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Cardiology Flashcards

1
Q

State the arterial supply to the lateral leads

A

Circumflex

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2
Q

Name the leads that correlate to the lateral area of the heart

A

I
aVL
V5
V6

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3
Q

State the arterial supply to the inferior leads

A

right coronary artery

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4
Q

State the arterial supply to the anteroseptal leads

A

LAD

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5
Q

Name the leads that correlate to the inferior area of the heart

A

II
III
aVF

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6
Q

Name the leads that correlate to the anteroseptal area of the heart

A

VI
V2
V3
V4

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7
Q

What is the initial management of ACS?

A 
o2 if <94%
12 lead ECG
IV access
sublingual GTN spray
aspirin 300mg
diamorphine IV + metaclopramide IV

?ticagrelor, clopidogrel or prasugrel

Glycoprotein IIb/IIIa inhibitors

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8
Q

What investigations would you do in ACS?

A

Bedside: ECG
Bloods: FBC U+E LFTs glucose lipids troponin I
Imaging: portable CXR

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9
Q

What are the indications for thrombolysis or PCI in STEMI?

A

<12hrs pain

\+ any of
ST elevation >1mm in 2 limb leads
ST elevation >2mm in 2 chest leads
posterior infarct
new onset LBBB
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10
Q

What are the absolute contraindications for thrombolysis?

A 
stroke <6m
CNS neoplasia
recent trauma or surgery
GI bleed <1m
bleeding disorder
aortic dissection
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11
Q

What are the relative contraindications for thrombolysis?

A

warfarin
pregnancy
advanced liver disease
infective endocarditis

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12
Q

State the complications of thrombolysis

A 
bleeding
hypotension
ICH
reperfusion arrhythmias
systemic embolisation of thrombus
allergic reaction
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13
Q

What drug is used for thrombolysis in STEMI?

A

reteplase

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14
Q

What are the complications of a STEMI?

A 
S udden death
P ericarditis
R upture papillary muscles
E mbolism
A rrhythmias
D ressler's syndrome
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15
Q

What drugs should a patient be prescribed post MI?

A 
Aspirin
ACEi
Beta blocker
Clopidogrel/prasugrel (STEMI)/ticegralor (NSTEMI)
Statin
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16
Q

In terms of work and driving, what should a patient be advised post MI?

A

off work for 1 month

need to inform DVLA - no driving for 1 month

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17
Q

How can you distinguish between NSTEMI and unstable angina?

A

troponin I 12hrs after onset
+ve for NSTEMI
-ve for unstable angina

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18
Q

How is an NSTEMI treated?

A

MONA

LMWH - fondaparinux
Beta blocker or calcium chanel blocker
nitrates

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19
Q

When should PCI be considered in a patient with NSTEMI?

A 
rise in troponin I
recurrent angina/ischaemic ECG changes despite therapy
heart failure develops
poor LV function
haemodynamically unstable
PCI <6m
previous CABG
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20
Q

Name some narrow complex tachycardias

A 
regular:
sinus tachy
accessory pathway
atrial tachy
junctional tachy - - AVNRT/AVRT
multifocal atrial tachycardia

irregular:
AF

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21
Q

How do you manage a regular narrow complex tachycardia?

A

ABC
O2
IV access

vagal manoeuvres
adenosine 6mg IV bolus
monitor ECG

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22
Q

How does adenosine work?

A

inhibition SAN and AVN

Leads to AV block

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23
Q

What are the vagal manouevres?

A

carotid sinus massage

Valsalva - hold breath and bear down

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24
Q

If adenosine fails, and the patient is haemodynamically compromised in regular SVT, what next?

A

Senior help!!!

