Cardiology Flashcards
1
Q
What are the causes of ST elevation?
A
myocardial infarction, pericarditis (saddle-shaped), normal variant (high take off), left ventricular aneurysm, prinzmetal’s angina and rarely subarachnoid haemmorhage
2
Q
Causes of peaked T waves?
A
Myocardial ischaemia and hyperkalaemia
3
Q
Causes of inverted T waves?
A
myocardial ischaemia, digoxin toxicity, subarachnoid haemorrhage, arrhythmogenic right ventricular cardiomopathy, brugada syndrome.
4
Q
Causes of a prolonged PR interval?
A
Idiopathic (athletes), ischaemic heart disease, digoxin toxicity, hypokalaemia, rheumatic fever, aortic root pathology, lyme disease, sarcoidosis, myotonic dystrophy,
5
Q
What is the criteria defining Stage 1 hypertension?
A
Clinic BP >140/90mmHg and subsequent ABPM or HBPM average BP >135/85mmHg
6
Q
What is the criteria defining Stage 2 hypertension?
A
Clinc BP >160/100mmHg and subsequent ABPM or HBPM average BP >150/95mmHg
7
Q
What is the criteria defining severe hypertension?
A
Clinic systolic BP>180mmHg or Clinic diastolic >110mmHg
8
Q
Describe Atrial Fibrillation
A
A chaotic irregular atrial rhythm with variable AV response causing an irregularly irregular pulse.
May be split into fast and slow AF, Fast AF more than 100bpm, Slow considered less than 60bpm.
9
Q
Describe the management of Acute AF
A
Anticoagulate with LMWH, if haemodynamically unstable do not delay treatment for anticoagulantion and proceed to emergency cardioversion or IV amiodarone if unavailable.
If stable aim to control ventricular rate with verapamil or bisoprolol. If that fails try digoxin or amiodarone.
10
Q
Describe the management of Chronic AF and Paroxysmal AF
A
Rate control: CCB (verapamil/diltiazem) or beta-blocker (propanolol). Consider digoxin (heart failure)
Anticoagulation: CHADS-VASc score - if male with 1 consider. if 2 or more - offer
Warfarin INR - 2-3
NOACs
- Factor Xa inhibitor: Rivaroxaban/epixaban (safer in renal failure)
- Direct: Dabigatran
Rhythm control may be appropriate if symptomatic or CCF, younger, or there is a correctable underlying cause.
- Medical: 1st - propanolol; 2nd - sotolol; 3rd - if no heart problems give flecainide; if heart problems give amiodarone
- Electrical DC cardioversion/ AF ablation
Paroysmal AF may be treated by pill in the pocket flecainide PRN.
11
Q
Describe the CHADS-VASc score
A
if male with 1 - consider. if 2 or more - offer
C ongestive cardiac failure H ypertension A ge >75 (2 points) D iabetes S troke (2 points) V ascular disease A ge >65 Sc - Sex catergory female
12
Q
Describe the HAAS-BLED score
A
Score of 3 or more indicates high risk of bleeding and alternatives to anticoagulation should be considered
H ypertension A lcohol abuse A bnormal renal or liver function S troke B leeding disorder or previous major bleed L abile INR E lderly >65 D rug abuse
13
Q
What is a bounding pulse a sign of?
A
CO2 Retention, liver failure, sepsis
14
Q
What is a small volume pulse a sign of?
A
Aortic stenosis, shock, pericardial effusion
15
Q
What is a collapsing pulse a sign of?
A
Aortic regurgitation, AV malformation, patent ductus arteriosus
16
Q
What is a slow rising pulse a sign of?
A
Aortic stenosis
17
Q
What is a bisferiens pulse a sign of?
A
AR (+/-AS)
HOCM
18
Q
What is pulsus alternans a sign of?
A
Large pericardial effusion
Left ventricular failure
Asthma
19
Q
What is a jerky pulse a sign of?
A
HOCM
20
Q
What is pulsus paradoxus and what is it a sign of?
A
Systolic pressure drop in inspiration >10mmHg occurs in severe asthma, constrictive pericarditis or cardiac tamponade.
21
Q
Describe the 1st heart sound (S1)
A
S1 represents the closure or mitral (M1) and tricuspid (T1) valves. splitting in inspiration may be heard and is normal.
22
Q
What is a loud S1 a sign of?
A
Mitral stenosis
23
Q
What is a soft S1 a sign of?
A
occurs if PR interval prolonged or mitral valve incompetent e.g. mitral regurgitation
24
Q
Describe the 2nd heart sound S2
A
S2 represents the closure of the aortic (A2) and pulmonary (P2) valves.
