicine for viral pericarditis
- Avoid strenuous physical activity until symptom resolution
What are common features of pulmonary embolism?
- Chest pain (typically pleuritic)
- Dyspnoea
- Haemoptysis
- Tachycardia
- Tachypnoea
What are the common clinical signs of pulmonary embolism according to the PIOPED study?
- Tachypnea (96%)
- Crackles (58%)
- Tachycardia (44%)
- Fever (43%)
What is the primary cause of venous leg ulcers?
Venous hypertension due to chronic venous insufficiency
What are the features of venous insufficiency?
- Oedema
- Brown pigmentation
- Lipodermatosclerosis
- Eczema
What is the Waterlow score used for?
To screen for patients at risk of developing pressure ulcers
What is defined as a transient loss of consciousness due to global cerebral hypoperfusion?
Syncope
What is the most common cause of syncope?
Reflex syncope, particularly vasovagal syncope
What is the typical duration of vasovagal syncope?
Less than 1-2 minutes
What are the classifications of syncope according to the European Society of Cardiology?
- Reflex syncope (neurally mediated)
- Orthostatic syncope
- Cardiac syncope
What is the typical management for pressure ulcers?
- Maintain a moist wound environment
- Use hydrocolloid dressings and hydrogels
- Consider referral to tissue viability nurse
What is Marjolin’s ulcer?
Squamous cell carcinoma occurring at sites of chronic inflammation
What is considered diagnostic for a symptomatic fall in blood pressure?
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.
What is the first test recommended for all patients experiencing sudden visual loss?
ECG for all patients
This helps assess cardiac causes of symptoms.
What additional tests may be needed for patients with sudden visual loss?
Other tests depend on clinical features
Typical features with a normal ECG may not require further investigations.
What does the term transient monocular visual loss (TMVL) refer to?
A sudden, transient loss of vision that lasts less than 24 hours
This condition is alarming for patients and may indicate serious issues.
What are the most common causes of sudden painless loss of vision?
- Ischaemic/vascular causes
- Vitreous haemorrhage
- Retinal detachment
- Retinal migraine
Ischaemic causes may include thrombosis, embolism, and temporal arteritis.
What does ‘amaurosis fugax’ refer to?
Ischaemic/vascular causes of transient monocular visual loss
It is associated with various vascular issues affecting vision.
What is a common treatment for transient ischaemic attack (TIA) related to sudden vision loss?
Aspirin 300mg
This treatment is used to prevent further vascular events.
What visual defect is often described as ‘curtain coming down’?
Altitudinal field defects
This description is common in cases of ischaemic optic neuropathy.
What are the common causes of central retinal vein occlusion?
- Glaucoma
- Polycythaemia
- Hypertension
The incidence of this condition increases with age.
What are the features of central retinal artery occlusion?
- Afferent pupillary defect
- ‘Cherry red’ spot on a pale retina
This condition is often caused by thromboembolism or arteritis.
What conditions can lead to vitreous haemorrhage?
- Diabetes
- Bleeding disorders
- Anticoagulants
Symptoms may include sudden visual loss and dark spots.
What are the features of retinal detachment?
- 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.
Fill in the blank: The features of posterior vitreous detachment include _______.
Flashes of light (photopsia) in the peripheral field of vision
Floaters are often seen on the temporal side of central vision.
What differentiates retinal detachment from vitreous haemorrhage?
- 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.
What does acute coronary syndrome (ACS) encompass?
ACS includes ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina.
What is ischaemic heart disease synonymous with?
Ischaemic heart disease is synonymous with coronary heart disease and coronary artery disease.
What are the two main problems caused by the gradual buildup of fatty plaques in coronary arteries?
- Gradual narrowing leading to angina
- Risk of sudden plaque rupture causing occlusion
List three unmodifiable risk factors for developing ischaemic heart disease.
- Increasing age
- Male gender
- Family history
List four modifiable risk factors for developing ischaemic heart disease.
- Smoking
- Diabetes mellitus
- Hypertension
- Hypercholesterolaemia
What triggers initial endothelial dysfunction in ischaemic heart disease?
- Smoking
- Hypertension
- Hyperglycaemia
What is the role of macrophages in the development of atherosclerosis?
Monocytes migrate from the blood, differentiate into macrophages, phagocytose oxidized LDL, and turn into foam cells.
What are the classic symptoms of acute coronary syndrome (ACS)?
- Chest pain
- Dyspnoea
- Sweating
- Nausea and vomiting
What is the most common feature of ACS?
Chest pain.
What are the two most important investigations in assessing a patient with chest pain?
- ECG
- Cardiac markers (e.g., troponin)
What does the acronym MONA stand for in ACS management?
- Morphine
- Oxygen
- Nitrates
- Aspirin
What is the priority of management for patients presenting with STEMI?
Revascularise the blocked vessel.
What is the first step in managing a confirmed STEMI?
Assess eligibility for coronary reperfusion therapy.
What are the two types of coronary reperfusion therapy for STEMI?
- Percutaneous coronary intervention (PCI)
- Fibrinolysis
Fill in the blank: In NSTEMI, a risk stratification tool called _______ is used.
[GRACE]
What is the minimum lifelong drug therapy for patients who have had an ACS?
- Aspirin
- Second antiplatelet (if appropriate)
- Beta-blocker
- ACE inhibitor
- Statin
What ECG changes are associated with an anterior myocardial infarction?
ST elevation in leads V1-V4.
True or False: Oxygen should be given to all patients with ACS.
False.
What should be considered if a patient’s ECG shows persistent ST elevation after fibrinolysis?
Transfer for PCI.
What is the significance of new left bundle branch block (LBBB) in STEMI criteria?
