Cardiovascular Flashcards
1
Q
Describe the CHA2Ds2VASc Score
A
Congestive Cardiac Failure (1 Point) Hypertension (1 Point) Age > 75 (2 Points) Diabetes (1 Point) Stroke/TIA/TE (2 Points) Vascular Disease (1 Point) Sex (F) (1 Point)
2
Q
What scale is used toa ssess risk of bleeding in AF
A
ORBIT screening tool
3
Q
Signs of Atrial Fibrillation on an ECG
A
Absent p waves
Irregular QRS Complexes
4
Q
What blood test is first line for Atrial Fibrilation
A
TFTs (hypethyroidism can cause Atrial Fibrilation)
5
Q
How to manage acute Atrial Fibrilation (usually in young people or first presentation)
A
<48 Hours: Offer flecainide or amiodarone AS LONG AS THERE ARE NO STRUCTURAL or ISCHAEMIC HEART DISEASE
Or Just Amiodarone in the presence of structural or ischaemic heart disease
6
Q
How is an acute stroke managed after 48 hours
A
Rate control: Beta Blockers or Dilitazem
7
Q
Why is Dilitazem used instead of verapamil
A
Verapamil + Beta blocker can cause a heart block
8
Q
Name two types of rhythm control
A
DC Cardioversion or Flecainide
9
Q
If Cardioversion is chosen as the intended intervention, what must be done in advance
A
Anticoagulation fore 3 weeks first
10
Q
If there is a risk of heart failure, what should be done prior to Cardioversion
A
4 Weeks of Amiodarone and 12 months after
11
Q
If beta blockers or dilitazem are not working to control the rate, what can be given as an adjunct
A
Digoxin
12
Q
First line management of paroxysmal AF
A
Sotalol or Flecainide
13
Q
At what Chads2vasc score should anticoagulation be offered
A
2 or more
Considered at 1
14
Q
What is Paroxysmal AF
A
Episode sof AF that come and go (last 48 hours)
15
Q
What is Persistent AF
A
Lasts over 7 days but returns back to normal
16
Q
What is Permenant AF
A
Episodes of AF that do not go back to normal, usually after unsuccessful treatment
17
Q
What is the main cause of AF
A
High BP
18
Q
What conditions in teh elderly can predispose them to AF
A
Infections
Pericarditis
19
Q
What is the first line investigation for AF
A
ECG
20
Q
When is a 24-hour ECG indicated
A
If AF comes and goes and was not detected in the ECG at time of recording
21
Q
What is the main drug given for cardioversion
A
IV Adenosine
22
Q
What is the criteria for cardioversion (more indicated in the following situations)
A
- Recent AF
- <65
- Successful treatment of underlying cause for AF
- No other heart abnormality
- Acute HF or Unstable Angina being worsened by AF
23
Q
What is Catheter Ablation
A
Where a catheter is passed into th eheart chambers via a large blood vessel in the leg
24
Q
COmplications of AF
A
- HF
- Dilated Cardiomyopathy
- Angina
- Strokes/ Falls
25
If DOACs are contraindicated (first line for ChadsVasc/AF), what can be given
Vit K Antagonist
26
Under what circumstances are people under 65 contraindicated for DOAC use
Only has sex as a risk factor in Cha2ds2vasc
27
What criteria can be used to check risk of bleeding from anticoagulants in AF
ORBIT or HASBLED
28
When should patients with AF be referred to hospiatl or specialist referral
4 weeks after failed management
29
What scan should be done before someone goes through cardioversion
ECHO
30
What should be done to cardioversion if acute AF lasts over 48 hours
Be delayed
31
WHat should be done before DOACs are stopped?