25
What is a soft A2 a sign of?
aortic stenosis
26
What is a loud P2 a sign of?
Pulmonary hypertension
27
What is a soft P2 a sign of?
Pulmonary stenosis
28
Describe the splitting of the second heart sounds under normal and abnormal conditions
In inspiration the sounds are normally split with A2 followed by P2 this is due to the variation of right heart venous return with respiration delaying the pulmonary component.
Wide splitting of the heart sounds - RBBB, pulmonary stenosis, deep inspiration, mitral regurgitation and VSD.
Fixed wide splitting - ASD
Reversed splitting P2 followed by A2 with splitting increasing on expiration - LBBB, aortic stenosis, PDA
29
Describe the 3rd heart sound
S3 may occur just after S2, it is low pitched and best heard with the bell. S3 is pathological over the age of 30.
30
What is a loud S3 a sign of?
Mitral regurgitation, VSD, Dilated cardiomyopathy, post MI.
31
Describe the 4th heart sound
S4 occurs just before S1, always abnormal. it represents atrial contraction against a stiff ventricle i.e. aortic stenosis, HOCM
32
What is an ejection systolic click a sign of?
heard early in systole with bicuspid aortic valves may be aortic stenosis
33
What is a mid-systolic click a sign of?
mitral valve prolapse
34
What is an opening snap a sign of?
precedes the mid-diastolic murmur of mitral and tricuspid stenosis
35
What are the causes of an ejection-systolic murmur?
cresendo-decresendo murmur, may be due to aortic stenosis or sclerosis, pulmonary stenosis or HOCM
36
What are the causes of a pansystolic murmur?
monotoned murmur, and merges with S2. May be due to mitral or tricupsid regurgitation (also soft S1) or VSD.
37
What are the causes of a late-systolic murmur?
mitral valve prolapse may also have mid-systolic click
38
What are the causes of an early diastolic murmur?
high pitched murmur occurs in aortic regurge and tricuspid stenosis
39
What is a Graham-Steell murmur
A early diastolic murmur due to pulmonary regurgitation because of pulmonary hypertension from a stenotic mitral valve.
40
What are the causes of a mid-diastolic murmur?
Mitral stenosis
41
What is a tapping apex beat a sign of?
Palpable first hearts sound indicative of Mitral Stenosis
42
What is Corrigan's sign?
Cartoid pulsation may be seen in Aortic Regurgitation
43
What is Duroziez's sign?
In severe Aortic Regurgitation, gradual pressure over the femoral artery leads to a systolic and diastolic bruit.
The systolic murmur is heard best when the proximal femoral artery is compressed and the diastolic when the distal femoral artery is compressed.
44
What is de Musset's sign?
Head nodding with each heart beat a sign of Aortic Regurgitation
45
What is Quincke's sign?
Capillary pulsations in nail beds a sign of Aortic Regurgitation
46
What is Traube's sign?
'Pistol shot' sound over femoral arteries a sign of Aortic Regurgitation
47
What is Austin Flint murmur?
A mid-diastolic murmur due to the fluttering of the anterior mitral valve cusp caused by the regurgitant stream of Aortic Regurgitation.
48
What are Osler nodes?
Painful pulp infarcts in fingers or toes which together with janeway lesions is pathognomic of IE. Due to immune complex deposition
49
What are janeway lesions?
Non-tender erythematous, haemorrhagic or pustular spots on the palms or soles, which together with Osler nodes are pathognomic of IE. Due to infective embolic phenomena
50
Describe bradycardia and its treatment
If asymptomatic and rate greater than 40bpm, no treatment is required. Look for a cause (drugs, sick sinus syndrome, hypothyroidism) and stop any drugs that may be contributing (Beta-blockers, digoxin).
If rate less than 40bpm or patient is symptomatic give atropine 0.6-1.2mg IV up to max of 3mg. If no response, insert a temporary acing wire. If necessary, start an isoprenaline infusion or use external cardiac pacing.
51
Describe sick-sinus syndrome and its treatment
sinus node dysfunction causes bradycardia +/- arrest, sinoatrial block or SVT alternating with bradycardia/asystole. Pace if symptomatic
52
Causes of sinus tachycardia
Rate>100 Causes:
- Anaemia
- Anxiety
- Exercise
- Pain
- Fever
- Sepsis
- hypovolaemia
- Heart failure
- PE
- Pregnacy
- Thyrotoxicosis
- Beriberi
- CO2 retention
- caffeine, adrenaline, nicotine
53
Define Narrow Complex Tachycardias, the types, and principles of management.
