Cardiology Flashcards
1
Q
What is atherosclerosis?
A
A degenerative condition of arteries characterised by a fibrous and lipid rich plaque with variable inflammation, calcification and a tendency to thrombosis
2
Q
What are the risk factors for atherosclerosis?
A
Age, tobacco smoking, high serum cholesterol, obesity, diabetes, hypertension, family history
3
Q
What does an atherosclerotic plaque consisted of?
A
Lipid, necrotic core, connective tissue, fibrous cap
4
Q
Briefly describe the mechanism of atherosclerosis
A
- Fatty streaks
- Intermediate lesions - layers of smooth muscle, T lymph, platelets to vessel wall
- Fibrous plaques of advanced lesions - impedes blood flow, prone to rupture
- Plaque rupture - thrombosis formation and vessel occlusion
5
Q
How does atherosclerosis present?
A
Usually asymptomatic until artery is so narrowed the tissues no longer receive adequate blood supply
Coronary arteries - angina
Brain arteries - TIA
Peripheral arteries - peripheral artery disease
Renal arteries - high BP/ Kidney failure
6
Q
Give 2 examples of ‘good’ inflammation
A
Wound healing
Pathogens
7
Q
Give 2 examples of ‘bad’ inflammation
A
Atherosclerosis
Rheumatoid arthritis
8
Q
How is atherosclerosis managed?
A
Percutaneous coronary intervention
Aspirin
Statins
Clopidogrel/ ticagrelor
9
Q
What is ischaemic heart disease?
A
Ischaemic heart disease (coronary heart disease) is the umbrella term for angina, acute coronary syndromes and heart failure
10
Q
How is IHD managed?
A
Lifestyle - quit smoking, exercise Anti-platelets - reduce risk of MI Statins - lower cholesterol Beta blockers - prevent angina Coronary angioplasty
11
Q
How is hypertension managed (lifestyle)?
A
Treat all patients with BP >160/100mmHg
Life style changes - stop smoking, low fat diet, reduce alcohol and salt intake
12
Q
How is hypertension managed pharmacologically?
A
1st line - ACEi (e.g. ramipril)
2nd line - ACEi + CCB (e.g. amlodipine)
3rd line - ACEi + CCB + diuretics (e.g. bendroflumethiazide)
4th line - ACEi + CCB + diuretics + beta blocker (e.g. bisoprolol)
13
Q
What is angina pectoris?
A
Recurrent transient episodes of chest pain due to myocardial ischaemia
14
Q
What are the 4 types of angina?
A
Stable: induced by effort, relieved by rest
Unstable: occurs on minimal exertion or rest
Decubitus: Precipitated by lying flat
Prinzmetal: Caused by coronary artery spasm
15
Q
Describe the pathology of angina
A
Stenosis caused by atheroma increases the resistance within the vessel. During exercise, the resistance falls and increases flow - with atherosclerosis, this is impaired and resistance can’t decrease enough to meet the metabolic demand.
16
Q
What are the non-modifiable risk factors of angina?
A
Gender, family history, personal history, age
17
Q
What are the modifiable risk factors of angina?
A
Smoking, diabetes, hypertension, hypercholesterolaemia, sedentary lifestyle, stress
18
Q
What are the 3 main clinical features of angina?
A
- Constricting discomfort on the chest, jaw, neck, shoulders or arms
- Symptoms brought on by exertion
- Symptoms relieved within 5 min by rest or GTN spray
19
Q
Name a differential diagnosis of angina
A
Pericarditis
20
Q
How is angina diagnosed?
A
ECG - signs of IHD e.g. BBB
Echo - signs of previous infarcts
CXR
Physiological - stress echo
21
Q
How is angina managed?
A
Symptom relief - GTN spray
Betablockers - reduce work of heart and O2 demand
Nitrates - dilate systemic veins to reduce preload on the heart
22
Q
How is angina managed pharmacologically?