Re-assess using CHA2Ds2-Vasc first
32
What is an Abdominal Aortic Aneurysm
Irreversable dilation of a blood vessel by at least 50%
33
Two types of aorticaneurysms
Abdominal
| Thoracic
34
What causes an abdominal aneurysm
Degradation of elastic lamellae from leukocytic infiltate. Cause dilatation of all three layers of the arterial wall
35
What is a pseudoaneurysm
Blood leakage through the arterial wall but contained within the adventitia
36
What is the normal diameter of the aorta
2cm
37
What size defines an aortic diameter
3cm +
38
Under what structure do most abominal aortic aneurysms arise from
Below the renal arteries
39
What is considered a threatening AAA
A growth of 1-6mm over a year on average (consistent growth)
40
What features on an aneurysm make it more prone to rupture
```
The diameter (larger)
Growth Rate
```
Women
41
At what age are people screened for AAAs
Men over 65
42
Risk Factors for AAA
1. FH
2. Smoking
3. Male
4. Age
5. HTN
6. COPD
7. Hyperlipidaemia
43
Symptoms of an upnruptured AAA
Asymptomatic
Rarely, back, abdominal, loin or groin pain
Signs of limb ischaemia
44
Symptoms of a ruptured AAA
HYPOTENSION:
Shock, syncope or collapse
Postural Hypotension
SUDDEN pain in the abdomen, back or loin
45
What examination is done to feel for AAA
Bimanual palpation of supraumbilical region
46
What makes palpation for AAA tricky
Hard with larger waist sizes
47
What condition other than acute pancreatitis can cause th grey turner sign
AAA
48
What causes the grey turner sign
Retroperitoneal haemorrhage
49
First line blood tests done for AAA
FBC, Clotting, renal and LFTs
50
First line investigation for AAA (scans)
Abdominal USS (can assess accuracy of dilation to up to 3mm)
51
Why is a CT angiography helpful in AAA
If >3mm and to check for the crescent isgn
52
What is the crescent isgn
Blood within the thrombus - predicts imminent rupture
53
What three AAA types should be considered for repair
SYmptomatic
Asymptomatic (>4.0 cm AND growing >1cm a year)
Asymptomatic (5.5cm or larger)
54
Management of an uncomplicated AAA
<5.5 cm:
general monitoring
55
HOw often shouldl a 3-4.4cm AAA be screened
Annual USS
56
How often should a 4.5-5.4cm AAA be screened
3 monthly USS
57
AT what point should we consider surgery for AAA
5.5cm or bigger
58
Name two types of surgical repair for AAA
Surgical (open) repair
Endovascular repair (stent graft through femoral arteries)
59
How often are med over 65 screened for AAA
Just once at that age
60
Name four contraindications to radio-ablation therapy for arrythmias
1. Left atrial ablation for persistent AF with an atrial thrombus present
2. Mobile left ventricular thrombus
3. Mechanical heart valves
4. Preganncy
61
Indications for radioactive frequency ablation
1. Symptomatic SVT
2. AVNRT
3. WPW syndrome
4. Atrial tachycardia
5. Atrial Flutter
62
When is catheter ablation indicated fro AF
ONLY IF SYMPTOMATIC:
- AF is refractory to at least one rhythm control medication (flecainide or amiodarone) - mainly paroxysmal is affected here
- AF is symptomatic prior to starting rhythm control drugs
63
Which type of AF usually benefits from radiofrequency catheter ablation
Paroxysmal AF
64
First line management of Acute Coronary Syndrome
HOSPITAL ADMISSION - Medical Emergency
65
What is ACS
Acute myocardial ischaemic states:
ST- Elevated ACS
Non-ST Elevated ACS
66
What is Non STEMI signs on an ECG
ST-segment depression
T wave inversion
Flat T Waves
67
Lab Results in unstable Angina
Troponin levels are normal
68
Lab results seen in NSTEMI
A rise in troponin levels
69
Risk Factors for ACS in younger people
1. Endocarditis
2. Vasculitis
3. Cocaine and durg use
4. Increased oxygen requirement (hyperthyroidism)
70
Presentation of NST-ACS
1. Anginal pain at rest
2. New onset angina
3. Sweating, nausea, vomtiing, fatigue, shortness of breath, palpitations (nervousness)
71
What type of patients are less likely to present with chest pain from MIs
Elderly and patients with diabetes
72
How long does angina last for
20 mins
73
Where can angina spread
Arms, back and jaw
74
Should response to GTN be considered to make diagnosis for ACS
No
75
First line investigation for suspected ACS
12-Lead ECG
76
Why is troponin measured first in ACS rather than CKMB
Troponin sensitivity is superior in the first 6 HOURS
77
How long can troponin remain in the blood after an MI
14 Days
78
When do troponin I and T become detectable in th eblood
3-6 hours after infarction
79
If a patient presenting with unstable angina or NSTEMI is clincially unstable, what should be done after ECG and troponin test
CT Angiography
80
What happens to glucose levels inACS
Hyperglycaemia
81
What does hyperglycaemia in ACS predict about the prognosis
Poor
82
What would an ECHO demonstrate in ACS (what's its use?)
