Cardiology Flashcards
1
Q
List some differentials for chest pain
A
CARDIAC: angina, MI, pericarditis, aortic stenosis, aortic dissection, rupture of AAA, cardiac tamponade, myocarditis
RESP: pulmonary embolism, pneumothorax, pneumonia, asthma attack
MSK: MSK style chest pain, rib fracture, disc prolapse
GI: GORD, acute oesophagitis, peptic ulcer, acute pancreatitis
2
Q
Define pericarditis
A
inflammation of the pericardium
3
Q
What are the causes of pericarditis?
A
viral ** e.g. coxsackie trauma TB uraemia MI systemic diseases e.g. RA, SLE, scleroderma, rheumatic fever
4
Q
How does pericarditis present?
A
sharp retrosternal chest pain - worse on inspiration, relieved on bending forward, radiates to the back
+ dyspnoea, flu like symptoms, cough
5
Q
What are the signs of pericarditis O/E?
A
pericardial rub on auscultation (scratchy)
tachycardia, tachypnoea
6
Q
What are the ECG changes in pericarditis?
A
saddle shape ST elevation
PR depression
Tachycardia
7
Q
How is pericarditis treated?
A
NSAIDS + colchicine
treat underlying cause
(investigations: ECG, chest x ray, ECHO)
8
Q
How can constrictive pericarditis develop?
A
if inflammation continues, fibrosis and shrinking of pericardium restricts cardiac filling
can develop R sided heart failure
CXR: pericardial calcification
O/E: raised JVP on inspiration (Kussmauls sign)
auscultate: pericardial knock
9
Q
Define angina
A
chest pain caused by insufficient blood supply to the heart muscle
10
Q
How is angina caused?
A
** CORONARY ARTERY DISEASE **
also: valvular disease, hypertrophic obstructive cardiomyopathy and hypertensive heart disease
11
Q
Describe the clinical features of stable angina
A
central chest tightness/ pain/ crushing - radiates to neck/ shoulder (+ dyspnoea, sweating, nausea)
precipitated by exertion, emotional stress, cold, heavy meals
relieved by rest or GTN spray within 5-10 mins
12
Q
What are the signs O/E indicating high cholesterol?
A
xanthelasma
fatty deposits in achilles tendon
corneal arcus
13
Q
What initial investigations would you do for someone with stable angina?
A
FBC, cholesterol, TFT, U&E, LFTs ECG ECHO exercise tolerance test myocardial perfusion scintigraphy
14
Q
How is stable angina diagnosed 1st line?
A
CT coronary angiography - IV contrast given
70% narrowing = significant obstruction to the artery -> indicates need for PCI
15
Q
What are the adverse effects of coronary angiography?
A
IV contrast allergies IV contrast precipitates AKI, not good in kidney pts exposure to radiation tolerance of scan trauma MI infection and bleeding risk
16
Q
What is prescribed for relief of angina?
A
sublingual GTN spray (short acting nitrate) - to take for rapid relief of symptoms or before exertion
+ beta blocker or Ca channel blocker
17
Q
Which secondary prevention lifestyle measures are included for stable angina?
A
smoking cessation weight loss cardioprotective diet increase physical activity limit alcohol consumption educate patient
18
Q
What is involved in a cardioprotective diet?
A
reduced refined sugar <6g salt/day 5 portions fruit and veg/day use olive / rapeseed oil for cooking (avoid butter) 2 portions of fish a week choose wholegrain carbs
19
Q
Which medication is prescribed for someone with angina for secondary prevention?
A
- anti platelet - 75-100mg aspirin (COX1+2 inhibitor)
- statin - atorvastatin
- anti hypertensive - ACE-I
+ beta blocker + GTN spray
20
Q
What does acute coronary syndrome encompass?
A
- unstable angina
- NSTEMI
- STEMI
21
Q
Define myocardial infarction
A
necrosis of the myocardial tissue after occlusion of a coronary artery and subsequent ischamia
22
Q
how is ACS caused?
A
- atheromatous plaque builds up
- plaque ruptures in coronary artery
- thrombus formation
- partially or completely obstructs the coronary artery supplying the heart
23
Q
List the risk factors for coronary artery disease?
A
men elderly hypertension smoking hyperlipidaemia diabetes mellitus obesity inactivity / lack of exercise 1st degree relative with CHD south asian systemic diseases e.g. RA, CKD, psychiatric diseases
24
Q
What are the clinical features suggesting unstable angina?
A
severe crushing chest pain/ tightness that lasts longer than 15 MINUTES and comes on AT REST
+ sweating, dyspnoea, dizziness, nausea
25
what are the clinical features suggesting myocardial infarction?
