CardioResp Flashcards
1
Q
What is the 5-year survival rate for lung cancer?
A
13%
2
Q
What are the risk factors for lung cancer?
A
Smoking Airflow obstruction Increasing age Family history Carcinogens eg asbestos
3
Q
What is the performance scale for lung cancer used for?
A
To indicate patient’s level of fitness, used when deciding treatment options
4
Q
What staging is used for lung cancer?
A
TNM
5
Q
What is the use of PET scanning in lung cancer?
A
Helps detect small mets not seen on staging CT
Used if patient is surgical candidate and initial CT suggests low stage
6
Q
What are the 2 main histological types of lung cancer?
A
Small cell lung cancer
Non-small cell lung cancer
7
Q
What are the different types of non-small cell lung cancer?
A
Squamous cell
Adenocarcinoma
Large cell carcinoma
Bronchoalveolar cancer
8
Q
In what stages of lung cancer is surgery considered?
A
I and II (providing patient is fit for surgery)
9
Q
What is the prognosis for small cell lung cancer?
A
Poor
Median survival if untreated is 4-12 weeks
Rapid growth
Almost always too extensive for surgery
10
Q
What is the prognosis for non-small cell lung cancer?
A
Depends on stage
Stages I and II following resection 5y survival up to 70%
11
Q
What proportion of lung cancer cases are in smokers or ex-smokers?
A
85%
12
Q
What are the components of COPD?
A
Emphysema
Chronic bronchitis
13
Q
What is emphysema?
A
Alveolar wall destruction causing irreversible enlargement of air spaces, distal to the terminal bronchioles
14
Q
What are the causes of COPD?
A
Smoking
Alpha 1 antitrypsin deficiency
Industrial exposure eg soot
15
Q
What is the most effective way of preventing COPD progression?
A
Smoking cessation
16
Q
What are the aims of long term oxygen therapy in COPD?
A
Preventing renal and cardiac damage caused by long periods of hypoxia
17
Q
How long does oxygen therapy need to be given for per day in order to provide survival benefit?
A
At least 16 hours per day
18
Q
At what oxygen level is LTOT offered for COPD?
A
pO2 consistently below 7.3
Or below 8kPa with for pulmonale
19
Q
What are the conditions for patients having LTOT?
A
Must be non-smokers
Must not retain high levels of CO2
20
Q
What are the disadvantages of LTOT?
A
Loss of independence
Reduced activity
21
Q
Why are pulmonary rehabilitation classes beneficial for COPD?
A
Prevent muscles weakening
Prevent increasing breathlessness
Increase livelihood
Prevent social isolation
22
Q
What do pulmonary rehabilitation classes consist of?
A
Supervised exercise
Unsupervised home exercise
Nutritional advice
Disease education
23
Q
What are the signs of an infective exacerbation of COPD?
A
Change in sputum colour or volume
Fever
Raised WCC and/or CRP
24
Q
What nebs are given in a COPD exacerbation?
A
Salbutamol
Ipratropium
25
What steroids are used in COPD exacerbation?
Prednisolone 30mg stat
| Once daily for 7 days
26
When are antibiotics indicated for COPD exacerbation?
Raised CRP/WCC
| Purulent sputum
27
When is NIV considered for COPD exacerbation?
Type 2 resp failure
| pH 7.25 - 7.35
28
When should you consider ITU referral for exacerbation of COPD?
pH less than 7.25
29
What does ABPA stand for?
Allergic Bronchopulmomary Aspergillosis
30
What are the modifiable risk factors for cardiovascular disease?
Smoking
Diabetes
Hypertension
Hyperlipidaemia
31
What is S1?
Closure of AV valves (mitral and tricuspid)
32
What is S2?
Closure of outflow valves (aortic and pulmonary)
33
In terms of heart sounds, when is systole?
After S1, before S2 starts
34
When is a 3rd heart sound normal?
Below age 30
35
What are the causes of S3 and S4 being heard?
Heart failure
MI
Cardiomyopathy
Hypertension
36
What is a murmur?
Sound produced by turbulent flow of blood through heart, especially over abnormal valves
37
What murmurs are louder on inspiration? Why?
Right-sided
| Inspiration increases venous return to the right side of the heart
38
What is a thrill?
Palpable murmur
39
What are the causes of mitral stenosis?
Rheumatic fever
Old age
Calcification
40
What is the major association with mitral stenosis?
Atrial fibrillation - 60-70% of mitral stenosis patients
41
What is the murmur of mitral stenosis?
Mid-diastolic murmur 'rumbling'
42
Where is mitral stenosis best heard?
With the bell
In apex
Patient lying on left side
43
How may mitral stenosis lead to right axis deviation on ECG?
High LA pressure due to stenosis AV valve on left (mitral)
Pulmonary venous HTN, leading to pulmonary arterial HTN
Right ventricular hypertrophy
44
How can mitral stenosis lead to right heart failure?
High LA pressure causing pulmonary HTN
| Right ventricular hypertrophy leading to tricuspid regurgitation, and right heart failure
45
What is the murmur of mitral regurgitation?
Pansystolic - no gap between S1 and S2
| Radiates to axilla
46
What are the causes of mitral regurgitation?
```
Prolapsing mitral valve
Rheumatic mitral regurg
Papillary muscle rupture post-MI
Cardiomyopathy
Connective tissue disorders
```
47
What are the ECG signs of mitral regurgitation?
Bifid P waves
| Left ventricular hypertrophy
48
What are the symptoms of aortic stenosis?
Exercise-induced syncope, angina and SOB
49
What is the murmur of aortic stenosis?
Ejection systolic
Radiates to carotids
50
What are the other signs of aortic stenosis on examination?
Slow-rising pulse
Low volume pulse
Forceful apex beat
51
Describe what you hear in aortic stenosis
Murmur loudest straight after S1
| Audible gap before S2
52
What are the causes of aortic regurgitation?
Rheumatic fever
Bicuspid valve
Infective endocarditis
53
What does the pulse feel like in aortic regurgitation?
Collapsing - wide pulse pressure
54
What is the murmur of aortic regurgitation?
High-pitched early diastolic murmur
Best heard left sternal edge 4th IC space
Patient leaning forward with breath held in expiration
55
What are the 3 main causes of heart failure?
Ischaemic heart disease
Non-ischaemic dilated cardiomyopathy
Hypertension
56
What is the equation for cardiac output?
Cardiac output = stroke volume x heart rate
57
What is the end diastolic volume?
Volume of blood in a ventricle at the end of diastole
58
What is Starling's law?
More blood entering the heart during diastole, the more blood is ejected during systolic contraction
59
What is the ejection fraction?
Fraction of blood pumped out of ventricles with each heart beat
60
Define pneumonia
LRTI with new consolidation on X-Ray
61
What is the most common organism causing community acquired pneumonia?
Streptococcus pneumoniae
62
What are the symptoms of an LRTI?
```
Usually cough (new or changed in character)
Sputum production
Breathlessness
Wheeze
Chest pain
Fever
Sore throat
```
63
What clinical finding makes CAP likely?
Lung crackles
64
How may CAP present in elderly patients?
Confusion
Less likely to have fever
65
What is PUO?
Pyrexia of unknown origin
66
What 5 factors predict risk of death from pneumonia?
```
Respiratory rate
Blood pressure
Confusion
Blood urea
Age over 65 years
```
67
What respiratory rate indicates severe pneumonia?
Over 30 per minute
68
How do you assess confusion in pneumonia?
Abbreviated mental test
69
What CURB-65 score indicates severe pneumonia?
3 or more
70
What do you do if a patient has a CURB-65 score of 2?
Use clinical judgement to decide if short inpatient stay required, or hospital supervised outpatient care
71
What potential complications of pneumonia may be seen on CXR?
Parapneumonic pleural effusion
Empyema
Lung abscess
72
What are the side effects of beta blockers?
```
GI disturbances
Bradycardia
Fatigue
Cold peripheries
Heart failure
Hypotension
Dizziness
Sexual dysfunction
Peripheral vasoconstriction
Bronchospasm
```
73
Give three examples of beta blockers
Bisoprolol
Atenolol
Propranolol
74
What are the indications for beta blockers?
Hypertension
Angina
Following MI
Cardiac dysrhythmias e.g. AF
75
What are the contraindications to beta blockers?
Asthma
Marked bradycardia
Heart block
Hypotension
76
What are the three main processes responsible for asthma symptoms?
Bronchospasm
Smooth muscle hypertrophy
Mucus plugging
77
How do you calculate ejection fraction?
Stroke volume divided by end-diastolic volume
78
What is a normal ejection fraction?
Over 50%
79
What is REFHF?
Reduced ejection fraction heart failure
80
What is PEFHF?
