Cardiology (3) Flashcards
Define varicose veins
Subcutaneous permanently dilated veins >3mm diameter when measured in standing position, usually in the superficial veins of the lower leg due to valve insufficiency
Summarise the aetiology of varicose veins
Venous valve incompetence allowing backflow of blood and pooling
Primary:
Due to genetic or developmental weakness in the vein wall
Results in increased elasticity, dilatation and valvular incompetence
Secondary: Due to venous outflow obstruction Pregnancy Pelvic malignancy Ovarian cysts Ascites Lymphadenopathy Retroperitoneal fibrosis Due to valve damage (e.g. after DVT) Due to high flow (e.g. arteriovenous fistula)
What are the risk factors of varicose veins?
Increasing age Female Pregnancy Family history Caucasian Obesity Standing for prolonged periods of time Crossing knees for prolonged periods of time
Summarise the epidemiology of varicose veins
COMMON Prevalence higher in industrialised and developed regions Prevalence = 10-15% in men Prevalence = 20-25% in women More common in women Prevalence increases with age
What are the presenting symptoms of varicose veins?
Enlarged, tortuous, visible veins in the lower leg
Pain
Pruritis
Fatigue
Heaviness
Patients may complain about the cosmetic appearance
Aching in the legs - worse towards the end of the day or after standing for long periods of time
Swelling
Bleeding
Infection
Ulceration
What are the signs on physical examination of varicose veins?
Inspect when STANDING
Swelling of legs
Enlarged tortuous visible veins in the legs
Hyperpigmentation/darkening of leg (haemosiderin deposition)
Venous stasis ulcers
May feel fascial defects along the veins
Cough impulse may be felt over the saphenofemoral junction
Tap Test - tapping over the saphenofemoral junction will lead to an impulse felt distally (this would not happen if the valves were competent)
Palpation of a thrill or auscultation of a bruit would suggest an AV fistula
Leg is elevated and the veins are emptied
Signs of venous insufficiency: Varicose eczema Haemosiderin staining Atrophie blanche Lipodermatosclerosis Oedema Ulceration
What are the appropriate investigations for varicose veins?
Duplex USS - assess for reversed flow, valve closure time (>0.5 seconds indicative of reflux), locates sites of incompetence or reflux and excludes DVT
What is the appropriate management for varicose veins?
Conservative: Elevate legs above heart regularly Compression stockings to prevent venous stasis Manual compression Exercise - improve skeletal muscle pump# Weight loss Reduce long periods of standing
Surgical: Saphenofemoral ligation Stripping of the long saphenous vein Avulsion of varicosities Vein transplant Vein repair Vein removal
What are the possible complications of varicose veins?
Chronic venous insufficiency Venous ulceration Haemorrhage of varicose veins Lipodermatosclerosis Haemosiderin deposition Eczema Superficial thrombophlebitis
Complications of Sclerotherapy :
Skin staining, local scarring
Complications of Surgery:
Haemorrhage, infection, recurrence, paraesthesia, peroneal nerve injury
What is the prognosis of varicose veins?
Slowly progressive
High recurrence
Define pulmonary hypertension
An increase in mean pulmonary arterial pressure >25mmHg which can be caused by a variety of other conditions and can lead to originally right ventricular hypertrophy, followed by right heart failure.
Summarise the aetiology of pulmonary hypertension
Idiopathic Chronic lung disease eg COPD Hypoxia Left heart failure Left heart valve failure Methotrexate leading to lung fibrosis Chronic thromboembolic events leading to clots constricting pulmonary vessels causing to increased resistance
Summarise the epidemiology of pulmonary hypertension
Idiopathic pulmonary hypertension is RARE
More common in severe respiratory and cardiac disease
What are the presenting symptoms of pulmonary hypertension?
Progressive dyspnoea Orthopnoea Fatigue Weakness Exertional dizziness and syncope Swelling of legs Angina and tachyarrhythmia
What are the signs on physical examination of pulmonary hypertension?
Hepatomegaly Raised JVP Peripheral oedema Dullness on percussion due to pulmonary oedema Right ventricular heave Loud pulmonary second heart sound Murmur - pulmonary regurgitation Tricuspid regurgitation
What are the appropriate investigations for pulmonary hypertension?
Echo - shows elevated pressure in pulmonary arteries and right ventricle
Right heart catheterisation - allows diagnostic measurement of pressure in pulmonary vessels
CXR – exclude other lung diseases
ECG – right ventricular hypertrophy and strain
Pulmonary function tests
LFTs – liver damage - portal hypertension
Lung biopsy – interstitial lung disease
Define ventricular tachycardia
A regular broad QRS complex tachycardia, characterised by heart beat greater than 100bpm which originates from a ventricular ectopic focus.
Summarise the aetiology of ventricular tachycardia
Idiopathic
Secondary to: Coronary heart disease Hypertension Cardiomyopathy Post-MI
Electrical impulses arise from a ventricular ectopic focus
Can be caused by infectious diseases such as Chagas’ disease.
Risk Factors:
Coronary heart disease
Structural heart disease
Electrolyte deficiencies (e.g. hypokalaemia, hypocalcaemia, hypomagnesaemia)
Use of stimulant drugs (e.g. caffeine, cocaine)
Summarise the epidemiology of ventricular tachycardia
Fairly common
It is one of the shockable rhythms that is seen in cardiac arrest patients
VT incidence peaks in the middle decades of life
Most common cause of sudden cardiac death
What are the presenting symptoms of ventricular tachycardia?
Symptoms of hypoperfusion of end organs due to decreased CO Dizziness Syncope Weakness Palpitations Fatigue Chest pain Dyspnoea
What are the signs on physical examination of ventricular tachycardia?
Depends on degree of haemodynamic instability: Tachycardia Hypotension Weak pulse Impaired consciousness Cannon A waves Respiratory distress Bibasal crackles Anxiety Agitation Lethargy Coma
What are the appropriate investigations of ventricular tachycardia?
ECG:
Broad QRS complex tachycardia - >120ms
Monomorphic (re-entrant tachy above scar tissue or focal) or polymorphic waves (focal)
Electrolytes:
Hypokalaemia and hypomagnesaemia are associated with torsades-de-pointes
Drug levels to check for digoxin toxicity
Troponin and creatine kinase MB - elevated in MI
