CardioResp Flashcards
Describe the NYHA classification system.
- No limitation of physical activity
- Slight limitation on exertion
- Marked limitation but comfortable at rest
- Unable to carry out any physical activity without discomfort.
Give the symptoms that may be experienced during an acute myocardial infarction.
Crushing chest pain Pain the neck, jaw, and/or arm Sweating Nausea and vomiting Abdominal pain (especially if elderly) Anxiety
What is the acute treatment of an ST-elevated myocardial infarction?
Morphine 5mg Antiemetic Oxygen Nitrates Aspirin 300mg Prasugrel (or clopidogrel 300mg)
Admit to cath lab as soon as possible
What long-term medications should a patient be prescribed after an acute myocardial infarction?
Atorvastatin 80mg Bisoprolol Prasugrel (clopidogrel if over 80, high bleeding risk, under 60kg) Aspirin 75mg Ramipril
What are the potential complications of an acute myocardial infarction?
Heart failure
Arrhythmia
Cardiogenic shock
Cardiac arrest
What investigations might you use in a patient with angina?
Exercise ECG
Coronary angiogram
Thyroid function test if hyperthyroidism is suspected
FBC to check for anaemia
Give a short-acting nitrate that can be prescribed for the relief of angina pain.
Nitroglycerin
Glyceryl trinitrate
Explain how nitrates can relieve the pain in angina
They are metabolised to nitrous oxide in the blood, which can cause vasodilation in the coronary vessels. This is done by increasing the levels of cGMP which activates myosin light chain phosphatase, phosphorylating the myosin and causing it to dissociate, allowing relaxation of the muscle.
Give a long-acting nitrate that can be prescribed for the long-term control of angina.
Isosorbide mononitrate
Nicorandil
Aside from nitrates, what should be prescribed to patients with angina that reduces their morbidity and mortality?
Beta blockers such as atenolol and bisoprolol
Give two procedures which can help patients with angina.
Balloon angioplasty
Coronary artery bypass graft
How can angina be prevented?
Stop smoking
Lose weight
Improve diabetic and hypertensive control
Increase exercise
What symptoms would you expect in a patient with chronic aortic regurgitation?
Typically asymptomatic Progressive shortness of breath on exertion Orthopnoea Paroxysmal nocturnal dyspnoea Palpitations
How would you expect a patient with acute aortic regurgitation to present?
In heart failure with dyspnoea, fatigue, weakness, and oedema.
They may also have cardiogenic shock with hypotension combined with multisystem organ damage.
A patient in clinic is found to have a loud S2, mid-diastolic murmur, and a wide pulse pressure. What is the most likely cause?
Aortic regurgitation
What are the causes of an acute aortic regurgitation?
Infective endocarditis
Ascending aortic dissection
What are the causes of a chronic aortic regurgitation?
Rheumatic fever Infective endocarditis Trauma Thoracic aortic aneurysm Degeneration of the valve or root
What investigations would you use in a suspected aortic regurgitation and why?
Echocardiogram with doppler: assess flow across the valve, level of impairment, pulmonary hypertension, vegetations, pericardial effusions
ECG: left ventricular hypertrophy, left atrial enlargement, ST depression, T wave inversion
CXR: cardiomegaly, prominent aortic root
What can be used for symptom control in patients with aortic regurgitation who are not eligible for surgery?
Vasodilators
Nitrates
Diuretics
What is the typical triad of symptoms which may occur in aortic stenosis?
Syncope
Angina
Breathlessness
A patient in the clinic is found to have a quiet S2, systolic ejection murmur, and a slow rising carotid pulse. What is the most likely cause?
Aortic stenosis
What are the most common causes of aortic stenosis?
Aortic sclerosis (over 70)
Congenital bicuspid aortic valve (under 70)
Rheumatic heart disease
What investigations would you want for a patient with suspected aortic stenosis, and what would you expect to find?
Echocardiogram: assess structural damage or deformity, atrial thrombi
ECG: left ventricular hypertrophy with/without ST/T changes
CXR: check for cardiomegaly and calcification of the valves
Exercise ECG: can show severe LV dysfunction if the patient is asymptomatic.
What is the management for aortic stenosis?
Valve replacement via open heart surgery or TAVI
Balloon valvotomy, usually in congenital cases
Diuretics if there is fluid overload
Anti-arrhythmics if necessary
What are the changes seen in the lungs of asthmatics?
Bronchoconstriction, airway oedema and inflammation, airway hyper-reactivity, airway remodelling
What can trigger asthma exacerbations?
Environmental or occupational allergens Infections Exercise Inhaled irritants Emotion Aspirin Gastro-oesophageal reflux disease
What are asthmatics at increased risk of during pregnancy?
Prematurity Pre-eclampsia Growth restriction Maternal morbidity/mortality Caesarian delivery
What is status asthmaticus?
Severe persistent asthma with prolonged bronchospasm
What timing of symptoms in asthma is a red flag?
At night
How is asthma diagnosed?