LBBB should be considered new unless there is evidence otherwise.
What is the role of dual antiplatelet therapy prior to PCI?
It combines aspirin with another antiplatelet drug.
What is the GRACE tool used for?
Risk assessment in NSTEMI/unstable angina.
What does the acronym GRACE stand for in the context of risk assessment?
[Global Registry of Acute Coronary Events]
What are the ECG criteria for determining STEMI?
- Clinical symptoms of ACS
- Persistent ST elevation in ≥ 2 contiguous leads
What is the most widely used tool for risk assessment in acute coronary events?
Acute Coronary Events (GRACE)
Which factors are taken into account when calculating the GRACE score?
- age
- heart rate
- blood pressure
- cardiac (Killip class) and renal function (serum creatinine)
- cardiac arrest on presentation
- ECG findings
- troponin levels
What are the risk stratifications based on predicted 6-month mortality?
- 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
Which patients with NSTEMI/unstable angina should have coronary angiography immediately?
Patients who are clinically unstable (e.g. hypotensive)
When should coronary angiography be performed for patients with a GRACE score?
Within 72 hours for patients with a GRACE score > 3%
What is the recommended drug therapy for patients undergoing percutaneous coronary intervention (PCI)?
- unfractionated heparin
- dual antiplatelet therapy (aspirin + another drug)
- prasugrel or ticagrelor if not taking an oral anticoagulant
- clopidogrel if taking an oral anticoagulant
What is the treatment for patients with NSTEMI/unstable angina at high risk of bleeding?
Clopidogrel
What are poor prognostic factors in patients with acute coronary syndrome?
- 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
What does the Killip class system stratify?
Risk post myocardial infarction
What is the 30-day mortality for Killip class I?
6%
What is the most common cause of death following a myocardial infarction?
Cardiac arrest due to ventricular fibrillation
What is cardiogenic shock?
A condition where ejection fraction decreases due to a large part of the ventricular myocardium being damaged in an infarction
What are common arrhythmias following a myocardial infarction?
- Ventricular fibrillation
- Ventricular tachycardia
- Atrioventricular block
What is Dressler’s syndrome?
An autoimmune reaction occurring 2-6 weeks after a myocardial infarction characterized by fever, pleuritic pain, pericardial effusion, and raised ESR
What are the key drugs recommended for all patients following a myocardial infarction according to NICE guidelines?
- dual antiplatelet therapy
- ACE inhibitor
- beta-blocker
- statin
What is the recommended lifestyle change regarding diet for patients post-myocardial infarction?
Advise a Mediterranean style diet, switch butter and cheese for plant oil based products
What is the management for a ruptured abdominal aortic aneurysm (AAA)?
Surgical emergency - immediate vascular review and emergency surgical repair
What is the interpretation for an aorta width of < 3 cm during AAA screening?
Normal - No further action
What is the most important risk factor for aortic dissection?
Hypertension
What are the features of acute limb-threatening ischaemia?
- pale
- pulseless
- painful
- paralysed
- paraesthetic
- ‘perishing with cold’
What does an ankle-brachial pressure index (ABPI) of < 0.5 suggest?
Critical limb ischaemia
What classification is used for aortic dissection?
Stanford classification
What are the two types in the Stanford classification of aortic dissection?
- Type A - ascending aorta
- Type B - descending aorta
What is the main characteristic of type A aortic dissection in the Stanford classification?
Ascending aorta, 2/3 of cases
How does type B aortic dissection differ in the Stanford classification?
Descending aorta, distal to left subclavian origin, 1/3 of cases
In the DeBakey classification, what is the origin of type I aortic dissection?
Originates in ascending aorta, propagates to at least the aortic arch and possibly beyond it distally
What defines type II aortic dissection in the DeBakey classification?
Originates in and is confined to the ascending aorta
What is the characteristic of type III aortic dissection in the DeBakey classification?
Originates in descending aorta, rarely extends proximally but will extend distally
What key finding in diagnosing aortic dissection is identified on CT angiography?
A false lumen
What is the initial management for type A aortic dissection?
Surgical management with blood pressure control to a target systolic of 100-120 mmHg
What is the preferred management for type B aortic dissection?
Conservative management, bed rest, reduce blood pressure IV labetalol
Name a complication associated with backward tear in aortic dissection.
Aortic incompetence/regurgitation
Which murmur is characteristic of aortic regurgitation?
Early diastolic murmur
What is the most common cause of chronic aortic regurgitation in the developing world?
Rheumatic fever
What are the causes of aortic regurgitation due to valve disease? List at least three.
- Rheumatic fever
- Calcific valve disease
- Bicuspid aortic valve
What is Quincke’s sign?
Nailbed pulsation associated with aortic regurgitation
What is the management for symptomatic patients with severe aortic regurgitation?
Surgery
What are the clinical features of symptomatic aortic stenosis? List at least three.
- Chest pain
- Dyspnoea
- Syncope / presyncope
What is the most common cause of aortic stenosis in older patients?
Degenerative calcification
What is the treatment of choice for symptomatic aortic stenosis?
Valve replacement
What is the key characteristic of aortic regurgitation’s murmur during examination?
Intensity of the murmur is increased by the handgrip manoeuvre
What are the options for aortic valve replacement (AVR)? List at least two.
- Surgical AVR
- Transcatheter AVR (TAVR)
What is the major disadvantage of biological (bioprosthetic) valves?
Structural deterioration and calcification over time
What is the target INR for patients with mechanical mitral valves?
3.5
True or False: Long-term anticoagulation is usually needed for patients with biological valves.
False
What is a common complication associated with aortic stenosis?
Aortic regurgitation
Fill in the blank: Aortic regurgitation is the leaking of the _______ valve of the heart.