Amiodarone 300mg IV
DC cardioversion

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25
If adenosine fails, and the patient is haemodynamically stable in regular SVT, what next?
senior help!!! B blocker digoxin
26
What could cause a broad complex tachycardia?
VT - most common! until proven otherwise SVT with BBB SVT with aberrancy WPW antidromic
27
If the patient is unstable, how should a VT be managed?
senior help! sedation DC cardioversion amiodarone
28
If the patient is stable, how should a VT be managed?
amiodarone 300mg IV If SVT, give adenosine
29
What is the most common organism to cause endocarditis?
Streptococcus viridans Staph aureus in IVDU Staphylococcus epidermidis in valve surgery <2m ago
30
What are the key features of infective endocarditis?
fever | new heart murmur
31
What murmurs are seen in infective endocarditis?
aortic regurg | mitral regurg
32
What are the systemic signs of infective endocarditis?
oslers nodes janeway lesions clubbing splinter haemorrhages
33
What are the major criteria for diagnosis of IE?
+ve blood culture - typical organism on 2 separate cultures evidence of endocardial involvement - +ve echo (vegetation, abscess, prosthetic valve damage) or new valvular regurgitation
34
What are the minor criteria for diagnosis of IE?
``` predisposition - IVDU, prosthetic valve fever >38 vascular signs +ve blood culture +ve echo ```
35
What predisposes to IE?
``` prosthetic heart valves congenital defect valvular disease prev endocarditis prev rheumatic fever ```
36
What investigations if IE is suspected?
Bedside: ECG urinalysis Bloods: FBC U+E LFT CRP Micro: blood cultures X3 Imaging: CXR, Echo
37
Why is urinalysis done if IE is suspected?
glomerulonephritis can develop secondary to immune vasculitis
38
Treatment for IE
ABC microbiologist + cardiologist empirical abx - benzylpenicillin + gentamicin
39
How can you tell a posterior MI on an ECG?
reciprocal changes in V1-V3 ask for leads V7-V9
40
Which artery supplies the posterior aspect of the heart?
circumflex
41
What parts of the heart does the right coronary artery supply?
right atrium right ventricle SA Node AV Node
42
What parts of the heart does the left anterior descending supply?
left ventricle right ventricle interventricular septum
43
What parts of the heart does the circumflex supply?
left atrium | left ventricle
44
What parts of the heart does the left marginal artery supply?
left ventricle
45
What parts of the heart does the right marginal artery supply?
right ventricle | apex
46
Which antiplatelet should be given to which groups of patients in the long term management of ACS
STEMI - aspirin + prasugrel NSTEMI - aspirin + ticagrelor other - aspirin + clopidogrel
47
List some complications of an MI
``` Myocardium: cardiac arrest - VF cardiogenic shock chronic heart failure LV aneurysm ``` Electrics: VT AV block Pericardium: Pericarditis Dressler's syndrome Valves: mitral regurgitation
48
What is an LVAD? | What does it do?
Left Ventricular Assist Device tube that pulls blood from the left ventricle into a pump. which sends blood into the aorta Battery pack outside body used in people with heart failure as long term therapy or bridge to transplant
49
What is a CRT-D? What does it do?
Cardiac resynchronisation therapy - defibrillator resynchronizes the contractions of the heart’s ventricles by sending tiny electrical impulses to the heart muscle, which can help the heart pump blood throughout the body more efficiently. Used in heart failure Also cardioverter-defibrillator, to quickly terminate an abnormally fast, life-threatening heart rhythm
50
What is BNP used to measure?
BNP increases with right or left systolic or diastolic heart failure. It is an independent predictor of high left ventricular end-diastolic pressure. BNP levels decrease after effective treatment of heart failure.
51
When is BNP released?
in response to stretch of the ventricles | released in direct proportion to ventricular volume expansion and pressure overload
52
State the CHA2DS2-VASc score
C Congestive heart failure 1 H Hypertension (or treated hypertension) 1 A2 Age >= 75 years 2 Age 65-74 years 1 D Diabetes 1 S2 Prior Stroke or TIA 2 V Vascular disease (including ischaemic heart disease and peripheral arterial disease) 1 S Sex (female) 1
53
What counts as a vascular disease in CHA2DS2-VASc ?
ACS, PVD, MI, stent
54
What is the appropriate course of action in someone with a CHA2DS2-VASc score of 0?
no anticoagulation
55
What is the appropriate course of action in someone with a CHA2DS2-VASc score of 1?
Male - consider anticoagulation Female - no anticoagulation
56
What is the appropriate course of action in someone with a CHA2DS2-VASc score of 2 or more?
Offer anticoagulation
57
What is the purpose of the HAS BLED score?
formalise this risk assessment of the risk of bleeding on anticoagulation medication
58
State the components of the HASBLED score