Preserved ejection fraction heart failure
81
Give some differentials for bilateral leg swelling
```
Drug reaction
Heart failure
Abdominal mass
Obesity
Renal failure
Liver failure
```
82
Give some differentials for unilateral leg swelling
DVT
Trauma
Cellulitis (infective)
83
What blood results would indicate hepatic congestion?
Hyperbilirubinaemia
Elevated transaminases
Hypoalbuminaemia
84
What is the most common cause of REFHF?
Ischaemia heart disease
85
What is the most common risk factor for PEFHF?
Hypertension
86
What are the risk factors for PEFHF?
```
Diabetes
Hypertension
Obesity
Age
Renal impairment
Lung disease
```
87
What type of heart failure do arrhythmias commonly cause?
Right or left or congestive
88
What type of heart failure does obesity commonly cause?
Left PEFHF
89
Where do you feel for the character of the pulse?
Carotid ie blood leaving the heart
90
What does a collapsing pulse indicate?
Aortic regurgitation
91
What does a slow-rising pulse indicate?
Aortic stenosis
92
How should you determine the rate in AF?
Listen at the apex
93
What do you look for in the hands in CVS exam?
```
Clubbing
Splinter haemorrhages
Tar staining
Koilonychia
Peripheral cyanosis
```
Do capillary refill!
94
What is a thrill?
Palpable murmur
95
What are the 4 main risk factors for IHD?
Smoking
Diabetes
Hypertension
Hypercholesterolaemia
96
Give a quick way of doing a systems review
Bowels OK?
Problems with water works?
Breathing problems?
97
Describe the typical pain caused by an MI
Dull, Central crushing pressure
Radiating to shoulder, arms or jaw
98
What is pleuritic chest pain?
Sharp
Worse on inspiration
Associated with shortness of breath
99
What is pericardial pain like?
Sharp
| Improved by leaning forward
100
What is the pain of aortic dissection like?
Instant
Tearing
Inter scapular
May be retrosternal
101
What is musculoskeletal chest pain like?
Tender areas
| Pain reproduced by movement
102
What is a Stoke-Adams attack?
Collapse without warning plus loss of consciousness for a few seconds
Usually due to third degree heart block
103
What features of syncope suggest a cardiac cause?
Chest pain, palpitations or shortness of breath before the event
104
What features of syncope suggest a CNS cause?
Aura
Headache
Dysarthria
Limb weakness
105
How does the recovery from a syncopal episode help diagnosis?
Cardiac - quick recovery
| Seizure - prolonged drowsiness
106
What are the causes of slow palpitations?
Sick sinus syndrome
AV block
Occasional extrasystoles with compensatory pauses
107
What are the causes of increased stroke volume?
Valvular lesions
| High-output states e.g. Anaemia, pregnancy, thyrotoxicosis
108
What are the causes of regular, rapid palpitations?
Sinus tachy
Atrial flutter
Atrial tachy
SVT re-entry tachy
109
What are the ECG signs of aortic stenosis?
P-mitrale
| Left ventricular hypertrophy
110
What are the common bacterial causes of infective endocarditis?
Strep Viridans
Staph aureus or epidermis is
Enterococcus
111
What are the empirical antibiotics used for infective endocarditis?
Benzylpenicillin and gentamicin
112
What is the normal speed for ECG paper?
25mm/s
113
What does the T wave represent?
Ventricular depolarisation
114
What is the normal PR interval?
120-200ms
3-5 small squares
115
What is the normal QRS complex?
Less than 120ms
| Ie 3 small squares
116
When is T wave inversion OK?
aVR
| Isolated in lead III
117
How do you calculate rate from an ECG?
300 divided by RR interval (in large squares)
118
Which leads do you use to calculate the heart axis?
I and aVF
119
How do you check correct limb lead placement on an ECG?
Look at aVR - everything should be negative
120
What does atrial flutter look like on ECG?
Sawtooth P waves
121
What is the underlying rate in atrial flutter? Why is this not the true heart rate?
300
| Too fast for AV node to conduct - there is either a 2:1, 3:1 or 4:1 block
122
What rates may be atrial flutter?
300
150
100
75
123
What is p-mitrale?
Left atrial enlargement
| Bifid p waves
124
What is p-pulmonale?
Right atrial enlargement
| Tall p waves
125
What does biatrial enlargement look like on ECG?
Tall and bifid p waves
126
When is 1st degree heart block significant?
PR >300ms
Another conducting disease is present eg BBB
IE with aortic valve involvement
127
What is Mobitz I?
Wenckebach
Progressive lengthening of PR interval until 1 QRS is dropped
P waves occur at constant rate
128
What is Mobitz II?
Intermittent failure of AV node to conduct atrial depolarisations to ventricles
129
What does complete heart block look like on ECG?
No relationship between p waves and QRS
| Rate is slow, usually 30-50
130
What are the causes of complete heart block?
Coronary artery disease
Fibrosis of AV node or bundle of His
Drugs eg digoxin toxicity, diltiazem
131
What does a short PR interval indicate?
An accessory pathway
| The impulse is not going through the AV node (where it would be delayed before reaching the ventricles)
132
What does right ventricular hypertrophy look like on ECG?
R wave > 5 mm in right ventricular leads
| Plus right axis deviation
133
How can lead V1 be used to assess bundle branch block?
Major deflection up - Right BBB
| Major deflection down - Left BBB
134
What are the principles of AF treatment?
Reduce thromboembolic risk
Control ventricular rate
Alleviate symptoms
135
How do you estimate stroke risk in AF?
CHADSVASc
136
What factors predispose to AF?
```
Hypertension
Heart failure
IHD
Valvular heart disease
Thyroid disease
Excess alcohol
Drug misuse
Acutely unwell/periop
```
137
Define paroxysmal AF
Duration less than 7 days
138
Define persistent AF
Duration greater than 7 days
139
Define permanent AF
Duration greater than 7 days and resistant to therapy
140
What is the prevalence of AF?
1% general population
| 10% population over age 80
141
What is the rate in AF?
Can be fast or slow, depends on ventricular response
Irregularly irregular rhythm
142
Where do clots tend to form in AF?
Left atrial appendage
143
What is used for rate control in AF?
Beta blockers
Calcium channel blockers
Digoxin
144
Why is digoxin only used in sedentary patients?
It doesn't allow the heart rate to rise physiologically
145
When is cardio version used in AF?
If acute AF is causing cardiovascular compromise
146
How can you reduce the frequency of episode of paroxysmal AF?
```
Beta blockers
Class Ic (flecainide or propafenone)
Class III (amiodarone)
```
147
What is consolidation?
Replacement of alveolar air by fluid, cells, pus or other material
148
What is air bronchogram?
Air-filled bronchus surrounded by fluid-filled or solid alveoli
149
What is the clinical equivalent of air bronchogram?
Bronchial breathing
150
In what conditions do you get air bronchogram?
Consolidation eg pneumonia
Collapse
Pulmonary oedema
151
In acute asthma, what monitoring should be done?
Continuous pulse of, ECG and blood pressure
152
What is the medical management of acute asthma?
```
Nebulised salbutamol 5mg (every 15-30min)
Oral prednisolone 40mg
Nebulised Ipratropium 0.5mg (4-6hrly)
IV magnesium sulfate
IV aminophylline (senior)
```
153
What are the main inflammatory cells involved in asthma?
Eosinophils and mast cells
154
What are the main inflammatory cells involved in COPD?
Neutrophils
155
What is the most effective bronchodilator in COPD?
Anticholinergics eg Ipratropium bromide
156
When is steroid treatment beneficial in COPD?
Acute exacerbation a
157
What is step 1 for asthma treatment?
Inhaled short acting beta 2 agonist PRN
158
What is step 2 of asthma management?
Add inhaled steroid 200-800mcg/day
| Often start at 400mcg
159
What is step 3 of asthma management?
1. Add long acting beta 2 agonist
| 2. Increase steroid dose up to 800mcg as appropriate
160
What is step 4 of asthma management?
Consider trial of...
A) increase steroid up to 2000mcg/day
B) add a 4th drug e.g. Leukotriene receptor antagonist, theophylline or beta 2 agonist tablet
161
When is step 5 of asthma management appropriate?
Continuous or frequent use of oral steroids
162
What is step 5 of asthma management?
Daily steroid tablet at lowest dose providing adequate control
Maintain high dose (2000mcg/day) inhaled steroid
Refer to specialist care
163
What are the common precipitating factors for asthma?
```
Allergens
Viral infections
Occupational factors eg solder fumes, flour
Drugs eg beta blockers and NSAIDs
Others eg cold air, exercise, emotion
```
164
Define type 2 respiratory failure
PaO2 6.5kPa
165
What is the mechanism behind type 2 respiratory failure?
Ventilatory failure
166
What are the pulmonary causes of type 2 respiratory failure?
```
COPD
Asthma
Fibrosis
OSA
Pneumonia
```
167
What may cause a decreased respiratory drive?