Aortic
What is the most common valves that need replacing?
- Aortic valve
- Mitral valve
What is the management for asymptomatic patients with severe aortic regurgitation?
Medical management of any associated heart failure
What is a transient ischaemic attack (TIA)?
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’.
What was the original definition of a TIA?
A sudden onset of a focal neurologic symptom and/or sign lasting less than 24 hours, caused by a transient decrease in blood flow.
What is the new definition of a TIA?
A transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction.
List possible clinical features of a TIA. (7)
- 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
What should patients with suspected TIA receive immediately?
Aspirin 300 mg unless contraindicated.
What is the ABCD2 prognostic score used for?
It was used to risk stratify patients presenting with a suspected TIA, but is no longer recommended due to poor performance.
What imaging should be performed for patients with suspected TIA?
MRI is preferred to determine the territory of ischaemia or detect alternative pathologies.
What is the recommended management for patients who have had a TIA?
- Immediate antithrombotic therapy
- Antiplatelet therapy
- Lipid modification with high-intensity statin
- Carotid imaging if indicated
What is the aim of statin therapy in TIA management?
To reduce non-HDL cholesterol by more than 40%.
What is the difference between ischaemic and haemorrhagic strokes?
- Ischaemic: ‘Blockage’ in the blood vessel stops blood flow.
- Haemorrhagic: Blood vessel ‘bursts’ leading to reduction in blood flow.
What are the two main types of strokes?
- Ischaemic
- Haemorrhagic
What are common risk factors for strokes?
- Age
- Hypertension
- Smoking
- Hyperlipidaemia
- Diabetes mellitus
What symptoms might suggest a stroke?
- Motor weakness
- Speech problems (dysphasia)
- Visual field defects (homonymous hemianopia)
- Balance problems
What is the FAST campaign used for?
To raise awareness of stroke symptoms: Face, Arms, Speech, Time.
What is the purpose of emergency neuroimaging in suspected stroke cases?
To classify the stroke as either ischaemic or haemorrhagic and determine eligibility for thrombolytic therapy.
What should be given to ischaemic stroke patients once haemorrhagic stroke has been excluded?
Aspirin 300 mg as soon as possible.
What are the subtypes of ischaemic strokes?
- Thrombotic stroke
- Embolic stroke
What is a lacunar stroke?
A type of stroke that presents with either isolated hemiparesis, hemisensory loss, or hemiparesis with limb ataxia.
What is the Oxford Stroke Classification?
A classification system that categorizes strokes based on initial symptoms.
What defines a total anterior circulation infarct (TACI)?
Involves middle and anterior cerebral arteries with all three Oxford Stroke Classification criteria present.
What are the associated effects of an anterior cerebral artery lesion?
Contralateral hemiparesis and sensory loss, lower extremity > upper.
True or False: The symptoms of a TIA typically last longer than 24 hours.
False
Fill in the blank: The essential problem in ischaemic strokes is a ‘________’ in the blood vessel that stops blood flow.
Blockage
What should be done if a patient presents with a suspected TIA more than 7 days ago?
They should be seen by a stroke specialist clinician as soon as possible within 7 days.
What is the management approach for haemorrhagic stroke?
Supportive management, stopping anticoagulants and antithrombotic medications
Anticoagulation should be reversed quickly to minimize further bleeding.
What is the FAST screening tool used for?
To identify symptoms of stroke with a positive predictive value of 78%
FAST stands for Face, Arms, Speech, Time.
What is the ROSIER score?
A validated tool for assessing stroke risk in medical professionals
Recommended by the Royal College of Physicians.
What should be excluded first when using the ROSIER score?
Hypoglycaemia
What is the first line radiological investigation for suspected stroke?
Non-contrast CT head scan
What indicates a stroke in the ROSIER score?
A score of > 0
What are the key signs of acute ischaemic stroke on a CT scan?
Areas of low density, hyperdense artery sign
These changes may take time to develop.
What are the typical findings for acute haemorrhagic stroke on a CT scan?
Areas of hyperdense material (blood) surrounded by low density (oedema)
What should be maintained within normal limits in stroke management?
Blood glucose, hydration, oxygen saturation, temperature
What is the recommended initial treatment for a patient with an acute ischaemic stroke?
Aspirin 300mg if haemorrhagic stroke has been excluded
What is the time frame for administering thrombolysis after stroke onset?
Within 4.5 hours
What are the absolute contraindications to thrombolysis? (10)
- 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
What is mechanical thrombectomy used for?
Treatment for patients with acute ischaemic stroke
What are the recommendations for secondary prevention after an ischaemic stroke?
- Clopidogrel recommended ahead of aspirin + MR dipyridamole
- Aspirin only if clopidogrel is contraindicated
What is the Oxford Stroke Classification used for?
Classifying strokes based on initial symptoms
What are the criteria for Total Anterior Circulation Infarcts (TACI)?
All three criteria:
* Unilateral hemiparesis/sensory loss
* Homonymous hemianopia
* Higher cognitive dysfunction (e.g., dysphasia)
What are common clinical signs of pulmonary embolism?
- Tachypnea (96%)
- Crackles (58%)
- Tachycardia (44%)
- Fever (43%)
What is the PERC rule used for?
To rule out pulmonary embolism when the pre-test probability is low
What is the 2-level PE Wells score used for?
To assess the probability of pulmonary embolism
What is the initial recommended lung-imaging modality for non-massive PE?
CTPA (Computed Tomography Pulmonary Angiography)
What should be done if a PE is ‘likely’ according to the Wells score?
Arrange an immediate CTPA and consider interim therapeutic anticoagulation
What is the recommended action if a PE is ‘unlikely’ according to the Wells score?