A
Symptom relief - GTN spray 1st line
Nitrates - dilate systemic veins to reduce preload on the heart
Betablockers - reduce work of heart and O2 demand
Calcium channel antagonists - dilate systemic arteries to reduce afterload
Statins e.g. simvastatin reduces choelsterol
75mg aspirin daily
23
Q
How is angina managed surgically?
A
Revascularisation - PCI/ CABG
PCI - a balloon is inflated inside stenosed vessel, opening the lumen.
CABG - open heart surgery but less likely to need repeat revascularisation
24
Q
What is a myocardial infarction?
A
Myocardial cell death, releasing troponin. Full-thickness necrosis of an area of myocardium
25
What is ischaemia?
A lack of blood supply (sometimes cell death)
26
What is the most common cause of acute coronary syndromes?
Rupture of an atherosclerotic plaque and consequent arterial thrombosis.
Less common: arteritis, coronary artery thrombosis, LV hypertrophy, hypoxia
27
What are the modifiable risk factors for acute coronary syndromes?
Smoking, diabetes, hypertension, hyperlipidaemia, sedentary lifestyle, cocaine use
28
How are acute coronary syndromes managed?
Symptom control - manage chest pain with PRN GTN and opiates
Modify risk factors
Cardioprotective medication e.g. antiplatelets (clopidogrel)
Revascularisation
29
How does unstable angina present?
Sudden onset of prolonged ischaemic cardiac chest pain at rest or on minimal exertion
30
What is the difference between unstable angina and NSTEMI?
NSTEMI involves enough occlusion to cause myocardial damage and elevation in serum troponin and creatinine kinase. Unstable angina does not cause myocardial damage
31
Describe the pathology of a myocardial infarction
Results from rupture of an unstable coronary artery atherosclerotic plaque, stimulating the formation of a fibrin-rich thrombus over the plaque. Complete occlusion of the coronary artery leads to full-thickness necrosis
32
How do MIs present?
Unremitting, severe cardiac chest pain that occurs at rest.
| Associated with sweating, breathlessness, nausea, vomiting
33
How are MIs diagnosed?
MIs have troponin rises, unstable angina does not
| ECG to differentiate between NSTEMI and STEMI - ST elevation MI with LBBB are associated with larger infarct
34
How are MIs managed?
Initial: MOAN - morphine, oxygen (sats <94%), aspirin 300mg, nitrates
Beta blocker IV, thrombolysis (IV alteplase), PCI, CABG
Secondary prevention: 75mg aspirin daily, clopidogrel, statins, beta blockers, risk factor modification
35
What are the complications of MIs?
Cardiac arrest, cardiogenic shock, LVF, RVF, pericarditis, mitral regurgitation, Dressler's syndrome
36
What is the definition of cardiac failure?
The inability of the heart to keep up with the demands on it, and the failure of the heart to pump blood with normal efficiency - cardiac output is inadequate for the body's requirements
37
What is systolic failure and what causes it?
Inability of the ventricle to contract normally, resulting in low cardiac output
Causes: IHD, MI, cardiomyopathy
38
What is diastolic failure and what causes it?
Inability of the ventricles to relax and fill normally, causing increased filling pressures.
Causes: ventricular hypertrophy, constrictive pericarditis, restrictive cardiomyopathy, obesity
39
What is left ventricular failure and what causes it?
Pulmonary congestion and then overload of right side - heart can't pump efficiently so blood backs up in the veins that take blood through the lungs
IHD, hypertension, cardiomyopathy
40
What are the symptoms of LVF?
Dyspnoea, poor exercise tolerance, fatigue, orthopnoea, paroxysmal nocturnal dyspnoea, nocturnal cough, wheeze, Signs: cold peripheries, weight loss, pulmonary oedema, pleural effusion
41
What is right ventricular failure?
Venous hypertension and congestion - high pressure in the veins of the legs, caused by venous insufficiency where blood leads downwards due to the effect of gravity through leaky valves
42
What causes RVF?
LVF, pulmonary stenosis, lung disease, hypertension
43
What are the symptoms of RVF?