ECG shows rate of >100bpm and QRS complex duration of less than 120ms.
Types:
- sinus tachycardia
- Supraventricular tachycardia
- Atrial fibrillation
- atrial flutter
- multifocal atrial tachycardia
- junctional tachycardia
Management:
- if patient is compromised use DC cardio version
- otherwise identify rhythm and treat accordingly.
- generally vagal manoeuvres (carotid massage, Valsalva) attempted to correct/ unmask rhythm
- if unsuccessful adenosine 6mg IV bolus, if fails try 12mg and another 12mg.
54
Describe SVT and its management
Narrow complex tachycardia with ECG showing P waves absent or inverted after QRS complex.
Management:
- Vagal manoeuvres (breath-holding, vasalva, carotid massage) are 1st line
- IV adenosine is the drug of choice (6mg bolus)
- If adenosine fails use IV verapamil (5mg over 2mins)
- If drug therapy fails use DC cardioversion
55
Describe Junctional Tachycardia and its management
Narrow complex tachycardia with ECG showing rate of 150-250bpm, P wave either buried in QRS complex or occurring just after. There are 3 types of junctional tachycardia:
- AV nodal reentry tachycardia
- AV reentry tachycardia
- His bundle tachycardia
Management:
- Try vagal manoeuvres
- IV Adenosine will usually return to sinus rhythm
- If it re-occurs try amiodarone or beta-blocker
- Radiofrequency ablation is more frequently being used in AVRT and symptomatic AVNRT
56
Describe Wolff-Parkinson-White syndrome
Caused by congenital accessory conduction pathway between atria and ventricles. Resting ECG shows short PR interval, Wide QRS complex (due to slurred upstroke or delta wave) and ST-T changes. Refer to cardiologist for electrophysiology and ablation of accessory pathway
57
Define Broad Complex Tachycardia and list the differentials
ECG shows rate of >100bpm and QRS complexes >120ms. If no clear QRS complexes, it is VF of asystole.
Differential Diagnosis;:
- VT includes torsade de pointes
- VF
58
Define Torsades de pointes and its management
Looks like VF but is VT with varying axis. it is due to increased QT interval (a SE of antiarrhythmics)
Management:
- magnesium sulphate 2g IV over 10 mins
- look at drug chart for QT prolonging medications (Anti-psychotics)
59
Describe systolic versus diastolic heart failure
Systolic - impaired contraction (decrease cardiac output)
-- IHD/MI, dilated cardiomyopathy, hypertension, myocarditis
Diastolic - impaired filling
-- pericardial effusion/tamponade, restrictive/hypertrophic cardiomyopathy
60
Describe left-sided versus right-sided heart failure.
LVF and RVF may occur independently or together as Congestive Cardiac Failure.
Left ventricular failure: symptoms include dyspnoea, poor excercise tolerance, fatigue, orthopnoea, paroxysmal nocturnal dyponea, nocturnal cough (+/- pink frothy sputum) wheeze, nocturia, cold peripheries, weight loss, muscle wasting
Right ventricular failure: causes: LVF, Pulmonary stenosis, lung disease. Symptoms: Peripheral oedema, ascites, nausea, anorexia, facial engorgement, pulsation in neck and face (tricuspid regurgitation), epistaxis.
61
Describe low-output versus high-output failure
Low-output heart failure: cardiac output is decreased and fails to increase normally with exertion. Causes:
•pump failure - systolic or diastolic HF, low heart rate (drugs, post MI, heart block)
•excessive preload- mitral regurgitation or fluid overload
•chronic excessive afterload - Aortic stenosis, hypertension
High-output heart failure is rare. Output is normal or increased but unable to meet a large demand of the body e.g anaemia, pregnancy, hyperthyroidism, Paget's disease, arteriovenous malformation, beri beri
62
Describe the Framingham criteria for congestive cardiac failure
Diagnosis of CCF requires the simultaneous presence of at least 2 major criteria or 1 major and 2 minor
```
Major criteria:
•paroxysmal nocturnal dyspnoea
•crepitations
•S3 gallop
•cardiomegaly
•increased central venous pressure (>16cmH2O at right atrium)
• weight loss >4.5kg in 5 days of treatment
•neck vein distension
•acute pulmonary oedema
•hepatojugular reflux
```
```
Minor criteria:
•bilateral ankle oedema
•dyspnoea on ordinary exertion
•tachycardia
•nocturnal cough
•decreased vital capacity by 1/3 of maximum recorded
•hepatomegaly
•pleural effusion
```
63
Describe the management if chronic heart failure (for left ventricular systolic dysfunction)
Conservative: lifestyle e.g stop smoking, eat less salt, optimise weight and nutrition
```
Treat exacerbating factors such as anaemia, thyroid disease, infection, hypertension
Avoid NSAIDs (cause fluid retention) and verapamil (-ve inotrope), glitazones, K+ sparring diuretics
```
Medical
1: ACEi (ARB if intolerable) + beta-blockers (carvedilol)
2: Add spironolactone/epleronone
Others: digoxin, Ivabradine (sinus node inhibitor), sacubitril
Surgical
Cardiac resynchronisation therapy
Left ventricular assist device
Cardiac transplant
64
Describe the types of hypertension
Isolated systolic hypertension - the most common form of hypertension in the UK. Affects >50% of over-60s. It results from stiffening of the arteries. Doubles the risk of MI, triples the risk of CVA.