Arrange a D-dimer test
What are the potential features of pulmonary embolism?
- Chest pain (typically pleuritic)
- Dyspnoea
- Haemoptysis
- Tachycardia
- Tachypnoea
What is the recommended initial lung-imaging modality for non-massive PE?
CTPA
CTPA provides speed, ease of performance out-of-hours, and can offer alternative diagnoses.
What should be done if the CTPA is negative for pulmonary embolism?
Patients do not need further investigations or treatment for PE.
Under what circumstances may V/Q scanning be used initially?
If appropriate facilities exist, chest x-ray is normal, and no significant symptomatic concurrent cardiopulmonary disease.
What is the sensitivity and specificity of D-dimers?
Sensitivity = 95-98%, poor specificity.
What should be considered for patients over 50 years regarding D-dimer levels?
Age-adjusted D-dimer levels.
What classic ECG changes are seen in PE?
S1Q3T3 pattern: large S wave in lead I, large Q wave in lead III, inverted T wave in lead III.
What percentage of patients exhibit the classic ECG changes associated with PE?
No more than 20%.
What are the possible findings of a chest x-ray in PE?
Typically normal; possible findings include wedge-shaped opacification.
What is the sensitivity and specificity of V/Q scans?
Sensitivity around 75%, specificity 97%.
What other conditions can cause mismatch in V/Q scans? (4)
- Old pulmonary embolisms
- AV malformations
- Vasculitis
- Previous radiotherapy
What is the cornerstone of VTE management?
Anticoagulant therapy.
What is the first-line treatment for most people with VTE according to NICE 2020 guidelines?
Direct oral anticoagulants (DOACs).
What is the recommended treatment for patients with active cancer and VTE?
DOACs, as opposed to low-molecular weight heparin.
What tool does NICE recommend for determining the suitability of outpatient treatment for low-risk PE patients?
Validated risk stratification tool.
What is the Pulmonary Embolism Severity Index (PESI) score used for?
To assess suitability for outpatient treatment in PE.
What is the recommendation for the length of anticoagulation therapy?
At least 3 months.
What factors determine the continuation of anticoagulation treatment after the initial 3 months?
Whether the VTE was provoked or unprovoked.
What is the ORBIT score used for?
To assess the risk of bleeding.
What is the first-line treatment for massive PE with circulatory failure?
Thrombolysis.
What is pulmonary arterial hypertension (PAH) defined as?
Resting mean pulmonary artery pressure of >= 20 mmHg.
What are the classical features of pulmonary arterial hypertension?
- Progressive exertional dyspnoea
- Exertional syncope
- Exertional chest pain
- Peripheral oedema
- Cyanosis
What management strategies are used for PAH based on acute vasodilator testing results?
Positive response: oral calcium channel blockers
Negative response: prostacyclin analogues, endothelin receptor antagonists, phosphodiesterase inhibitors.
What are the WHO classifications of pulmonary hypertension?
- 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
What is the primary treatment for severe PAD or critical limb ischaemia?
- Endovascular revascularization
- Surgical revascularization
What drugs are licensed for use in peripheral arterial disease (PAD)?
- Naftidrofuryl oxalate
- Cilostazol
What is acute pericarditis characterized by?
Inflammation of the pericardial sac lasting less than 4-6 weeks.
What are common symptoms of acute pericarditis?
- Chest pain
- Non-productive cough
- Dyspnoea
- Flu-like symptoms
What is the most specific ECG marker for pericarditis?
PR depression.
What is the management for most patients with acute pericarditis?
Outpatient management; treat underlying causes.
What percentage of patients may have an elevated troponin indicating possible myopericarditis?
30%
Elevated troponin levels can indicate myopericarditis among other cardiac conditions.
How should patients with high-risk features like fever > 38°C or elevated troponin be managed?
Managed as an inpatient
High-risk features necessitate closer monitoring and treatment.
What is the first-line treatment for patients with acute idiopathic or viral pericarditis?
A combination of NSAIDs and colchicine
This treatment is effective until symptom resolution and normalization of inflammatory markers.
What are the classical features of cardiac tamponade known as Beck’s triad?
- Hypotension
- Raised JVP
- Muffled heart sounds
These features indicate the presence of cardiac tamponade.
What is a characteristic feature of cardiac tamponade in relation to JVP?
Absent Y descent
This is due to limited right ventricular filling.
What is a common mnemonic to remember the absent Y descent in cardiac tamponade?
TAMponade = TAMpaX
This mnemonic helps recall the features of cardiac tamponade.
What is the management for cardiac tamponade?
Urgent pericardiocentesis
This procedure helps relieve pressure on the heart.
Which infectious cause is particularly associated with constrictive pericarditis?
Tuberculosis (TB)
TB is a significant cause of constrictive pericarditis in certain populations.
What are common causes of pericardial effusion?
- 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.
What typically characterizes myocarditis?
Inflammation of the myocardium
Myocarditis can have various underlying causes, including infections.
What are the common symptoms of mitral regurgitation (MR)?
- Fatigue
- Shortness of breath
- Oedema
Symptoms arise when the left ventricle fails to compensate for the regurgitation.
What is the most common valve disease after aortic stenosis?
Mitral regurgitation (MR)
MR is prevalent and can affect heart efficiency.
What are the risk factors for developing mitral regurgitation?
- 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.
What is the typical auscultation finding in mitral regurgitation?
A pansystolic ‘blowing’ murmur
This murmur is best heard at the apex and may radiate to the axilla.
What is the management for symptomatic patients with mitral stenosis?
- Percutaneous mitral balloon valvotomy
- Mitral valve surgery (commissurotomy or valve replacement)
These interventions are considered for symptomatic relief.