Peripheral oedema, ascites, nausea, anorexia, SOB
| Signs: weight gain (fluid), pitting oedema, hepatomegaly
44
What are the risk factors for heart failure?
Past MI, male, 65+, obesity
45
What is the pathology behind heart failure?
Once the heart begins to fail, compensatory changes occur. As the heart failure progresses, these compensatory changes become overwhelmed and become pathological
46
How is heart failure diagnosed?
CXR - cardiomegaly, effusion, dilated upper lobe vessels of lung
ECG may indicate cause
Cardiac enzymes: creatinine kinase, troponin
47
What are the signs of heart failure?
Cardinal symptoms: SOB, fatigue, ankle swelling
| Cyanosis, decreased BP, narrow pulse pressure, displaced apex, pulmonary hypertension
48
How is acute cardiac failure managed?
Medical emergency - high flow O2 (100%), treat arrhythmias, IV opiates - diamorphine and GTN spray
IV furosemide - reduce fluid overload
49
How is chronic cardiac failure managed?
Stop smoking/ drinking/ eat less salt
Treat cause/ exacerbating factors
ABCD - ACEi, beta blockers, CCBs, diuretics
(Loop diuretics (furosemide) and ACEi to relieve symptoms)
Heart transplant
50
What is mitral regurgitation?
Backflow through the mitral valve during systole
Acute - back up into the lungs
Chronic - dilation as it has had time to adjust
51
What are the causes of mitral regurgitation?
Rheumatic fever, infective endocarditis, mitral valve prolapse, cardiomyopathy
52
How does mitral regurgitation present?
Exertional dyspnoea, pulmonary oedema, fatigue, AF, pansystolic murmur at apex radiating to the axilla
53
How is mitral regurgitation diagnosed?
ECG: AF, P-mitrale
CXR: Large LA and LV
Echo: assess LV size, function
54
How is mitral regurgitation managed?
Control heart rate - beta blockers
Anticoagulate
Vasodilators, diuretics
Surgery - repair/ replace valve
55
What is mitral valve prolapse?
The two valve flaps of the mitral valve do not close smoothly or evenly, but instead bulge upwards into the left atrium
56
How do mitral valve prolapses present?
Usually asymptomatic, may develop atypical chest pain or palpitations.
Mid-systolic click and/or late systolic murmur
57
What are the complications of a mitral valve prolapse?
Mitral regurgitation, cerebral emboli, arrhythmias, sudden death
58
How is a Mitral valve prolapse diagnosed?
Echocardiogram - diagnostic
59
How is a mitral valve prolapse managed?
Beta blockers may help palpitations and chest pain
| Surgery if severe
60
What is mitral stenosis?
Obstruction of LF inflow that prevents proper filling during diastole
61
What causes mitral stenosis?
Rheumatic fever, congenital, infective endocarditis, malignant carcinoid
62
How does a mitral stenosis present?
Pulmonary hypertension - dyspnoea, haemoptysis
Hoarseness - pressure from large LA on local structures
Dysphagia, bronchial obstructions, fatigue, palpitations, chest pain
63
What are the signs of a Mitral stenosis?
Signs of right-sided heart failure, mitral facies - pink patches on cheeks, low-volume pulse
64
How is a mitral stenosis diagnosed?
ECG: AF and LA enlargement
CXR: LA enlargement
Echo: assess mitral valve mobility and area
65
How is a mitral stenosis managed?
Rate control of AF - beta blockers
Anticoagulate with warfarin
Mitral balloon valvotomy, mitral valve replacement
66
What is aortic stenosis?
Narrowing of the aortic valve opening that restricts blood flow from the left ventricle to the aorta
67
Describe the pathophysiology of aortic stenosis
A pressure gradient develops between the left ventricle and the aorta (increased afterload).
LV function initially maintained by compensatory pressure hypertrophy.
When compensatory mechanisms exhausted, LF function declines
68
What causes aortic stenosis?
Senile calcification, congenital, rheumatic heart disease
69
How does an aortic stenosis present?