```
central crushing chest pain >15 minutes - radiates to neck and arm
nausea and vomiting
SOB
dizziness
sweating
palpitations
```
26
Who does "silent MI events" commonly happen to?
* elderly diabetics *
| 20-30% MI present with no/ atypical symptoms
27
How can a MI be divided?
1. NSTEMI - no ST elevation, caused by partial or intermittent blockage of artery
2. STEMI- ST elevation, caused by complete and continuing blockage of the coronary artery
28
What are the possible ECG changes in NSTEMI?
ST depression
| t wave inversion
29
Which initial investigations should be done in someone presenting with chest pain?
ECG!!!
if NSTEMI -> do a troponin T and I
if STEMI -> give aspirin and immediate PCI, do not wait for troponin
30
how is troponin used?
troponin T and I done in NSTEMI = cardiac biological markers of cardiac muscle death
if levels high after 4 hours of event -> MI
if levels low -> rule out MI
31
when are troponin levels high?
```
MI
pericarditis
arrhythmias
PE
myocarditis
sepsis
```
32
How is an acute MI managed?
1. ABCDE and resus , oxygen
2. dual anti platelet therapy: aspirin + ticagrelor
3. morphine + anti emetic
4. monitor with 12 lead ECG
5. primary percutaneous coronary intervention indicated within 12 hours of onset of symptoms AND if can be given within 120 minutes of time fibrinolysis could have been given
6. If not, give fibrinolysis
33
what advice is given after an mI?
no driving or sexual activity for 1 month (if PCI can drive after 1 week)
moderate physical activity
34
what other cardiac enzymes might be raised in ACS?
creatinine kinase
LDH
CK - myocardial band
AST (aspartate transaminase)
35
What secondary preventative advice is given after MI?
1. cardiac rehabilitation
2. lifestyle risk factors - smoking cessation, weight loss, 150 mins moderate exercise a week, cardioprotective diet, alcohol consumption within normal limits
3. medical management: aspirin + Ticagrelor + ACE-I + beta blocker + statin
36
Which risk score predicts risk of heart attack or stroke within next 10 years?
Q- RISK
score >10% = significant risk of event = start on statin
37
Define aortic dissection?
tear in the tunica intima in the wall of the aorta leading to separation of the layers and formation a false lumen
38
List the risk factors for aortic dissection?
```
hypertension *
trauma *
syndromes: Marfans, Ehlers Danlos, Noonans, Turners
pregnancy
cocaine and amphetamines
```
39
describe the clinical features of aortic dissection?
severe chest pain - radiates through to back, "tearing"
hypertension
aortic regurgitation
40
How are aortic dissection classified?
stanford classification
TYPE A (2/3)- AD in the ascending aorta and aortic arch (proximal to L subclavian)
TYPE B (1/3) - AD in the descending aorta (distal to L subclavian)
41
What are the complications of Aortic dissection?
```
aortic regurgitation
unequal arm pulses and bP
stroke
renal failure
cardiac tamponade
MI
```
42
how are type A aortic dissections managed?
1. morphine and oxygen
2. IV labetalol - BP controlled so systolic 100-120mmHg
3. surgical intervention
43
How are type B aortic dissections managed?
1. morphine and oxygen
2. IV labetalol to control BP *systolic 100-120*
3. bed rest and conservative management
44
How is aortic dissection diagnosed?
MRI
45
What are the possible complications after an MI?
```
heart failure - acute ro chronic
post infarction angina
sudden death from cardiac arrest or VF
cariogenic shock
Dresslers syndrome
```
46
What is dresslers syndrome?
pericarditis that occurs 2-6 weeks after MI
symptoms: fever, pleuritic chest pain, pericardial effusion, raised ESR
47
What is an abdominal aortic aneurysm?
dilatation of the layers of the aorta to create a large swelling
48
List the 4 main risk factors for abdominal aortic aneurysm?
hypertension
smoking
male
family history
49
Which connective tissue disorders are associated with AAA and aortic dissection?
marfans
| Ehlers danlos
50
When does a AAA become symptomatic?
when it RUPTURES!!!
| SEVERE back pain + hypotensive shock + pulsatile abdo swelling
51
What is the screening programme for AAA?
ultrasound done for >65 y/o
if no aortic aneurism (<3cm), then rule it out for life
3-4.4cm - small - rescan every 12 months
4.5-5.4 - medium - rescan every 3 months
>5.5cm - large - refer within 2 weeks to vascular surgery for intervention (1 in 1000)
52
How is AAA diagnosed?
ultrasound **
20% rupture into peritoneal cavity (poor prognosis)
80% rupture posteriorly into retroperitoneal cavity
53
when is intervention indicated in AAA?
if >5.5cm or patient symptomatic c
surgical/ endovascular: synthetic graft inserted to replace aneurysmal segment of aorta
54
what are the 3 types of AAA?