Demonstrates wall motion abnormalities ude to ischaemia
83
What is the gold standard for detecting th epresence and severity of ACS
CT Angiography
84
What is the first line management of a suspected ACS (ECG changes, elevated troponin levels)
300 mg Aspirin + 180mg Ticagrelor
85
If Aspirin is contraindicated for use in ACS, what shoudl be given instead
Clopidogrel monotherapy
86
What artery supplies the right atrium and right ventricle
Right Coronary Artery
87
What artery supplies the left atrium
Circumflex Artery
88
What artery supplies the Anterior Left Ventricle and Anterior aspect of the septum
Left Anterior Descending
89
If there is no ST elevation seen on an ECG, what should be done as second line investigation
Serum Troponin tests
90
What are other causes for raised troponin levels
1. CKD
2. Sepsis
3. Myocarditis
4. Aortic Dissection
5. PE
91
When should a Primary PCI be given for a STEMI
Within 12 hours of onset
92
When should thrombolysis be done for an acute STEMI
If PCI is not available within 2 hours
93
What is PCI
Catheter up femoral artery that identifies the blocked area + widens it
94
Name two type of thrombolysis agents
Streptokinase
| Aletplase
95
Treatment of an acute NSTEMI
BATMAN
```
B - Beta Blockers
A - Aspirin 300mg
T - Ticagrelor
M - Morphine
A - Anticoagulant (Fondaparinux)
N - Nitrates (GTN)
```
96
What score is used to assess the risk of death or repeat MI after an NSTEMI
Grace Score
97
If GRACE score is 5%+, what should be done
PCI
98
Complications of an MI
DREAD
```
D- Death
R - Rupture of septum
E - Oedema (Heart Failure)
A - Arrythmia and Aneurysm
D - Dressler's Syndrome
```
99
What is Dressler's Syndrome
A type of pericarditis that occurs after an MI
100
Symptoms of Dressler's Syndrome
Low grade fever, pleuritic chest pain and pericardial rub on auscultation
101
ECG changes in Dressler's Syndrome
ST Elevation
| T Wave Inversion
102
How is Dressler's Syndrome managed
NSAIDs (Aspirin/Ibuprofen)
103
Secondary Prevention Medical Management of ACS
AAAAAA (6As)
```
A - Aspirin 75mg
A - Antiplatlete (clopidogrel or ticagrelor)
A - Atorvastatin
A - Ace Inhibitors
A - Atenolol
A - Aldosterone Antagonist (eplenerone)
```
104
What is a Type 1 MI
Traditional MI due to ACS
105
What is a Type 2 MI
Ischaemia secondary to reduced oxygen (anaemia, tachycardia)
106
What is a Type 3 MI
Sudden cardiac arrest suggestibe of an ischaemic issue
107
What is a Type 4 MI
PCI/CABG or stunting causes
108
Threshold to treat hyperglycaemia
Keep blood glucose below 11.0 mmol/l using insulin bolus
109
What causes pulmonary oedema
Where fluid leaks from the pulmonary
110
What is Cardiogenic pulmonary oedema
Left sided heart failure (increased pressure)
111
Causes of Non-cardiogenic Pulmonary Oedema
ARDS
Lymphatic Insufficiency (lung transplant)
Narcotic overdose
High Altitude
112
What renal conditions can cause acute pulmonary oedema
AKI
CKD
Renal Artery Stenosis
113
How does high altitude and ARDS contribute to pulmonary oedema
Increases pulmonary capillary permeability
114
Presentation of pulmonary oedema
INITIIAL DRY or PINK PRODUCTIVE COUGH
```
Severe breathlessness
Sweaty
Neasua
Anxiety
Paroxysmal nocturnal dyspnoea or orthopnoea
```
115
Name two conditions that result in a gallop rhythm
Valve stenosis or regurgitation
116
What is the triad of cardiogenic shock
Hypotension, oliguria and low CO
117
How should pulmonary oedema be treated first line in a pre-hospital setting
FIRST LINE: NItrates (e.g., GTN) to solve orthostatic hypotension
IV Furosemide (vasodilation)
Opioids if in distress
118
Treratment of pulmonary congested HF
1. IV Furosemide (loop diuretic)
2. High Flow Oxygen
3. LMWH to reduce risk of PE
4. IV NItrates if systolic BP > 110 mmHg
119
What is the only circumstance in where opioids should be given tor elieve anxiety from HF
If we're still in the compensated phase of HF
120
What are inotropes
These change the force of heart contractions
121
What ar epositive and negative inotropes
Positive increase force, negative weaken force
122
Nmae two negative inotropes
Beta blockers
| CCB
123
Name a positive inotrope
Digoxin
124