Classic triad; angina, syncope, breathlessness
| Ejection systolic murmur
70
How is an aortic stenosis diagnosed?
Echo: LV size and function
| Cardiac catheter can access valve gradient, LV function, CAD
71
How is an aortic stenosis managed?
Valve replacement - definitive treatment
| Percutaneous valvuloplasty/ transcatheter aortic valve implantation
72
What is aortic regurgitation?
Leakage of blood into LV during diastole due to ineffective coaptation of the aortic cusps
73
What are the causes of aortic regurgitation?
Acute: infective endocarditis, chest trauma
Chronic: congenital, connective tissue disorders, rheumatic fever
74
How does aortic regurgitation present?
Breathlessness, orthopnoea, palpitations, diastolic blowing murmur
75
How is aortic regurgitation diagnosed?
CXR: enlarged cardiac silhouette
Echo
Cardiac catheterisation to assess severity of lesion
76
How is aortic regurgitation managed?
Medical - vasodilators
Serial echocardiograms to monitor progression
Surgical treatment: definitive
77
What is tricuspid regurgitation?
A disorder in which the tricuspid valve does not close tight enough. This problem causes blood to flow backward into the right atrium when the right ventricle contracts
78
What causes tricuspid regurgitation?
Rheumatic fever, infective endocarditis, carcinoid syndrome
79
How does tricuspid regurgitation present?
Fatigue, hepatic pain on exertion, ascites, oedema, pan systolic murmur, jaundice
80
How is tricuspid regurgitation managed?
Diuretics for systemic congestion
Treat underlying cause
Valve repair or replacement
81
What is tricuspid stenosis?
Narrowing of the tricuspid valve opening. It restricts blood flow between the upper and lower part of the right side of the heart
82
What causes tricuspid stenosis?
Rheumatic fever, congenital, infective endocarditis
83
How does tricuspid stenosis present?
Fatigue, ascites, oedema, AF, opening snap, early diastolic murmur heard at the left sternal edge in inspiration
84
How is tricuspid stenosis diagnosed and managed?
Echocardiogram
| Diuretics, surgical repair
85
What is pulmonary stenosis?
A condition characterised by obstruction to blood flow from the right ventricle to the pulmonary artery.
86
How does pulmonary stenosis present?
Dyspnoea, fatigue, oedema, ascites, dysmorphic facies, ejection click
87
How is pulmonary stenosis diagnosed and managed?
ECG: P-pulmonale, RBBB
CXR and cardiac catheterisation
Treat - pulmonary valvuloplasty
88
Describe the pathology of rheumatic fever?
An antibody to the carbohydrate cell wall of the streptococcus cross-reacts with valve tissue and may cause permanent damage to the heart valves
89
What is infective endocarditis?
Infection of the heart valves or other endocardial lined structures within the heart (infection that showers infectious material around the bloodstream)
90
What pathogens can cause infective endocarditis?
S. aureus gains access to the blood from the skin
S. viridian's gains access to the blood from the oropharynx (tooth brushing)
Enterococci gain access to bloodstream following instrumentation of bowel
91
How does infective endocarditis present?
Signs of systemic infection - fever, sweats
Petechiae (skin lesions)
Splinter haemorrhages (bruised nails)
Osler's nodes (small, tender, purple nodules on the pulp of the digits)
92
How is infective endocarditis diagnosed?
Modified Duke Criteria - 2 major/1 major +3 minor/ 5 minor
Major: bugs grown from cultures, evidence on echo
Minor: fever, vascular phenomena, immune phenomena, equivocal blood cultures
93
How is infective endocarditis managed?
Antimicrobials via IV
Treat complications: arrhythmia, HF, heart block, embolisation
Surgery if severe valve damage/ large vegetations
94
How are structural heart defects diagnosed?
Echocardiography
| CT and MRI are used to provide precise anatomical/functional info
95
What is a ventricular septal defect and how is it caused?
An abnormal connection between the 2 ventricles (a hole)
| Causes: congenital, acquired (MI)
96
How does a ventricular septal defect present?