'Malignant' or accelerated phase hypertension - refers to a rapid rise in BP leading to vascular damage. Hypertension is usually severe (systolic >200, diastolic >130) + bilateral retinal haemorrhages. Symptoms are common e.g. visual disturbance and headache. It is more common in younger patients and in black patients.
Essential hypertension - cause unknown
Secondary hypertension - due to renal disease, endocrine disease (cushing's, conn's, phaeochromocytoma), coarctation, pregnancy, steroids, the pill
65
Describe the management of hypertension.
Treatment goal: ideally less than 140/90mmHg, less than 130/80mmHg in diabetics, 150/90 if older than 80. Reduce slowly.
Lifestyle changes: stop smoking, low fat diet, reduce alcohol and salt intake, increase excercise and reduce weight if obese.
Drug therapy:
- Monotherapy if older than 55 and/or Afro-carribean 1st line is Ca channel blocker e.g. Amlodopine. Otherwise ACE-i e.g. Ramipril is first line also first in diabetics.
- Dual therapy, both Ca channel blocker and ACE-i
- If this fails add diuretic
- if this fails and potassium less than 4.5mmol/L add spironolactone if K+ high dose diuretic. If further diuretic therapy not tolerated or ineffective consider alpha or beta blocker.
66
Describe Acute Coronary Syndrome, its risk factors, symptoms, and tests.
ACS includes unstable angina, and evolving MI. MI can be further divided into STEMI or new onset LBBB, and NSTEMI.
Risk factors: age, male, family history, smoking, hypertension, DM, hyperlipidaemia, obesity, sedentary lifestyle, cocaine use.
Symptoms: Acute central chest pain, lasting >20min, often associated with nausea, sweatiness, dyspnoea, palpitations. May present without chest pain e.g. in the elderly or diabetics, in which syncope, pulmonary oedema, epigastric pain, vomiting, post-op hypotension, oliguria, acute confusional state.
Tests: ECG (in 20% ECG may be normal at first repeat ECG!)
-STEMI: Classically hyperacute (tall) t waves, ST elevation or new LBBB, T wave inversion and pathological Q waves follow over hours-days.
-NSTEMI: ST depression, t-wave inversion, non-specific changes.
CXR,Bloods, cardiac enxymes. Troponin elevated after 3-12h of onset if normal 6h after onset chance of missing MI is small.
67
Describe acute pericarditis, its features, tests and treatment
Inflamation of pericardium it may be idiopathic or secondary due to infection, MI, drugs (procainamide, hydralazine, penicillin, isoniazid), uraemia, RA, SLE, sarcoidosis, radiotherapy.
Features: central chest pain worse on inspiration or lying flat and relieved by sitting forward. A pericardial friction rub may be heard. look for evidence of pericardial effusion or cardiac tamponade. Fever may occur.
Tests: ECG classically shows saddle-shaped ST elevation, but can be normal. Troponin may be raised. Cardiomegaly on CXR may indicate pericardial effusion.
Treatment: Analgesia e.g. NSAIDs. Treat underlying cause.
68
Describe cardiac tamponade, its causes, signs, and management.
Accumulation of pericardial fluid raise intrapericardial pressure hench poor ventricular filling and fall in cardiac output. Beck's triad, falling BP, rising JVP, muffled heart sounds. Echo is diagnostic.
Causes: any cause of pericarditis, aortic dissection, haemodialysis, warfarin, transeptal puncture at cardiac catheterisation, post cardiac biopsy.
Signs: increased PR, decreasing BP, pulsus paradoxus, increased JVP, kussmaul's sign, muffled heart sounds.
Management: seek expert help, pericardial effusion needs urgent drainage.
