Cardiology 2 Flashcards
1
Q
What is angina?
A
The result of myocardial ischaemia, where blood supply < metabolic demand
2
Q
Describe stable angina
A
- Chest pain precipitated by exposure to cold/exercise- Lasts 1-5 minutes- Relieved by rest/GTN
3
Q
Describe unstable angina
A
- Chest pain at rest- Prolonged, lasts longer than 20 minutes- No relief by rest/GTN spray- No significant rise in troponin levels
4
Q
Give 7 features of a myocardial infarction
A
- Cardiac chest pain2. Unremitting3. Occur at rest4. Associated with sweating, breathlessness, nausea and/or vomiting5. One third occur in bed at night6. Non-Q-wave or Q-wave MI7. NSTEMI or STEMI
5
Q
What will most likely lead to pathological Q-wave formation, heart failure or death?
A
STEMI or MI associated with LBBB as they are associated with larger infarcts unless effectively treated
6
Q
Describe NSTEMI
A
- Non-ST-elevation myocardial infarction- Increase in troponin, myoglobin and creatine kinase levels- Retrospective diagnosis - no ST elevations on ECG (nearly complete blockage)
7
Q
Describe STEMI
A
- ST-elevation myocardial infarction- Increase in troponin, myoglobin and creatine kinase levels- Diagnosis at presentation - ST elevations on ECG (complete blockage)
8
Q
Describe Prinzmetal’s angina
A
- Caused by coronary artery spasms- Occur at rest/night
9
Q
Describe initial management of ACS
A
- Call 999/get to hospital quickly- Take aspirin 300mg immediately- Take pain relief if required
10
Q
Describe hospital management of ACS
A
- Confirm/make diagnosis
- Oxygen therapy
- Pain relief (opiates/nitrates)
- Aspirin +/- P2Y12 inhibitor (clopidogrel) (dual antiplatelet therapy)
- Antianginal therapy (beta blockers, nitrates, calcium antagonists)
- PPCI if STEMI (fibrinolytic therapy if not available)
- Revascularisation
- Cardiac monitoring for arrhythmias
11
Q
What is required to confirm/make a diagnosis of ACS?
A
- History- ECG- Troponin levels (potentially also myoglobin and CK levels)- Sometimes coronary angiography
12
Q
When should you give oxygen therapy in ACS?
A
If the patient is hypoxic
13
Q
Why might you choose to use opiates over nitrates and vice versa?
A
- Opiates my delay the absorption of P2Y12 inhibitors- Nitrates used for unstable angina/coronary vasospasm but may be ineffective for MI
14
Q
What might you use in addition to dual antiplatelet therapy?
A
An anticoagulant e.g. fondaparinux or heparin
15
Q
Describe PPCI
A
- Primary percutaneous coronary intervention- Treatment choice for STEMI- Predilate occluded coronary artery- Position stent- Deploy stent- Repeat angiogram 3 months later
16
Q
Describe CABG
A
- Coronary artery bypass graft surgery- Used in about 10% of patients with NSTE ACS
17
Q
What are reasons for patients not having obstructive coronary artery disease?
A
- The actual diagnosis is not ACS
- Plaque rupture occurs without significant stenosis and obstructed thrombus is resolve by time of angiography
- Stress induced (Tako-Tsubo) cardiomyopathy without obstructive CAD
18
Q
What are acute coronary syndromes?
A
- Unstable angina- NSTEMI- STEMI
19
Q
What are 11 predisposing factors for IHD (ischaemic heart disease)?
A
- Age2. Smoking3. Family history4. Diabetes mellitus5. Being Male6. Hyperlipidaemia7. Hypertension8. Kidney disease9. Obesity10. Physical inactivity11. Stress
20
Q
What are 4 pros and 4 cons of PCI?
A
Pros - less invasive, convenient, repeatable and acceptableCons - risk stent thrombosis, risk restenosis, can’t deal with complex disease, dual antiplatelet therapy
21
Q
What are 2 pros and 6 cons of CABG?
A
Pros - better prognosis, deals with complex diseaseCons - invasive, risk of stroke/bleeding, can’t do if frail/comorbid, one time treatment, length of stay, time for recovery
22
Q
What is acute pericarditis?
A
An inflammatory pericardial syndrome with or without effusion
23
Q
What are infectious causes of pericarditis?
A
- Viral (enteroviruses (coxsackie), adenoviruses etc.)
- Bacterial (mycobacterium tuberculosis)
- Fungal (histoplasma spp)
24
Q
What are 5 non infectious causes of pericarditis?
A
- Trauma/iatrogenic
- Uraemia
- MI
- Secondary metastatic tumour
- Autoimmune (rheumatoid arthritis, Sjogren’s syndrome, systemic lupus erythematosus)
25
What are 4 signs of pericarditis?
1. Pericardial friction rub (auscultation)2. Tachycardia3. Peripheral oedema4. Increased JVP
26
What are 2 extra signs of pericarditis if there is pericardial effusion?
1. Bronchial breathing at left base2. Muffled heart sounds
27
What are 6 symptoms of pericarditis?
1. Chest pain (relieved by sitting/leaning forward, exacerbated by inspiration)2. Fever3. Shortness of breath/dyspnoea4. Cough5. Hiccups6. Myalgia
28
What are 3 investigations for patients with pericarditis?
1. ECG - tachycardia2. Echo/CXR if suspect effusion3. Blood tests (FBC, ESR & CRP, troponin)
29
What does an ECG look like in patients with pericarditis?
- Saddle shaped ST elevation- PR depression
30
What will blood test results look like in patients with pericarditis?
- FBC - modest increase in WCC and mild lymphocytosis
- ESR & CRP - high ESR may suggest aetiology, ANA in young females indicates SLE
- Troponin - elevations suggest myopericarditis
31
What is the treatment for pericarditis?
- NSAIDs with gastric protection (ibuprofen, aspirin)- Colchicine for 3 months- Reduce physical activity until symptoms resolve- Treat the cause- Pericardiocentesis (if effusion)
32
What is the main complication of pericarditis?
Cardiac tamponade
33
What is cardiac tamponade?
Accumulation of fluid in pericardial space - life threatening condition
34
Describe the pathophysiology of cardiac tamponade
- Build up of fluid in pericardial space- Compression of heart chambers- Decrease in venous return- Decrease in filling in the heart- Reduced cardiac output
35
What are 2 signs of cardiac tamponade?
1. Beck's triad:- Falling BP- Rising JVP- Muffled heart sounds2. Pulsus paradoxus (large decrease in stroke volume - systolic BP drops by >10mmHg on inspiration)
36
What is the gold standard investigation for patients with cardiac tamponade?
Echocardiogram
37
What is the treatment for cardiac tamponade?
Pericardiocentesis
38
What is pericardial effusion?
Build up of fluid in the pericardium
39
What are 6 exacerbating factors (decreased supply) for chronic coronary syndromes?
1. Anaemia2. Hypoxemia (low oxygen in blood)3. Polycythemia (high conc of RBC in blood)4. Hypothermia5. Hypovolaemia (result of major blood/fluid loss)6. Hypervolaemia (too much fluid volume)
40
What are 5 exacerbating factors (increased demand) for chronic coronary syndromes?
1. Hypertension2. Tachyarrhythmia3. Valvular heart disease4. Hyperthyroidism5. Hypertrophic cardiomyopathy
41
What does OPQRST stand for regarding pain in chronic coronary syndromes?
OnsetPositionQualityRelationship (with exertion/posture/meals/breathing)RadiationRelieving/exacerbating factorsSeverityTimingTreatment
42
What is the treatment for chronic coronary syndromes?
- Lifestyle advice (smoking cessation, weight loss, exercise more)
- Medication (aspirin, GTN spray, beta blockers, long acting nitrates, calcium channel blockers, ACE inhibitors)
43
Who should you not give beta blockers to?
Someone with severe asthma
44
What do nitrates do?
Venodilators. Reduce the preload on heart and dilates the coronary arteries
45
What is an atrial septal defect?