Severe heart failure in infancy, breathless, poor feeding, failure to thrive
Small, breathless, skinny baby
Tachycardia, big heart on X-ray
97
What is Eisenmenger's syndrome?
Complication of VSD: pulmonary hypertension from initial left->right shunt. De-oxygenated blood enters systemic circulation, patient becomes blue
98
How are ventricular septal defects diagnosed?
CXR: normal heart, large pulmonary arteries
| Cardiac catheter: step up in oxygen sats in RV
99
How are ventricular septal defects managed?
May close spontaneously. Reasons for surgery include failed medical therapy, symptomatic, shunt >3:1
100
What is an atrial septal defect?
An abnormal connection between the two atria. There is a slightly higher pressure in LA than RA, shunt is left to right, increased flow into right heart and lungs
101
How does an atrial septal defect present?
SOB on exertion, increased chest infections, chest pain, palpitations, big pulmonary arteries on CXR, big heart heart
102
How is an atrial septal defect diagnosed?
ECG: RBBB with LAD or RAD
CXR: small aortic knuckle, pulmonary plethora, atrial enlargement
103
How is an atrial septal defect managed?
May close spontaneously
| Close if symptomatic - transcatheter closure
104
What is an atria-ventricular septal defect?
A hole in the very centre of the heart - involves the ventricular septum, atrial septum, mitral and tricuspid valves
105
How does a complete AVSD present?
Poor feeding, poor weight gain, torrential pulmonary blood flow, breathless as neonate, needs repair or PA band in infancy
106
How does a partial AVSD present?
Presents like a small VSD/ASD, can present in late adulthood, may be left alone if there is no right heart dilatation
107
What is patent ductus arteriosus?
The ductus arteriosus fails to close after birth, leaving a vessel connecting the aorta and pulmonary artery
108
How does patent ductus arteriosus present?
Continuous murmur, big heart, breathlessness, Eisenmenger's syndrome
109
How is a patent ductus arteriosus treated?
Closure done surgically, under local anaesthetic
110
What is coarctation of the aorta?
Congenital narrowing of the descending aorta
111
How does coarctation of the aorta present?
Radiofemoral delay, weak femoral pulse, high blood pressure, cold feet, scapular bruit
112
How is a coarctation of the aorta diagnosed?
CXR: rib notching as blood diverts down intercostal arteries to reach the lower body, causing these vessels to dilate and erode local rib bone
113
How is a coarctation of the aorta managed?
Surgery/ balloon dilatation
114
What is tetralogy of fallot?
A congenital heart condition involving 4 abnormalities occurring together, including a defective septum between the ventricles and narrowing of the pulmonary artery, and accompanied by cyanosis
115
What are the 4 defects present in tetralogy of fallot?
Ventricular septal defect
Pulmonary stenosis
Right ventricular hypertrophy
Overriding aorta - accepting right heart blood
116
How does tetralogy of fallot present?
Cyanotic (decreasing blood flow to the lungs)
| Hypoxic spell - child becomes restless and agitated
117
How is tetralogy of fallot managed?
Surgery done before age of 1 - closure of VSD and correction of pulmonary stenosis
118
What are cardiomyopathies?
Primary heart muscle diseases - often genetic. The heart doesn't pump as well as it should
119
What is acute myocarditis and what are the causes?
Inflammation of the myocardium
| Causes: viral, bacterial protozoan, drugs e.g. penicillin, toxins e.g. cocaine, immunological e.g. transplant rejection
120
How does acute myocarditis present?
ACS-like symptoms, heart failure symptoms, palpitations, tachycardia
121
How is acute myocarditis diagnosed?
ECG: ST changes and T-wave inversion, atrial arrhythmias
Echo: diastolic dysfunction
122
How is acute myocarditis managed?
Supportive, treat underlying cause, treat arrhythmias and heart failure
123
What is dilated cardiomyopathy?
A dilated, flabby heart of unknown cause. Most autosomal dominant, but some recessive and X-linked.