H Hypertension, uncontrolled, systolic BP > 160 mmHg 1 A Abnormal renal function (dialysis or creatinine > 200) 1 for any renal abnormalities Or Abnormal liver function (cirrhosis, bilirubin > 2 times normal, ALT/AST/ALP > 3 times normal 1 for any liver abnormalities S Stroke, history of 1 B Bleeding, history of bleeding or tendency to bleed 1 L Labile INRs (unstable/high INRs, time in therapeutic range < 60%) 1 E Elderly (> 65 years) 1 D Drugs Predisposing to Bleeding (Antiplatelet agents, NSAIDs) 1 for drugs Or Alcohol Use (>8 drinks/week) 1 for alcohol
59
What can the HASBLED score tell you?
>=3 = high risk of bleeding eg. intracranial haemorrhage, hospitalisation, haemoglobin decrease >2 g/L, and/or transfusion.
60
Where can AF conduct through?
AVN | accessory pathways
61
State some causes of AF
``` HTN ischaemia cardiomyopathy hyperthyroidism mitral stenosis obstructive sleep apnoea CCF ```
62
State some drugs used for rate control in AF
bisoprolol | verapamil
63
State some drugs used for rhythm control in AF
flecainide sotalol amiodarone
64
When is flecainide contraindicated?
ischaemic heart disease structural heart disease valvular heart disease
65
In what groups of patients are NOACs not licensed for use?
prosthetic valves | mitral stenosis
66
When are NOACs indicated for prevention of stroke and systemic embolism in AF?
non-valvular disease ``` + one or more of: prior stroke or transient ischaemic attack age 75 years or older hypertension diabetes mellitus heart failure ```
67
Name some NOACs
dabigatran rivaroxiban apixaban
68
What is the mechanism of action of the NOACs?
dabigatran + rivaroxaban = direct factor Xa inhibitors apixaban = direct thrombin inhibitor
69
What length is a broad complex tachycardia?
>120ms, >3 small squares
70
What is seen in VT on ECG?
``` positive QRS concordance LAD AV dissociation or AV block fusion beats capture beats ```
71
What is a fusion beat?
= normal QRS + VT = unusual complex
72
What is a capture beat?
= normal QRS between abnormal beats
73
Which cardiac arrest rhythms are shockable?
VF | pulseless VT
74
Which cardiac arrest rhythms are non-shockable?
pulseless electrcal activty | asystole
75
What are the reversible causes of cardiac arrest?
hypoxia hypovolaemia hypo/hyperkalaemia hypothermia thrombosis tamponade toxins tension pneumothorax
76
What is VT? | Why is it considered an emergency?
broad-complex tachycardia originating from a ventricular ectopic focus. has potential to precipitate ventricular fibrillation
77
What causes monomorphic VT?
myocardial infarction
78
What causes polymorphic VT eg torsades de pointes?
prolongation of QT interval
79
Give some causes of QT interval prolongation
``` sotalol amiodarone TCA fluoxetine hypocalcaemia ```
80
What is bifascicular block?
both the right bundle branch AND one of the left bundle branch fascicles is not conducting.
81
How is bifascicular block seen on ECG?
combination of RBBB with left anterior or posterior hemiblock e.g. RBBB with left axis deviation
82
What is trifascicular block?
combination of RBBB with left anterior or posterior hemiblock AND 1st degree heart block
83
What murmur is most likely to occur in and IVDU with IE?
Tricuspid regurg
84
What murmur is most likely to occur with IE?
mitral or aortic regurgitation
85
When is valve replacement considered in IE?
If the infection is not clearing despite optimal Abx | heart failure starts to develop
86
What is the difference between AVRT and AVNRT?
AVRT - accessory pathway between ventricles and atria AVNRT - accessory pathway between AVN and atria alpha = slow, beta = fast. causes loop
87
Give lifestyle interventions used in management of hypertension
``` smoking cessation, weight reduction, reduction of excessive intake of alcohol and caffeine, reduction of dietary salt, reduction of total and saturated fat, increasing exercise, increasing fruit and vegetable intake. ```
88
What investigations are carried out in suspected HTN?
clinicn BP >140/90 | confirmed using ambulatory blood pressure monitoring or home blood pressure monitoring
89
What are some causes of secondary HTN?
``` phaeochromocytoma renal disease pre-eclampsia renal artery stenosis Conn's hyper/hypothyroid coarctation aorta ```
90
Describe systolic heart failure
inability of the ventricles to contract to give sufficient cardiac output
91
Describe diastolic heart failure
inability of the ventricles to relax and fill to provide sufficient cardiac output
92
What can the ejection fraction tell us in heart failure?
<40% = systolic >50% = diastolic
93
What are the causes of systolic heart failure
IHD dilated cardiomyopathy MI
94
What are the causes of diastolic heart failure
constrictive periccarditits tamponade restrictive or hypertrophic cardiomyopathy HTN
95
What are the causes of high output heart failure?
anaemia pregnancy hyperthyroidism
96
What are the symptoms of left heart failure?
``` breathlessness, reduced exercise tolerance, PND, orthopnoea, fatigue, nocturnal cough, wheeze, nocturia, weight loss. ```
97
What are the signs of left heart failure?
``` cool peripheries, muscle wastage, crepitations on auscultation, S3 gallop, pleural effusion, displaced apex beat due to LV dilatation, Low BP, narrow pulse pressure due to low stroke volume, tachycardia, ```
98
What are the symptoms of right heart failure?