Abnormal connection between the two atria due to failure of the septal tissue to form between the atria
46
Describe the epidemiology of ASD
- Common- Often present in adulthood- 10% of all congenital abnormalities of the heart
47
Describe the pathophysiology of ASD
- Higher pressure in the LA - Blood shunted from left to right- Increased flow into the right side of the heart and lungs
48
What occurs in large ASDs that doesn't occur in small ASDs?
Right heart dilatation
49
What is the difference between ostium primum and secundum ASD?
Ostium primum ASD = associated with AV valve anomalies and presents earlyOstium secundum ASD = usually asymptomatic until later in life
50
What are 3 signs of ASD?
1. Pulmonary flow murmur2. Fixed split second heart sound (due to delayed closure of pulmonary valve)3. Ejection systolic murmur on auscultation
51
What are 3 symptoms of ASD?
Usually asymptomatic1. Dizziness2. Palpitations3. SOBOE (shortness of breath on exertion)
52
What are 3 investigations for patients with ASD?
1. Echocardiogram2. ECG3. CXR
53
What does an ECG look like in patients with ASD?
- RBBB with left axis deviation (primum)- Prolonged PR interval (primum)- Right axis deviation (secundum)
54
What does a CXR look like in patients with ASD?
Big heart and pulmonary arteries
55
Describe the treatment for ASD
- Most close spontaneously- Surgical/percutaneous closure (before 10 in children, in adults if symptomatic)
56
What is a complication of ASD?
Eisenmenger's syndrome (pulmonary hypertension --> shunt reversal --> cyanosis)
57
What is cyanosis?
Poor blood circulation
58
What is Eisenmenger's syndrome?
- High pressure pulmonary flow- Damage to delicate pulmonary vasculature- Resistance to blood flow through the lungs increases- RV pressure increase- Reversal of shunt direction (right to left)- Deoxygenated blood enters patient's circulation
59
What is ventricular septal defect?
Abnormal connection between the two ventricles
60
Describe the epidemiology of VSD
- Common- 20-25% of all congenital heart defects
61
Describe the pathophysiology of VSD
- Higher pressure in LV- Blood moves from high to low pressure (left to right) chambers- Increased blood flow through the lungs
62
What are 7 signs of a large VSD?
1. Small, breathless, skinny baby2. Increased respiratory rate3. Tachycardia4. Harsh systolic murmur5. Severe heart failure in infancy6. Poor weight gain/feeding7. Failure to thrive
63
What is a sign of a small VSD?
Loud pansystolic murmur
64
What are 2 symptoms of a large VSD?
1. Exercise intolerance2. Breathless
65
What is a symptom of a small VSD?
Thrill (buzzing sensation)
66
What are the investigations for patients with VSD?
- Echocardiogram- CXR- ECG
67
What does an ECG look like in patients with VSD?
- Normal (small VSD)- Left axis deviation and left ventricular hypertrophy (medium/large VSD)
68
What does a CXR look like in patients with VSD?
- Pulmonary plethora- Cardiomegaly and large pulmonary arteries (large VSD)
69
Describe the treatment for VSD
- Many close spontaneously during childhood- No intervention (if small and asymptomatic)- Surgery
70
What is the main complication of VSD?
Eisenmenger's syndrome
71
What are 6 complications of VSD?
1. Aortic regurgitation2. Infundibular stenosis3. Infective endocarditis4. Subacute bacterial endocarditis5. Pulmonary hypertension6. Cardiac failure
72
What is atrioventricular septal defect?
Hole in the centre of the heart, involving the ventricular septum, atrial septum and tricuspid valves
73
Describe the epidemiology of AVSD
- 2/10,000 live births- Strong association with Down's syndrome
74
Describe the pathophysiology of AVSD
One big malformed AV valve instead of two separate AV valves
75
Describe a partial AVSD
- Can present in late adulthood- Presents like a small VSD/ASD- May be left alone if there is no right heart dilatation
76
Describe a complete AVSD
- Breathless as neonate- Poor weight gain/feeding- Torrential pulmonary blood flow- Needs repair or pulmonary artery band in infancy
77
What is Tetralogy of Fallot?
Combination of four congenital heart defects - pulmonary infundibular stenosis, overriding aorta, ventricular septal defect, right ventricular hypertrophy
78
Describe the epidemiology of Tetralogy of Fallot
- Most common of the complex cardiac abnormalities- 10% all of congenital heart defects- 1/100 live births- 15% have associated genetic abnormality (22q11 deletion)
79
Describe the pathophysiology of Tetralogy of Fallot
- Pulmonary infundibular stenosis, overriding aorta, ventricular septal defect and right ventricular hypertrophy
- Stenosis of RV outflow
- Higher pressure in RV than LV
- Deoxygenated blood moves from RV to LV
- Deoxygenated blood travels around body (patient becomes blue)
80
What are 4 signs of Tetralogy of Fallot?
1. Pulmonary stenosis2. Cyanosis3. Systolic murmur4. Increased haemoglobin concentration
81
What are 2 investigations for patients with Tetralogy of Fallot?
1. Echocardiogram - shows anatomy and degree of stenosis2. CXR - boot shaped heart
82
What is the treatment for patients with Tetralogy of Fallot?
Surgical repair in early life
83
What are 2 complications of Tetralogy of Fallot?
1. Usually death before adult life2. Right heart failure
84
What is coarctation of aorta?
Narrowing of the aorta (at the site of insertion of the ductus arteriosus)
85
Describe the epidemiology of coarctation of aorta
5% of all congenital abnormalities
86
Describe the pathophysiology of coarctation of aorta
- Narrower aorta increases afterload on LV - Collateral circulation forms to increase flow to the lower part of the body- Intercostal arteries become dilated and tortuous
87
What are 4 signs of coarctation of aorta?
1. Right arm/upper limb hypertension2. Lower pressure in vessels distal to coarctation3. Bruits (buzzes) over the scapulae and back from collateral vessels4. Murmur
88
What are symptoms for coarctation of aorta?
Often asymptomatic
89
What are 2 investigations for patients with coarctation of aorta?
1. CT/MRI
2. CXR - shows rib notching
90
What is the treatment for coarctation of aorta?
Surgical or percutaneous repair- Coarctation angioplasty- Subclavian flap repair- End to end repair
91
What are 7 complications of coarctation of aorta?
1. Hypertension2. Re-coarctation requiring repeat intervention3. Aneurysm formation at the site of repair4. Rupture of a dissecting aneurysm5. Congestive heart failure6. Intracerebral haemorrhage7. Bacterial endocarditis
92
What is bicuspid aortic valve?
Aortic valve with only two cusps instead of three
93
Describe the epidemiology of bicuspid aortic valve
1-2% of the general population
94
Describe the pathophysiology of bicuspid aortic valve
Abnormal degradation of aortic valve over time
95
What is a sign of bicuspid aortic valve?
Undetected at birth (works fine)1. Exercise exacerbates complications
96
What are 2 investigations for patients with bicuspid aortic valve?
1. Echocardiogram2. MRI
97
What is the treatment for bicuspid aortic valve?
Valve replacement (once complications develop)
98
What are 4 complications of bicuspid aortic valve?
1. Aortic regurgitation2. Infective endocarditis3. Subacute bacterial endocarditis4. Aortic dissection/dilation
99
What is patent ductus arteriosus?
Failure of ductus arteriosus to close
100
Describe the epidemiology of patent ductus arteriosus
- 0.02% of live births- More common in prem babies
101
Describe the pathophysiology of patent ductus arteriosus
- Abnormal shunt of blood from aorta to pulmonary artery- Increased pulmonary arterial flow - Right sided heart strain (right ventricular hypertrophy)- Lack of oxygenated blood to the body results in left sided heart strain (left ventricular hypertrophy)
102
What are 2 signs and the symptoms of a small patent ductus arteriosus?
Usually asymptomatic1. Continuous 'machinery' murmur2. Loudest at second heart sound
103
What are 6 signs and symptoms of a large patent ductus arteriosus?
1. Left ventricular impulse2. Cardiomegaly3. Shortness of breath/breathlessness4. Failure to thrive/poor feeding5. Eisenmenger's syndrome6. Differential cyanosis (clubbed/blue toes, normal fingers)
104
What are 2 investigations for patients with patent ductus arterious?