Pharmacology of digoxin
INcreases amount of calcium in teh heart, by blocking calcium channels from where they normally leave
125
When are inotropes indicated in acute pulmonary oedema
Only when patient is hypotensive (<85 mmHg)
126
Why should inotropes be avoided in pulmonary oedema or HF
They cause sinus tachycardia = arrythmias
127
What inotrope can be given to counteract bet ablockers in people with acute HF
Levosimendan (calcium sensitiser)
128
After stabilising someone with acute pulmonary oedema, what should be done
ACEi or ARB if not already being given ASAP
Beta blockers
Aldosterone
Digoxin to control ventricular rate in AF
129
How does digoxin function to control rate rhythm
Controls ventricular rate
130
Lifestyle advice for someone with acute pulmonary oedema
Restrict sodium intake to <2g a day and fluid to 1.5L a day
131
If people with acute pulmonary oedema still struggle to breathe following medical intervention, what should be done
CPAP
132
When should someone with acut epulmonary oedema be intubated
Respiratory failure leading to hypoxia, hypercapnia and acidosis
133
Who should be referred for ABPM monitoring
140/90mmHg or higher to confirm diagnosis of hypertension
134
Under what condition should an ABPM be done
First line before HBPM always.
```
HTN poorly controlled
Signs of pereclampsia
High risk patients
White coat hypertension
Reverse white coat hypertension
Postural hypotension
```
135
What is the upper limit of normal for an ABPM
135/85 mmHg
136
Some disadvantage sto ABPM
1. Sleep disturbances
2. Training required
3. Brusing from cuff
4. Poor Technique
137
When does BP normally fall when doing an ABPM
Normally at night as a physiological hing
If rises at night = concerning
138
What are true aneurysms
Involve all three of the layers of the artery wall (intima, media and adventitia)
139
What are pseudo aneurysms
These are collections of blood held around the vessel wall by connective tissue which can end up reputuring and lead to thrombosis
140
Signs of a false aneurysm
Pulsatile mass
141
What can cause an aneurysm
Atherosclerosis
Vasculitis
Syphilis
Congenital (Berry Aneurysm)
142
Risk Factors for aneurysms
1. Anomalous vessels
2. Coarctation of aorta
3. PCKD
4. Fibromuscular dysplasia
5. Connective tissue disorders
143
Where are cerebral aneurysms typically found
At the bifurcation of the middle cerebral artery at the circle of willis
144
Most common type of peripheral aneurysm
Popliteal
145
What causes an aortic dissection
When a tear in the tunica intima causes blood to spill in the tunica media which spreads
146
Signs of a carotid dissection
1. Headache
2. Neck and facial pain
3. Stroke symptoms and transient blindness and syncope
147
What artery is usually involved in a carotid dissection
Internal carotid artery
148
Investigations for a carotid dissection
Duplex Carotid USS
Then an MRI scan of the brain with/without angiography
149
Contraindications to ACEi
1. Pregnancy
2. Hypersensitivity to ACE
3. Angiooedema
4. Breast-feeding
150
What drugs do ACEi interact with
NSAIDs
Heparin
Lithium
151
Side-effects of ACEi
1. Impaired renal function
2. Hyperkalaemia
3. Persistent dry cough
152
How should a persistent dry cough be corrected
Switch to ARBs
153
What two things should be done before giving someone an ACEi
Check serum U+E and Creatinine before starting
Reduce furosemide if >80 mg a day
154
When should ACEi be stopped
1. Worsening renal function
2. Persistent dry cough
3. Hypotension
4. Hyperkalaemia
155
Function of Class I anti-arrythmic drugs (procainamide, dispyramide, lidocaine and flecanide)
Membrane stabilising
156
Why are beta blockers given in AF
Reduce adrenergic input to the heart
157
How does amiodarone and sotalol work to regulate heart
Potassium blockers
158
How does verapamil regulate the heart
Blocks influx of calcium ions
159
First line management of Haemophilia and vWD
Desmopressin (boosts factor VIII concentration)
160
Role of aspirin
Irreversible inhibitor of COX-2, reducing Thromboxane A2
161
Pharmacology of clopidogrel
ADP receptor antagonist
162
Presentation of Aortic Dissection
1. Chest Pain