peripheral pitting oedema ascites nausea anorexia
99
What are the signs of right heart failure?
``` Neck vein distension, S3 gallop, raised JVP, hepatomegaly, hepatojugular reflex, RV heave ```
100
How should a person with suspected heart failure be investigated if they have had a previous MI?
Bedside: ECG Bloods: U+E, eGFR, FBC, TFT, LFT, HbA1c, and fasting lipids. Imaging: echo within 2 weeks, CXR Refer: specialist
101
How should a person with suspected heart failure be investigated if they have not had a previous MI?
Bedside: ECG Bloods: BNP!!! U+E, eGFR, FBC, TFT, LFT, HbA1c, and fasting lipids. Imaging: CXR, echo
102
How does the management of heart failure change depending on BNP level?
If the BNP level is above 400 pg/mL refer for specialist assessment and echocardiography to be seen within 2 weeks. If the BNP level is between 100-400 pg/mL, refer for specialist assessment and echocardiography to be seen within 6 weeks. If BNP levels are less than 100 pg/mL a diagnosis of heart failure is unlikely. Consider referral if a clinical suspicion of heart failure persists and conditions are present which may cause a false negative result.
103
What can cause a false negative BNP result?
``` Obesity Diuretics ACE inhibitors Beta-blockers Angiotensin 2 receptor blockers Aldosterone antagonists ```
104
What can cause a increase the levels of BNP?
Age over 70 years. Female gender. Left ventricular hypertrophy, myocardial ischaemia, or tachycardia. Hypoxia. Pulmonary hypertension. Pulmonary embolism. Chronic kidney disease (estimated glomerular filtration rate less than 60 mL/min/1.73m2). Sepsis. Chronic obstructive pulmonary disease (COPD). Diabetes mellitus. Liver cirrhosis.
105
What is BNP?
BNP is a biologically active peptide and has vasodilator and natriuretic properties released from the cardiac ventricles in response to stretching of the chamber. The release of BNP appears to be in direct proportion to ventricular volume expansion and pressure overload. BNP increases with right or left systolic or diastolic heart failure. It is an independent predictor of high left ventricular end-diastolic pressure. BNP levels decrease after effective treatment of heart failure.
106
Describe the New York Heart Association classification of class I heart failure
no symptoms | no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations
107
Describe the New York Heart Association classification of class II heart failure
mild symptoms slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea
108
Describe the New York Heart Association classification of class III heart failure
moderate symptoms | marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms
109
Describe the New York Heart Association classification of class IV heart failure
severe symptoms unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity
110
What is the management of heart failure?
first-line = ACE-inhibitor + beta-blocker second-line = aldosterone antagonist, angiotensin II receptor blocker or a hydralazine in combination with a nitrate third line = cardiac resynchronisation therapy or digoxin diuretics should be given for fluid overload offer annual influenza vaccine offer one-off** pneumococcal vaccine cardiac rehabilitation
111
Which beta blockers are suitable to use in heart failure?
bisoprolol, carvedilol, and nebivolol.
112
Which drugs can worsen pre-existing heart failure?
NSAIDs, beta-blockers, calcium-channel blockers`.
113
What are the symptoms of pericarditis
chest pain - improves on sitting forwards, worse on inspiration SOB non-productive cough flu like
114
What are the signs of pericarditis
pericardial friction rub tachycardia tachypnoea fever
115
What can cause pericarditis
``` idiopathic coxsackie b Dressler's syndome uraemia systemic - RA, SLE TB ```
116
How should suspected pericarditis be investigated?
bedside: ECG bloods: FBC, U+E, troponin I , autoantibodies Mirco - blood cultures, viral serology Imaging: CXR, echo
117
What are the signs on ECG of pericarditis
widespread ST elevation PR depression T wave inversion/depresssion
118
What is a complication of pericarditis
pericardial effusion
119
How is pericarditis treated
analgesia | treat cause
120
What is the sign of pericardial effusion on CXR
water bottle heart
121
what is the sign of pericardial effusion on ECG
electical alternans
122
What is constrictive pericarditis
heart encased in rigid pericardium
123
Pericarditis can lead to constrictive pericarditis. What is a major cause of constrictive pericarditis
TB
124
What are the symptoms of constrictive pericarditis
dyspnoea | oedema
125
What are the signs of constrictive pericarditis
right heart failure: elevated JVP, ascites, oedema, hepatomegaly Kussmaul's sign pericardial knock third heart sound
126
What is Kassmaul's sign
JVP rising paradoxically with inspiration`
127
What is seen on CXR in constrictive pericarditis
pericardial calcification
128
How is the JVP changed in cardiac tamponade
absent Y descent tamponade = TAMpaX
129
What are the signs of cardiac tamponade
``` dyspnoea tachycardia hypotension muffled heart sounds raised JVP pulsus paradoxus ```