CNS trauma
Sedative drugs
Trauma
168
What neuromuscular problems can cause type 2 resp failure?
Cervical cord lesions
Guillain-Barre
Myasthenia gravis
Diaphragm paralysis
169
What is the underlying reason for type I respiratory failure?
V/Q mismatch
170
What are the causes of type I resp failure?
PE
Pulmonary oedema
Pneumonia
Acute severe asthma
171
When is CPAP used in type I resp failure?
When pO2 remains less than 8kPa despite 60% O2
172
What is the difference between CPAP and NIV?
CPAP is constant pressure and so not a form of ventilators support
NIV has 2 pressures (one inspiratory and one expiratory) and is a form of ventilatory support
173
What are the clinical features of hypoxia?
Cyanosis
Confusion
Restlessness and agitation
Shortness of breath
174
What are the clinical features of hypercapnia?
```
Drowsiness
Tremor
Headache
Confusion
Peripheral vasodilatation
Papilloedema
Tachycardia
Bounding pulse
```
175
What are the risk factors for PE?
```
Surgery
Obs: late pregnancy, C-section
Lower limb fracture
Varicose veins
Malignancy
Reduced mobility
Previous proven VTE
```
176
When is D dimer increased?
```
Thrombosis
Inflammation
Post-op
Infection
Malignancy
```
177
What are the symptoms of PE?
Pleuritic chest pain
Shortness of breath
Haemoptysis
178
What are the ECG signs of PE?
```
Sinus tachy
RV strain pattern in V1-3
Right axis deviation
RBBB
AF
Deep S wave in I
Q waves in III
Inverted T waves in III
```
179
What are the clinical signs of PE?
```
Pyrexia
Cyanosis
Tachypnoea
Tachycardia
Hypotension
Raised JVP
Pleural rub
Pleural effusion
```
180
How do you manage a PE?
```
ABCDE approach
Oxygen if hypoxia
Fluid rests if hypotensive
Morphine 5-10mg + metoclopramide 10mg
Thrombolysis if massive PE
HEPARIN: dalteparin 17,000units
```
181
When is thrombolysis considered for PE?
Hypotensive
Imminent cardiac arrest
Signs of R heart strain on CT/echo
Check for contraindications
182
What are the absolute contraindications to thrombolysis?
Hemorrhagic stroke/ischaemic stroke
183
What are the relative contraindications to thrombolysis?
Warfarin
Pregnancy
Advanced liver disease
Infective endocarditis
184
What are the complications of thrombolysis?
```
Bleeding
Hypotension
Intracranial haemorrhage
Stroke
Reperfusion arrhythmias
Systemic embolisation/thrombus
Allergic reaction
```
185
What are the causes of pneumothorax?
```
Spontaneous
Chronic lung disease
Infection
Traumatic
Carcinoma
Connective tissue disorders
```
186
What does a pneumothorax look like on CXR?
Area with no lung markings lateral to the edge of the collapsed lung
187
What are the symptoms of pneumothorax?
Asymptomatic
Sudden onset sob
Pleuritic chest pain
Sudden deterioration of chronic disease
188
What are the signs of pneumothorax?
Reduced expansion
Hyper-resonance to percussion
Diminished breath sounds
Deviation of trachea in tension pneumothorax
189
When should you aspirate a pneumothorax?
If SOB, and rim of air>2cm on CXR
190
How should you manage a secondary pneumothorax?
Chest drain if: SOB, >50y, rim of air >2cm on CXR
IF criteria not met, aspirate and admit for 24h
191
Why is tension pneumothorax a medical emergency?
Pushes the mediastinum into the opposite hemithorax which compresses the great veins
Leads to Cardiorespiratory arrest if the air is not removed quickly
192
How do you manage a tension pneumothorax?
Don't delay with a CXR
Wide bore needle & syringe into 2nd IC space, midclavicular line
Remove plunger to allow trapped air to bubble through syringe, using saline as a water seal
Alternatively, large bore cannula in same location
193
What are Light's criteria?
Used if protein in pleural effusion is 25-35g/L
It is an exudate if any 1 of the following are true:
Pleural fluid : serum protein ratio>0.5
Pleural fluid : serum LDH ratio>0.6
Pleural fluid LDH >2/3 upper limit of normal
194
What are the causes of an exudative pleural effusion?
Infection
Inflammation
Malignancy
195
What are the underlying causes of a transudative pleural effusion?
Raised venous pressure
Hypoproteinaemia
196
What are the causes of raised venous pressure?
Cardiac failure
Constrictive pericarditis
Fluid overload
197
What are the causes of Hypoproteinaemia?
Cirrhosis
Nephrotic syndrome
Malabsorption
198
What are the clinical signs of pleural effusion?
```
Decreased expansion
Stony dull percussion
Reduced breath sounds
Bronchial breathing above effusion
Tracheal deviation
Signs of associated disease
```
199
What are the symptoms of pleural effusion?
May be none
| May be SOB and have pleuritic chest pain
200
When is a chest drain indicated in pleural effusion?
If symptomatic
| Don't insert drain until the diagnosis is well-established
201
What are the signs of pleural effusion on CXR?
Blunting of costophrenic angles
| Meniscus sign
202
Where should a pleural effusion be aspirated?
One or two IC spaces below the top of the effusion
| Just above the upper rib border
203
What are the criteria for scoring pneumonia severity?
Confusion
Urea > 7mmol/L
Resp rate > 30
BP
204
What does clear and colourless sputum indicate?
Chronic bronchitis
205
What does yellow-green sputum indicate?
Pulmonary infection
206
What does red sputum indicate?
Haemoptysis
207
What does black sputum indicate?
Smoke or coal dust
208
What does frothy white-pink sputum indicate?
Pulmonary oedema
209
What are the three most common causative organisms in CAP?
Strep pneumoniae
Haemophilus influenzae
Mycoplasma pneumoniae
210
What are the three most common organisms causing hospital-acquired pneumonia?
Gram negative bacilli
Staph aureus
Pseudomonas
Klebsiella
211
What antibiotics are used to treat CAP?
Amoxicillin
Clarithromycin
Doxycycline
212
What are the symptoms of pneumonia?
```
Fever
Rigors
Malaise
Anorexia
Dyspnoea
Cough
Purulent sputum
Haemoptysis
Pleuritic chest pain
```
213
What are the signs of pneumonia?
```
Pyrexia
Cyanosis
Confusion
Tachypnoea
Tachycardia
Hypotension
Pleural rub
Consolidation: decreased expansion, dullness to percussion, increased tactile vocal fremitus, bronchial breathing
```
214
What are the clinical signs of consolidation?
Reduced chest expansion
Dullness to percussion
Increased tactile vocal fremitus
Bronchial breathing
215
What are the potential complications of pneumonia?
```
Pleural effusion
Empyema
Lung abscess
Resp failure
Septicaemia
Brain abscess
Pericarditis
Myocarditis
Cholestatic jaundice
```
216
What is the prevalence of angina?
In over 55s:
Men 12%
Women 5%
217
Describe angina
Heavy/crushing central chest pain
Pain on exertion
Relieved by rest of GTN spray
218
What is CCS class I angina?
Angina only during strenuous or prolonged physical activity
219
What is CCS class 4 angina?
Inability to perform any activity without angina - angina at rest
220
What are the non-modifiable risk factors for ischaemic heart disease?
Age
Male
Family history
Personal history of IHD
221
What is primary prevention?
Control or reversal of risk factors to prevent disease occurring
222
What factors exacerbate angina?
Cold
Exertion
Large meals
Stress
223
Why can angina cause breathlessness?
Ischaemic may lead to LV systolic impairment
Causes increased pressure in pulmonary vasculature
Leads to SOB
224
What is stable angina?
Pain brought on by exertion and relieved by rest or GTN spray, within 10 minutes
225
What things would make you worry a patient's angina was unstable?
Increase in severity or duration of symptoms
| Reduction of threshold for symptoms
226
What functional tests are used for angina?
Exercise ECG
Perfusion scanning
Stress ECHO
Perfusion MRI
227
What symptomatic therapies are used for angina?
Nitrates
Calcium channel blockers
Potassium channel blockers
228
Give an example of a calcium channel blocker used for angina
Amlodipine
229
How do beta blockers work in angina?
Reduce sympathetic stimulation of myocardium and reduce work load
230
How does aspirin work?
Anti platelet
| Reduces platelet function to prevent progression of atherosclerotic plaques
231
When is PCI used in angina?
For pain uncontrolled by medical therapy
232
Describe PCI
Balloon used to force open narrowed coronary artery lumen
Squeezes the fatty plaque to one side
A stent is inserted to keep the plaque in position and maintain the lumen
233
What vessel is used for CABG?
Long saphenous vein or
| Internal mammary artery
234
What is the incidence of STEMI?
5 people per 1000 in the UK per year
235
Who is at increased risk of silent MI?