TRUE: saccular and fusiform
FALSE
55
Define heart failure
output of heart is inadequate to meet the needs of the body
56
Describe the pathology behind heart failure with reduced ejection fraction
reduction in contractility of the heart so stroke volume is reduced
ejection fraction = the fraction of the blood that is pumped out of the L ventricle into the aorta from the L ventricle
e.g. total volume of blood in L ventricle is 110ml but only 70ml of that is pumped out into aorta = 70/100 = 64% ejection fraction
57
what is a reduced ejection fraction?
<40% ejection fraction = reduced
58
Describe the NYHA classification for heart failure?
NEW YORK HEART ASSOCIATION CLASSIFICATION
1- no symptoms or limitation to daily activities
2- mild symptoms and slight limitation to daily activities
3- marked symptoms and limitations on activities, comfortable at rest
4- severe symptoms and uncomfortable at rest
59
what are the causes of L sided heart failure?
caused by damage to the myocardium so there is impaired contractility and reduced output of the L ventricle
1. ischaemic heart disease **
2. hypertension **
3. valvular disease
4. cardiomyopathy
5. arrhythmias
60
What are the symptoms of L sided heart failure
```
dyspnoea
orthopnoea
fatigue
peripheral oedema
poor exercise tolerance
cough + pink frothy sputum
wheeze
```
61
What are the signs of L sided heart failure?
```
bibasal pulmonary crackles
peripheral oedema
displaced apex beat
muscle wasting
3rd and 4th heart sound
```
62
What are the causes of R sided heart failure?
R ventricle has to pump against increase resistance in pulmonary vasculature....
1. progression from L sided heart failure
2. chronic lung disease e.g. cor pulmonate, PE
63
What are the signs of R sided heart failure?
```
raised JVP
pitting oedema
hepatomegaly
splenomegaly
nausea
ascites
```
64
If suspect heart failure, what is the 1st line investigation of choice?
BNP (B Natriuretic peptide)
65
How is BNP levels interrupted for heart failure?
if very high -> ECHO and 2 week wait for specialist
if moderately raised -> ECHO and 6 week wait for specialist
66
When is BNP raised?
it is released in response to ventricular stretch
heart failure, LVH, Ischaemia, sepsis, COPD, diabetes, cirrhosis
67
How do you assess ejection fraction for heart failure?
ECHO
68
what changes would you see on Chest Xray for heart failure?
```
A- alveolar oedema
B- Kerley B lines
C- cardiomegaly (>50% cardiothoracic ratio)
D- dilated upper lobe vessels
E- pleural effusion
```
69
What is included in the 6 monthly review of heart failure?
1. clinical state - medication adherence, side effects, symptoms
2. screen for depression with PHQ9
3. review co-morbidities
4. bloods- U&E, creatinine, eGFR
5. functional capacity
6. nutritional status
70
How is heart failure managed conservatively?
education on heart failure
manage lifestyle - smoking cessation, weight loss, restrict alcohol
cardiac rehabilitation programmes
discuss ways to make life easier e.g. benefits, mobility aids, disability parking badge
vaccinations
71
How is heart failure with reduced ejection fracture managed medically?
1. LOOP DIURETIC e.g. furosemide - relieve congestion symptoms
2. ACE-I - improve long term survival
3. BETA BLCOKER - improve long term survival
consider statin, anti platelet
2nd line: + thiazide diuretic
3rd line: + ivabradine / digoxin
72
What are the risk factors for peripheral vascular disease?
smoking **
hypertension
hyperlipidaemia
diabetes
+ CAD risk factors
73
which classification system is used for PVD?
FONTAINE CLASSIFICATION
1. asymptomatic
2. intermittent claudication
3. ischaemic rest pain
4. critical limb ischaemia
5. acute limb Ischaemia
(can also use Rutherford classification)
74
describe the features of intermittent claudication?
burning/ cramping pain in back of calf, thigh or buttock (common iliac artery or internal iliac stenosis) on walking
symptoms worse uphill and "claudication distance"
relieved by rest
75
describe the features of ischaemic rest pain?
severe unremitting pain in foot
worse at night and wake up with pain
relieved by hanging foot over side of bed or on a cold floor
ABPI <0.5
76
Describe the features of critical limb ischaemia?
rest pain in foot for >2 weeks
ulceration
gangrene
ABPI <0.3
77
What examination findings would you see in peripheral vascular disease?
prolonged cap refill
trophic changes: pallor, hairloss, cold, skin change
ulcerations , poorly healing wound
absent/ reduced femoral pulse
78
How is Ankle Brachial Pressure Index calculated?
using doppler ultrasound
79
what score on ABPI indicates PVD?