2. Aortic Regurgitation
3. MI
4. Congestive HF
4. Syncope
5. Stroke symptoms
6. Mesenteric Ischaemia
7. Kidney Injury
FIRST PHASE: Severe pain and pulse loss, bleeding then stops
SECOND PHASE: Pressure erupts and causes bleeding into the mediastium and elsewhere = cardiac tamponade
163
Onset of aortic dissection
Male in 60s with hypertension and SUDDEN ONSET
164
What happens to the pain felt in an aortic dissection as the dissetcion progresses
Migrates retrosternally (proximal dissection) or between scapula and the back (distal)
165
What causes paraplegia in an aortic dissection
Blocking spinal arteries
166
First line investigation for a suspected aortic dissection
ECG to discard an MI
167
What should be used to check the extent and site of an aortic dissection
Transthoracic or oesophageal USS
168
What is the definitive diagnostic for an aortic dissection
MRI scanning
169
Management of an aortic dissection
1. IV MORPHINE
| 2. Manage Hypertension with beta blockers
170
What are the three types of Aortic Dissections
Type I; Aorta, arch and descending aorta
Type II; Ascending Aorta only
Type III: Descending aorta distal to left subclavian
DeBakey Classification
171
Surgical intervention for Type III aortic dissections
TEVAR
172
Management of chronic aortic dissections
Medical treatment only
173
What heart murmur may be heard in aortic dissections
A diastolic murmur from aortic regurgitation
174
What is a poor prognosis of an aortic dissection
Hypotension
175
Lifelong prophylaxis of aortic dissections
Beta BLockers and USS screens
176
Name three conditions that may cause aortic regurgitation
1. Bicuspid aortic valve
2. Rheumatic Fever
3. Infective Endocarditis
177
Most common cause ofAortic regurgitation
Rheumatic heart disease
178
Onset of Aortic Regurgitation
40-60
179
What chronic conditions can cause aortic regurgitation
SLE
Marfan's
Ehler-Danlos
Turner
180
Characteristic of pulse heard in aortic regurgitation
Bounding and collapsing peripheral pulses (water hammer)
181
Describe the pulse pressure found in Aortic Regurgitation
Wide with a sudden collapse of the pulse at the end
182
Signs of Aortic Reguratation
Head Bopping
| Pulsus Bisferiens
183
What is Pulsus Bisferiens
single central pulse wave with two peaks and a dip
184
How does the patient need to sit in order to hear the aortic regurgitation murmur
Sitting forward and breathing out
185
What murmur is heard in AR
S1 is soft + Early diastolic murmur
186
Definitive diagnosis of AR
ECHO with doppler
187
How often do patients with AR need to be monitored for
1. Yearly review and ECHo every 2 years
188
Medical Management of AR
1. Vasodilators and inotropic agents
189
Indications for surgery for AR
1. Symptomatic
| 2. Asymptomatic when left ventricular function is deteriorating
190
Presentation of aortic stenosis
Shortness of breath
Angina
Dizziness or syncope
HF
191
Sounds heard in AS
PULSUS PRAVUS et Tardus (slow rising and flat)
Disappearance of second aortic sound or softening
Harsh systolic murmur
192
Pulse pressure characteristic of Aortic Stenosis
Narrow pulse pressure
193
Where does teh systolic murmur in AS transmit to in AS and how does this differ from AR
AS transmits to the carotids unlike in AR
194
Describe the nature of the systolic ejection murmur in AS
Crescendo-Decrescendo
195
Where is the AS murmur typically found
Second right intercostal space
196
Investigation of AS
1. ECG for LVH
| 2. ECHO (transoeosphageal)
197
Should excercise testing be used to check for As
NO unless symptoms are being masked
198
What serum level dictates prognosis in AS
Natriuretic peptides
199
Role of Cardiac Catheterisation
Measures pressure across valves and chambers
200
Main complication of symptomatic AS
Left ventricular ejection fraction deteriorates (left sided heart failure)
201
Surgical intervention for AS
Transcatheter aortic valve implantation or Aortic Valve replacement
202
At what K+ level should blood tests be repeated within a day
Over 6 mmol
203
Over what serum K+ level should a patient be admitted to hospital
Over 6.5mmol/mol
204
Side Effects of CCB
Pitting Oedema
| Low BP