124
How does dilated cardiomyopathy present?
Fatigue, dyspnoea, pulmonary oedema, RVF, emboli, high pulse, low BP, hepatomegaly
125
How is dilated cardiomyopathy diagnosed?
CXR: cardiomegaly, pulmonary oedema
ECG: tachycardia, non-specific T-wave changes
Echo: low ejection fraction
126
How is dilated cardiomyopathy managed?
Bed rest, diuretics, beta blockers, anticoagulation, transplantations
127
What is hypertrophic cardiomyopathy?
LV outflow tract obstruction from asymmetrical septal hypertrophy
128
How does hypertrophic cardiomyopathy present?
Sudden death, cardiac hypertrophy and dysrhythmia, angina, palpitations, dizziness
129
How is hypertrophic cardiomyopathy diagnosed?
Echo: shows asymmetrical septal hypertrophy, small LV cavity
ECG: progressive T-wave inversion, deep Q waves
130
How is hypertrophic cardiomyopathy managed?
Beta blockers for symptoms, amiodarone for arrhythmias, anticoagulant for systemic emboli
131
What is restrictive cardiomyopathy?
Restrictive filling of the ventricles
132
How does restrictive cardiomyopathy present?
Features of RVF - hepatomegaly, oedema, ascites
133
How is restrictive cardiomyopathy diagnosed and managed?
Diagnosed: Echocardiogram and MRI
Managed: Treat the cause
134
What are the causes of acute pericarditis?
Infections (viral, bacterial, fungal)
STEMI
Severe renal failure, hypothyroidism, multi system autoimmune diseases
135
How does acute pericarditis present?
Central chest pain which is worse on inspiration or lying flat, and relieved by sitting forward
Breathlessness
Fever
136
How is acute pericarditis diagnosed?
ECG shows concave ST segment elevation
CXR - cardiomegaly
CT shows localised inflammation
137
How is acute pericarditis managed?
NSAIDs or aspirin with gastric protection
138
What are the causes of constrictive pericarditis?
Rigid pericardium - myocardial rupture, aortic dissection, pericardium filling with pus, malignancy
139
How does constrictive pericarditis present?
Dyspnoea, chest pain, signs of local structures being compressed, nausea, bronchial breathing
140
How is constrictive pericarditis diagnosed?
CXR shows an enlarged, globular heart
ECG shows low-voltage QRS complexes
Echo: an echo-free zone surrounding the heart
141
How is constrictive pericarditis managed?
Treat the cause
Pericardiocentesis - diagnostic
Send pericardial fluid for culture and cytology
142
What is a cardiac arrhythmia?
A condition in which the heart beats with an irregular or abnormal rhythm
143
What are the causes of arrhythmias?
IHD, structural changes, cardiomyopathy, pericarditis, caffeine, smoking, alcohol, pneumonia
144
How do arrhythmias present?
Palpitations, dizziness, chest pain, syncope, hypotension, pulmonary oedema
Heart failure, sudden death
145
How are arrhythmias diagnosed?
ECG: signs of IHD, AF, short PR interval, long QT interval, U waves
24 hour ECG monitoring
Echo: look for structural heart disease e.g. mitral stenosis
146
How are arrhythmias managed?
Conservatively - reducing alcohol intake
Medical management - regular tablets
Interventional management - pacemakers, ablation, implantable cardioverter defibrillators
147
What is sinus tachycardia and what are the causes?
Conduction impulses are initiated at high frequency. Causes include infection, pain, exercise, anxiety, dehydration, fever, heart failure
148
What are the two types of cardiac dysrhythmias?
Bradycardia - slow heart rate, <60bpm
Tachycardia - fast heart rate, >100bpm
Supraventricular tachycardias - arises from the atrium or AV junction
Ventricular tachycardias - arise from the ventricles
149
What are narrow and broad complex tachycardia and how are they managed?
```
ECG shows rate of >100bpm
Narrow QRS complexes <120ms
Treat underlying rhythm
Broad QRS complexes >120ms.