```
1= normal
<0.9 = mild PAD
<0.5 = ischaemic rest pain
<0.3= critical limb ischameia
```
80
how does acute limb ischaemia present and how is it caused?
when acute thrombus or embolus blocks vasculature so no blood supply
6 P's: pale, perishingly cold, pulseless, painful, paraesthesia, paralysis
81
How is acute limb ischaemia managed?
urgent revascularisation within 4-6 hours + heparin
82
What are the complications of peripheral vascular disease?
```
acute limb ischaemia
infection
poor wound healing
ulcers
amputation
```
83
How is peripheral vascular disease managed conservatively / medically?
lifestyle measures: smoking cessation **, good control of diabetes, weight loss, manage HTN
anti platelet therapy: clopidogrel
pain relief: paracetamol + opioid
84
How is PVD managed surgically?
revascularisation with angioplasty and stunning / bypass surgery OR amputation
85
Describe the pathology of aortic regurgitation?
1. aortic valve is between the L ventricle and aorta
2. the aortic valve closes on diastole and if it doesn't close the whole way, the aortic valve becomes incompetent
3. this allows diastolic blood to flow from the aorta back into the L ventricle
4. causes dilatation of the L ventricle
5. leads to left ventricular hypertrophy
86
What are the causes of aortic regurgitation?
1. infective endocarditis
2. rheumatic fever
3. bicuspid valve
4. degeneration
5. associations : ankylosing spondylitis, aortic dissection, Marfans, Turners, Ehlers Danlose, SLE
87
What are the symptoms fo aortic regurgitation?
cardiovascular collapse
| L sided heart failure - SOBOE etc
88
Name the murmur in aortic regurgitation
early decrescendo diastolic murmur
| + Austin flint (soft rumbling low pitched diastolic murmur)
89
What are the signs of aortic regurgitation?
early diastolic murmur + Austin flint murmur
collapsing water hammer pulse
wide pulse pressure (high systolic but low diastolic blood pressure)
De mussets (head bobbing)
90
How are valve incompetencies diagnosed?
ECHO
91
How is asymptomatic aortic regurgitation treated?
watch and wait
review early with 2 yearly ECHO
for HF: ACE-I , diuretics
92
How is symptomatic aortic regurgitation treated?
valve replacement
93
what is the most common valvular heart disease?
aortic stenosis
94
What are the causes of aortic stenosis?
degenerative calcification**
bicuspid valve
rheumatic fever
williams syndrome
95
What is the triad for aortic stenosis?
1. chest pain
2. syncope
3. L sided heart failure - dyspnoea
96
Describe the aortic stenosis murmur
ejection systolic (crescendo decrescendo)
radiates to carotids
best heard sitting forward and at end of expiration
97
What are the complications of aortic stenosis?
heart failure
microangiopathic haemolytic anaemia
predisposes infective endocarditis
98
How is aortic stenosis managed?
valve replacement + warfarin (target INR 2.5-3.5)
99
describe the pathology behind mitral stenosis
the mitral valve is between the L atrium and L ventricle -> when mitral valve stiff, increases L atrial pressure -> distention of L atrium -> increases pulmonary artery pressure -> R ventricular failure
100
List the causes of mitral stenosis
rheumatic fever
infective endocarditis
degenerative calcification
associations: RA, SLE, amyloid
101
How does mitral stenosis present?
often asymptomatic
| R sided heart failure symptoms
102
Describe the murmur in mitral stenosis?
mid late diastolic murmur - heard in L lateral
103
What are the signs O/E of mitral stenosis?
malar flush
| signs of RHF: raised JVP, splenomegaly, oedema , displaced apex beat
104
what are the complications of mitral stenosis ?
AF
pulmonary hypertension
R sided heart failure
105
List the causes of mitral regurgitation?
post MI
infective endocraidtis
rheumatic fever
mitral valve prolapse
106
Describe the murmur in mitral regurgitation
pan systolic murmur - radiates to axilla
107
describe the pathology behind infective endocarditis?
1. abnormal valve / previously damaged valve
2. inflammation
3. destruction and scarring
4. vegetations grow on valves
5. valvular regurgitation
6. vegetations throw off emboli and cause ischaemia elsewhere in the body
108
What are the main causes of infective endocarditis?
streptococcus viridan's *** - dental procedures
staphylococcus aureus ** - IVDU, indwelling catheters
enterococcus faecalis - pelvic surgery
staph epidermidis - IVDU, prosthetic valves
109
List the risk factors for infective endocarditis?