Elderly
Heart transplant patients
Diabetics
236
What comprises acute coronary syndrome?
Unstable angina
NSTEMI
STEMI
237
What is the pathogenesis of acute coronary syndrome?
Plaque becomes unstable
Fissures and exposes underlying plaque to flowing blood
Stimulates platelet aggregation and clotting cascade
Clot forms and acutely obstructs the artery
Sudden reduction in blood flow to myocardium
238
What is the pathogenesis of MI?
When the ischaemia from a clot concluding a coronary artery is not reversed within 10 minutes, myocardial necrosis results (MI)
239
Why does unstable angina require admission?
It is potentially pre-myocardial infarction
240
What are the diagnostic criteria for MI?
Clinical history suggestive of ACS
| Evidence of cardiac myocyte death - increase in serum troponin I or T
241
Why do you do a CXR in ACS?
To excuse pulmonary oedema or aortic dissection
242
What are the ECG findings during an MI?
Immediate: hyper acute T waves
ST elevation
T wave inversion
Pathological Q waves
243
What leads does an anterior MI present in?
V1-4 (ST elevation)
244
What vessel is affected if there is ST elevation in leads V1-4?
Left anterior descending
245
What part of the myocardium is affected if there is ST elevation in leads V3 and 4?
Septal LV (LAD)
246
What vessel is affected when the lateral LV is infarcted?
Left circumflex
247
What leads would show a posterior MI?
V 7-9
248
What leads show an infarction in the right ventricle? What artery is occluded?
V1
RCA
249
How do you differentiate between NSTEMI and unstable angina?
Cardiac bio markers raised in MI but not in unstable angina
Ie troponin I/T and CK
250
What immediate medications are given for an NSTEMI?
Aspirin 300mg
Clopidogrel
LMWH
IV nitrates and opiates
251
What secondary prevention is given for NSTEMI?
Statin
Beta blocker
ACE inhibitor
252
Why is a STEMI more serious than an NSTEMI?
More likely to present with complications due to larger area of myocardium involved
253
What is the mortality of STEMI?
4.4% for patients reaching hospital
30% of patients die before reaching hospital
254
What is the immediate management of ACS?
Opiates (morphine 5mg + metoclopramide 10mg)
Nitrates
Aspirin 300mg
Oxygen via reservoir mask
255
What oxygen therapy is unsuitable for COPD patients and why?
Reservoir mask
Simple face mask
High FiCO2 which is bad for patients who already retain CO2
256
Define pulmonary hypertension
Mean systolic pressure in pulmonary artery >25mmHg at rest or >30mmHg during exercise
257
What is the most common cause of primary pulmonary hypertension?
Pulmonary embolism
258
What causes secondary pulmonary hypertension?
Gradual changes in pulmonary circulation as a result of chronic diseases of the lung or heart
Eg COPD or congestive cardiac failure
259
Define cor pulmonale
When chronic hypoxic lung disease causes pulmonary hypertension and right heart failure
260
What are the signs of cor pulmonale?
```
Central cyanosis
Ankle oedema
Raised JVP
Atrial gallop rhythm
Loud pulmonary second sound
Tricuspid regurgitation
```
261
What does a loud P2 indicate?
High pressure in the pulmonary artery causing forceful closure of the pulmonary valve
262
Why may patients with cor pulmonale complain of chest pain?
Due to right ventricular hypertrophy which increased myocardial oxygen demand
263
Why may cor pulmonale patients experience syncope?
Inability to increase cardiac output during exercise
264
What are the signs of right ventricular hypertrophy?
Parasternal heave
265
What are the signs of right heart failure?
Additional S3 - mid-diastolic gallop
| S4 heart sound - pre-systolic gallop caused by a poorly compliant hypertrophied RV
266
What are the clinical signs of tricuspid regurgitation?
Left para sternal pan systolic murmur
Visible S waves in JVP
Pulsatile hepatorenal you
267
What is the only non-invasive test that can measure pulmonary arterial pressure?
Echo
268
How do you take a history of syncope?
```
FAINTS:
Frequency
Associated symptoms
Initiating events
Nature of recovery
Timing
Speed of onset
```
269
Give a cause of cardiac syncope
LV outflow obstruction e.g. Aortic stenosis
270
What is neurocardiogenic syncope?
A stimulus causes an abnormal autonomic reflex leading to hypotension, tachycardia or both
= Vasovagal
271
Describe cardiac syncope
Sudden onset, rapid recovery
May be brought on by exercise
Associated with chest pain and palpitations
272
What is the underlying pathophysiology of bradycardia?
Conditions reducing the automaticity or causing infiltration or fibrosis of the conduction tissues
273
What is sinus node disease also called?
Sinus mode dysfunction
| Sick sinus syndrome
274
What arrhythmias can result from sick sinus syndrome?
```
Sinus pauses
Sinus tachy or Brady
Atrial tachycardia
Chronotropic incompetence
Atrial fibrillation
```
275
What is chronotropic incompetence?
Heart rate is normal at rest, but fails to rise in response to exercise or physiological stress
276
What ECG factors indicate severity in complete heart block?
Slower ventricular escape rate
Broader QRS
Both mean the rhythm is more unstable
277
What is Virchow's triad?
Abnormality of vessel wall
Abnormality of blood components
Abnormality of blood flow
278
What is the mechanism of action of warfarin?
Competitively antagonises reduction of oxidised Vit K
| So vit K dependent clotting factors cannot be synthesised
279
How can warfarin be reversed and why?
Vitamin K
| Because warfarin is a competitive inhibitor, so can be displaced
280
What are the vitamin K dependent clotting factors?
2, 7, 9 and 10
281
Why does warfarin have a slow onset of action?
It takes time for the clotting factors already in the system to be removed
282
Why does warfarin have to be stopped 3 days prior to any surgery?
It has a slow offset of action, as there has to be time for new clotting factors to be synthesised
283
How is warfarin metabolised?
CYP450 system
284
How is warfarin monitored?
INR
| International normalised ratio - time taken for clotting compared to average for specific age and gender
285
What is the target INR for warfarin therapy in AF?
2.0 - 3.0
286
What is the target INR for warfarin therapy in mechanical prosthetic heart valves?
2.5 - 4.5
287
What are the side-effects of warfarin?
Haemorrhage: GI, epistaxis, intracranial, excess bruising
| Pregnancy - teratogenic
288
How is warfarin reversed?
Vitamin K
| Fast reversal: fresh frozen plasma (in emergency)
289
What is the mechanism of action of heparin?
Acts on anti-thrombin III to inhibit thrombin and factor Xa
290
How does unfractionated heparin work?
Binds to Anti-thrombin III
| Inhibits thrombin AND factor Xa
291
How does low molecular weight heparin work?
Inhibits only factor Xa (no inhibition of thrombin)
292
Why is heparin never administered IM?
Would cause bleeding into the muscle
293
Why is heparin administered IV or subcutaneously?
Poor GI absorption
294
How is the dose and effect of heparin monitored?
APTT - activated partial thromboplastin time
295
Why are LMWHs used for prophylaxis of VTE?
They are as effective as unfractionated, but have a lower risk of heparin-induced thrombocytopenia
296
How is heparin used in treatment of VTE?
Initial management before warfarin to cover whilst warfarin loading is achieved
297
Why is heparin preferred to warfarin during surgery?
Heparin has a quicker offset of action, so can be stopped quickly if severe haemorrhage occurs
298
What are the side effects of heparin?
Haemorrhage eg intracranial, injection sites, GI, epistaxis
| Heparin-induced thrombocytopenia
299
How is heparin reversed?
Protamine sulfate
Causes dissociation of the heparin-AT III complex and binds irreversibly to heparin
300
How does aspirin work?
It is a COX inhibitor and inhibits production of thromboxane A2 to prevent platelet aggregation
301
What is the function of thromboxane A2?
Released from activated platelets to promote further platelet aggregation/vasoconstriction
302
How does furosemide work in heart failure?
Reduces ECV to reduce oedema
| Venodilatory effect to reduce after load on the heart
303
What is the mechanism of action of furosemide?
Inhibits NKCC2 channel in thick ascending limb of loop of henle
304
Why are thiazides used to prevent renal calculi?
They promote calcium reabsorption to limit calcium loss
305
Give an example of a potassium sparing diuretic
Amiloride
306
How does amiloride work?
Acts on ENaC in late DCT/CD
Prevents Na+ reabsorption
No effect on K+ reabsorption
307
How does Spironolactone work?
Inhibits action of aldosterone on mineralocorticoid receptors
Reduces expression of Na+/K+-ATPase and ENaC
308
What are the side effects of Spironolactone?
Hyperkalaemia
| Gynaecomastia
309
What are the indications for Spironolactone?
Heart failure
Hypertension
Liver failure
Conn's syndrome
310
What are the side effects of thiazides?