1. Echocardiogram2. CXR (cardiomegaly if large)
105
What is the treatment for patent ductus arteriosus?
- Surgical/percutaneous closure- Venous approach (sometimes requires an AV loop)
106
What is patent foramen ovale?
Failure of the foramen ovale to close in the weeks after birth
107
Describe the epidemiology of patent foramen ovale
1/4 people
108
Describe the pathophysiology of patent foramen ovale
Deoxygenated blood shunted from right atrium into left atrium
109
What are symptoms of patent foramen ovale?
Usually asymptomatic
110
What are 2 investigations in patients with patent foramen ovale?
1. ECG2. Bubble test (watch a bubble go across the heart)
111
What is the treatment for patent foramen ovale?
- None usually- Cardiac catheterization
112
What is a complication of patent foramen ovale?
- None usually- Thromboembolic stroke (extremely rare)
113
What is pulmonary stenosis?
Narrowing of the outflow of the right ventricle
114
Describe the epidemiology of pulmonary stenosis
8-12% of all congenital heart defects
115
Describe the pathophysiology of pulmonary stenosis
- RV hypertrophy/failure- Poor pulmonary blood flow- Tricuspid regurgitation
116
What are 4 signs and symptoms of pulmonary stenosis?
1. Well tolerated (mild/moderate)2. Murmur3. Shortness of breath4. Chest pain
117
What is the treatment for pulmonary stenosis?
- Balloon valvuloplasty- Open valvotomy- Shunt to bypass blockages
118
What is cardiomyopathy?
Deterioration of the myocardium's ability to contract (mechanical and/or electrical dysfunction)
119
What are the 4 types of cardiomyopathy?
1. Dilated (DCM)2. Hypertrophic (HCM)3. Arrhythmogenic (ACM)4. Restrictive (RCM)
120
What is dilated cardiomyopathy?
Dilatation of the left ventricle leading to thin muscle and poorly generated contractile force
121
Describe the epidemiology of DCM
- Most frequent cause of heart transplant- 35/100,000- Median age = 50- More common in males
122
What are the 4 causes of DCM?
1. Ischaemia2. Alcohol3. Thyroid disorder (thyrotoxicosis)4. Genetic (often caused by cytoskeletal gene mutations)
123
Describe the pathophysiology of DCM
- Enlargement/dilatation of LV chamber- Disrupts heart's ability to pump blood effectively - Systolic dysfunction of left/both ventricles
124
What are 9 signs of DCM?
1. Congestive heart failure2. Arrhythmia3. Thromboembolism4. Increased JVP5. Sudden death6. Pulmonary oedema7. Oedema8. Cardiomegaly9. 3rd/4th heart sounds
125
What are 3 symptoms of DCM?
Asymptomatic1. Shortness of breath2. Fatigue3. Weakness
126
What are 3 investigations for patients with DCM?
1. CXR - cardiomegaly and pulmonary oedema2. ECG - tachycardia3. Echocardiogram - dilated ventricles
127
What is the treatment for DCM?
- Treat the cause- Bed rest- Loop/thiazide diuretics for fluid overload- ACE inhibitors- Beta blockers- Potentially an ICD (implantable cardioverter defibrillator)
128
What are 2 complications of DCM?
1. Progressive heart failure2. Sudden cardiac death
129
What is hypertrophic cardiomyopathy?
Ventricular hypertrophy leading to the obstruction of the outflow tract
130
Describe the epidemiology of HCM
- Most common cause of sudden death in young people- Most common genetic CVD- 1/500- More common in black men
131
What are the 2 causes of HCM?
1. Genetic - autosomal dominant (sarcomeric protein gene mutations)2. 50% sporadic
132
Describe the pathophysiology of HCM
- Genetic mutation of sarcomere protein- Left ventricular hypertrophy- Impaired diastolic filling - Reduced stroke volume/cardiac output- Abnormal mitral valve- Dynamic obstruction of left ventricular outflow tract
133
What are 5 signs of HCM?
1. Late ejection systolic murmur (augmented by standing)2. Jerky carotid pulse (forceful apex beat)3. Left ventricular outflow tract obstruction (LVOTO) 4. Alpha wave in JVP5. Sudden death
134
What are 5 symptoms of HCM?
Asymptomatic1. Chest pain/angina2. Dyspnoea/SOB3. Palpitations4. Dizziness5. Syncope
135
What are 3 investigations for patients with HCM?
1. ECG2. CXR - left atrial enlargement (especially with mitral regurgitation)3. Genetic analysis
136
What does an ECG look like in patients with HCM?
- T wave inversion- Deep Q waves- Left ventricular hypertrophy
137
What is the treatment for HCM?
- Amiodarone (to reduce risk of arrhythmias and sudden death) - Calcium channel blockers and beta blockers for pain- ICD (to reduce risk of sudden death)- Septal myectomy (severe)
138
What is a complication of HCM?
Sudden death
139
What is arrhythmogenic cardiomyopathy?
Inherited heart muscle disorder involving loss of myocytes and fibro fatty replacement of right ventricular myocardium
140
Describe the epidemiology of ACM
- 1/2,000- Italy/Greece- More common in males- Genetic predisposition in 30-50% of cases (autosomal dominant)
141
What are 3 causes of ACM?
1. Unknown2. Response to apoptosis, inflammation or genetics (desmosome gene mutations)3. Naxos disease (due to autosomal recessive condition)
142
Describe the pathophysiology of ACM
- Genetic mutation of desmosomes- Fibro fatty replacement of RV myocytes- Impaired ability of the RV muscle due to loss of myocytes
143
What are 4 signs of ACM?
1/2 patients have a normal examination1. Sudden death2. Arrhythmia3. RV changes/failure4. Biventricular pump failure (mimics DCM)
144
What are 2 symptoms of ACM?
1. Palpitations2. Syncope/pre syncope
145
What are 3 investigations for patients with ACM?
1. RV angiography (to evaluate RV function)2. MRI3. Echocardiogram
146
What does an MRI look like in patients with ACM?
- RV enlargement- Fatty infiltration- Fibrosis- Wall motion abnormalities
147
What does an echocardiogram look like in patients with ACM?
- RV wall abnormalities- RV dysfunction
148
What is the treatment for ACM?
- Standard heart failure medication- Beta blockers (if asymptomatic)- ICD (if high risk)- Heart transplant (if refractory treatment)
149
What are complications of ACM?
- Progressive disease- Mortality rate = 1-3%
150
What is restrictive cardiomyopathy?
Failure of ventricles to contract properly due to the replacement of normal heart muscle with scar tissue causing rigid ventricles - heart failure with normal systolic function
151
Describe the epidemiology of RCM
- 1/1000-5000- 5% of all cardiomyopathies- Elderly- Tropical Africa- Not familial
152
What are 5 causes of RCM?
1. Amyloidosis2. Sarcoidosis3. Idiopathic4. End myocardial fibrosis5. Infiltrative myocardial disease
153
Describe the pathophysiology of RCM
- Increased myocardial stiffness in ventricular cavities with normal size and systolic function- Impaired ventricle filling- Ventricles become incompliant (fill predominantly in early diastole)- Bi-atrial enlargement
154
What are 5 signs of RCM?
1. Increased JVP (elevated on inspiration)2. Congestive heart failure3. Oedema/pulmonary oedema4. 3rd/4th heart sounds5. Murmur
155
What are 2 symptoms of RCM?
1. Dyspnoea/SOB2. Fatigue
156
What are 3 investigations for patients with RCM?
1. Echocardiogram - thickened ventricular walls, valves and atrial septum2. MRI (to distinguish between cardiomyopathies)3. Cardiac catheterisation
157
What is the treatment for RCM?
- Standard heart failure medication- ICD (if high risk)- Transplant
158
What are complications of RCM?
- Heart failure- Sudden death- Poor prognosis
159
What is an arrhythmia?
An abnormality in cardiac rhythm
160
What is tachycardia?
Fast heart rate >100bpm
161
What is sinus tachycardia?