```
prosthetic valves
IVDU
dental procedures
surgery
rheumatic heart disease
previous IE
```
110
When would you suspect infective endocarditis?
fever + new murmur
normally aortic regurgitation (early diastolic murmur) but iVDU more likely for tricuspid regurg (pansystolic murmur)
111
List the signs + symptoms of infective endocarditis?
fever + new murmur
Janeway lesions - painless red macule on thenar
Oslers nodes - painful red blisters at end of toes/ fingers
Roth spots - retinal haemorrhages with pale centre
Splenomegaly
splinter haemorrhages
petechiae / purprua
112
what are the complications of infective endocarditis?
MI
stroke
glomerulonephritis
113
How is infective endocarditis diagnosed?
1. blood cultures: 3 separate +ve cultures, 12 hours in between, different sites
2. ECHO
114
How is infective endocarditis treated?
amoxicillin + gentamicin
115
what are the primary causes for hypertension?
unknown causes but multifactorial RF including:
- genetic
- obesity
- alcohol
- caffeine
- high salt diet
- socioeconomic factors
116
what are the secondary causes for hypertension?
- renal: polycystic kidney disease, renal artery stenosis
- endocrine: cushings, phaeochromocytoma, acromegaly, thyroid dysfunction,
- CV: coarction of the aorta (radio-radial delay)
- pregnancy: pre-eclampsia
- drugs: contraceptives, anabolic steroids, adrenaline
- obstructive sleep apnoea
117
What is classed as hypertension?
BP >140/90 mmHg
118
What are the features of benign hypertension?
slow gradual rise in hypertension over many years
| causes gradual changes in vessels -> constriction, reduced size of lumen, more likely to haemorrhage
119
what are the features of malignant hypertension?
sudden rapid rise in BP leading to vascular damage of intimal fibrosis thickening and accelerated arteriosclerosis (*fibrinoid necrosis*)
symptoms: headache, visual disturbance due to papilloedema, retinal haemorrhages
120
What are the complications of hypertension?
```
CAD- MI, angina
stroke
haemorrhage
pulmonary oedema
eclampsia
papilloedema
retinopathy
AF
```
121
How is hypertension staged?
STAGE 1: BP > 140/90 mmHg
STAGE 2: BP >150/95 or stage 1 + end organ damage/ CVD/ diabetes/ renal pathology/ Q risk >20%
STAGE 3: systolic >180, diastolic >110mmHg
122
How is stage 1 hypertension treated?
```
LIFESTYLE MODIFICATION
low salt diet
weight loss
reduce alcohol intake
stop smoking
exercise
```
123
How is stage 2 hypertension and above treated medically?
if <55 y/o -> ACE-I e.g. ramipril, lisinopril
if >55 y/o or afro Caribbean -> calcium channel blocker e.g. amlodipine
if ineffective, ACE-I + Ca channel blocker
+ thiazide like diuretic
+ spironolactone
+ alpha or beta blocker
124
What are the differentials for fall/ collapse
```
cardiovascular causes of syncope- AV heart block, AF, MI
vasovagal
hypoglycaemia
epilepsy/ seizure
postural hypotension
shock
```
125
List the differentials for cardiac arrest / sudden death?
```
MI
cardiomyopathy
ventricular arrhythmias
drug toxicity
electrolyte abnormalities e..g. hyperkalaemia
aortic dissection
aortic stenosis
```
126
which bacteria causes rheumatic fever?
group A beta haemolytic streptococci
127
When does rheumatic fever occur?
2-4 weeks after post strep infection e.g. pharyngitis, skin infection
128
What is the criteria for rheumatic fever?
1. evidence of recent strep infection
2. 2 major or 1 major + 2 minor of:
```
J- joints large arthritis
O- valvular disease
N- nodules painless, extensor surfaces
E- erythema marginatum (pale red macule)
S- syndenham chorea - upper limb jerking
```
```
P- PR interval prolonged
E- ESR raised
A- arthralgia
C- CRP raised
E- elevated temp
```
129
Describe the ECG of rheumatic fever?
ST saddle shape elevation
| PR interval prolonged
130
How is rheumatic fever managed?
1. bed rest
2. benzylpenicillin
2. NSAIDs
131
Define myocarditis
inflammation of the myocardium
132
How is myocarditis caused?
viruses ** e.g. coxsackie
bacteria - chlamydia
drugs - alcohol, lead poisoning, methyldopa, chloroquine
133
How does myocarditis present?
MI + fever (sudden unexplained cardiac death)
134
How is myocarditis diagnosed?
endo-myocardial biopsy
| FBC, CK, troponin T/I
135
What is cardiac tamponade?
collection of fluid/ pus/ gas/ blood in the pericardial space - results in impaired cardiac ventricular filling -> haemodynamic compromise
136
How is cardiac tamponade caused?