Spirometry before and after the use of salbutamol to confirm airway reversibility. More than 20% reduction of symptoms is required.
Methacholine or histamine can be used to trigger symptoms.
Induced sputum with >1% eosinophils can confirm a diagnosis of eosinophilic asthma.
What are the stages in the pharmacological management of asthma?
Salbutamol inhaler PRN with low-dose corticosteroid inhaler
ADD salmeterol inhaler BD
ADD moderate-dose corticosteroid inhaler
What are the features of a moderate asthma exacerbation, and how would you manage it?
PEF 50-75% of predicted
No features of a severe exacerbation
Manage with nebulised salbutamol and oral steroids
Maintain O2 sats of 94-98%
What are the features of a severe asthma exacerbation, and how would you manage it?
PEF 33-50% of predicted
RR >25/min, hr 110/min
Can’t complete sentences in one breath
Manage with nebulised ipratropium bromide and back to back salbutamol. Oxygen to maintain saturations 94-98%.
Take and ABG and inform a senior.
What are the features of a life threatening asthma exacerbation, and how would you manage it?
PEF <33% of predicted.
Sat <92%, pO2 <8kPa
Cyanosis, poor respiratory effort, fully silent chest
Exhaustion, confusion, arrhythmia
Manage with nebulised salbutamol and tiotropium bromide, IV aminophylline, and O2 if needed.
ITU and anaesthetics assessment
ICU or anaesthetic assessment
Urgent portable CXR
What is the defining feature of near fatal asthma?
CO2 levels normal or high
What symptoms may a patient with atrial fibrillation present with?
Palpitations
Heart failure: dizziness, dyspnoea, peripheral oedema
Stroke
Renal failure due to systemic emboli
What signs would you expect to find in a patient with atrial fibrillation?
Pulse deficit
Irregularly irregular pulse
Loss of the A wave in the JVP
What are the common causes of atrial fibrillation?
Hypertension Cardiomyopathy Mitral or tricuspid valve disorders Hyperthyroidism Binge drinking
What investigations would you want in a patient with suspected atrial fibrillation?
ECG: irregularly irregular narrow complex tachycardia with no P waves
Echocardiogram: check for structural heart defects and thrombi in the atria
Thyroid function tests
Describe the CHADS VASC scoring system.
Congestive heart failure Hypertension Age >75 (2) Diabetes Stroke/TIA (2) Vascular disease Age >65 Sex Female
A score of 2 or more should have anticoagulation therapy
Describe the HAS BLED scoring system.
Hypertension Abnormal renal or hepatic function Stroke Bleeding Labile INR Elderly (>65) Drugs/alcohol
What is the mechanism of action for rivaroxaban and apixaban?
Selective factor Xa inhibitor
What is the mechanism of action of warfarin?
Vitamin K antagonist
Why should you be cautious using atenolol in patients with diabetes?
It augments the function of metformin and insulin, as well as other anti-hyperglycaemic medications
What is the mechanism of action of diltiazem?
Calcium channel blocker
What are the side effects of diltiazem and verapamil?
Heart block
Constipation
Symptoms related to bradycardia
What is the mechanism of action of digoxin?
Cardiac glycoside which inhibits the sodium/potassium exchange to reduce the rate of contraction but increase the force.
What drug monitoring is required when using digoxin?
Serum electrolytes
Renal function
What rate control medications are commonly used in atrial fibrillation?
Atenolol/bisoprolol
Diltiazem/verapamil
Digoxin
What rate control medications used in atrial fibrillation should not be used together?
Beta blockers and calcium channel blockers
What medications can be used for rhythm control in atrial fibrillation?
Amiodarone
Flecainide
In a patient with atrial fibrillation and haemodynamic instability, what should be the first management?
Electrical cardioversion
How can patients with atrial fibrillation for less than 24 hours be managed differently than those where it has been present for more than 24 hours?
Less: cardiovert immediately
More: anticoagulate for three weeks before cardioversion irrespective of CHADS VASC score
What is the mechanism of action of amiodarone?
Class III anti-arrhythmic
Slows the conduction rate and increases the refractory period in the SAN and AVN
What drug monitoring is important with amiodarone?
Chest x-ray
Liver function tests
Urea and electrolytes
Thyroid function tests
Every 6 months
What are the major side effects of amiodarone?
Pulmonary fibrosis Photosensitivity Renal impairment Liver impairment Thyroid dysfunction Pneumonitis Optic neuritis
Why must amiodarone be administered via a central line?
It causes severe thrombophlebitis if administered through a peripheral vein
What is the mechanism of action of flecainide?
Sodium channel blocker
What are the side effects of flecainide?
Constipation Faintness Headache Nausea Chest pain Tachycardia
When should you avoid using flecainide?
Heart block
History of severe heart problems
When should you avoid using amiodarone?
Thyroid dysfunction
Conduction disturbance
What are the typical symptoms of bronchiectasis?
Chronic productive cough
Dyspnoea
Wheezing
Pleuritic chest pain
May cause massive haemoptysis
What would you expect to see on a chest x-ray for someone with bronchiectasis?