- >100bpm- Physiological response to exercise and excitement (also occurs in anaemia, fever, heart failure, thyrotoxicosis, acute PE, hypovolaemia, atropine)- Treatment = correction of cause and beta blockers
162
What is atrial tachycardia?
- >150bpm- Abnormal P waves- Normal QRS complexes
163
What would an ECG look like in patients with ventricular tachycardia?
- No P waves- Regular, wide QRS complexes- No T waves
164
What is supraventricular tachycardia?
- Arises from the atrium or AV junction- Atrial fibrillation, atrial flutter, AVRT, AVNRT- P waves may not be visible- Pre-excitation on resting ECG- Short PR interval
165
What is ventricular tachycardia?
- Arises from the ventricles
166
What is atrial fibrillation?
An irregularly irregular heart rhythm
167
Describe the epidemiology of AF
- Most common sustained arrhythmia- 5-10% of patients >65- More common in males
168
What are 6 causes of AF?
1. Idiopathic2. Heart failure3. Valvular heart disease (particularly mitral valve stenosis)4. Cardiac surgery5. Cardiomyopathy6. Rheumatic heart disease
169
What are 6 risk factors for AF?
1. Over 602. Diabetes3. Hypertension4. CAD5. Previous MI6. Structural heart disease
170
What is CHA2DS2-VASc?
Used to calculate stroke risk for patients with AF
171
What does CHA2DS2-VASc stand for?
- Congestive heart failure- Hypertension- Age >75- Diabetes- Stroke/TIA- Vascular disease- Age 65-74- Sex (female)
172
What is ORBIT?
Used in patients with AF to assess the risk of major bleeding with anticoagulation
173
What does ORBIT stand for?
- Older than 74- Reduced haemoglobin (<13g/dL (m) or <12g/dL (f))- Bleeding history- Insufficient kidney function- Treatment with antiplatelets
174
Describe the pathophysiology of AF
- Continuous rapid activation of the atria with no organised mechanical action at 300-600bpm- Irregular ventricular rate
175
What are 3 signs of AF?
1. Irregularly irregular pulse2. Stroke/TIA3. Apical pulse > radial
176
What are 5 symptoms of AF?
Asymptomatic1. Palpitations2. Dyspnoea/SOB3. Syncope4. Chest pains5. Fatigue
177
What does an ECG look like in patients with AF?
- No P waves- Rapid/irregular QRS (variability in PR intervals)
178
What is the treatment for AF?
- Treat underlying cause- Beta blockers and calcium channel blockers to control rate- Cardioversion and defibrillator to control rhythm- LMWH to prevent thromboembolism
179
What are 2 complications of AF?
1. Stroke (static blood in atria pools and clots and them embolises)2. Heart failure
180
What is atrial flutter?
Organised atrial rhythm at a rate of 250-350bpm
181
What are 7 causes of atrial flutter?
1. Idiopathic2. CAD3. Obesity4. Hypertension5. Heart failure6. COPD7. Pericarditis
182
What is a risk factor for atrial flutter?
Atrial fibrillation
183
Describe the pathophysiology of atrial flutter
- Electrical signal recirculates in a self-perpetuating loop due to an extra electrical pathway- Signal goes round the atria without interrupting- Signal makes it into the ventricles every second lap due to the long refractory period
184
What are 6 symptoms of atrial flutter?
1. Palpitations2. Chest pain3. Syncope4. Fatigue5. SOB6. Dizziness
185
What does an ECG look like in patients with atrial flutter?
Sawtooth flutter waves (F waves)
186
What is the treatment for atrial flutter?
- Treat underlying condition- Anticoagulation- Radiofrequency catheter ablation of the re-entrant rhythm- Beta blockers to control rate- Cardioversion or amiodarone to control rhythm
187
What is Wolff-Parkinson White Syndrome?
Atrioventricular re-entrant tachycardia (AVRT) - when there is an accessory pathway for conduction
188
What are 7 causes of AVRT?
1. Congenital2. Hypokalaemia3. Hypocalcaemia4. Drugs (amiodarone, TCAs)5. Bradycardia6. Acute MI7. Diabetes
189
Describe the pathophysiology of AVRT
- There is an accessory pathway (bundle of Kent) between the atria and ventricles- When the SAN depolarises, the impulse can travel quicker to the AVN and ventricle as there are two paths
190
What are 4 symptoms of AVRT?
1. Palpitations2. Severe dizziness3. Dyspnoea4. Syncope
191
What does an ECG look like in patients with AVRT?
- Short PR interval- Wide QRS complex that begins slurred (delta wave)
192
What is the treatment for AVRT?
- Vagal manoeuvre (breath holding, carotid massage, valsalva manoeuvre)- IV adenosine (cause a complete heart block for a fraction of a second)- Surgery - catheter ablation of pathway
193
What is AVNRT?
Atrioventricular nodal re-entry tachycardia
194
Describe the epidemiology of AVNRT
- Most common type of SVT- Twice as common in women than men
195
What are 3 risk factors for AVNRT?
1. Exertion2. Caffeine3. Alcohol
196
Describe the pathophysiology of AVNRT
- The presence of a 'ring' of conducting pathways in the AV node with the 'limbs' all having different conduction times and refractory periods- Allows a re-entry circuit
197
What are 5 symptoms of AVNRT?
1. Regular rapid palpitations (abrupt onset and sudden termination)2. Neck pulsation (JV pulsations)3. Polyuria4. Chest pain5. Shortness of breath
198
What does an ECG look like in patients with AVNRT?
- P waves either not visible or seen immediately before/after QRS complex- QRS complex is a normal shape
199
What is the treatment for AVNRT?
- Vagal manoeuvre (breath holding, carotid massage, valsalva manoeuvre)- IV adenosine (cause a complete heart block for a fraction of a second)
200
What is prolonged QT syndrome?
Increased time taken by the ventricles to repolarise
201
What are 7 causes of prolonged QT syndrome?
1. Congenital2. Hypokalaemia3. Hypocalcaemia4. Drugs (amiodarone, TCAs)5. Bradycardia6. Acute MI7. Diabetes
202
Describe the pathophysiology of prolonged QT syndrome
- Long repolarisation periods can result in random spontaneous depolarisation (afterdepolarisations)- These spread through the ventricles which result in ventricular contraction prior to ventricular repolarisation
203
What are 2 symptoms of prolonged QT syndrome?
1. Palpitations2. Syncope
204
What does an ECG look like in patients with prolonged QT syndrome?
Prolonged QT interval
205
What is the treatment for prolonged QT syndrome?
- Treat underlying cause- Cardioversion- IV isoprenaline (if acquired, not congenital)- Beta blockers- Pacemaker or ICD
206
What are 3 complications of prolonged QT syndrome?
1. Progression to Torsades de Pointes2. Sudden cardiac death3. Seizures
207
What is Torsades de Pointes?
When prolonged QT syndrome progresses so that the ventricles stimulate recurrent contractions without normal repolarisation
208
What does an ECG look like in patients with Torsades de Pointes?
- QRS complexes appear to be twisted around baseline- Height of QRS complex progressively get smaller, then larger, then smaller etc- Prolonged QT interval
209
What is the treatment for Torsades de Pointes?
- May terminate spontaneously - Treat underlying cause- Magnesium infusion- Beta blockers- Pacemaker or ICD
210
What is a complication of Torsades de Pointes?
Progression into ventricular tachycardia which can lead to cardiac arrest
211
What are ventricular ectopics?
Premature ventricular beats caused by random electrical discharges from outside the atria
212
What are the risk factors for ventricular ectopics?
Pre existing heart conditions e.g. IHD and heart failure
213
What is the main symptom for ventricular ectopics?
Random, brief palpitations
214
What does an ECG look like in patients with ventricular ectopics?
Random, broad QRS complexes
215
What is 1st degree heart block?
Delayed atrioventricular conduction through the AV node
216
What are 4 causes of 1st, 2nd and 3rd degree heart blocks?
1. Previous MI2. Structural damage to the heart3. Drugs e.g. beta blockers, CCBs4. Rheumatic fever
217
What is the main sign of 1st and 2nd degree heart block?