Gout
| Erectile dysfunction
311
Which diuretics interact with digoxin to cause hypokalaemia?
Thiazides
| Loop diuretics
312
Define diuretic resistance
Patient unable to meet their clinically required de congestive targets despite large doses of loop diuretics
313
What drugs are potentially nephrotoxic?
```
ACE inhibitors
Amino glycosides eg gentamicin
Penicillins
Ciclosporin A
Metformin
NSAIDs
```
314
In a 40 year old Caucasian lady, what is the first step of anti-hypertensive therapy?
ACE inhibitor
315
What is step 2 of anti-hypertensive therapy?
ACE inhibitor + calcium channel blocker
Or
ACE inhibitor + thiazides
316
What is step 3 of anti-hypertensive therapy?
ACE inhibitor + calcium channel blocker + thiazide diuretic
317
In a 40 year old Afro Caribbean lady, what is the first anti-hypertensive agent you would use?
Calcium channel blocker
| Or thiazide diuretic
318
What is the mechanism of action of losartan?
Angiotensin receptor blocker
| Inhibits vasoconstriction and aldosterone stimulation
319
Give 2 examples of dihydropyridines. What is their mechanism of action?
Nifedipine
Amlodipine
L-type calcium channel blockers mainly acting on peripheral vascular smooth muscle
320
What are the side effects of dihydropyridines?
Sympathetic activation - tachycardia, palpitations, flushing, sweating, throbbing headache
Oedema
Gingival hyperplasia
321
What is the mechanism of action of ramipril?
ACE inhibitor, preventing formation of angiotensin II
322
What are the side effects of ramipril?
Dry cough
Angioedema
Renal failure
Hyperkalaemia
323
What is the mechanism of action of verapamil?
Calcium channel blocker
Class IV anti-arrhythmic
Peripheral vasodilation, decreased cardiac preload and myocardial contractile th
324
What are the side effects of verapamil?
Constipation
Risk of bradycardia
Can worsen heart failure due to decreased contractility
325
What is the mechanism of action of doxasozin?
Alpha receptor blocker
| Reduces contractile effects of noradrenaline on vascular smooth muscle to reduce TPR
326
What are the side effects of doxasozin?
```
Postural hypotension
Dizziness
Headache
Fatigue
Oedema
```
327
How do calcium channel blockers affect the pacemaker potential?
Reduce calcium ion influx in upstroke of action potential
| Blocking these channels means it takes longer to depolarise/reach peak
328
How do beta agonists affect the cardiac pacemaker potential?
Increase slope of funny current
329
How does adenosine affect the pacemaker potential?
Muscarinic agonist
| Decreases slope of funny current to slow HR
330
How do class I anti-arrhythmic agents work?
Sodium channel blockers
Bind to Na+ channels and inhibit AP propagation in myocytes
Affect phase 0 of depolarisation
331
What are class II anti-arrhythmic agents?
Beta blockers
332
What are the effects of beta blockers on the heart?
Negative chronotropic and inotropic
333
What drug is used to treat WPW syndrome?
Flecainide
334
Give an example of Class Ib anti-arrhythmics and its mechanism of action
Lidocaine
Used for acute VT and VF
Affects fast-beating/ischaemic tissue, as it is fast-binding/offset
335
What are class III anti-arrhythmic agents?
Potassium channel blockers
336
How does amiodarone work?
```
Potassium channel blocker
Increases refractory period
Slows speed of AV conduction
Increases threshold for AP firing
Effective for most arrhythmias
```
337
What is sotalol?
Potassium channel blocker
338
What are class IV anti-arrhythmic agents?
Calcium channel blockers
Eg verapamil and diltiazem
339
How does adenosine work?
Binds to A1 receptors in AVnode
Activates K+ currents in AV and SA nodes to hyper polarise cardiac tissue and decrease heart rate
Causes transient temporary heart block
340
What is adenosine used to treat?
SVT
341
How does digoxin work?
Enhances vagus nerve activity
| Slows AV conduction and heart rate
342
How does atropine work?
Selective muscarinic antagonist
| Blocks bagel activity to speed AV conduction and heart rate
343
What are the potential complications of pneumonia?
```
Pleural effusion
Empyema
Lung abscess
Respiratory failure
Septicaemia
Brain abscess
Pericarditis
Myocarditis
Cholestatic jaundice
```
344
Define COPD
Fixed airflow obstruction
Minimal or no reversibility with bronchodilators
Slowly progressive and irreversible deterioration in lung function, causing worsening symptoms
345
What are the signs of COPD?
```
Increased respiratory rate
Barrel chest
Pursed lip breathing
Quiet breath sounds and wheeze
Signs of cor pulmonale and CO2 retention
```
346
Define mild COPD
FEV1 > 80% predicted
347
Define moderate COPD
FEV1 50-80% predicted
348
Define severe COPD
FEV1 30-49% predicted
349
Define very severe COPD
FEV1
350
What is stage 1 on the MRC dyspnoea scale?
Only short of breath with strenuous exercise
351
What is stage 3 on the MRC dyspnoea scale?
Walks slower than contemporaries or has to stop for breath on level ground
352
What is stage 4 on the MRC dyspnoea scale?
Stops after 100 m or a few minutes
353
What is stage 5 on the MRC dyspnoea scale?
Too breathless to leave the house or breathless when dressing
354
What is the BODE grading for COPD?
BMI
Obstruction (FEV1)
Dyspnoea
Exercise capacity (6min walk distance)
355
When are inhaled steroids indicated for COPD?
FEV1
356
How do steroids work in COPD?
Reduce frequency of exacerbations but don't slow decline in lung function
357
Name a mucolytic agent used in COPD
Carbocisteine
358
How do you ensure you've got the correct diagnosis in COPD?
Use pulmonary function tests and chest x Ray to assess severity
Ensure there are no other causes for the symptoms
359
What is the outcome of exacerbations in COPD?
Many don't regain the lung function they had before the exacerbation
Frequent exacerbations cause a more rapid decline in lung function
360
Define an acute exacerbation of COPD
Acute increase in symptoms beyond normal daily variation
361
What are the common bacterial causes of COPD exacerbation?
H.influenzae
S.pneumoniae
Moraxella catarrhalis
362
What are the common viral causes of COPD exacerbation?
Rhinovirus
Influenza
Coronavirus
Adenovirus
363
What are the differential diagnoses to COPD exacerbation?
PE
Pneumothorax
Pulmonary oedema
364
What are the symptoms of COPD exacerbation?
Increased cough/sputum production/purulence
Increased shortness of breath and wheeze
Chest tightness
Fluid retention
365
How do you assess severity of an acute exacerbation of COPD?
```
Resp rate
Sats
Air entry
Tachycardia
Peripheral perfusion and BP
Conscious level
Mental state
```
366
What initial investigations would you order in a suspected acute exacerbation of COPD?
Blood gas
CXR
ECG
Blood: WCC, CRP, UEs, FBC etc
367
What O2 therapy would you give in an acute exacerbation of COPD?
24-35% via a Venturi
| Aiming for sats of 88-92%
368
What nebs would you give in an acute exacerbation of COPD?
Salbutamol 2.5 - 5 mg
| Ipratropium 500micrograms
369
When do you use NIV in COPD exacerbation?
pH
370
When are antibiotics indicated in COPD exacerbation?
Purulent sputum
Pyrexia
Raised CRP
New changes on CXR
371
When are oral steroids indicated for COPD exacerbation?
All exacerbations requiring admission, or if they are significantly more breathless than usual
372
What steroids would you prescribe in COPD exacerbation?
Prednisolone 30mg per day for 1-2 weeks
373
What are the side effects of aminophylline?
Tachycardia
| Nausea
374
What are the complications of COPD?
```
Polycythaemia
Respiratory failure
Lung carcinoma
Cor pulmonale
Pneumothorax
Malnutrition
Depression
```
375
What are the signs of COPD on chest X-Ray?
```
Hyperinflation
Flat hemidiaphragms
Large central pulmonary arteries
Decreased peripheral vascular markings
Bullae
```
376
What may the ECG show in COPD?
Right atrial and ventricular hypertrophy due to cor pulmonale
377
What are the indications for surgery in COPD?
Recurrent pneumothorax
Isolated bulbous disease
Lung volume reduction surgery
378
What conservative measures help in COPD?
```
Smoking cessation
Exercise
Treat poor nutrition/obesity
Influenza and pneumococcal vaccination
Pulmonary rehabilitation
Palliative care
```
379
What is symbicort made up of?
Budesonide and formoterol
380
What are the majority of deaths in COPD patients due to?
Heart failure
381
What are the clinical signs of cor pulmonale?
```
Cyanosis
Tachycardia
Raised JVP
RV heave
Loud S2
Pansystolic murmur of tricuspid regurgitation
Hepatomegaly
Oedema
```
382
What are the symptoms of cor pulmonale?