130
What is pulsus paradoxus
abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration
131
What is Beck's triad?
cardiac tamponade: falling BP rising JVP muffled heart sounds
132
What investigations should be done in cardiac tamponade
Bedside: ECG Imaging: CXR, echo
133
What is the management of cardiac tamponade
urgent drainage!
134
Define AF
irregular atrial electrical activity causing disorganised atrial depolarisations and ineffective contractions due to the AVN receiving more impulses than it can conduct, the ventricular rate is irregular
135
Define paroxysmal AF
lasting less than 7d, self terminating
136
Define persistent AF
lasting >7days, terminates with cardioversion
137
Define permanent AF
fails to terminate
138
What investigations should be carried out in suspected AF?
ECG FBC, U+E, troponin, TFT, echo
139
What are the main aims of treatment in AF
rate/rhythm control | stroke prevention
140
Describe situations where rate or rhythm control are more suitable in the treatment of AF
rate - first line. rhythm - if easily reversible cause, HF, new onset AF
141
When can digoxin be used in the treatment of AF
as rate control in patients with HF or who are mianly sedentary due to it being less effective at controlling the heart rate during exercise
142
State Virchow's triad
hypercoaguability stasis vessel wall injury
143
State what Well's score is used for
to determine the likelihood of a DVT
144
State the factors involved in calculating a well's score
``` Active cancer (treatment ongoing, within 6 months, or palliative) 1 Previously documented DVT 1 ``` Paralysis, paresis or recent plaster immobilisation of the lower extremities 1 Recently bedridden for 3 days or more or major surgery within 12 weeks requiring general or regional anaesthesia 1 Entire leg swollen 1 Calf swelling at least 3 cm larger than asymptomatic side 1 Pitting oedema confined to the symptomatic leg 1 Localised tenderness along the distribution of the deep venous system 1 Collateral superficial veins (non-varicose) 1 An alternative diagnosis is at least as likely as DVT -2
145
How does management of DVT chnage depending on the outcome of the Well;s score
<2 = perform a D-dimer test ifit is positive arrange: a proximal leg vein ultrasound scan within 4 hours (if a proximal leg vein ultrasound scan cannot be carried out within 4 hours low-molecular weight heparin should be administered whilst waiting) >=2 = a proximal leg vein ultrasound scan should be carried out within 4 hours if the result is negative, a D-dimer test (if a proximal leg vein ultrasound scan cannot be carried out within 4 hours a D-dimer test should be performed and low-molecular weight heparin administered whilst waiting)
146
How is a DVT treated?
enoxaparin 1.5mg/kg/24h or fondaparinux warfarin for 3 months if provoked, 6m if unprovoked, lifelong if recurrent stop LMWH when INR is 2-3 for 24hrs
147
How should patients with an unprovoked DVT be investigated
a physical examination (guided by the patient's full history) and a chest X-ray and blood tests (full blood count, serum calcium and liver function tests) and urinalysis. CT CAP if >40y thrombophilia screening if family history
148
What are the signs of heart failure on CXR
``` Alveolar oedema Kerley B lines Cardiomegaly Dilated prominent upper lobe vessels pleural Effusion ```
149
What are the symptoms of aortic stenosis?
syncope angina dyspnoea dizziness
150
What are the causes of aortic stenosis
degenerative calcification bicuspid valve rheumatic fever
151
What are the signs of aortic stenosis
``` slow rising pulse wide pulse pressure heaving apex beat ejection click soft S2 ejection systolic murmur radiating to carotids ```
152
How is aortic stenosis investigated?
ECG FBC, U+E, cholesterol, glucose CXR, echo, doppler echo
153
What are the signs of aortic stenosis on ECG
p mitrale LAD LBBB
154
What are the signs of aortic stenosis on CXR
LVH | calcified aortic valve
155
Who is aortic valve replacement offered to in aortic stenosis
those who are symptomatic | asymptomatic, but valvular pressure gradient >40mmHg + LV dysfunction
156
Who is ballon valvuloplasty offered to in aortic stenosis
those who need a replacement but are unfit for valve replacement
157
What is an important differential for aortic stenosis
hypertrophic cardiomyopathy
158
What is the appropriate management for asymptomatic aortic stenosis
monitoring every 6 months | stress test and echo
159
in patients unfit for any surgical treatment, how should aortic stenosis be treated
tx of HTN or HF
160
What are the causes of aortic regurgitation
valve insufficiency - IE, rheumatic fever, SLE aortic root dilation - aortic dissection, HTN, ankylosing spondylitis, marfan's, ehlers-danlos
161
What are the symptoms of AR
dyspnoea PND orthopnoea
162
What are the signs of aortic regurgitations
``` collapsing pulse wide pulse pressure hyperdynamic apex beat early diastolic murmur S3 Quinke's de Musset's corrigan's pistol shot femorals ```
163
What is Quinke's sign
visible pulsation in nail beds due to AR
164
What is de Musset's sign
head bobbing in time with pulse in AR
165