Correct electrolyte problems - low potassium, magnesium, calcium
```
150
What are the 4 types of supra ventricular tachycardia?
Atrial fibrillation, Atrial flutter, AV nodal re-entry tachycardia, AV reciprocating tachycardia
151
What is atrial fibrillation and how is it caused?
A chaotic, irregular atrial rhythm at 300-600bpm. Heart failure, hypertension, IHD, PE, mitral valve disease, pneumonia
152
How does atrial fibrillation present?
Asymptomatic, chest pains, palpitations, dyspnoea, faintness
Signs - irregularly irregular pulse, signs of LVF
153
How is atrial fibrillation diagnosed?
ECG: irregularly irregular, absent P waves, irregular rapid QRS complexes
Echo: left atrial enlargement, mitral valve disease, poor LV function
154
How is atrial fibrillation managed?
Amiodarone if AF started <48h ago.
Bisoprolol if AF started >48h ago.
Rhythm control: elective DC conversion
Anticoagulant with warfarin
155
What is the CHADS2VASc score?
A score used to calculate stroke risk in AF
Congestive heart failure, hypertension, 65-74, diabetes mellitus, stroke, vascular disease, female = 1 point
75+ = 2 points
Anticoagulant if score of 2
156
What is atrial flutter and what causes it?
Organised atrial rhythm, rate 250-350bpm
| Obesity, hypertension, excess alcohol, COPD, heart failure, CHD
157
How does atrial flutter present?
Palpitations, breathlessness, dizziness, chest pain, fatigue, syncope
158
How is atrial flutter diagnosed?
ECG: narrow QRS complex, sawtooth flutter waves - F waves (no P waves), 2:1 QRS
159
How is atrial flutter managed?
Amiodarone (anti-arrhythmic drug), beta blockers, LMW heparin, catheter ablation
160
What is heart block?
Disrupted passage of electrical impulse through the AV node
Block in AVN/ Bundle of His - AV block
Block in lower conduction system - L/RBBB
161
What causes complete (3rd degree) heart block, how does it present and how is it managed?
CHD, infection, hypertension
Syncope, dyspnoea, chest pain, confusion
ECG: P waves and QRS complexes occur independently
IV atropine, permanent pacemaker
162
What is ventricular ectopic?
Premature ventricular contraction, usually after MI - extra/missed/heavy beats
163
How is ventricular ectopic diagnosed and managed?
ECG: bizarre QRS - under 0.12s
| Reassure patient, give beta blockers if symptomatic
164
What is prolonged QT syndrome and how is it caused?
Ventricular depolarisation grossly prolonged
| Low K+, Ca2+, acute MI, diabetes, amiodarone, amitriptyline
165
How does prolonged QT syndrome present and how is it managed?
```
Syncope, palpitations
IV isoprenaline (if required)
```
166
What is Wolf-Parkinson-White syndrome?
An extra electrical pathway in the heart, leading to periods of tachycardia (congenital accessory conduction pathway between atria and ventricles)
167
What is an aortic aneurysm?
An abnormal bulge that occurs in the wall of the major blood vessel (aorta) that carries blood from your heart to your body. An artery with a dilatation >50% of its original diameter has an aneurysm
168
What is the difference between a true and a false aneurysm?
True aneurysms are abnormal dilatations that involve all layers of the arterial wall
False aneurysms involve a collection of blood in the outer layer only which communicates with the lumen
169
Describe the pathology and causes of an aortic aneurysm
Aneurysms suggest either congenital or acquired weakness of the vessel walls.
Atheroma, trauma, infection, connective tissue disorders, inflammatory
170
What are the common sites for aneurysms?
Aorta (most common), iliac, femoral, popliteal arteries
171
How do aortic aneurysms present?
Ruptured - abdominal pain, collapse, shock
| Unruptured - often none, abdominal/back pain
172
How is an aortic aneurysm diagnosed?
X-ray, echocardiogram, CT, ultrasound
173
How are aortic aneurysms managed?