Bradycardia
218
What are the symptoms of 1st degree heart block?
Usually asymptomatic
219
What does an ECG look like in patients with 1st degree heart block?
Prolonged QT interval >0.2 seconds
220
What is the treatment for 1st degree heart block?
None needed
221
What is 2nd degree heart block?
Some atrial impulses do not go through the AV node to reach the ventricles
222
What are the two types of 2nd degree heart block and describe their pathophysiology
Mobitz type 1:- Atrial impulses become gradually weaker until eventually, they do not pass through the AV nodeMobitz type 2:- Intermittent failure/interruption of AV conduction
223
What are 3 symptoms of Mobitz type 1 2nd degree heart block?
1. Light headedness2. Dizziness3. Syncope
224
What are 3 symptoms of Mobitz type 2 2nd degree heart block?
1. Shortness of breath2. Postural hypotension3. Chest pain
225
What does an ECG look like in patients with Mobitz type 1 2nd degree heart block?
Progressively increasing PR intervals until an absent QRS complex (cycle then repeats)
226
What does an ECG look like in patients with Mobitz type 2 2nd degree heart block?
Sustained PR intervals with missing QRS complexes - usually set ratio of P waves to QRS complexes
227
What is the treatment for 2nd degree heart block?
- May be managed with monitoring- Pacemaker
228
What is 3rd degree (complete) heart block?
Failure of atrial impulses to reach the ventricles
229
Describe the pathophysiology of complete heart block
- All atrial activity fails to conduct to ventricles- Ventricular contraction is maintained by spontaneous escape rhythm from below the side of block
230
What are the 2 symptoms of complete heart block?
Stokes-Adams attacks:1. Dizziness2. Blackouts
231
What does an ECG look like in patients with complete heart block?
- Complete dissociation of P waves and QRS complexes- Abnormally shaped QRS complexes
232
What is the treatment for complete heart block?
- Permanent pacemaker- IV atropine
233
What is bundle branch block?
A block in the conduction of one of the bundle branches, so the ventricles don't receive impulses at the same time
234
What are 4 causes of left bundle branch block (LBBB)?
1. IHD2. Aortic valve disease3. Left ventricular hypertrophy4. Following cardiac surgery
235
What are 5 causes of right bundle branch block (RBBB)?
1. PE2. IHD3. Congenital heart disease4. AVSD5. Right ventricular hypertrophy
236
Describe the pathophysiology of bundle branch block
One of the bundles doesn't conduct, so impulse spreads from one ventricle to another resulting in late activation of that bundle
237
What is a symptom for bundle branch blocks?
- Usually asymptomatic- Syncope/pre syncope
238
What does an ECG look like in patients with LBBB?
- WiLLiaM (V1 = W, V6 = M)- Second R wave in left ventricular leads (I, AvL, V4-V6)- Slurred S waves in leads V1 and V2
239
What does an ECG look like in patients with RBBB?
- MaRRoW (V1 = M, V6 = W)- Wide QRS complex- Second R wave in lead V1- Slurred S wave in leads V5 and V6
240
What is the treatment for bundle branch blocks?
- Pacemaker- Cardiac resynchronisation therapy- Reduce blood pressure- Treat underlying condition
241
What is rheumatic fever?
Systemic infection caused by an antibody from the cell wall - cross-reacts with valve tissue and can cause permanent damage to the heart valves
242
What are the 5 signs of rheumatic fever?
1. Tachycardia2. Murmur3. Pericardial rub4. Erythema marginatum (red rash with raised edges and centre centre)5. Prolonged PR interval
243
What are 6 symptoms of rheumatic fever?
1. Fever2. Painful, tender joints (arthritis)3. Chest pain4. Shortness of breath5. Fatigue6. Chorea (jerky movements)
244
What is the Jones criteria for rheumatic fever?
To diagnose, must have recent strep infection (Lancefield group A B-haemolytic streptococci) and either:- 2 major criteriaOR- 1 major criteria and 2 minor criteria
245
What are the 4 major criteria for rheumatic fever?
1. Carditis (tachycardia, murmur, pericardial rub, cardiomegaly)2. Arthritis 3. Erythema marginatum4. Sydenham's chorea
246
What are the 5 minor criteria for rheumatic fever?
1. Fever2. Raised ESR/CRP3. Arthralgia4. Prolonged PR interval5. Previous rheumatic fever
247
What is the treatment for rheumatic fever?
- Bed rest until CRP is normal for 2 weeks consistently- Benzylpenicillin IV, then phenoxymethylpenicillin for 10 days- Aspirin for analgesia- Haloperidol/diazepam for chorea
248
What is an aneurysm?
Weakening of vessel walls followed by dilation due to increase wall stress
249
What are the 6 risk factors for aortic aneurysms?
1. Smoking2. Family history3. Connective tissue disorders (Marfan's, Ehlers-Danlos)4. Age5. Atherosclerosis6. Male
250
Describe the pathophysiology of aortic aneurysms
- Inflammation and degeneration of SMC- Loss of structural integrity of aortic wall- Mechanical stress acts on weakened wall tissue- Widening of vessel, dilation and rupture- Dilatation of vessel wall causes disruption of laminar blood flow and turbulence- Possible formation of thrombi in aneurysm (--> peripheral thromboembolism)
251
What are 2 signs of aortic aneurysms?
1. Pulsatile mass on palpation2. Bruit on auscultation
252
What is a symptom of aortic aneurysms?
Usually asymptomatic1. Lower back/abdominal pain (if expanding rapidly)
253
What are 2 investigations for patients with aortic aneurysms?
1. 1st line = ultrasonography (ultrasound)2. Usually discovered on routine examinations and imaging
254
What is the treatment for ruptured aortic aneurysms?
Urgent repair whilst maintaining haemodynamic stability (EVAR - endovascular aneurysmal repair)
255
What is the treatment for unruptured aortic aneurysms?
Surveillance of diameter - repair required if high risk of rupture (when diameter exceeds 5.5cm in men or 5cm in women)
256
What are 3 complications of aortic aneurysms?
1. Rupture2. Thromboembolism3. Formation of fistula
257
What are the 5 signs and symptoms of a AAA rupture?
1. Acute onset of severe, tearing abdominal pain with radiation to back, flank and groin2. Painful pulsatile mass3. Hypovolemic shock4. Syncope5. Nausea/vomiting
258
What is aortic dissection?
A tear in the intimal layer of the aorta leading to a collection of blood between the intima and medial layers
259
Describe the epidemiology of aortic dissection
- Most common in men aged 50-70- 65% of cases in the ascending aorta (before brachiocephalic artery?)
260
What are 5 risk factors of aortic dissection?
1. Hypertension2. Trauma3. Vasculitis4. Cocaine use5. Connective tissue disorders
261
Describe the pathophysiology of aortic dissection
- Tear in the intimal layer- Blood passes through the media, propagating distally or proximally- Haematoma forms which separates the intima from the adventitia, creating a false lumen- As the dissection propagates, flow through the false lumen can occlude flow through branches of the aorta- Causes ischaemia of supplied regions
262
Where are the 2 most common sites of aortic dissection?
1. Within 2-3cm of aortic valve (before brachiocephalic artery)2. Distal to (after) the left subclavian artery in the descending aorta
263
What are 3 signs of aortic dissection?
1. Hypotension2. Asymmetrical blood pressure3. Pulse loss
264
What are 2 symptoms of aortic dissection?
1. Sudden and severe tearing pain in chest (radiates to back)2. Syncope
265
What are 4 investigations for patients with aortic dissection?
1. ECG (20% will have evidence of ischaemia/MI)2. Ultrasound (indicates site/extent)3. MRI/CT (for confirmation)4. CXR (appears normal - poor indicator)
266
What is the treatment for aortic dissection?
- Stent graft- Surgery (if the dissection appears to be progressing)
267
What are the complications of aortic dissection?
Rupture (80% mortality) into pericardium (cardiac tamponade), mediastinum or pleural space
268
What is peripheral vascular disease?