```
pericarditis
malignancy
dresslers syndrome
infection
trauma
connective tissue e.g. SLE, RA
```
137
What is Becks triad for cardiac tamponade?
1. muffled
2. JVP
3. hypotension
138
How does cardiac tamponade present?
```
oedema
dyspnoea
tachycardia
tachypnoea
fatigue
anxiety
```
139
how is cardiac tamponade diagnosed?
echo
140
How is cardiac tamponade managed?
1. oxygen
2. volume expansion
3. increase venous return with legs up
4. inotrope e.g. dobutamine
141
Describe sinus tachycardia
focal tachycardia of HR 100-120 bpm, every p wave followed by QRS
142
List some causes of sinus tachycardia?
```
exercise
stress
anxiety
hyperthyroidism / thyrotoxicosis
sepsis
caffeine
alcohol
```
143
Describe atrial flutter
type of supraventricular tachycardia where there is a succession of rapid atrial depolarisation
144
Describe atrial flutter ECG
SAWTOOTH BASELINE - not every p wave followed by QRS
145
What are the possible causes of atrial flutter?
```
CAD
HTN
hyperthyroid
COPD
alcohol
```
146
How is atrial flutter treated?
same as AF
147
Describe supraventricular tachycardia on ECG
** narrow complex regular tachycardia **
absence of p waves, narrow QRS, >100 bpm
148
What are the symptoms of SVT?
angina type symptoms - chest pain, faintness, SOB
149
How is SVT managed acutely?
1. vagal manoeuvres - carotid sinus massage
2. IV adenosine
3. electrical cardio version
150
What is Wolff Parkinson white syndrome?
= atrioventricular re-entry tachycardia (AVRT), type of SVT
caused by an accessory conduction pathway called the bundle of Kent -> the additional pathway causes arrhthymias through pre-excitation and re-entry circuits that conduct faster than the AVN
151
Describe the features on ECG of Wolff Parkinson's white syndrome
1. short PR interval
2. wide QRS
3. delta wave (upsloping to QRS - indicates abherant pathway)
L/R axis deviation depending on R/L accessory pathway
152
How is Wolff Parkinson white syndrome treated?
radio frequency ablation of the accessory circuit (medication of amiodarone if refuse)
153
Describe ventricular tachycardia on ECG
** broad complex regular tachycardia **
no p waves, broad QRS, tachycardia, regular
154
How is VT assessed and subsequently treated?
pulse present -> amiodarone, lidocaine
pulse absent -> need to synchronise with DC shock or cardioversion
155
Describe ventricular fibrillation on ECG
** broad complex irregular tachycardia"
no p waves, no identifiable QRS or T wave, chaotic, rate 150-500 bpm
156
How does VF present?
cardiac arrest!!! LOC, death as no effective output
157
How is VF treated?
defibrillation
158
What is torsades de pointes?
type of "polymorphic" ventricular tachycardia
159
describe the ECG of torsades de pointes?
prolonged QT, prominent U waves
160
How is torsades de pointes caused?
drugs - anti arrhthymics, TCA, erythromycin, clarithromycin
hypokalaemia
hypomagnesaemia
IHD
161
How is torsades de pointes treated?
IV magnesium sulphate
162
Describe the ECG change in Brugada syndrome?
elevated J point , ST elevation
at risk of sudden death (AD inherited condition)
163
How is brugada syndrome treated?
ICD implantable cardioverter defibrillator
164
What is an atrioventricular heart block?
prolonged PR interval suggesting there is atrioventricular delay -> impaired conduction between the atria and ventricle
165
what are the possible causes of AV heart block?
MI/ ischaemia
myocarditis
infection e.g. Lyme disease, infective endocarditis
SLE
166
Describe first degree heart block ECG
fixed prolonged PR interval (>200ms/5 little squares)
167
How is first degree heart block treated?
asymptomatic and requires no treatment
168
Describe second degree heart block mobitz type 1?
PR interval slowly increases until there is a dropped QRS complex
169
How is 2nd degree heart bloc mobitz type 1 managed?
asymptomatic and no treatment
170
Describe second degree heart block mobitz type 2?
fixed PR interval but sudden dropped beats
171
How is 2nd degree heart block mobitz type 2 treated?
dangerous as at risk of sudden cardiac death
| need pacing if symptomatic
172
describe 3rd degree heart block?
when there is complete heart block - no association between p and QRS waves
173
How does 3rd degree heart block present?
syncope
heart failure
regular bradycardia
wide pulse pressure
174
Describe what atrial fibrillation is?
irregularly irregular narrow QRS complex with absent p waves
| due to atrial myocytes depolarising in uncoordinated fashion
175
What are the causes of AF?