What is corrigan's sign
visible carotid pulsations in AR
166
What investigations should be carried out in AR
ECG FBC blood cultures CXR, echo
167
What is seen on CXR in AR
cardiomegaly aortic dissection pulmonary oedema
168
What is seen on ECG in AR
LAD | increased R wave amplitude in aVL, I, V4-6
169
Where is the AR mumur heard best
leaning forwards in expiration at lower left sternal edge
170
What is the treatment for AR
conservative - ACEi - to decrease symptoms.review every 6m with echo surgical - replacement or balloon valvuloplasty
171
What are the indications for surgery in aortic regurgitation
incrreasing symotoms enlarging heart ECG deterioration IE refractory to medical therapy
172
what are the causes of mitral stenosis
rheumatic fever
173
what causes rheumatic fever
2-6 weeks post Streptococcus pyogenes infection | molecular mimicary means there is immune targeting of the heart tissue
174
what are the symptoms of mitral stenosis
exertional dyspnoea PND orthopnoea palpitations
175
Why does mitral stenosis cause RHF
increased pressure in the left atrium leads to venous congestions and pulmonary hypertension right heart failure
176
Why does mitral stenosis cause AF
stretch of myocytes irritation AF!
177
What are the signs of mitral stenosis
``` low volume pulse AF mitral facies tapping non-displaced apex beat opening snap mid-late diastolic murmur ``` Right ventricular heave raised JVP bibasal crackles peripheral oedema
178
Where is the murmur in mitral stenosis best heard
in mitral area lying on left during expiration with bell
179
What investigations should be carried out in mitral stenosis
ECG CXR echo
180
What is seen on CXR in mitral stenosis
left atrial enlargement double right heart border elevation of left bronchus
181
What is the treatment for mitral stenosis
conservative: diuretics, rate control and anticoagulation in AF, yearly follow up with echo surgical: Percutaneous mitral commissurotomy (PMC) or mechanical valve replacement
182
When is surgery indicated for mitral stenosis
severe | pulmonary hypertension
183
What are the causes of mitral regurgitation
primary = damage to valve IE, rheumatic fever, papillary muscles damaged in MI secondary = due to left ventricular dilation, valve incompetency results. idiopathic cardiomyopathy or coronary heart disease, left heart failure
184
What are the symptoms of mitral regurgitation
dyspnoea | fatigue
185
What are the signs of mitral regurgitation
``` AF displaced hyperdynamic apex beat soft S1 split S2 pansystolic murmur ```
186
What investigations should be carried out in mitral regurgitation
ECG CXR echo
187
What are the signs of mitral regurgitation on CXR
left atrial and ventricular enlargement | pulmonary oedema
188
What is the treatment for mitral regurgitation?
conservative: rate control and anticoagulation for AF, diuretics and ACEi for pulmonary oedema surgical: valve replacement or repair
189
When is surgery indicated in mitral regurgitation
signs of left ventricular dysfunction, symptoms bad
190
where is mitral regurgitation murmur radiate to?
the axilla
191
What are some risk factors for ischaemic heart disease
Increasing age Male gender Family history ``` Smoking Diabetes mellitus Hypertension Hypercholesterolaemia Obesity ```
192
State the pathophysiology of IHD
initial endothelial dysfunction fatty infiltration of the subendothelial space by low-density lipoprotein (LDL) particles monocytes migrate from the blood and differentiate into macrophages. macrophages then phagocytose oxidized LDL, slowly turning into large 'foam cells'. smooth muscle proliferation and migration from the tunica media into the intima formation of a fibrous capsule covering the fatty plaque.
193
Describe the pathophysiology of angina
the plaque forms a physical blockage in the lumen of the coronary artery. This may cause reduced blood flow and hence oxygen flow to the myocardium, particularly at times of increased demand
194
What are the potential systemic consequences of infective endocarditis
Cerebrovascular accident (CVA) from embolism Finger/toe gangrene caused by embolism ± vasculitis. • Renal or splenic abscess or infarction. • Mesenteric embolism (ischaemic bowel and an acute abdomen). • Joint infection. • Bone infection • Acute renal failure: this may occur from immune complex disease, haemodynamic upset (acute heart failure), damage during cardiac surgery and nephrotoxic antibiotics. Close monitoring of renal function throughout the illness is mandatory
195
When would surgery be indicated in infective endocarditis
Severe valvular destruction causing heart failure. • Abscess formation. • Failure to eradicate infection despite prolonged antibiotic therapy. • Prosthetic valve endocarditis.
196
Describe the pathophysiology of infective endocarditis
damaged valve endothelium thrombosis (fibrin and platelets aggregate) bacterial adhesion to form biofilm = vegetation
197
Where could the bacterial source be in IE
open wound mouth - poor dentition gut - more likely if colorectal cancer or UC IVDU
198
Describe the characteristic signs of WPW on ECG
short PR interval slurring QRS delta wave