69
Describe SVC obstruction, its causes, signs and symptoms, investigation, and management
SVC obstruction is not an emergency unless there is tracheal compression with airway compromise.
Causes: malignancy account for >90%, 3/4 of which are lung cancer. rare causes include mediastinal enlargement, thymus malignancy, mediastinal lymphadenopathy (sarcoid, lymphoma).
Signs + symptoms: dyspnoea, orthopnoea, plethora/cyanosis, swollen face and arm, cough, headache, engorged veins.
Investigations: urgent contrast enhanced CT
Management: biopsy if cause unknown, dexamethasone PO 8-16mg/d. Consider balloon venoplasty and SVC stenting for rapid relief of symptoms
70
Describe Mitral stenosis its causes, symptoms, signs, tests and management
Causes: Rheumatic, congenital, carcinoid, prosthetic valve.
Symptoms: Dyspnoea, fatigue, palpitations, chest pain, systemic emboli, haemoptysis, chronic bronchitis-like picture
Signs: malar flush on cheeks (due to decreased cardiac output), low-volume pulse, AF, tapping non-displaced apex beat (palpable S1). On auscultation, loud S1, opening snap, rumbling mid-diastolic murmur heard best in expiration with the patient on the left side.
Tests: ECG may show AF, P-mitrale, RVH, Progressive RAD. Echo is diagnostic.
Management: If AF rate control and warfarin. Diuretics decreased preload and pulmonary venous congestion. May need valve replacement.
71
Describe mitral regurgitation its causes, symptom, signs, tests, and management
Causes: functional (LV dilatation), annular calcification (elderly), rheumatic fever, infective endocarditis, mitral valve prolapse, ruptured chordae tendinae, papillary muscle dysfunction, congenital, connective tissue disorders, cardiomyopathy.
Symptoms: dyspnoea, fatigue, palpitation, infective endocarditis
Signs: AF, displaced hyperdynamic apex, RV heave, soft S1, Loud P2 (due to pulmonary hypertension), pansystolic murmur at apex radiating to axilla.
Tests: ECG may show AF +/- P-mitrale, LVH, Echo is diagnostic.
Management: rate control AF and warfarin, diuretics improve symptoms, valve replacement needed
72
Describe mitral valve prolapse, its symptoms, signs, complications, tests and management.
Most common valvular abnormality (prevalence ~5%), occurs alone or with ASD, patent ductus arteriosus, cardiomyopathy, turner's syndrome, marfans syndrome, osteogenesis imperfecta, WPW
Symptoms: asymptomatic or atypical chest pain and palpitations.
Signs: mid-diastolic click
Complications: mitral regurgitation, cerebral emboli, arrhythmias, sudden death
Tests: Echo is diagnostic, ECG may show inferior T-wave inversion
Management: beta-blockers may help palpitations and chest pain, surgery needed if progressive to MR
73
Describe aortic stenosis its causes, symptoms, signs, tests and management
Causes: Senile calcification is the commonest, congeitial (bicuspid valve, williams syndrome), rheumatic heart disease.
Symptoms: Think AS in any elderly person wit chest pain, exertional dyspnoea, or syncope. The classic triad includes angina, syncope and heart failure. May also have dyspnoea, dizziness, faints
Signs: slow-rising pulse with narrow pulse pressure, heaving non-displaced apex beat, LV heave, aortic thrill, ejection systolic murmur heard best at the base, left sternal edge and aortic area and radiates to the carotids.
Tests: ECG shows P-mitrale, LVH with strain pattern, LAD poor R wave progession LBBB or complete AV block. Echo is diagnostic
Management: valve replacement is usually recommended
74
Describe aortic regurgitation its causes, symptoms, signs, tests and management
Causes:
- Acute = IE, ascending aortic dissection, chest trauma
- Chronic = congenital, connective tissue disorders, rheumatic fever, takayasu arteritis, RA, SLE, hypertension,
Symptoms: Exertional dyspnoea, orthopnoea, PND, palpitations, angina, syncope, CCF.
Signs: collapsing 'water-hammer' pulse, wide pulse pressure, displaced, hyperdynamic apex beat. high pitched early diastolic murmur best head in expiration with patient sitting forward. Also corrigan's sign, de Musset's sign, duroziez's sign, quincke's sign and traube's sign.
Tests: ECG shows LVH. Echo is diagnostic.
Management: Reduce systolic hypertension, ACE-i are helpful. If increasing symptoms, signs of developing heart failure, or ECG deterioration surgery is indicated. Aim to replace valve before significant LV dysfunction.