What is the primary cause of mitral stenosis?
Rheumatic fever
This condition is the most common cause, particularly in developing countries.
What is the management for patients with mitral valve prolapse?
Typically no treatment unless complications arise
Most patients with mitral valve prolapse are asymptomatic.
What are the two main types of heart valve replacements?
- Biological (bioprosthetic) valves
- Mechanical valves
Each type has its own advantages and risks.
What is the target INR for patients with mechanical mitral valves?
3.5
This target helps minimize thromboembolic risks.
What is the investigation of choice for diagnosing acute mesenteric ischaemia?
CT scan
CT is crucial for identifying vascular occlusions.
What are common features of bowel ischaemia?
- Abdominal pain
- Rectal bleeding
- Diarrhoea
- Fever
These symptoms can vary based on the type of ischaemia.
What is a common predisposing factor for mesenteric ischaemia?
Atrial fibrillation
Atrial fibrillation increases the risk of embolic events leading to mesenteric ischaemia.
What are the cardiovascular disease risk factors?
Smoking, hypertension, diabetes
What condition is sometimes seen in young patients following cocaine use?
Ischaemic colitis
What is a common feature of acute mesenteric ischaemia?
Sudden onset abdominal pain
What clinical signs are associated with acute mesenteric ischaemia?
- Rectal bleeding
- Diarrhoea
- Fever
- Elevated white blood cell count
- Lactic acidosis
What is the investigation of choice for diagnosing mesenteric ischaemia?
CT scan
What typically causes acute mesenteric ischaemia?
Embolism resulting in occlusion of an artery supplying the small bowel
What is the management approach for acute mesenteric ischaemia?
Urgent surgery is usually required
What is chronic mesenteric ischaemia often referred to as?
‘Intestinal angina’
What does ischaemic colitis describe?
Acute but transient compromise in blood flow to the large bowel
In which areas is ischaemic colitis more likely to occur?
‘Watershed’ areas such as the splenic flexure
What radiological feature may be seen in ischaemic colitis on an abdominal x-ray?
‘Thumbprinting’
What is the initial management for ischaemic colitis?
Supportive care
What are the three main conditions associated with ischaemia to the lower gastrointestinal tract?
- Acute mesenteric ischaemia
- Chronic mesenteric ischaemia
- Ischaemic colitis
What is the strongest risk factor for developing infective endocarditis?
A previous episode of endocarditis
Which heart valve is most commonly affected in infective endocarditis?
Mitral valve
What is the most common cause of infective endocarditis?
Staphylococcus aureus
What type of bacteria was historically the most common cause of infective endocarditis?
Streptococcus viridans
What is a common association of Streptococcus bovis?
Colorectal cancer
What are the major criteria for diagnosing infective endocarditis?
- Positive blood cultures
- Evidence of endocardial involvement on echocardiogram
What are some minor criteria for diagnosing infective endocarditis?
- Predisposing heart condition
- Fever > 38ºC
- Vascular phenomena
- Immunological phenomena
Which organism is associated with a 30% mortality rate in infective endocarditis?
Staphylococci
What is the first-line treatment for haemochromatosis?
Venesection
What is the typical iron study profile in a patient with haemochromatosis?
- Transferrin saturation > 55% in men or > 50% in women
- Raised ferritin
- Low TIBC
What condition is characterized by the death of body tissue due to lack of blood supply?
Gangrene
What is the appearance of dry gangrene?
Dry, shrivelled, and blackened tissue
What distinguishes wet gangrene from dry gangrene?
Swollen, moist, and blistered tissue with a foul odour
What is gas gangrene caused by?
Infection with Clostridium bacteria
What is a severe condition characterized by rapid tissue necrosis and infection?
Necrotising fasciitis
What is gas gangrene?
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.
What are the key symptoms of gas gangrene?
Severe pain, swelling, crepitus, systemic symptoms like tachycardia, hypotension, and shock.
Crepitus is the crackling sound produced by gas in the tissues.
What is necrotising fasciitis?
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.
What are the symptoms of necrotising fasciitis?
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.
What are the key management strategies for gangrene?
Urgent intervention, surgical intervention, antibiotic therapy, supportive care, hyperbaric oxygen therapy.
These strategies focus on controlling infection, restoring blood supply, and removing necrotic tissue.
What does surgical intervention for gangrene involve?
Debridement, amputation, revascularisation.
Debridement is the surgical removal of necrotic tissue to prevent infection spread.
What is the purpose of antibiotic therapy in managing gangrene?
To control infection with empirical broad-spectrum antibiotics followed by targeted therapy.
High-dose penicillin and clindamycin are often recommended for gas gangrene.
Fill in the blank: The surgical removal of necrotic tissue is called _______.
debridement
True or False: Hyperbaric oxygen therapy is used to enhance oxygen delivery to ischaemic tissues in some cases of gas gangrene.
True
What are some systemic symptoms that may require supportive care in gangrene management?
Fluid resuscitation, pain control, nutritional support, monitoring of comorbid conditions.
Comorbid conditions may include diabetes and cardiovascular disease.
What are the potential outcomes of untreated gas gangrene?
Rapid progression to systemic sepsis and high mortality.
Timely medical intervention is crucial to prevent these severe outcomes.
What are angiotensin-converting enzyme (ACE) inhibitors primarily used for?
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.
How do ACE inhibitors work?
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.
What are common side effects of ACE inhibitors?
- Cough
- Angioedema
- Hyperkalaemia
- First-dose hypotension
Cough occurs in around 15% of patients and may occur up to a year after starting treatment.
In which patients should ACE inhibitors be avoided?
- 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.
What is the role of calcium channel blockers?