Thick airway walls
Tram lines
Tubular opacity (mucus plugs)
Ill-defined linear hilar density
What would you expect to see on CT for someone with bronchiectasis?
Airway dilation
Signet ring sign
Tram lines
May also have atelectasis, consolidation, and mucus plugs
What would you expect to find on pulmonary function tests in bronchiectasis? Why are they important?
Reduced FEV1, FVC, and FEV1:FVC ratio
May have a decreased DLCO
Used to document the baseline and monitor progression of the disease.
Describe the management of chronic bronchiectasis.
Respiratory therapy to ensure proper clearing of airway secretions
Salbutamol
Corticosteroids
How should bronchiectasis be managed during an acute exacerbation?
Antibiotics
Nebulised saline
Inhaled bronchodilators
What are the predisposing factors for bronchiectasis?
Persistent or recurrent infections
Alpha-1 antitrypsin deficiency
Cystic fibrosis
Primary ciliary disorders (Kartageners syndrome)
Primary or secondary immunodeficiency
Connective tissue disorder
Airway obstruction (tumour or foreign body)
What can cause radial-radial delay?
Coarctation of the aorta
What can cause a collapsing pulse?
Aortic regurgitation Fever Pregnancy Patent ductus arteriosus Anaemia AV fistula Thyrotoxicosis
What can cause a slow rising carotid pulse?
Aortic stenosis
What can cause a narrow pulse pressure?
Aortic stenosis
What can cause a wide pulse pressure?
Aortic regurgitation
What can cause a raised JVP?
Fluid overload
Right ventricular failure
Tricuspid regurgitation
What murmur is heard in mitral regurgitation?
Pansystolic murmur
What murmur is heard in aortic stenosis?
Mid-systolic ejection murmur
What murmur is heard in mitral stenosis?
Early diastolic decrescendo murmur with an opening snap
What murmur is heard in aortic regurgitation?
Early diastolic decrescendo murmur
What can cause pathological splitting of the S2 heart sound?
Aortic stenosis
Left bundle branch block
Hypertrophic cardiomyopathy
What can cause fixed splitting of the S2 heart sound?
Atrial septal defect
Bundle branch block
What can cause a loud S2?
Pulmonary hypertension
What changes will be seen on spirometry in a patient with COPD?
Low FEV1 and FEV1:FVC ratio
Describe the MRC dyspnoea score.
- Not troubled by breathlessness except on strenuous exercise
- Shortness of breath when hurrying on a level or walking up a slight hill
- Walks slower than most people on a level, stop after a mile or so, or stops after 15 minutes of walking at own pace.
- Stops for breath walking 100 yards or a few minutes on level ground.
- Too breathless to leave the house or breathless when dressing/undressing
Describe the management of COPD.
Smoking cessation, pulmonary rehabilitation, and dietetics
Tiotropium bromide inhaler
Combined steroid and bronchodilator inhaler if tiotropium is not sufficient.
Which patients with COPD should be offered long-term oxygen therapy?
Persistently low oxygen saturations <7.3kPa if no cor pulmonale, <8kPa with cor pulmonale
Non-smoker
Able to use for at least 16 hours per day
No high CO2 retention
Which patients with COPD can be eligible for lung volume reduction surgery?
Localised areas of emphysema
The rest of their lung is healthy
What interventions reduce mortality in COPD?
Smoking cessation
Long term oxygen therapy
Lung volume reduction surgery
How can COPD cause right heart failure?
It causes chronic hypoxic vasoconstriction which increases the afterload of the right ventricle.
What can be prescribed for COPD patients with right heart failure?
Furosemide
What are some of the side effects for patients using long-term steroids?
Weight gain Osteoporosis Mood changes and psychosis Bruising GI symptoms
How should COPD exacerbations be managed?
Controlled oxygen therapy (Venturi masks)
Nebulised tiotropium bromide
Oral steroids
IV aminophylline
Antibiotics if there is a raised CRP or WCC
If a patient with a COPD exacerbation has been treated but their ABG does not improve, how should they be managed?
BIPAP (non-invasive ventilation)
Who is BIPAP (non-invasive ventilation) contraindicated in?
Untreated pneumothorax GCS <8 Facial injury Life-threatening hypoxia Vomiting Agitation
Why is therapeutic drug monitoring required for aminophylline?
It has a narrow therapeutic index
What are the side effects of aminophylline?
Palpitations
Gastric irritation
Hypotension
Convulsions
Describe the main presentation of cystic fibrosis.
Newborn screening
Meconium ileus
Chest infections
Intestinal malabsorption
What are the typical respiratory effects of cystic fibrosis?
Recurrent or chronic infections
Pneumothorax
Haemoptysis
Cor pulmonale
What are the typical gastrointestinal effects of cystic fibrosis?
Meconium ileus (abdominal distention, vomiting, failure to pass meconium)
GORD
Malnourised
Constipation or bowel obstruction
Bulky and offensive stools (pancreatic insufficiency)
Features of vitamin ADEK deficiency