Narrowing of arteries distal to the aortic arch
269
Describe the epidemiology of PVD
- Affects 4-12% of people aged between 55-70- Affects 15-20% of people aged 70+- 50% mortality at 5 years- 70% mortality at 10 years
270
What is the main cause of PVD?
Atherosclerotic damage
271
What are 7 risk factors of PVD?
1. Smoking2. Diabetes3. Hypertension4. Sedentary lifestyle5. Hyperlipidaemia6. History of CAD7. Age >40
272
Describe the pathophysiology of PVD
- Atherosclerosis causes stenosis of vessels leading to claudication- Claudication can also be caused by aortic coarctation, temporal arteritis and Buerger's disease- Gradual progression to sudden deterioration
273
What is Buerger's disease?
Inflammation and clotting in arteries and veins of hands and feet
274
What are 4 signs of PVD?
1. Absent femoral pulse2. Absent popliteal pulse3. Absent foot pulse4. Cold, pale legs
275
What are 3 symptoms of PVD?
Usually asymptomatic1. Intermittent claudication of lower limbs on exercise2. Unremitting pain in foot especially at night3. Loss of leg hair and skin changes
276
What are 2 investigations for patients with PVD?
1. ECG (evidence of CAD in 60% of patients)2. Doppler ultrasonography (ankle brachial pressure index) <0.90
277
What is ankle brachial pressure index?
Measures ratio of systolic BP at ankle and arm to provide a measure of blood flow at level of ankle (normal value = 1)
278
What is treatment for PVD?
- Control risk factors- Antiplatelet therapy (aspirin/clopidogrel)
279
What are complications of PVD?
Critical limb ischaemia which can lead to gangrene, infection, poor healing, ulceration
280
What is the treatment for critical limb ischaemia?
- Revascularisation (e.g. stenting, angioplasty, bypassing)- Amputation
281
What are the clinical presentations of critical limb ischaemia?
6 Ps:1. Pain2. Paraesthesia3. Pulselessness4. Pallor5. Paralysis6. Poikilothermia (intrinsic thermoregulatory failure)
282
What is the WHO classification of hypertension?
140/90mmHg on at least two readings on separate occasions
283
What are 5 causes of secondary HTN?
1. Renal e.g. CKD2. Endocrine e.g. Conn's, acromegaly, Cushing's3. Coarctation of aorta4. Pre-eclampsia5. Drugs e.g. oestrogen containing oral contraceptives, NSAIDs, vasopressin
284
What are 6 modifiable risk factors of HTN?
1. Alcohol intake2. Sedentary lifestyle3. Unhealthy diet4. Obesity5. Smoking6. Sleep apnoea
285
What are 4 non modifiable risk factors for HTN?
1. Family history2. Old age3. Male4. Afro-Caribbean
286
What are the stages of HTN?
Stage 1 = >140/90mmHgStage 2 = > 160/90mmHgStage 3 = >180/120mmHg (malignant HTN)
287
What is a symptom of HTN?
Usually asymptomatic1. Occasionally headache
288
What are 2 investigations for patients with HTN?
1. Blood pressure - 24-hour ambulatory BP monitor2. Check for end organ damage
289
What are 5 investigations for patients with HTN and end organ damage?
1. Urinalysis 2. ECG/echo for LV hypertrophy3. Fundoscopy4. Blood (serum creatinine, eGFR, glucose)5. Clinical history (previous MI/stroke)
290
What is the 1st line treatment for HTN?
Lifestyle changes:- Smoking cessation- Low fat/salt diet- Reduce alcohol intake- Increase exercise- Weight loss
291
What is the next line of treatment for HTN?
ACEI or angiotensin receptor blocker plus1. CCB2. Diuretic3. Beta blocker
292
What is malignant HTN?
Blood pressure >180/120mmHg leading to vascular disease
293
What are 2 signs of malignant HTN?
1. Severe hypertension2. Bilateral renal haemorrhage --> exudates --> papilloedema (AKI)
294
What are 2 symptoms of malignant HTN?
1. Headache2. Visual disturbance
295
What is the treatment for malignant HTN?
Sodium nitroprusside
296
What are 3 complications of malignant HTN?
Hypertensive emergencies:1. AKI2. HF3. Encephalopathy
297
What is aortic stenosis?
Narrowing of the aorta
298
Describe the epidemiology of aortic stenosis
Most common valvular condition
299
What are 4 causes of aortic stenosis?
1. Idiopathic2. Calcification of congenital bicuspid valve3. Calcific degeneration of normal valve4. Rheumatic valvular disease
300
What is the main risk factor for aortic stenosis?
Congenital bicuspid aortic valve
301
Describe the pathophysiology of aortic stenosis
- Aortic valve thickened/calcified which obstructs the normal flow- This increases LV pressure- CO decreases- Compensatory LV hypertrophy- Relative ischaemia due to increased myocardial oxygen demand
302
What are 5 signs of aortic stenosis?
1. Soft/absent 2nd heart sound2. Ejection systolic high pitched crescendo decrescendo murmur 3. LV hypertrophy4. Heart failure5. Slow rising and weak carotid pulse
303
What are 3 symptoms of aortic stenosis?
SAD:- Syncope- Angina- Dyspnoea
304
What are 4 investigations for patients with aortic stenosis?
1. Echocardiogram2. ECG - LV hypertrophy, ST depression and T wave inversion (leads aVL, V5 and V6)3. CXR - LV hypertrophy, valvular calcification and prominence of ascending aorta4. Cardiac catheterisation (to exclude CAD)
305
What is the treatment for aortic stenosis?
- Surgery - aortic valve replacement or surgical valvuloplasty- Balloon valvuloplasty- Transcatheter aortic valve replacement
306
What are 2 complications of aortic stenosis, aortic regurgitation, mitral stenosis and mitral regurgitation?
1. Clotting from valve replacement2. Endocarditis
307
What are 2 other complications of aortic stenosis?
1. Left sided heart failure2. Sudden death
308
What is aortic regurgitation?
Leakage of blood into LV during diastole due to ineffective coaptation of aortic cusps
309
What are 4 causes of aortic regurgitation?
1. Idiopathic2. Congenital bicuspid aortic valve3. Rheumatic heart disease4. Infective endocarditis
310
Describe the pathophysiology of aortic regurgitation
- Aortic valve fails to prevent reflux of blood- LV hypertrophy to maintain CO- Reduced diastolic BP- Relative ischaemia
311
What are 6 signs of aortic regurgitation?
1. Corrigan's pulse (collapsing pulse)2. Austin Flint murmur (heard at apex, early diastolic rumbling)3. Quincke's sign (capillary pulse in nails beds)4. De Musset's sign (head nodding with each heart beat)5. Muller's sign (visible pulsation of uvula)6. Early diastolic soft blowing murmur
312
What are 5 symptoms of aortic regurgitation?
1. Exertional/paroxysmal nocturnal dyspnoea2. Orthopnoea (SOB while lying flat)3. Palpitations4. Angina5. Syncope
313
What are 3 investigations for patients with aortic regurgitation?
1. Echocardiogram2. ECG - LV hypertrophy3. CXR - cardiomegaly and occasional dilatation of ascending aorta
314
What is the treatment for aortic regurgitation?
- IE prophylaxis- ACE inhibitors if symptomatic/hypertensive- Replace valve before LV dysfunction
315
What is mitral stenosis
Narrowing of mitral valve causing obstruction of LV inflow that prevents proper filling during diastole
316
What are 4 causes of mitral stenosis?
1. Rheumatic heart disease (rheumatic fever - streptococcus pyogenes)2. Infective endocarditis3. Mitral annular calcification4. Congenital
317
What are 2 risk factors for mitral stenosis?
1. History of rheumatic fever2. Untreated streptococcus infections
318
Describe the pathophysiology of mitral stenosis
- Inflammation causes thickening/calcification and immobility of valve- Leads to obstruction and blood flow from LA to LV- Increased LA pressure- Pulmonary hypertension- Right heart dysfunction
319
What are 3 signs of mitral stenosis?
1. Malar flushes on cheeks2. Atrial fibrillation3. Low pitched mid diastolic murmur
320
What are 8 symptoms of mitral stenosis?