1. elderly , idiopathic **
2. congestive heart failure **
3. hypertension **
```
cardiomyopathy
CAD
mitral stenosis
alcohol, caffeine
thyrotoxicosis
sepsis
```
176
How does AF present?
```
asymptomatic
palpitations, chest pain
SOB
syncope
dizziness
fatigue
```
177
What is the worrying complication with AF?
stasis of blood from ineffective atrial contraction predisposes patient to a thrombus within the L atrium which can throw off emboli causing ischaemic STROKE or ischaemia in other organs
178
Describe the ECG findings on AF?
irregular QRS
| absent P waves
179
Which further investigations might you do if find AF on ECG?
```
FBC (anaemia?)
TFTs** (thyrotoxicosis)
UandE (potassium?)
ECHO (assess for heart failure or valvular abnormalities)
CXR
d- dimer, troponin (ACS?)
```
180
which score is used to assess stroke risk in AF patients?
```
CHADS2VASC
C- congestive heart failure
H- hypertension
A- age >75 (2)
D- diabetes
S2- previous stroke or TIA (2)
V- vascular problems e.g. MI
A- age 65-74
SC - sex category (female = 1)
```
181
How are CHADS2VASC scores interrupted ?
```
<2 = low risk -> consider anticoagulant
>2 = high risk -> start on anti coagulant
```
182
How is AF managed?
```
RATE CONTROL:
beta blocker (atenolol) OR
cardio selective calcium channel blocker (verapamil) OR
digoxin (better in elderly, sedentary)
Aim for ventricular rate 60-80bpm
```
RHYTHM CONTROL:
cardioversion medical: amiodarone
electrical: DC cardio version (if acute)
LONG TERM: warfarin or apixiban
183
How should AF patients be managed conservatively?
reduce caffeine and alcohol intake
control BP
treat thyroid disease
inform DVLA is symptoms affect driving
184
when is electrical cardioversion indicated?
if a patient unstable
1. 120-150 J cardioversion
2. 3x attempts
3. IV 300mg amiodarone via central line
185
Describe the pathology behind bundle branch blocks
1. conduction blocked in one of the bundle branches of the interventricular septum
2. the affected area of the myocardium will be stimulated later by conduction from unaffected areas of the myocardium
3. leads to widening of the QRS
186
What are the possible causes of RBBB?
```
physiological normal variant
rheumatic heart disease
IHD
myocarditis
cardiomyopathy
```
187
Describe the ECG changes in RBBB?
M wave in V1 (second R wave)
| W wave in V6 (deeper S wave)
188
What are the causes of LBBB?
coronary artery disease ** - more extensive disease
hypertensive heart disease
dilated cardiomyopathy
189
Describe the ECG changes in LBBB?
W wave in V1 (deep S wave)
| M wave in V6 (broad notched R wave)
190
List the reversible causes of bradycardia and cardiac arrests
```
H - hypoxia
H - hypothermia
H - hypovolaemia
H - hypokalaemia
T - thrombus
T - toxin
T- tension pneumothorax
T - tamponade
```
191
How is bradycardia assessed?
1. ABCDE
2. obtain IV access, give oxygen
3. monitor ECG, BP, SpO2, 12 LEAD ECG
4. identify and treat reversible causes
5. adverse features present ? shock, syncope, MI, HF?
192
How is bradycardia treated?
atropine 500mcg IV
193
What is the mechanism of atropine?
blocks vagus nerve to increase the sinus rate and increase AV conduction
194
What are the side effects of atropine?
```
blurred vision
dilated pupils
dry mouth
urinary retention
confusion
```
195
What is sick sinus syndrome?
dysfunction of SA node with impairment of ability to generate a pulse causing bradycardia
196
What are the causes of sick sinus syndrome?
idiopathic fibrosis of node
ischaemia
digoxin toxicity
197
How is symptomatic sick sinus syndrome treated?
dual chamber pacemaker
198
Describe the mechanism of amiodarone?
blocks Na/K/Ca channels and an alpha beta adrenergic antagonist
lengthens duration of action potential to slow conduction
199
what are the side effects of amiodarone?
hypotension, AV block, grey skin colour
| pneumonitis , hepatitis
200
Describe the mechanism of adenosine?
blocks conduction through AV node so slows sinus rate and slows conduction
201
How is adenosine given?
```
short duration (half life of 10s)
IV 6mg
```
202
what are the side effects of adenosine?
bradycardia
| systole
203
What are the side effects of Ca channel blockers?