Dyspnoea
Fatigue
Syncope
383
How does COPD cause cor pulmonale?
High pressure in pulmonary arterial system means RV has to work harder to push blood into pulmonary system
RV hypertrophied and eventually fails
384
Which other lung diseases cause cor pulmonale?
Bronchiectasis
Pulmonary fibrosis
Severe chronic asthma
Lung resection
385
What are the symptoms of pulmonary hypertension?
```
Shortness of breath
Dizziness and fainting
Leg swelling
Fatigue
Non-productive cough
Angina
```
386
How does pulmonary venous hypertension present?
Orthopnoea
| Paroxysmal nocturnal dyspnoea
387
What are the clinical signs of pulmonary hypertension?
Split S2
Loud S2 due to pulmonary valve closure
Right ventricular (para sternal) heave
Signs of systemic congestion due to right heart failure
388
Describe the pathogenesis of pulmonary hypertension due to chronic lung disease
Hypoxic pulmonary vasoconstriction (initially a protective response aiming to direct blood away from damaged areas of lung not containing O2)
Widespread and prolonged damage means vasoconstriction occurs across a large portion of the pulmonary vascular bed
389
What are the general clinical features of interstitial lung disease?
```
Shortness of breath on exertion
Non-productive paroxysmal cough
Abnormal breath sounds
Abnormal CXR / HR CT
Restrictive spirometry
Low DLCO
```
390
What are the pathological features of interstitial lung disease?
Fibrosis and remodelling of the interstitium
Chronic inflammation
Hyperplasia of type II epithelial cells/pneumocytes
391
Why is gas transfer reduced in interstitial lung disease?
Scarring and thickening of tissue around alveoli makes it difficult for oxygen to diffuse into the blood
392
What are the categories of causes of interstitial lung disease?
Occupational
Environmental
Systemic
Drugs
393
What are the types of interstitial lung disease with no known cause?
Idiopathic pulmonary fibrosis (=usual interstitial pneumonia)
COP - cryptogenic organising pneumonia
LIP - lymphocytic interstitial pneumonia
394
What are the general symptoms of interstitial lung disease?
```
Dry cough
Exertional dyspnoea
Malaise
Weight loss
Arthralgia
```
395
What are the classical clinical findings in interstitial lung disease?
Clubbing
Cyanosis
Reduced chest expansion
Fine inspiratory crepitations (like pulling Velcro)
May have features of pulmonary hypertension
396
What is the commonest form of interstitial lung disease?
Idiopathic pulmonary fibrosis
397
What are the complications of IPF?
Respiratory failure
| Increased risk of lung cancer
398
What is the management of IPF?
```
Oxygen
Pulmonary rehabilitation
Opiates
Palliative care
Clinical trials? Lung transplant?
```
399
What is the prognosis for IPF?
50% 5 years survival
400
What is extrinsic allergic alveolitis?
= hypersensitivity pneumonitis
| Hypersensitivity reaction to allergens inhaled
401
What are the different types of extrinsic allergic alveolitis?
Acute
| Chronic
402
What are the symptoms of acute extrinsic allergic alveolitis?
```
Fever
Rigors
Myalgia
Dry cough
Dyspnoea
Inspiratory crackles
```
403
What is the management of acute EAA?
Remove allergen
Give 35-60% O2
Oral prednisolone 40mg/24hr
404
What are the features of chronic EAA?
Increased SOB especially on exertion
Weight loss
Type I respiratory failure
Cor pulmonale
405
What are the histological features of sarcoidosis?
Non-caseating granulomas
406
Define bronchiectasis
Abnormal dilation of the bronchi
407
What are the common pathogens in mild bronchiectasis?
H.influenzae
S.pneumoniae
M.catarrhalis
S.aureus
408
What organism is commonly involved in moderate bronchiectasis?
Pseudomonas aeruginosa
409
What is the most common cause of bronchiectasis?
Idiopathic
410
What proportion of cases of bronchiectasis are caused by airways inflammation?
25%
| Eg COPD, ABPA, RA
411
Why do bacteria colonise the lungs in bronchiectasis?
Bronchial dilation and epithelial damage disrupts mucociliary clearance
412
Why do patients develop purulent phlegm in bronchiectasis?
Chronic bacterial infection leads to neutrophil if inflammatory response
Causes increased mucus production and purulent phlegm
413
Why do patients with severe bronchiectasis get airway obstruction?
Inflammation of bronchi also spreads to small airways
414
What are the classic clinical features of bronchiectasis?
Cough
| Daily sputum production
415
What are the additional symptoms of bronchiectasis?
```
Minor haemoptysis
Malodorous breath
Malaise
Fatigue
Shortness of breath on exertion
Wheeze
MSK-type chest pain
```
416
What are the clinical signs of bronchiectasis?
Finger clubbing
Focal creps, usually bi basal
Signs of airway obstruction in severe disease
417
What does CT scanning show in bronchiectasis?
Bronchial dilatation - to a width greater than that of the accompanying vessel
Bronchial wall thickening
418
What further investigations (after CT diagnosis) are required in bronchiectasis?
Pulmonary function testing
Sputum culture
Specific tests for potential causes eg IgG levels
419
What are the management principles for bronchiectasis?
Identify and treat the cause
Improve QoL by minimising sputum production and reducing exacerbation frequency
Maintain/improve pulmonary function
420
How is pulmonary function maintained in bronchiectasis?
Minimise active chronic infection
Reduce frequency and severity of exacerbations
Regular bronchodilator use
421
How can sputum production and frequency of exacerbations be reduced in bronchiectasis?
Self-administered lung clearance techniques
Prolonged ABx course to effectively treat exacerbation
Oral/nebulised prophylactic ABx for severe disease
Long-term azithromycin
422
What are the effects of long-term azithromycin in bronchiectasis?
Anti-inflammatory effects
| Very effective in reducing sputum production and exacerbation frequency
423
What percentage of patients die from their bronchiectasis?
15%
424
What is the incidence of cystic fibrosis?
1 in 2000-3000 newborns
425
What is the genetic defect in cystic fibrosis?
Autosomal recessive in CFTR gene
426
What does the CFTR gene code for?
Transmembrane chloride channel,found in respiratory epithelium, expiring glands and sweat ducts
427
What happens when the CFTR gene is not working properly?
Chloride ion flow across membranes is impaired
Means sodium and water don't move out of the cell
Mucus is inadequately hydrated, forming thick sticky mucus
428
What are the clinical features of cystic fibrosis?
Chronic phlegm production and recurrent infective exacerbations
429
What characteristics of cystic fibrosis are different to non-CF bronchiectasis?
Usually starts in early childhood
Worse in lung apices
Almost always results in fatal respiratory failure due to severe airways obstruction
430
What are the signs of cystic fibrosis?
```
Clubbing
Low BMI
Extensive crepitations in both lungs
Obvious signs of airways obstruction
Poor respiratory function
```
431
What are the extra-pulmonary complications of cystic fibrosis?
Pancreatic insufficiency
Chronic sinusitis
Infertility
Abnormal LFTs
432
What is the diagnostic test for cystic fibrosis?
Measure sweat chloride concentration - increased in CF
433
What are the main principles for cystic fibrosis management?
Regular Physio supported by chest clearance devices
Frequent antibiotics for bronchial infections
Regular use of inhaled beta agonists
434
What prophylactic therapy is used in cystic fibrosis?
Flucloxacillin and azithromycin
435
What is the median age of death in cystic fibrosis?
Mid-40s
436
What is the medical management of anaphylaxis?
High-flow O2
0.5mg adrenaline IM - every 5mins until CVS stable
200mg hydrocortisone IV
10mg chlorpheniramine IV
Salbutamol and adrenaline nebs as required for bronchospasm and laryngeal oedema respectively
437
What are the features of anaphylaxis?
```
Pruritis
Urticaria
Angioedema
Hoarseness
Stridor
Wheeze
```
438
What medications are given for an acute asthma attack?
5mg salbutamol nebs
40mg prednisolone PO
Ipratropium bromide 500ug neb if severe
IV aminophylline if life-threatening
439
How do you manage an exacerbation of COPD?
O2 via Venturi
Nebs: salbutamol and Ipratropium
Prednisolone 30mg stat and OD for 7 days
ABx if raised WCC/CRP or purulent sputum
Consider IV aminophylline
440
When is NIV indicated in exacerbation of COPD?
If type 2 respiratory failure and pH 7.25-7.35
441
Define massive haemoptysis
>240ml in 24hrs
| >100ml/day for consecutive days
442
How do you manage massive haemoptysis?
Lie patient on side of suspected lesion
Oral tranexamic acid for 5 days
Stop NSAIDs, aspirin and anticoagulants
Consider vit K
443
Name a long-acting anti muscarinic agent
Tiotropium
444
What are the ADRs of antimuscarinics?