75
Describe tricuspid regurgitation, its causes symptoms and signs, management
Causes: right ventricular infarction, pulm hypertension, rheumatic fever, infective endocarditis (IV drug user), carcinoid syndrome, congenital (e.g. ASD/Ebstein's anomaly).
Symptoms: Fatigue, hepatic pain on exertion, ascites, oedema. If the cause if LV failure orthopnoea and dyspnoea
Signs: Giant V waves, and prominent y descent in JVP. RV heave, pansystolic murmur heard best at lower sternal edge in inspiration, pulsatile hepatomegaly, jaundice ascites.
Management: Treat underlying cause. Diuretics, ACE-i, valve replacement.
76
Describe tricuspid stenosis, its causes, symptoms, signs and treatment.
Causes: main cause is rheumatic fever, which almost always occurs with mitral or aortic valve disease. rarer causes congenital, infective endocarditis
Symptoms: fatigue, ascites, oedema
Signs: giant a wave and slow y descent in JVP. opening snap, early diastolic murmur heard best at the left sternal edge in inspiration. AF can also occur.
Treatment is with diuretics and surgical repair.
77
Describe pulmonary stenosis, its causes, symptoms signs, and treatment
Causes: usually congenital, acquired causes rheumatic fever, carcinoid syndrome.
Symptoms: dyspnoea, fatigue, oedema, ascites
Signs: dysmorphic facies (congenital causes), prominent a wave in JVP, RV heave, in mild stenosis there is an ejection click, ejection systolic murmur which radiates to the left shoulder. widely split S2. in severe stenosis the murmur becomes longer and obscures A2. P2 becomes softer and may be inaudible.
Treatment: pulmonary valvuloplasty or valvotomy
78
Describe pulmonary regurgitation
It is caused by any cause of pulmonary hypertension. A decrescendo murmur is heard in early diastole at the left sternal edge (known as the graham steell murmur if associated with mitral stenosis and pulmonary hypertension)
79
Which coronary artery is associated with anteroseptal ECG changes and what leads indicate this?
Anteroseptal = V1-V4
| supplied by the left anterior descending artery
80
Which coronary artery is associated with inferior ECG changes and what leads indicate this?
Inferior = II,III aVF
| supplied by the right coronary artery
81
Which coronary artery is associated with anterolateral ECG changes and what leads indicate this?
anterolateral = V4-6 I aVL
| supplied by the left anterior descending artery or left circumflex artery
82
Which coronary artery is associated with lateral ECG changes and what leads indicate this?
lateral = I, aVL, +/- V5,V6
| supplied by the left circumflex artery
83
Which coronary artery is associated with posterior ECG changes and what leads indicate this?
Posterior = Tall R waves V1 V2
| usually supplied by left circumflex also right coronary
84
Describe Buerger's test
It is a test for critical ischaemia:
- first lie the patient on the bed
- Elevate legs to 45 degress
- look for palor
- Buerger's angle is the angle at which the legs go pale
- less than 25 degrees is a sign of critical ischaemia
- sit the patient up hanging legs of the side of the bed
- look for reactive hyperaemia which makes the legs appear dusky red.
85
What are causes of LBBB?
- Ischaemic Heart Disease
- Hypertension
- Aortic Stenosis
- Cardiomyopathy
- Rarely: Idiopathic fibrosis, digoxin toxicity, hyperkalaemia
86
Describes the types of heart block, and the management of each
1st degree heart block: prolonged PR
2nd degree mobitz type 1: PR lengthening each successive beat until dropped beat then return to normal
2nd degree mobitz type 2: 2:1, 3:1 missed beat, requires permanent pacing due to risk of progression to complete heart block.
3rd degree complete heart block: no association between p waves nad QRS complex, requires permanent pacing, untreated can lead to asystole and decreased cardiac output.
87
Describe pulmonary oedema, its causes, symptoms + signs, management and investigations.
Causes:
- Cardiovascular, usually LVF (post MI or IHD), also valvular heart disease, arrhythmias, malignant hypertension
- ARDS from any cause e.g. trauma, malaria, drugs
- Fluid overload
- Neurogenic e.g. head injury
Symptoms + Signs: Dyspnoea, orthopnoea (e.g. paroxysmal), pink frothy sputum, distressed, pale, sweaty, tachycardic, tachypnoeic, pulsus alternans, raised JVP, fine lung crackles, triple/gallop rhythm, wheeze, sitting up leaning forward.
Management:
- Sit patient upright
- Oxygen 100% if no lung disease
- IV access and ECG, treat any arrhytmias e.g. AF
- Bloods: U+E, troponin, ABG, consider BNP.