199
Why is there shortening of the PR interval and a delta wave in WPW
atrioventricular reentrant pathway means that excitation passes from the atria to the ventricles more quickly than through the AVN this means the PR interval is shortened the excitation travels slowly through the myocardium, which is why the slurred upstroke (delta wave) occurs
200
What is used to treat an SVT in the long term?
B blocker or digoxin as prophylaxis | radiofrequency ablation to cure
201
What are the differences between a monomorphic VT and a polymorphic VT
mono caused by structural problem does not often convert to VF uniform QRS complexes poly caused by metabolic or electrophysiological lengthening of QT interval quickly converts to VF less regular and chaotic QRS complexes
202
What is the treatment for polymorphic VT
stop drugs that prolong QT interval correct metabolic abnormalities IV magnesium sulfate 2mg over 10mins
203
What class as adverse features in tavhycardia
shock syncope myocardial ischaemia heart failure
204
What are the possoble signs of ACS on CXR
pulmonary oedema | cardiomegaly
205
What are the signs of heart failure on CXR
``` alveolar oedema Kerley B lines Cardiomegaly upper lobe diversion pleural effusion ```
206
What is the role of palliative care in severe heart failure?
40% die within in a year of diagnosis need to educate, advande care plan prescibe meds for pain and symptoms relief - opiates and O2 help
207
How can you distinguish between tricuspid and mitral regurgitation
mitral - pansystolic radiating to axilla tricuspid - pansystolic heard best in inspiration at the lower sternal edge
208
What is mitral valve prolapse?
mitral valave leaftlets bulge into left strium during ventricular systole
209
What can cause mitral valve prolapse
ASD patent ductus srteriosis cardiomyopathy Marfan's
210
What are the signs of mitral valve prolapse
mid systolic click | late systolic murmur
211
To which patients with mitral valve prolapse should prophylactic antibiotics be given to?
A systolic click and murmur on examination. Myxomatous degeneration and mitral regurgitation on echocardiography. 'High-risk' features, such as LV dilatation, left atrial enlargement, leaflet thickening, redundant chordae, Age over 50, hypertension or obesity. Moderate-to-severe mitral regurgitation. Mitral regurgitation during exercise but not at rest. Echocardiographic findings of mitral leaflet thickness >5 mm, posterior leaflet prolapse or increased LV dimensions. Atrial fibrillation. Reduced LV systolic function. Left atrial enlargement.
212
What are the key questions to ask a patient with HTN
``` changes in vision kidney problems - haematuria? sweating/palpitations? - phaeochromocytoma weight gain? - Cushing's diabetic? CV disease smoking, alcohol medications ```
213
What signs are present in HTN
LVH retinopathy palpable kidneys - renal disease signs of Cushing's or hyperthyroid
214
What are the causes of HTN
primary essential ``` secondary: Cushing's renal Conn's phaeochromocytoma coarctation of the aorta drugs: steroids, COCP, NSAIDs ```
215
What is a normal BP
<140/90
216
Define the korotkov sounds
sounds heard when auscultating manual blood pressure reading between systolic and diastolic pressure
217
What are the 5 kortokov sounds
``` 1 = tapping 2 = soft swishing 3 = crisp 4 = blowing 5 = silence ```
218
What are eh features of ohypertensive retinopathy
arteriolar narroqing etinal haemorrhages papilloedema cotton wool spots
219
What are the key investigations in HTN
24 hour ambulatory BP, urine dipstick, ECG FBC, U+E, glucose, lipid profile, urine catecholamines, urine free cortisol USS kidneys
220
What is the difference between arteriosclerosis and atherosclerosis
Arteriosclerosis is the stiffening or hardening of the artery walls. Atherosclerosis is the narrowing of the artery because of plaque build-up. It is a type of arteriosclerosis
221
When should antihypertensive medication be considered?
if Stage 2 or ``` if < 80 years of age AND target organ damage, established cardiovascular disease, renal disease, diabetes 10-year cardiovascular risk equivalent to 20% or greater ```
222
Define Stage 1 HTN
Clinic BP >= 140/90 mmHg | ABPM daytime average or HBPM average BP >= 135/85 mmHg
223
Define stage 2 HTN
Clinic BP >= 160/100 mmHg | ABPM daytime average or HBPM average BP >= 150/95 mmHg
224
If the clinic reading of BP is >140/90, what is the next step
ABPM or HBPM
225
What are the complications of untreated HTN
``` stroke AF MI PVD CKD HF retinopathy AAA vascular dementia ```
226
What are the stages in management of HTN
Step 1 treatment < 55-years-old: ACE inhibitor >= 55-years-old or of Afro-Caribbean origin: calcium channel blocker Step 2 treatment ACE inhibitor + calcium channel blocker (A + C) Step 3 treatment add a thiazide diuretic (D) chlorthalidone or indapamide Step 4 treatment consider further diuretic treatment if potassium < 4.5 mmol/l add spironolactone 25mg od if potassium > 4.5 mmol/l add higher-dose thiazide-like diuretic treatment
227
What is resistant HTN
clinic BP >= 140/90 mmHg after step 3 treatment with optimal or best tolerated doses