Primarily used in the management of cardiovascular disease
They affect myocardial cells, the conduction system, and vascular smooth muscle.
What are the side effects of Verapamil?
- Heart failure
- Constipation
- Hypotension
- Bradycardia
- Flushing
It is highly negatively inotropic and should not be given with beta-blockers.
What is the definition of hypertension according to NICE?
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.
What are some common causes of secondary hypertension?
- Renal parenchymal disease
- Renal vascular disease
- Coarctation of the aorta
- Phaeochromocytoma
- Congenital adrenal hyperplasia
Essential hypertension becomes more common as children age.
What should be checked to assess for end-organ damage in hypertension?
- 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.
What is the recommended method for diagnosing hypertension?
Use 24-hour blood pressure monitoring or home blood pressure monitoring
This helps avoid white coat hypertension and provides a more accurate assessment.
What is the significance of using 24-hour blood pressure monitoring?
It correlates better with clinical outcomes and helps prevent overdiagnosis of hypertension
ABPM is a more accurate predictor of cardiovascular events than clinic readings.
What are the criteria for Stage 1 hypertension?
Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
This classification is important for treatment decisions.
What is the procedure for ambulatory blood pressure monitoring (ABPM)?
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.
What are the acceptable changes in creatinine and potassium after starting ACE inhibitors?
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.
Fill in the blank: ACE inhibitors are activated by _______ metabolism in the liver.
[phase 1]
What are the common drugs used to treat hypertension?
- 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.
What is the threshold for treating stage 1 hypertension in patients under 80 years according to NICE guidelines?
Lowered from 20% to 10%
This change was made in 2019 to include patients with a 10-year cardiovascular risk below 10%.
At what blood pressure measurements is stage 1 hypertension classified?
Clinic BP >= 140/90 mmHg and ABPM/HBPM average BP >= 135/85 mmHg
What drug treatment is recommended for patients with stage 2 hypertension?
Offer drug treatment regardless of age
What lifestyle advice is recommended for managing hypertension?
- 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
What is the blood pressure classification for stage 2 hypertension?
Clinic BP >= 160/100 mmHg and ABPM/HBPM average BP >= 150/95 mmHg
What are the first-line treatments for patients under 55 years or with type 2 diabetes mellitus?
ACE inhibitor or Angiotensin receptor blocker (ACE-i or ARB)
What is a common cause of secondary hypertension?
Primary hyperaldosteronism, including Conn’s syndrome
What are the features of primary hyperaldosteronism?
- Hypertension
- Hypokalaemia
- Metabolic alkalosis
What is the first-line investigation for suspected primary hyperaldosteronism?
Plasma aldosterone/renin ratio
What management is recommended for adrenal adenoma?
Surgery (laparoscopic adrenalectomy)
What are common adverse effects of thiazide diuretics?
- Dehydration
- Postural hypotension
- Hypokalaemia
- Hyponatraemia
- Hypercalcaemia
- Gout
- Impaired glucose tolerance
- Impotence
What is the cornerstone of VTE management?
Anticoagulant therapy
What anticoagulants are now recommended as first-line treatment for most people with VTE?
Direct oral anticoagulants (DOACs) such as apixaban or rivaroxaban
What is the two-level DVT Wells score used for?
To assess the probability of DVT based on clinical features
What should be done if a DVT is ‘likely’ according to the Wells score?
A proximal leg vein ultrasound scan should be carried out within 4 hours
What should be done if a DVT is ‘unlikely’ according to the Wells score?
Perform a D-dimer test
What is the recommended length of anticoagulation for a provoked VTE?
Typically stopped after 3 months
What is the recommended length of anticoagulation for an unprovoked VTE?
Typically continued for up to 6 months
What are the clinical features of DVT?
- Lower limb pain (often calf pain)
- Tenderness along the deep veins
- Swelling
- Erythema
- Pitting oedema
- Distension of superficial veins
What is the primary underlying cause of arterial ulcers?
Atherosclerosis
What is the management for bilateral adrenocortical hyperplasia?
Aldosterone antagonist e.g. spironolactone
What recent change did NICE make regarding the use of DOACs for patients with active cancer?
DOACs are now recommended instead of low-molecular weight heparin
What should be assessed before step 4 treatment for resistant hypertension?
- Confirm elevated clinic BP with ABPM or HBPM
- Assess for postural hypotension
- Discuss adherence
What are arterial ulcers also known as?
Ischemic ulcers
Arterial ulcers are chronic wounds caused by insufficient blood supply, typically from peripheral arterial disease (PAD).
What is the primary underlying cause of arterial ulcers?
Atherosclerosis
Atherosclerosis leads to the narrowing and hardening of arteries, resulting in reduced blood flow.
List some clinical features of arterial ulcers.
- 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
What does an Ankle-Brachial Pressure Index (ABPI) of less than 0.9 indicate?
Peripheral arterial disease (PAD)
ABPI is a non-invasive test measuring blood pressure ratios in the ankle and arm.
What are the key management strategies for arterial ulcers?
- Risk factor modification
- Optimisation of blood flow
- Wound care
- Infection control
True or False: Chest compressions in CPR are given at a ratio of 30:2.
True
This is the recommended compression to ventilation ratio during CPR.
What should be done if IV access cannot be achieved during cardiac arrest?
Use intraosseous route (IO)
Delivery of drugs via tracheal tube is no longer recommended.
What are the ‘Hs’ in the reversible causes of cardiac arrest?
- Hypoxia
- Hypovolaemia
- Hyperkalaemia
- Hypokalaemia
- Hypoglycaemia
- Hypocalcaemia
- Acidaemia
- Hypothermia
Name one of the major changes in the 2015 Resuscitation Council guidelines for paediatric basic life support.