- Diamorphine 1.25-5mg IV slowly (caution in liver and COPD)
- Furosemide 40-80mg IV slowly (larger doses needed in renal failure)
- GTN spray 2 puffs SL, or 2 x 0.3mg tablets SL (Dont give if systolic BP less than 90)
- Investigation: CXR, consider ECHO
- If systolic BP greater than 100 start a nitrate infusion e,g, isosorbide dinitrate 2-10mg/h IVI keeping systolic above 90
- If patient worsening consider further dose of furosemide, CPAP or increase nitrate infusion
- if systolic BP less than 90 treat for cardiogenic shock
88
What is malar flush and what is it a sign of.
Plum-red discolouration of the high chicks classically associated with mitral stenosis due to resulting CO2 retention and its vasodilatory effects.
89
Describe Peripheral Arterial Disease (PAD), its symptoms, signs, classification, and tests.
PAD occurs due to athersclerosis causing stenosis of arteries. 65% have co-existing cerebral or coronary artery disease.
Symptoms: cramping pain is felt in the calf, thigh or buttocks after walking for a given distance (claudication distance) and relieved by rests. (Calf claudication suggests femoral disease while buttock claudication suggests iliac disease). Ulceration, gangrene and foot pain at rest are the cardinal features of critical ischaemia.
Signs: absent femoral, popliteal or foot pulses, cold white legs, atrophic skin, punched out ulcers (often painful) postural dependent colour change. delayed cap refil
```
Fontaine classification for PAD:
1 = Asymptomatic
2 = intermittent claudication
3 = ischaemic rest pain
4 = ulceration/gangrene
```
Tests: Exclide DM, arteritis, do ABPI normal is 1-1.2 PAD = 0.5-0.9 and critical limb ischaemia = less than 0.5. Colour duplex USS is 1st line imaging. If considering intervention e.g. percutaneous transluminal angioplasty, MR/CT angiography is used to assess disease extent and location of stenoses.
90
Describe Leriche's syndrome and its symptoms
A syndrome caused by aorto-occlusive disease, commonly due to a saddle embolus ad the aortic bifurcation or stenosis from PAD.
Symptoms: Absent femoral pulse, claudication/wasting of the buttock, a pale cold leg, erectile dysfunction.
91
Describe Carotid Artery Disease and its management
Accounts for 20% of strokes and TIAs.
Management: Symptomatic patients with ipsilateral stenosis >70% should have carotid endarterectomy within 2 weeks of symptom onset.
92
Describe Varicose Veins, it's signs and symptoms, and treatment
Valves prevent blood from passing from deep to superficial veins. If they become incompetent there is venous hypertension and dilatation of the supervicial veins occurs. Risk factors include prolonged standing, obesity, pregnancy, family history and the Pill. There are 3 main sites:
- lateral lower leg = short saphenous
- Medial leg = long saphenous
- Medial lower leg = calf perforators
Symptoms: 'my legs are ugly' pain, cramps, tingling, heaviness, and restless legs.
Signs: oedema, eczema, ulcers, haemosiderin, haemorrhage, phlebitis, atrophie blanche (previous ulcer scar), lipodermatosclerosis.
Treatment:
- Endovascular treatment e.g. radiofrequency abalation, endovenous laser ablation or injection sclerotherapy.
- Surgery stripping
93
What ECG changes would be seen in a posterior MI?
ST depression, R waves, Upright T waves.
Upside down appears normal.
94
Describe Angina Pectoris, symptoms, and management.
Symptoms: Due to myocardial ischaemia and presents as central rightness or heaviness which is brought on by exertion and relieved by rest. Precipitates, stress, cold weather and heavy meals. May slo be associated dyspnoea, nausea, sweatiness, and faintness.
Management:
- modify risk factors e.g. Stop smoking, encourage excercise, weight loss, control hypertension and diabetes.
- aspirin + statin
- sublingual glyceryl trinitrate for acute attacks
- b-blocker or Ca blocker first line
- consider dual therapy if fails
- if unable to tolerate the above dual therapy consider long-acting nitrat, ivabradine, nicorandil, or ranolazine.
- if steal symptomatic refer for PCI or CABG.
95
Describe Coarctation of the Aorta, its symptoms, investigations and management.
Congenital narrowing of the descending aortas usually occurs just distal to the origin of the left subclavian artery. More common in boys. It is associated with bicuspid aortic valve and turners syndrome. Can lead to heart failure and increased risk of infective endocarditis.
Symptoms: Radiofemoral delay, weak femoral pulse, raised BP scapular bruit, systolic murmur.