Dry mouth
Constipation
Cough
Headache
445
Name 2 xanthines
Aminophylline
| Theophylline
446
How do xanthines work?
Block phosphodiesterases to decrease cAMP breakdown and cause bronchodilation
Also have positive chronotropic and inotropic effects, and a diuretic action
447
What are the side effects of aminophylline?
```
Headache
GI upset
Reflux
Palpitations
Dizziness
```
448
What is the therapeutic window of theophylline?
10-20mg/L
449
What are the toxic effects of aminophylline?
Serious arrhythmias
Seizures
Nausea and vomiting
Hypotension
450
Give 3 examples of inhaled glucocorticoids
Beclomethasone
Budesonide
Fluticasone
451
What are the side effects of inhaled steroids?
Cough
Oral thrush
Unpleasant taste
Hoarse voice
452
Give some side effects of systemic steroid use
```
Hyperglycaemia
Psychosis
Insomnia
Indigestion
Mood swings
Diabetes
Osteoporosis
Muscle wasting
Skin thinning
Cushingoid appearance
```
453
Give 2 examples of long-acting beta agonists
Formoterol
| Salmeterol
454
What are the side effects of beta agonists?
```
Tremor
Headache
GI upset
Palpitations
Tachycardia
Hypokalaemia
```
455
Give 2 examples of short-acting beta agonists
Salbutamol
| Terbutaline
456
What questions do you need to ask about a cough?
```
Dry vs productive
Triggers and relieving factors
Associated with eating/dyspepsia
Positional
Nasal secretions
Fever
```
457
What questions do you need to ask about shortness of breath?
```
Exercise tolerance
Triggers/relieving factors
Diurnal variation
Orthopnoea
PND
```
458
What are the presenting complaints for respiratory?
```
Shortness of breath
Chest pain
Wheeze
Cough
Sputum
Haemoptysis
```
459
What social history do you need to include in a respiratory history?
```
Smoking
Occupation
Pets
Recent foreign travel
Immobility
Activities of daily living
Alcohol
```
460
Why can RBBB cause either LAD or RAD?
The LBB contains anterior and posterior fascicles which can both conduct action potentials
461
What do ventricular escape rhythms look like?
Broad QRS because the impulse has to travel further, ie not via the usual fast conducting system
462
What does a regular rhythm in AF mean?
There is an escape rhythm, due to complete heart block (none of the atrial depolarisations are being conducted through to the ventricles)
463
What causes ST elevation?
Acute MI
| Pericarditis
464
What causes ST depression?
Ischaemia
465
Which is a better indicator of coronary artery disease: horizontal ST depression or down-sloping?
Down-sloping: 90% have CAD
| Horizontal: 82% have CAD
466
What is the normal length of the QRS complex?
467
How do you calculate QTc?
QT(ms) / square root of RR (s)
468
What do delta waves signify?
There is an extra circuit conducting electrical signals from the atria to the ventricles
469
How can AF lead to sudden death?
Superconductor, so an extra circuit conducts signals from the atria to the ventricles
Eg WPW
470
What are torsades de pointes?
A form of polymorphic VT
| The depolarisation is twisting on its electrical axis
471
What are the causes of a regular tachycardia with broad QRS complexes?
VT
SVT with aberrancy or BBB
WPW antidromic
472
What are the causes of an irregular tachycardia with broad QRS complexes?
VF
Polymorphic VT
Torsades
Pre-excited AF
473
What are the causes of an irregular tachycardia with narrow QRS complexes?
AF
474
How do you treat tachycardia?
Carotid sinus massage
| Valsalva manoeuvre
475
What are the hallmarks of ventricular tachycardia?
1. VA dissociation
2. Capture beat
3. Fusion beat
476
What are capture beats?
A narrower beat than the broad-complex VT that's going on elsewhere
477
What are fusion beats?
Not as broad/narrow as others. Happen when VT is colliding with the sinus beat
478
What are the ECG features of Wolff-Parkinson White syndrome?
Delta waves
| Short PR interval
479
What are the non-cardiac causes of bradycardia?
```
Sleep
Athletic training
Beta blockers
Amiodarone
Hypothyroidism
Hypothermia
Deranged potassium/calcium/magnesium/sodium
OSA
```
480
What are the cardiac causes of bradycardia?
Sinus node disease (sick sinus syndrome)
Heart block
Atrial fibrillation
Chronotropic incompetence
481
How is Mobitz II treated?
Permanent pacemaker if symptomatic
482
What does complete heart block look like on ECG?
Regular p waves
Regular QRS
But no association between the two
483
What are the symptoms of bradycardia?
```
Palpitations
Light headedness
Dizziness
Collapse
Syncope
```
484
What is the management of bradycardia causing acute cardiac instability?
Transcutaneous pacing (pads)
Transvenous temporary pacing
IV drug infusion eg atropine
485
What is automaticity?
All cells in the heart are able to regularly produce an action potential
Some are more inclined to do so than others (eg SA node)
486
What does a narrow complex tachycardia indicate?
Supra ventricular tachycardia (SVT)
487
What is the most common form of SVT?
AVNRT - atrioventricular nodal re-entry tachycardia
488
What symptoms can tachycardia cause?
```
Palpitations
Shortness of breath
Fatigue
Ischaemic chest pain
Low BP
```
489
What are the vagal manoeuvres used to treat tachycardia?
Valsalva manoeuvre
| Carotid sinus massage
490
What medication is used to treat tachycardia?
Beta blockers
| Calcium channel blockers
491
What drugs are used to treat tachycardia in WPW?
Flecainide
| Amiodarone
492
Why is ventricular tachycardia more malignant than SVT?
It can cause VF which can lead to cardiac arrest and death
493
What does VT look like on ECG?
Regular broad complex tachycardia
VA dissociation
Capture and fusion beats
494
What are the causes of torsades de pointes?
```
Long QT syndrome
Hypokalaemia
Hypomagnaesemia
Amiodarone
Erythromycin
Methadone
```
495
How is VT classified?
Pulsed vs pulse less
Sustained (>30s)
Mono- or polymorphic (QRS appearance consistent or changing?)
496
What are the symptoms of VT?
Palpitations
Syncope
Symptoms of heart failure in sustained VT
497
What is AV dissociation?
Regular P waves and regular QRS complexes, but at different rates
498
When is emergency synchronised DCCV indicated in VT?
Any patient whose condition is compromised eg hypotension or ischaemia
499
What drugs are used to treat VT?
Amiodarone
| Beta blockers
500
How do ICDs work?
Don't reduce the frequency of ventricular arrhythmia, but restore sinus rhythm if arrhythmia occurs
501
What is the myocardium doing in ventricular fibrillation?
There is no coordinated electrical or mechanical activity, so there is no cardiac output
502
Why is VF so dangerous?
There is no cardiac output and it always results in cardiac arrest
503
What are the components of CHADS-VASc?
```
Coronary failure
Hypertension
Age > 75 (2 points)
Diabetes
Previous Stroke or TIA
Vascular disease
Age 65-74
Sex female
```
504
What is used to control rate in AF?
Beta blockers
Calcium channel blockers
Digoxin
505
Who is digoxin prescribed for and why?
Sedentary patients
| Doesn't allow the heart rate to rise physiologically
506
Why are the conditions for DCCV in AF strict?
Risk of inducing stroke
507
What drugs can be used to reduce the frequency of paroxysmal AF?
Beta blockers
Class Ic drugs eg flecainide
Class III drugs eg amiodarone
508
What is decubitus angina?
Angina precipitated by lying flat
509
Define angina
Central chest tightness or heaviness
| Brought on by exertion and relieved by rest
510
What symptoms are associated with angina?
Shortness of breath
Nausea
Sweatiness
Fatigue
511
What is the medical management of angina?
Aspirin
Beta blockers
Nitrates
Long-acting calcium antagonists eg amlodipine 10mg OD
K+ channel activator if still not controlled eg nicorandil
512
What nitrate prophylaxis may be prescribed in angina?
Isosorbide mononitrate 20-40mg BD
513
How effective is aspirin in angina?
Decreases mortality by 34%
514
Define an acute MI
```
Increase then decrease in cardiac biomarkers plus either...
A) symptoms of ischaemia
B) ECG changes of new ischaemia
C) development of pathological Q waves
D) loss of myocardium on imaging
```
515
What is the initial management of ACS?
```
Airway Breathing Circulation
IV access
12-lead ECG
Give:
Oxygen
Nitrates
Aspirin
Morphine + anti-emetic
```
516
When does cardiac troponin peak during an MI?
24-48 hrs
517
What is the target level for cholesterol?
Total cholesterol
518
When is treatment indicated for hypercholesterolaemia?
High CVS risk (smoker, HTN, gender)
Not responsive to conservative measures
Familial hypercholesterolaemia
Coronary, carotid or peripheral artery disease
519
What is the 1st line lipid-lowering therapy?