1. Progressive exertional dyspnoea2. Cough3. Haemoptysis (coughing up blood)4. Palpitations5. Chest pain6. Fatigue7. Weakness8. Abdominal/lower leg swelling
321
What are 3 investigations for patients with mitral stenosis?
1. Echocardiogram2. CXR - LA enlargement, pulmonary hypertension and sometimes calcified mitral valve3. ECG - AF and LA enlargement
322
What is the treatment for mitral stenosis?
- Beta blockers (for AF)- Anticoagulants (for AF)- Diuretics - Percutaneous mitral balloon valvuloplasty
323
What is another complication of mitral regurgitation?
Congestive heart failure
324
What is mitral regurgitation?
Backflow of blood from LV to LA during systole
325
What are 6 causes of mitral regurgitation?
1. Idiopathic2. Myxomatous degeneration (mitral valve prolapse)3. Rheumatic heart disease4. Infective endocarditis5. Ischaemic mitral valve6. Dilated cardiomyopathy
326
What are 5 risk factors for mitral regurgitation?
1. Being female2. Lower BMI3. Advanced age4. Renal dysfunction5. Previous MI
327
Describe the pathophysiology of mitral regurgitation
- Leakage from LV into LA- Causes LA dilatation/enlargement- LV hypertrophy- Increased contractility- Pulmonary hypertension
328
What are 3 signs of mitral regurgitation?
1. Collapsing pulse with wide pulse pressure2. Hyperdynamic and displaced apex beat3. Pansystolic high pitched whistling murmur
329
What are 3 symptoms of mitral regurgitation?
1. Exertional dyspnoea2. Fatigue/lethargy3. Palpitations
330
What are 3 investigations for patients with mitral regurgitation?
1. CXR - shows enlarged LA and LV2. Echocardiogram - estimation of LA and LV size and function3. ECG
331
What is the treatment for mitral regurgitation?
- Consider IE prophylaxis- ACE inhibitors- Beta blockers/CCBs- Anticoagulants- Diuretics- Surgical valve replacement
332
What is infective endocarditis?
An infection of the endocardium or vascular endothelium of the heart
333
Describe the epidemiology of infective endocarditis
- More common in males- 10 year survival = 60-90%
334
What are the 3 most common causes of infective endocarditis?
1. Staphylococcus aureus (IV drug users, diabetes, surgery)2. Streptococcus viridans (poor dental health)3. Staphylococcus epidermidis (prosthetic valves)
335
What are 7 risk factors for infective endocarditis?
1. IV drug users2. Immunocompromised patients3. Regurgitant/prosthetic valves4. Aortic/mitral valve disease5. Poor dental hygiene6. IV cannula7. Pacemakers
336
Describe the pathophysiology of infective endocarditis
- Damage to endothelium- Platelet and fibrin deposition- Organisms in the bloodstream adhere and grow = IE- Virulent organisms destroy valve
337
What are 5 signs of infective endocarditis?
1. Anaemia2. Splenomegaly3. Clubbing4. New murmur5. Sepsis of unknown origin
338
How does infective endocarditis manifest in patients?
- Skin - embolic skin lesions, petechiae- Hands - splinter haemorrhages, osler nodes, janeway lesions- Eyes - roth spots
339
What are 7 symptoms of infective endocarditis?
1. Fever2. Fatigue3. Loss of appetite4. Rigors5. Night sweats6. Malaise7. Weight loss
340
What is the rule about investigating infective endocarditis?
Fever + new murmur = infective endocarditis until proven otherwise
341
What are 5 investigations for patients with infective endocarditis?
1. Echocardiogram (gold standard) - transoesophageal (more sensitive but uncomfortable) or transthoracic (non invasive but lower sensitivity)2. ECG - long PR interval3. CXR - cardiomegaly4. C-reactive protein test - raised CRP5. Modified Duke's critera
342
What are the 2 major criteria for infective endocarditis from Duke's criteria?
1. Pathogen grown from blood cultures2. Evidence of endocarditis on echo or new valve leak
343
What are the 5 minor criteria for infective endocarditis from Duke's criteria?
1. Risk factors e.g. IVDUs, poor dental hygeine2. Fever3. Vascular phenomena4. Immune phenomena5. Equivocal blood cultures
344
Using Duke's criteria, what is a definite diagnosis of infective endocarditis?
- 2 major criteria- 1 major criteria + 3 minor critera- 5 minor criteria
345
What is the treatment for infective endocarditis?
- Antibiotics- Treat complications- Surgery- Prevention
346
What antibiotics are used for infective endocarditis?
- Benzylpenicillin/flucloxacillin and gentamycin- If MRSA = vancomycin, rifampicin and gentamycin
347
What surgery may be done for infective endocarditis?
- Replace valve- Remove and replace infected devices- Remove large vegetation at risk of embolising- Treat complications e.g. aortic root abscess
348
What is deep vein thrombosis?
Occlusion in normal vessels, most commonly deep veins of the leg
349
Describe the epidemiology of deep vein thrombosis
1/1000 per year
350
What are 6 causes of deep vein thrombosis?
1. Surgery2. Immobility3. Leg fracture4. Oral contraceptives5. Long haul flights6. Pregnancy
351
Besides usual (obesity, smoking, age, male, family history etc.), what are 5 risk factors for deep vein thrombosis?
1. Varicose veins2. Plasminogen deficiency3. Thrombophilia4. Pregnancy5. Cancer
352
What is a sign of DVT?
Often progresses to PE before presenting1. Oedema
353
What are 2 symptoms of DVT?
1. Limb pain and tenderness along the lines of the deep veins2. Swollen, red, warm calf
354
What are 4 investigations for patients with DVT?
1. Doppler ultrasound
2. D-dimer = raised
3. Well's score
355
What is the D-dimer test?
- Type of coagulation screening
- Fibrinogen degradation product
- Negative = no DVT
- Positive = potentially DVT
- Also elevated in cancer, pregnancy and post op (sensitive but not specific)
356
What is the treatment for DVT?
- DOACs (direct-acting oral anti-coagulants) e.g. apixaban, rivaroxaban (FIRST LINE)
- LMWH (for pregnant patients)
- Warfarin
- 3 months (if reversible cause), 3+ months (if unclear cause, recurrent VTE etc.), 3-6 months (cancer)
357
What are 3 things done to prevent DVT?
1. Compression stockings
2. Early mobilisation
3. Leg elevation
358
What are 3 complications of DVT?
1. PE
2. Post thrombotic syndrome
3. Recurrence of thrombosis
359
What is a pulmonary embolism?
A blood clot in the lungs
360
What are 5 general risk factors for PE?
1. Change in blood flow (e.g. immobility, pregnancy)2. Change in blood vessels (e.g. smoking, HTN)3. Change in blood constituents (e.g. dehydration, COC pill)4. Recent surgery (especially abdominal/pelvic)5. Family history/past history of thromboembolism
361
What are 6 signs of PE?
1. Hypotension2. Tachypnoea3. Pleural rub4. Pleural effusion5. Tachycardia6. Raised JVP
362
What are 3 symptoms of PE?
1. Sudden onset dyspnoea2. Pleuritic chest pain3. Haemoptsysis
363
What are 8 investigations for patients with PE?
1. CXR2. Bloods3. GOLD STANDARD - CT PULMONARY ANGIOGRAPH4. ECG5. ABG6. Plasma D-Dimer7. Ultrasound8. Echocardiography
364
What is the treatment for PE?
- LMWH- IV fluids and inotropic agent- High flow oxygen - Thrombolysis for massive PE- Analgesia- Surgical embolectomy
365
Define heart failure
Inability of the heart to deliver blood and O2 at a rate commensurate with the requirements of the metabolising tissues, despite normal or increased cardiac filling pressures
366
Describe the epidemiology of heart failure
- Annual incidence of 10% in patients over 65- 50% of patients die within 5 years
367
What are 6 causes of left sided heart failure?
1. CAD2. MI3. Cardiomyopathy4. Congenital heart defects5. Valvular heart disease6. Arrhythmias
368
What are 5 causes of right sided heart failure?