Investigations: 4 limb BPs, CT or MRI angiogram, CXR shows rib notching.
Management:
Surgery, or ballon dilatation +/- stenting.
96
Describe Takotsubo Cardiomyopathy, its symptoms and management.
Stress-induced cardiomyopathy e.g. Patient found out family member dies then develops chest pain and features of heart failure. There is transient apical ballooning of the myocardium.
Symptoms: Chest pain, breathlessness.
Management:
- supportive
- reassure is temporary and reversible
97
Describe Abdominal Aortic Aneurysm, its symptoms and management.
An artery with dilatation more than 50% of its original diameter has an aneurysm. They are typically caused by atheroma, trauma, infection, connective tissue disorders, or inflammatory disorders (e,g. Takayau's). All men are screened at 65YRS.
Symptoms: Intermittent or continuous abdominal pain that radiates to the back, iliac fossa ear groins, collapse, an expansive abdominal mass, shock if ruptured. Unruptured my be asymptomatic or present with abdominal pain and the mass.
Investigations:
- if unruptured monitoring, if larger than 5.5cm, or expanding at 1cm/yr or symptomatic elective surgery with stenting.
- if ruptured suspected ABCDE assessment get help from vascular surgeons and anaethetist.
- do ECG, Bloods, cross-match
- prophylactic Cefuroxime + metronidazole
- straight to theatre.
98
Describe the different parts of the JVP waveform and possible abnormalities.
JVP provides information on the right atrial pressure but also clues to underlying valvular disease. A non-pulsatile JVP is seen in superior vena caval obstruction. Kussmaul's sign describes a parodoxical rise in JVP during inspiration seen in constrictive pericarditis.
There are 5 parts to the wave form:
- 'a' wave - atrial contraction, it is large if atrial pressure is increased e.g. Tricuspid stenosis, pulmonary stenosis, pulmonary hypertension and it is absent in AF. May have Cannon appearance which is due to atrial contraction against a closed tricuspid valve and is seen in complete heart block
- 'c' wave - marks closure of the tricuspid valve and is not normally visible.
- 'v' wave - due to passive billing of blood into the atrium against a closed tricuspid valve, giant v waves occur in tricuspid regurgitation
- 'x' descent - fall in atrial pressure during ventricular systole
- 'y' descent - opening of the tricuspid valve.
99
What are some causes of a Narrow Pulse Pressure?
Considered narrow if less than 25% of systolic value or 25mmHg.
Causes: AS, Cardiac tamponade, Congestive heart failure, shock.
100
Causes of AF
```
Causes:
IHD/hypertension
Mitral valve disease
Thyrotoxicosis
Constrictive pericarditis
Chronic pulmonary disease
```
101
Symptoms of AF
Symptoms may be none or chest pain, palpitations, dyspnoea, faintness. May be acute, chronic or paroxysmal
102
Investigations in AF
Tests:
ECG- absent p waves, narrow QRS complex, irregularly irregular.
Blood tests- U+E, cardiac enzymes, TFTs to look for underlying cause
Echo
Holter monitor
103
Causes of right axis deviation
Causes of RAD:
- Right ventricular hypertrophy
- Right ventricular strain e.g. PE
- Lateral STEMI
- Chronic lung disease e.g. COPD
- Hyperkalaemia
- Sodium channel blockade e.g. TCA poisoning
- WPW syndrome
- Dextrocardia
- ventricular ectopy
- ASD
- Normal paediatric ECG
- Vertical heart e.g. emphysema
104
Causes of left axis deviation
Causes of LAD:
- Left ventricular hypertrophy
- LBBB
- Inferior MI
- Ventricular pacing
- WPW syndrome
105
Hypertension aetiology
PREDICTION
- Primary (95%)
- Renal: RAS, GN, APKD, PAN
- Endo: High T4, Cushings, phaeo, acromegaly, Conn
- Drugs: Cocaine, NSAIDs, OCP
- ICP increased
- Coarctation
- Toxaemia in preg (PET)
- Increased viscosity
- Overload
- Neurogenic: diffuse axonal injury, spinal section
106
features of Long QT syndromes
Long QT1 - usually associated with exertional syncope, often swimming
Long QT2 - often associated with syncope occurring following emotional stress, exercise or auditory stimuli
Long QT3 - events often occur at night or at rest
sudden cardiac death
107
What is Wellen's syndrome
Deeply inverted or biphasic T waves in V2-V3 due to critical stenosis of left anterior descending artery.
High risk of imminent occlusion and needs coronary angio