Statins
520
How do statins work?
HMG-CoA reductive inhibitors - this enzyme is responsible for cholesterol synthesis
521
Why are statins taken at night?
Most cholesterol synthesis occurs overnight, so they have greater effect
522
What are the side effects of statins?
```
Indigestion
Headache
Diarrhoea
Insomnia
Liver injury
Myalgia, myosotis, myopathy
Rhabdomyolysis
```
523
What are the contraindications to statins?
Severe liver or renal disease
Myopathy
Pregnancy or breast-feeding
524
What are the second line lipid-lowering agents?
Fibrates
525
How do fibrates work?
Increase lipoprotein lipase activity by activating PPAR
| Increases lipid metabolism and lowers LDL and triglycerides
526
What are the side effects of fibrates?
Indigestion
Myosotis
Rash
Anaemia
527
How does ezetimibe work?
Brush border lipase inhibitor
| Inhibits uptake of dietary cholesterol from the gut at the brush border epithelium, so reducing plasma LDL levels
528
How does colestyramine work?
Bile acid sequestrant - combines with bile acids in intestines to cause them to be excreted in faeces
Increases oxidation of cholesterol to form bile acids, increasing the activity of HMG-CoA reductase to reduce circulating LDL
529
What are the side effects of colestyramine?
Itching
Diarrhoea
Abdominal pain
Constipation
530
How does heart failure present?
```
Shortness of breath
Fatigue and weakness
Nocturia
Cough
Epi gastric discomfort
Anorexia
```
531
What are the causes of shortness of breath in heart failure?
Pulmonary oedema
Impaired skeletal muscle function
Depressed respiratory muscle function
Reduced lung function
532
What different types of dyspnoea can heart failure present with?
Exertional shortness of breath
Orthopnoea
Paroxysmal nocturnal dyspnoea
533
Explain the process of orthopnoea in heart failure
Central blood volume increases when the patient is lying flat, which the failing heart can't cope with, leading to pulmonary oedema
534
What is NYHA Class I?
Asymptomatic during normal activity
535
What is NYHA Class II?
Mild symptoms during normal activity
536
What is NYHA Class III?
Marked limitation to normal activity, comfortable only at rest
537
What is NYHA Class IV?
Symptoms at rest
538
Why may patients get a cough with pink, frothy sputum in heart failure?
Pulmonary oedema
539
Why may patients get a dry, nocturnal cough in heart failure?
Bronchial oedema/cardiac asthma
540
What does the pulse feel like in heart failure?
Rapid, weak and thready
541
What does palpation of the chest reveal in heart failure?
LV enlargement causing a downward and laterally displaced apex beat
Diffuse apex beat indicates severe LV dysfunction
542
What does the heart sound like in heart failure?
Gallop rhythm - 3rd heart sound and tachycardia
543
What valvular lesion can heart failure cause?
```
Mitral regurgitation (functional)
Due to LV dysfunction
```
544
What are the signs of heart failure on chest X-Ray?
```
Alveolar oedema
Kerry B lines
Cardiomegaly
Dilated prominent upper lobe vessels
Pleural Effusion
```
545
What is the conservative management of heart failure?
```
Low level exercise
Low salt diet
Smoking cessation
Education
Vaccination
```
546
What are the main drugs used in heart failure?
Diuretics - furosemide
ACE inhibitors
Beta blockers
Spironolactone
547
What dose of furosemide should you start at in heart failure?
40mg
| Titrate up as needed
548
Why are beta blockers used in heart failure?
Catecholamine levels are high in heart failure (sympathetic activation)
549
How can the patient help decide how effective diuretics are in heart failure?
Monitor their own weight and degree of breathlessness
550
How does weight help decide diuretic dose in heart failure?
Weight gain - increase dose
| Weight loss - decrease dose
551
How do nitrates work in heat failure?
Veno- and arteriolar dilators so reduce load on the heart
552
How does digoxin work?
Cardiac glycoside
Inhibits sodium-potassium pump in sarcolemma cell membranes to reduce calcium transport out of the cell
Digoxin thus increases intracellular calcium and is positively inotropic
At AV node: increased calcium prolongs refractory period to decrease AV node conduction and is negative chronotropic
553
What are the signs of digoxin toxicity?
Bradycardia, AV block or sinus arrest
Nausea and vomiting
Xanthopsia
554
When are bi ventricular devices indicated for heart failure?
Class III or IV
| Ejection fraction
555
What 4 processes can lead to pulmonary oedema?
Increased afterload (raised LA pressure)
Increased preload (too much fluid)
Decreased oncotic pressure
Leaky vessels
556
What is the most common cause of increased LA pressure?
LV diastolic failure
557
What are the causes of raised LA pressure?
```
LV diastolic or systolic failure
Hypertension
Aortic stenosis
Mitral regurgitation
Mitral stenosis
Aortic regurgitation
Atrial fibrillation
VT
Left atrial myxoma
```
558
How does malignant hypertension present?
One of...
A) pulmonary oedema
B) papilloedema
C) stroke
559
What are the causes of malignant hypertension?
Phaeochromocytoma
Conn's syndrome
Cushing's syndrome
560
Why are beta blockers useful in angina?
Slowing the heart rate makes diastole longer, giving more time for the coronary arteries to be perfused and hence reducing the ischaemia
561
How do IABPs work?
1. Suddenly deflates at the beginning of systole to decrease the afterload and increase cardiac output
2. Beginning of diastole: inflates and increases coronary perfusion
562
How do you treat acute pulmonary oedema?
```
O2 60-100%
Furosemide 80mg IV
Morphine 5-10mg IV
Metoclopramide 10mg IV
Nitrates: GTN or buccal
CPAP
```
563
How does CPAP work in acute pulmonary oedema?
Increases pressure in alveoli to force water out
| Works quickly and is safe
564
How do morphine and metoclopramide work in pulmonary oedema?
Anxiolytics - decrease the sympathetic drive
565
When should you NOT give nitrates?
Severe aortic stenosis - further decreases the blood pressure and can kill!
566
What is the typical presentation of acute pulmonary oedema?
```
Pale
Increased resp rate
Sat up
Tachycardic
Hypertensive
Sats 95%
Clammy, distressed and sweaty
```
567
Why is preload increased in heart failure?
Sodium and water retention leading to increased ECV
568
Describe the 'vicious cycle' of the physiological response to heart failure
Decreased cardiac output leads to activation of RAAS and the sympathetic nervous system
This causes sodium and water retention, and vasoconstriction, further increasing the work load of the heart causing it to fail even more
569
What are the causes of right heart failure?
Chronic lung disease
PE or pulmonary hypertension
Tricuspid or pulmonary valve disease
570
What are the signs of right heart failure?
```
Increased JVP
Cardiomegaly
Hepatic enlargement
Ascites
Dependent pitting oedema
```
571
What are the signs of left heart failure?
```
Displaced apex beat
Gallop rhythm
Mitral regurgitation features
Basal lung crackles
Pitting oedema
```
572
What is the leading cause of sudden cardiac death in young people?
Hypertrophic cardiomyopathy
573
What is the inheritance of hypertrophic cardiomyopathy?
Autosomal dominant
574
What are the poor prognostic factors for hypertrophic cardiomyopathy?
Younger than 14y or syncope at presentation
| Family history of HCM or sudden cardiac death
575
What is dilated cardiomyopathy associated with?
```
Alcohol
Hypertension
Haemochromatosis
Viral infection
Autoimmune
Peri or post-party's
Thyrotoxicosis
Congenital
```
576
What are the causes of pericarditis?
Viruses, bacteria, fungi
MI
Drugs eg penicillin, isoniazid
Uraemia, RA, SLE
577
How does pericarditis present?
Central chest pain worse on inspiration or lying flat
Relieved by sitting forward
Pericardial friction rub
578
What does the ECG look like in pericarditis?
Concave/saddle-shaped ST elevation
579
How do you treat pericarditis?
Analgesia and treat cause
580
Define pericardial effusion
Fluid accumulation in the pericardial sac
581
Define constrictive pericarditis
When the heart is encased in a rigid pericardium, preventing it from contracting properly
582
What is the purpose of pericardiocentesis?
Diagnostic or therapeutic
583
Define cardiac tamponade
Accumulation of pericardial fluid causing raised intrapericardial pressure leading to poor ventricular filling and a fall in cardiac output
584
What are the causes of cardiac tamponade?
```
Anything causing pericarditis
Aortic dissection
Haemodialysis
Warfarin
Cardiac catheterisation
Post-cardiac biopsy
```
585
What is Beck's triad?
Signs of cardiac tamponade:
1. Falling BP
2. Rising JVP
3. Muffled heart sounds
586
What does echo show in cardiac tamponade?
Echo-free zone around the heart of > 2cm or > 1cm if acute