```
ankle swelling
flushing
headache
bradycardia
constipation
```
204
What are the side effects of beta blockers?
fatigue
cold extremities
headache
impotence
205
what is digoxin used for?
reduce ventricular rate in AF
severe heart failure (3rd line)
= reduces conduction at the AVN
206
Describe the symptoms of digoxin toxicity?
```
arrthymias
nausea and vomiting
diarrhoea
dyspnoea
confusion
dizziness
```
207
What are the 3 types of cardiomyopathy?
1. dilated = most common
2. hypertrophy
3. restrictive
208
How is cardiomyopathy diagnosed?
ECHO
209
What are the risk factors for dilated cardiomyopathy?
alcohol **
familial/ idiopathic **
+ ischaemia, chemotherapy, post partum, hypertension
210
how does dilated cardiomyopathy present?
usually asymptomatic until sudden death
211
How is hypertrophy cardiomyopathy caused?
familial AD
212
how is restrictive cardiomyopathy caused?
elderly
| amyloidosis
213
what are the types of AF?
1. paroxysmal - spontaneous termination of AF within 7 d
2. persistent - lasts more than 7d, not self limiting
3. permanent - longstanding AF over a year
214
Which score can be used to assess bleeding risk in a patient?
```
HASBLED
Hypertension
Abnormal liver, renal function
Stroke
Bleeding history
Labile INR
Elderly
Drugs
```
215
what do scores on HASBLED indicate?
```
0-2 = consider anticoagulant
3-5 = alternative to anti coagulants should be used
>5 = high risk of bleeding
```
216
what are the benefits of DOACs?
do not need INR monitoring
faster onset
faster offset
set doses
217
What are the disadvantages of DOACs (direct oral anti coagulants)?
limited antidotes
218
what should you tell a patient taking warfarin?
```
do not miss doses
take at same time every day
do not get pregnant
do not eat food high in Vitamin K e.g. broccoli, kale, spinach
limit alcohol
```
219
List the differentials for palpitations?
```
atrial fibrillation
atrial flutter
VT
WPW
AVNRT
ectopics
```
220
How are any tachyarrhythmias investigated?
1. ECG
2. ECHO
3. stress testing for exercise related
221
How is HF patient treated in an emergency?
1. ABCDE
2. furosemide IV
3. monitor renal function - AKI, monitor K, ABG if hypoxic
4. daily weights
5. fluid restrict <1.5L/day
6. catheter
7. repeat CXR
8. refer to cardiology
222
What is the mechanism of furosemide (loop diuretic)?
competitively inhibits the Na-K- 2Cl co transporter in the thick ascending limb in the loop of Henle
223
Outline the mechanism of aspirin?
irreversibly inhibits COX enzyme causing reduced production of prostaglandins and thromboxane A2 - this stops platelet aggregation and prevents further cardiac events
224
outline the mechanism of Ticagrelor
P2Y12 receptor antagonist preventing platelet activation and aggregation
SE: dizziness, dyspnoea, hypotension, headache, haemorrhage
225
what is a capture beat?
occur when the sinoatrial node transiently 'captures' the ventricles, in the midst of AV dissociation, to produce a QRS complex of normal duration.
226
what are shockable rhythms?
VF
| pulseless VT
227
when do you give adrenaline in an arrest?
adrenaline 1 in 10,000 (100mcg/mL)
| IV injection repeated every 3-5 minutes
228
What are the signs of pulmonary oedema?
```
tachycardia
tachypnoea
raised JVP
widespread fine crackles
dull percussion at bases
gallop rhythm
```
229
How is pulmonary oedema managed?
1. furosemide
2. oxygen
3. morphine
4. GTN/ nitrates
230
describe the ECG changes after MI?
pathological Q wave
| T wave inversion
231
why should metformin be stopped before angiogram?
metformin interacts with IV contrast and precipitates lactic acidosis
232
what are the indications for amputation?
```
gangrene
trauma
necrosis
acute limb ischaemia
necrotising fasciitis
```
233
what are the considerations for an amputation?
large enough joint for prosthetic limb?
adequate blood supply to heal stump?
retain as many working joints as possible?
234
what is phantom limb pain?
pain experienced below an amputation
| = due to hypersensitivity of divided nerves
235
How can phantom limb pain be managed?
neuropathic analgesia e.g. gabapentin, pregabalin, amitriptyline
236
what are the complications of an amputation?
infection
stump ischaemia
failure to mobilise
pressure sore
237
what are the stages of wound healing?
haemostasis
inflammation
proliferation
remodelling
238
how do varicose veins form?
incompetent valves in veins allowing vein dilatation and tortuous
239
what are the risk factors for varicose veins?
obesity
pregnancy
prolonged standing
conditions: eczema, venous ulceration, oedema
240
what are the possible long term complications of varicose veins?
pain
ulceration
psychological effects