Compression:ventilation ratio changed to 30:2 for lay rescuers
For two or more rescuers, the ratio is 15:2.
What features of pulmonary oedema can be seen on a chest x-ray?
- Interstitial oedema
- Bat’s wing appearance
- Upper lobe diversion
- Kerley B lines
- Pleural effusion
- Cardiomegaly
What is the first-line blood test for diagnosing heart failure according to NICE guidelines?
N-terminal pro-B-type natriuretic peptide (NT-proBNP)
This test is now recommended for all patients regardless of previous myocardial infarction.
What are the normal levels of BNP and NT-proBNP?
- BNP: < 100 pg/ml (29 pmol/litre)
- NT-proBNP: < 400 pg/ml (47 pmol/litre)
What is the first-line therapy for all patients with heart failure?
ACE-inhibitor and beta-blocker
Clinical judgement is used to determine which one to start first.
Fill in the blank: The standard second-line treatment for heart failure is an _______.
Aldosterone antagonist
Examples include spironolactone and eplerenone.
What criteria must be met for ivabradine to be initiated?
Sinus rhythm > 75/min and a left ventricular fraction < 35%
Ivabradine is used in heart failure treatment.
What does the New York Heart Association (NYHA) Class II indicate?
Mild symptoms with slight limitation of physical activity
Comfortable at rest but ordinary activity results in fatigue, palpitations, or dyspnoea.
What is acute heart failure (AHF)?
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.
What are common precipitating causes of acute heart failure?
- Acute coronary syndrome
- Hypertensive crisis
- Acute arrhythmia
- Valvular disease
What is the diagnostic workup for patients with AHF?
- Blood tests
- Chest X-ray
- Echocardiogram
- B-type natriuretic peptide
What is the purpose of tests in heart failure diagnosis?
To look for any underlying abnormality such as anaemia, abnormal electrolytes or infection.
What findings can be seen in a Chest X-ray for heart failure?
Pulmonary venous congestion, interstitial oedema and cardiomegaly.
When is an Echocardiogram recommended?
For patients with new-onset heart failure and for known heart failure patients with suspected change in cardiac function.
What do raised levels of B-type natriuretic peptide indicate?
Myocardial damage and support the diagnosis of heart failure.
What are the recommended treatments for all patients with heart failure?
IV loop diuretics, e.g., furosemide or bumetanide.
What is the recommended oxygen saturation level for patients with heart failure?
94-98%.
What is a major contraindication for using nitrates in heart failure treatment?
Hypotension.
True or False: Opiates should be routinely offered to people with acute heart failure.
False.
What should be done for patients with severe left ventricular dysfunction and cardiogenic shock?
Consider inotropic agents, e.g., dobutamine.
How is heart failure defined?
A clinical syndrome where the heart is unable to pump enough blood to meet the metabolic needs of the body.
What are the two classifications of heart failure by ejection fraction?
- Heart failure with reduced ejection fraction (HF-rEF) * Heart failure with preserved ejection fraction (HF-pEF)
What is the typical left ventricular ejection fraction (LVEF) for HF-rEF?
< 35 to 40%.
What is the difference between systolic and diastolic dysfunction?
Systolic dysfunction is impaired myocardial contraction during systole, while diastolic dysfunction is impaired ventricular filling during diastole.
What are some causes of systolic dysfunction?
- Ischaemic heart disease * Dilated cardiomyopathy * Myocarditis * Arrhythmias * Hypertrophic obstructive cardiomyopathy * Restrictive cardiomyopathy * Cardiac tamponade * Constrictive pericarditis
How is heart failure classified by time?
Acute or chronic.
What typically causes acute heart failure?
Acute exacerbation of chronic heart failure.
What are the consequences of left ventricular failure?
- Pulmonary oedema * Dyspnoea * Orthopnoea * Paroxysmal nocturnal dyspnoea * Bibasal fine crackles
What are the consequences of right ventricular failure?
- Peripheral oedema * Ankle/sacral oedema * Raised jugular venous pressure * Hepatomegaly * Weight gain due to fluid retention * Anorexia (‘cardiac cachexia’)
What characterizes high-output heart failure?
A ‘normal’ heart unable to pump enough blood to meet the metabolic needs of the body.
What are some causes of high-output heart failure?
- Anaemia * Arteriovenous malformation * Paget’s disease * Pregnancy * Thyrotoxicosis * Thiamine deficiency (wet Beri-Beri)
What is atrial fibrillation (AF)?
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.
How is atrial fibrillation classified?
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.
What are the common symptoms of atrial fibrillation?
Symptoms include:
* Palpitations
* Dyspnoea
* Chest pain
Many cases are asymptomatic and found incidentally.
What is a key sign of atrial fibrillation?
An irregularly irregular pulse.
This sign can also be present in other conditions, so an ECG is essential for diagnosis.
What is essential for diagnosing atrial fibrillation?
An ECG is essential to make the diagnosis.
Other conditions can cause an irregular pulse, such as ventricular ectopics or sinus arrhythmia.
What are the two key parts of managing patients with atrial fibrillation?
- Rate/rhythm control
- Reducing stroke risk
What are the two main strategies for managing the arrhythmia in atrial fibrillation?
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.
What is the first-line treatment for rate control in atrial fibrillation?
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.
What should be considered before attempting cardioversion in patients with atrial fibrillation?
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.
What scoring system is used to assess stroke risk in atrial fibrillation?
CHA2DS2-VASc score.
This score helps determine the need for anticoagulation.
List the points associated with the CHA2DS2-VASc score.
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
What is the recommended anticoagulation strategy based on the CHA2DS2-VASc score?