228
What is teh blood pressure target in HTN
<140/90 if <80y | <150/90 if >80y
229
What are ACEi used for?
HTN kidney protection in diabetes post MI HF
230
What is the mechanism of action of ACEi
Inhibit the conversion angiotensin I to angiotensin II therefore causing vasodilation and preventing aldosterone release reduces BP
231
What are teh common adverse effects of ACEi
dry cough angioedema hyperkalaemia
232
Why might ACEi be contraindicated
hypersensitivity to ACEi
233
What is bisoprolol used for
HF | angina
234
What are some contraindications for beta blockers
``` Asthma; - risk of bronchspasm cardiogenic shock; hypotension; marked bradycardia; second or third-degree AV block; severe peripheral arterial disease; uncontrolled heart failure ```
235
What are some things to be careful of in treatment with loop diuretics?
Elderly - particularly susceptible to the side-effects. Potassium loss - In hepatic failure, hypokalaemia caused by diuretics can precipitate encephalopathy, particularly in alcoholic cirrhosis. Urinary retention - If there is an enlarged prostate, urinary retention can occur
236
What info should be given to patients about loop diuretics
may cause dizziness, electrolyte abnormalities, tummy upset need to have blood tests to monitor electrolyte levels best taken in morning - so that not weeing during night! you may find you need to go to the toilet a couple of times within a few hours of taking the tablet.
237
What kind of drug is simvastatin
inhibitor of HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis lowers cholesterol
238
When should statins be taken? Why?
before bed | most cholesterol is made at night
239
What are the side effects of statins
myalgia rarely - myositis, rhabdomyolysis liver impairment
240
What monitoring should take place in statin therapy
checking LFTs at baseline, 3 months and 12 months. baseline CK and lipid profile
241
What can cause bradycardia
physiological (e.g. during sleep, in athletes) cardiac causes (e.g. atrioventricular block or sinus node disease) non-cardiac causes (e.g. vasovagal, hypothermia, hypothyroidism, hyperkalaemia) drugs (e.g. beta-blockade, diltiazem, digoxin, amiodarone) in therapeutic use or overdose.
242
What defines bradycardia
HR <60BPM
243
Describe the management of bradycardias
A-E assessment if signs of adverse features, give atropine 500mcg IV if unsuccessful, arrange senior help and transvenous pacing if no adverse features, assess for risk of asystole if risk of asystole, ger senior help and arrange transvenous pacing
244
What are the adverse features of bradycardias
shock - hypotension (systolic blood pressure < 90 mmHg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness heart failure syncope myocardial ischaemia
245
What is the mechanism of action of atropine
o antagonises acetylcholine at postganglionic nerve endings | o increases sinus rate and sinoatrial and AV conduction.
246
What makes a patient at risk of asystole in bradycardia
previous asystole Mobitz II heart block complete heart block ventricular pause >3s
247
What are some interim measures that you can do whilst waiting for transvenous pacing in bradycardia
further atropine up to 3mg transcutaenous pacing adrenaline
248
What is a PDA
patent ductus arteriosus | between descending aorta and pulmonary trunk
249
What are the signs of PDA
continuous machinery murmur left supraclavicular palpable thrill wide pulse pressure collpasing pulse
250
What are the signs of ASD
ejection systolic murmur
251
What are the signs of coarctation of the aorta
radiofemoral delay HTN midsystolic murmur
252
What are the INR targets for pts taking warfarin
venous thromboembolism: target INR = 2.5, if recurrent 3.5 atrial fibrillation, target INR = 2.5 mechanical heart valves, target INR depends on the valve type and location. Mitral valves generally require a higher INR than aortic valves.
253
Describe the pathophysiology of aortic dissection
tear in tunica intima | high pressure in artery forces blood between tunica intima and tunica media to form a fulse lumen
254
What is the difference between Type A and B aortic dissections
``` A = ascending B = descending dital to subclavian ```
255
What are some causes of aortic dissection
HTN CT disease - Ehler's-danlos or Marfan's aneurysms
256
What are the symptoms and signs of aortic dissection
chest pain - tearing, radiating to back weak pulses hypotension AR
257
What is the long term management of acute heart failure
Daily weights, aim reduction of 0.5kg/day Repeat CXR. • Change to oral furosemide or bumetanide. • If on large doses of loop diuretic, consider the addition of a thiazide (eg bendroflumethiazide or metolazone 2.5–5mg daily po). • ace-i if lvef <40%. If ace-i contraindicated, consider hydralazine and nitrate (may also be more effective in African-Caribbeans). • Also consider β‎-blocker and spironolactone (if lvef <35%). • Is the patient suitable for biventricular pacing or cardiac transplantation? • Optimize management of AF if present; consider anticoagulation.

Finals (32 decks)

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