1. Right ventricular infarct2. Pulmonary hypertension3. PE4. COPD5. Progression of left sided heart failure
369
What are 3 causes of systolic heart failure?
1. IHD2. MI3. Cardiomyopathy
370
What are 2 causes of diastolic heart failure?
1. Aortic stenosis2. Chronic HTN
371
What are 4 risk factors for heart failure?
1. Age 65+2. Obesity3. Male4. Previous MI
372
What is right sided heart failure?
Inability of the right ventricle to pump adequate amounts of blood leading to systolic venous congestion
373
What is left sided heart failure?
Inability of the left ventricle to pump adequate amounts of blood leading to pulmonary circulation congestion
374
What is systolic heart failure?
Inability of the heart to contract efficiently to eject adequate volumes of blood (heart failure reduced ejection fraction)
375
What is diastolic heart failure?
Reduction in the heart's compliance resulting in compromised ventricular filling and therefore ejection (heart failure preserved ejection fraction)
376
What is cor pulmonale?
Right sided heart failure caused by chronic pulmonary arterial hypertension
377
What is low output HF?
- Decreased CO- Due to pump failure, mitral regurgitation, aortic stenosis, hypertension etc.
378
What is high output HF?
- High demand- Due to anaemia, pregnancy, hyperthyroidism etc.
379
What are the 4 main compensatory changes that occur during heart failure?
1. Sympathetic stimulation2. RAAS3. Cardiac changes4. Myocyte hypertrophy
380
What are the 4 main signs of left sided heart failure?
1. Tachycardia2. Displaced apex beat3. 3rd and 4th heart sounds4. Heart murmur
381
What are the 3 main signs of right sided heart failure?
1. Tachycardia2. Raised JVP3. Hepatomegaly
382
What are the 4 common symptoms of heart failure?
1. Shortness of breath2. Fatigue3. Peripheral oedema (ankle swelling)4. Exertional/paroxysmal nocturnal dyspnoea
383
What are the investigations for patients with HF?
- CXR- ECG- Bloods- Cardiac enzymes- Echocardiogram
384
What does a CXR look like in patients with HF?
ABCDE:- Alveolar oedema- kerley B lines- Cardiomegaly- Dilated upper lobe vessels of lung- Effusion (pleural)
385
What do bloods show in patients with MI?
Raised brain natriuretic peptide (secreted by ventricles in response to increased myocardial wall stress)
386
What cardiac enzymes are you looking for patients with HF?
- Creatinine kinase- Troponin I- Troponin T- Myoglobulin
387
What drug management is given for HF?
- ACE inhibitors e.g. ramipril- Beta blockers e.g. bisoprolol- Diuretics e.g. furosemide- Calcium glycoside e.g. digoxin
388
What are other managements of HF?
- Lifestyle changes- Ventricular assist device- Surgery- Heart transplant
389
What is treatment for acute HF?
OMFG- Oxygen- Morphine- Furosemide- GTN spray
390
What is treatment for chronic HF?
ABCD:- ACE inhibitors- Beta blockers- Calcium channel blockers- Diuretics
391
What are 3 causes of HF?
1. Chronic lung disease2. Pulmonary vascular disorders3. Neuromuscular and skeletal diseases
392
What are 7 signs of cor pulmonale?
1. Cyanosis2. Tachycardia3. Raised JVP4. RV heave5. Pan-systolic murmur 6. Hepatomegaly7. Oedema
393
What are 3 symptoms of cor pulmonale?
1. Dyspnoea2. Fatigue3. Syncope
394
What is the investigation for patients with cor pulmonale?
ABG - hypoxia +/- hypercapnia (build up of CO2 in bloodstream)
395
What is the treatment for cor pulmonale?
- Treat underlying cause- Give oxygen- Drugs - Consider venesection if haematocrit >55- Consider heart-lung transplantation in young patients
396
What is hypervolaemic shock?
Inability of the heart to adequately perfuse tissues
397
What are 3 causes of hypovolaemic shock?
1. Low fluid volume (loss of >20% of body's blood/fluid supply)2. Haemorrhage3. Dehydration
398
Describe the pathophysiology of hypovolaemic shock?
- Lower blood volume- Leads to reduced stroke volume and CO- Causes reduced perfusion
399
What are 4 signs of hypovolaemic shock?
1. Weak rapid pulse2. Cyanosis3. Increased CRT4. Hypotension
400
What are 6 symptoms of hypovolaemic shock?
1. Tachypnoea2. Anxiety3. Low urine output4. Sweating5. Dizziness6. Confusion
401
What are the investigations for patients with hypovolaemic shock?
1. Bloods (electrolytes)2. Ultrasound (visualise organs)
402
What is the treatment for hypovolaemic shock?
- ABCDE- Resuscitation (CPR, fluids and oyxgen)- Vasodilator (GTN)
403
What are 4 complications of hypovolaemic shock?
1. Death2. Organ failure (especially kidneys)3. Gangrene4. Heart attack
404
What is anaphylactic shock?
Type I IgE-mediated hypersensitivity reaction
405
Describe the pathophysiology of anaphylactic shock
- Release of histamine from mast cells- Excess vasodilation and bronchoconstriction
406
What are 2 signs of anaphylactic shock?
1. Hypertension2. Tachycardia
407
What are 3 symptoms of anaphylactic shock?
1. Puffy face2. Cheek flushing3. Urticaria (hives)
408
What is the treatment for anaphylactic shock?
- ABCDE- 0.5mg intramuscular adrenaline
409
What is septic shock?
Shock as a result of infection (medical emergency)
410
What is the cause of septic shock?
Sepsis - toxins in the blood
411
Describe the pathophysiology of septic shock
- Bacterial infection damages the blood vessels- This causes them to leak fluid into the surrounding tissues- This decreases the mean arterial pressure- Causes a derangement in physiology
412
What are 3 signs of septic shock?
1. Hypotension2. Tachycardia3. Decreased oxygen
413
What are 7 symptoms of septic shock?
1. Dizziness2. Confusion3. Diarrhoea and vomiting4. Cold clammy skin5. Tachypnoea6. Fever7. Decreased urinary output
414
What are the investigations for patients with septic shock?
- FBC = leucocytosis and low platelets- U&E = raised urea and creatinine
415
What is the treatment for septic shock?
- Broad spectrum IV antibiotics- Fluids- Oxygen- Vasopressors
416
What is cardiogenic shock?
Failure of the pump action of the heart
417
Describe the epidemiology of cardiogenic shock?
5-10% of patients with MI
418
What are 2 causes of cardiogenic shock?
1. Pump failure2. MI/cardiac arrest
419
Describe the pathophysiology of cardiogenic shock
- Decreased CO- Decreased MAP- Inability to perfuse vital organs and tissue
420
What are 4 signs of cardiogenic shock?
1. Tachycardia2. Hypotension3. Pale, mottled skin4. Peripheral oedema
421
What are 6 symptoms of cardiogenic shock?
1. Tachypnoea2. Reduced urinary output3. Cold peripheries4. Chest pain5. Nausea6. Profuse sweating
422
What are the investigations for patients with cardiogenic shock?
- U&Es (assess renal function)- FBC (exclude anaemia)- Echocardiogram (assess cause)
423
What is the treatment for cardiogenic shock?
- ABCDE- Resuscitation- Revascularisation with thrombolysis (if MI)
424
What is neurogenic shock?
Sympathetic innervation due to CNS damage
425
What is the main cause of neurogenic shock?
Damage to the CNS and spinal cord above T6
426
Describe the pathophysiology of neurogenic shock?
- Sympathetic tone loss leads to pooling of blood in extremities- Trauma causes a sudden loss of background sympathetic stimulation to blood vessels- This causes sudden vasodilation and therefore a sudden drop in BP
427
What are 2 signs of neurogenic shock?
1. Instantaneous hypotension2. Bradycardia
428
What are 2 symptoms of neurogenic shock?
1. Priapism2. Warm flushed skin
429
What are the investigations for patients with neurogenic shock?
- Physical examination- FBC- U&E- CT (to assess condition)
430
What is the treatment for neurogenic shock?
- Inotropic (dopamine)- Vasopressin- Vasopressors