Score:
* 0: No treatment
* 1: Males: Consider anticoagulation; Females: No treatment
* 2 or more: Offer anticoagulation.
What anticoagulants are recommended by NICE for atrial fibrillation?
Recommended DOACs include:
* Apixaban
* Dabigatran
* Edoxaban
* Rivaroxaban
Warfarin is now a second-line treatment.
What is the ORBIT scoring system used for?
To assess bleeding risk in patients requiring anticoagulation.
This system helps evaluate the risk/benefit profile of starting anticoagulation.
What variables are included in the ORBIT score?
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
What are the two scenarios where cardioversion may be used in atrial fibrillation?
- Electrical cardioversion as an emergency if the patient is haemodynamically unstable
- Elective electrical or pharmacological cardioversion where rhythm control is preferred.
What is the recommended approach for cardioversion if AF onset is less than 48 hours?
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.
What should be done if AF has lasted more than 48 hours before cardioversion?
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.
What is the significance of the R wave in electrical cardioversion?
Electrical cardioversion is synchronised to the R wave to prevent shocks during vulnerable cardiac repolarisation periods.
What is the traditional anticoagulant of choice?
Warfarin
Warfarin requires regular monitoring, unlike newer alternatives.
What are Non-Vitamin K Antagonist Oral Anticoagulants (NOACs)?
Alternatives to warfarin that do not require regular monitoring
NOACs are more convenient for patients.
What are the two options for managing heart rate in atrial fibrillation?
- Restore normal sinus rhythm
- Slow the heart rate down
The latter reduces the adverse consequences of persistent tachycardia.
What is the primary management strategy for atrial fibrillation?
Rhythm control strategy
This is often preferred as patients may revert back to AF after cardioversion.
Which medications are first-line for controlling heart rate in atrial fibrillation?
- Beta-blockers
- Calcium channel blockers
- Digoxin (second line)
Digoxin is not preferred for patients with high physical activity.
List agents with proven efficacy in the pharmacological cardioversion of atrial fibrillation. (6)
- Amiodarone
- Flecainide (if no structural heart disease)
- Quinidine
- Dofetilide
- Ibutilide
- Propafenone
Some agents are less commonly used in the UK.
What should be excluded before starting anticoagulation or antiplatelet therapy after a stroke or TIA?
Haemorrhage
This is crucial to prevent complications from anticoagulation.
When should anticoagulation for atrial fibrillation start after a TIA?
Immediately once imaging has excluded haemorrhage
This is vital for stroke prevention.
What is the recommended timing for starting anticoagulation after an acute stroke?
After 2 weeks in the absence of haemorrhage
Antiplatelet therapy should be given in the intervening period.
What is the first-line treatment strategy for patients with atrial fibrillation?
Rate control
Except in specific cases such as reversible causes or new-onset AF.
What are the three types of heart block?
- First-degree heart block
- Second-degree heart block
- Third-degree heart block
Each type has distinct characteristics in PR interval and symptoms.
What is the first-line treatment for bradycardia with adverse signs?
Atropine (500mcg IV)
If there’s an unsatisfactory response, higher doses or transcutaneous pacing may be used.
What is Torsades de Pointes?
A form of polymorphic ventricular tachycardia associated with a long QT interval
It may deteriorate into ventricular fibrillation.
What are the causes of a prolonged QT interval?
- Congenital syndromes
- Antiarrhythmics
- Electrolyte imbalances
- Myocarditis
- Hypothermia
- Subarachnoid haemorrhage
These factors can lead to serious cardiac events.
What is the management for ventricular tachycardia (VT) with adverse signs?
Immediate cardioversion
If no adverse signs, antiarrhythmics may be used.
What should be done if drug therapy fails in managing VT?
- Electrophysiological study (EPS)
- Implantable cardioverter-defibrillator (ICD)
Particularly indicated in patients with impaired left ventricular function.
What is the significance of CHA2DS2-VASc score in anticoagulation therapy?
- Score = 0: 2 months anticoagulation recommended
- Score > 1: long-term anticoagulation recommended
This score helps assess stroke risk in atrial fibrillation patients.
What ECG finding is characteristic of atrial flutter?
‘Sawtooth’ appearance of flutter waves
The atrial rate is often around 300/min.
What is the recommended approach for catheter ablation in atrial fibrillation?
For patients who have not responded to or wish to avoid antiarrhythmic medication
The aim is to ablate faulty electrical pathways.
In a peri-arrest situation, what is assumed to be the origin of the condition?
Ventricular
The assumption is based on guidelines from the resuscitation council.
What adverse signs indicate immediate cardioversion is needed?
Systolic BP < 90 mmHg, chest pain, heart failure, syncope
These signs suggest significant hemodynamic instability.
What may be used in the absence of adverse signs before considering electrical cardioversion?
Antiarrhythmics
If antiarrhythmics fail, synchronized DC shocks may be required.
Which drug is ideally administered through a central line?
Amiodarone
This method ensures better delivery and reduces complications.
Which drug should be used with caution in severe left ventricular impairment?
Lidocaine
Caution is necessary due to potential adverse effects on heart function.
Which drug is contraindicated in ventricular tachycardia (VT)?
Verapamil
Verapamil can worsen VT by causing further hemodynamic instability.
What are the next steps if drug therapy fails?
Electrophysiological study (EPS), implantable cardioverter-defibrillator (ICD)
ICDs are particularly indicated in patients with significantly impaired left ventricular function.
Fill in the blank: If a patient has adverse signs, _______ is indicated.
immediate cardioversion
This is crucial for stabilizing the patient.
True or False: Procainamide is a drug that can be used in the treatment of VT.
True
Procainamide is an antiarrhythmic that may be used in certain situations.