Annual check ups and monitoring with US scans
| Surgery - open or endovascular: the graft is inserted into a blood vessel in your groin then passed up into the aorta
174
What is aortic dissection?
A tear in the wall of the aorta. Blood can flow in between the layers of the blood vessel wall, leading to aortic rupture or decreased blood flow to organs
175
What are the risk factors for aortic dissection?
Ageing, atherosclerosis, blunt trauma to the chest, high BP, coarctation of the aorta
176
How does aortic dissection present?
Chest pain - sharp, stabbing, tearing or ripping, anxiety, fainting, heavy sweating, nausea and vomiting, pale skin, rapid, weak pulse
177
How is aortic dissection diagnosed?
Aortic angiography, chest X-ray, chest MRI, CT scan of chest, echo, transoesophageal cardiogram
178
How is aortic dissection managed?
Pain relievers, beta blockers (BP lowering), dissections in ascending aorta require surgery
179
What is peripheral vascular disease?
Blood supply to the leg muscles is restricted due to atherosclerosis in the arteries
180
How does peripheral vascular disease present?
Cramping pain in the calf, thigh or buttock after walking for a given distance, ulceration, gangrene, foot pain at rest
Absent femoral, popliteal or foot pulses, cold white legs. atrophic skin, punched out ulcers
181
How is peripheral vascular disease diagnosed?
ECG: cardiac ischaemia
Ankle-brachial pressure index
FBC: anaemia, polycthaemia
182
How is peripheral vascular disease managed?
Risk factor modification - quit smoking, treat hypertension and high cholesterol
Management of claudication - exercise programmes
Clopidogrel (anti-platelet therapy) 1st line
Surgical reconstruction/ amputation
183
What is shock?
Circulatory failure resulting in inadequate organ perfusion. Often defined by low BP - systolic <90mmHg with evidence of tissue hypoperfusion
184
What is cardiogenic shock?
A state of inadequate tissue perfusion primarily due to cardiac dysfunction
185
What are the causes of cardiogenic shock?
MI, arrhythmias, PE, tension pneumothorax, cardiac tamponade, aortic dissection
186
How does cardiogenic shock present?
Agitation, pallor, cool peripheries, tachycardia, slow capillary refill, oliguria
187
How is cardiogenic shock diagnosed?
ECG, CXR, Echo, monitor every hour until diagnosis made
188
How is cardiogenic shock managed?
Oxygen, diamorphine
Correct arrhythmias, optimise filling pressure
Look for and treat any reversible cause
189
What is cardiac tamponade?
Compression of the heart by an accumulation of fluid in the pericardial sac.
Pericardial fluid collects -> intrapericardial pressure rises -> heart cannot fill -> pumping stops
190
What causes cardiac tamponade?
Trauma, lung/breast cancer, pericarditis, MI, bacteria
191
What is syncope?
A temporary loss of consciousness caused by a fall in blood pressure (fainting)
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Describe the mechanism of syncope
A state of consciousness is maintained by adequate cerebral blood flow. Cerebral vascular autoregulation ensures that the cerebral blood flow is kept within a narrow range, independent of the underlying systemic blood pressure. If the blood pressure drops below this range, the lack of blood causes syncope
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What presentations are linked to each cause of syncope?
CNS - aura, headache, dysarthria, Limb weakness all indicate CNS cause
Cardiac - chest pain, palpitations and dyspnoea indicate cardiac cause
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How is syncope diagnosed?
Blood pressure in supine and standing positions, on immediate standing, and after 3 minutes of standing
Basic neurological exam, ECG
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What are the red flag syncope symptoms?
Chest pain, syncope with exercise, palpitations, back pain, haematemesis
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How is syncope managed?
Treat underlying cause
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What causes bundle branch block and how is it managed?
Acute: ischaemia and MI, myocarditis
Chronic: HTN, cardiomyopathies
Cardiac pacemaker
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How does RBBB present on an ECG?
WILLIAM - W in V1, M in V6
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How does LBBB present on an ECG?
MARROW - M in V1, W in V6
