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Conditions > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

Supraventricular Tachycardia: Definition (3)

A

HR > 100, QRS <120ms, narrow complexes
E.g. Atrial fibrillation, AV Re-entry Tachycardia (AVRT), AV Nodal Re-entry Tachycardia (AVNRT)

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2
Q

Supraventricular Tachycardia: Pathophysiology

A

Re-entry circuit is established at or above the AV node

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3
Q

Supraventricular Tachycardia: Atrioventricular nodal re-entry tachycardia (AVNRT) Definition (3)

A

Re-entry pathway exists in AV node, not re-rentry, stable rhythm

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4
Q

Supraventricular Tachycardia: Atrioventricular re-entry tachycardia (AVRT) (3)

A

Extra-accessory pathway/tissue separate to AV node exists, Re-rentry pathway, Unstable rhythm

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5
Q

Supraventricular Tachycardia: General Symptoms (3)

A

Palpitation, SOB, Chest pain

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6
Q

Supraventricular Tachycardia: AVNRT specific symptoms

A

Pre-syncope

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7
Q

Supraventricular Tachycardia: AVNRT prognosis

A

Generally safe rhythm

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8
Q

Supraventricular Tachycardia: AVRT symptoms

A

Syncope

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9
Q

Supraventricular Tachycardia: AVRT cause of mortality

A

Rhythms conducted much faster than normal cardiac tissue.
If AF occurs on top, can be conducted 1:1 without AV block which can be fatal.

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10
Q

Supraventricular Tachycardia: AVNRT ECG Signs (3)

A

Lead V1: Variable p-wave, >300ms, can be hidden in QRS complex

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11
Q

Supraventricular Tachycardia: AVRT Signs on ECG (3)

A

Lead V1: Sinus ECG, Delta wave, short PR interval

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12
Q

Supraventricular Tachycardia: Investigations (4)

A
  1. ECG
  2. EP study
  3. 24 Hour ambulatory ECG
  4. Echo
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13
Q

Supraventricular Tachycardia: Echo Results (2)

A

LV failure or cardiomyopathy

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14
Q

Supraventricular Tachycardia: Management (AVNRT) (2)

A
  1. Vagal manœuvres (carotid sinus massage or valsalva manœuvre)
  2. Adenosine
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15
Q

Supraventricular Tachycardia: Management (AVRT)

A

Treat as Atrial Fibrillation
1. DC cardioversion (if Haemodynamic Instability)
2. Anticoagulation with rate/rhythm control (If no Haemodynamic instability)

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16
Q

Supraventricular Tachycardia: Prophylaxis

A
  1. Beta-blockers
  2. Pace and ablate re-entry pathway
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17
Q

Aortic Regurgitation: Definition

A

Blood flow across the aortic valve in diastole from the aorta into the left ventricle, due to incompetence of the valve.

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18
Q

Aortic Regurgitation: Epidemiology

A

More common in men than women

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19
Q

Acute causes of Aortic Regurgitation (4)

A
  1. Infective endocarditis (valve destruction and leaflet perforation)
  2. Iatrogenic
  3. Traumatic rupture
  4. Aortic Dissection
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20
Q

Chronic causes of Aortic Regurgitation (3)

A

Most common are:
1. Congenital heart disease (bicuspid aortic valve)
2. Rheumatic fever
3. Aortic root dilatation

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21
Q

Aortic Regurgitation: Causes of aortic root dilatation (3)

A
  1. Genetic syndromes like Marfans or Ehlers-Danlos
  2. Systemic vasculitis
  3. Congenital bicuspid valve disease
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22
Q

Aortic Regurgitation: Pathophysiology of Aortic Root Dilatation

A

Dilatation stretches the annulus the cusps are attactched to, so the valves are unable to meet/close

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23
Q

Aortic Regurgitation: Pathophysiology

A

Inadequate closure - back flow of blood and decrease in aortic diastolic pressure - pressure in LA and Vasc - increased wall tension , enlargement and hypertrophy - congestive heart failure

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24
Q

Aortic Regurgitation: Pathophysiology of wide pulse pressure

A

Increased systolic volume but rapid fall of aortic pressure as blood flows back during systole.

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25
Q

Aortic Regurgitation: Pathophysiology of acute regurgitation

A

End-diastolic pressure in LV increases sharply - HR increases - this fails to maintain stroke volume - cariogenic shock

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26
Q

Aortic Regurgitation: Acute symptoms (5)

A
  1. Sudden cardiovascular collapse
  2. Pulmonary oedema
  3. Pallor
  4. Sweating
  5. Peripheral vasoconstriction
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27
Q

Aortic Regurgitation: Primary Chronic Symptoms (3)

A
  1. Exertional Dyspnoea
  2. Orthopnea
  3. Paroxysmal nocturnal dyspnoea
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28
Q

Aortic Regurgitation: Secondary Chronic Symptoms (3)

A
  1. Syncope
  2. Palpitations
  3. Angina
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29
Q

Aortic Regurgitation: Clinical Findings (3)

A
  1. War-hammer - collapsing pulse
  2. Wide-pulse pressure
  3. Displaced, hyperdynamic apex-beat
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30
Q

Aortic Regurgitation: Corrigan’s sign

A

Large volume, collapsing pulse in the carotid arteries

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31
Q

Aortic Regurgitation: De Musset’s sign

A

Bobbing of the head in synchrony with the beating of the heart

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32
Q

Aortic Regurgitation: Quincke’s sign

A

Pulsation of the nail beds

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33
Q

Aortic Regurgitation: Traube’s sign

A

“Pistol shot” like bruit heard on auscultation of the femoral pulse

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34
Q

Aortic Regurgitation: Duroziez sign

A

Diastolic femoral murmur

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35
Q

Aortic Regurgitation: Müller’s sign

A

Pulsation or bobbing of the uvula

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36
Q

Aortic Regurgitation: Auscultation Finding

A

High pitched early diastolic murmur (heard best when patient is leant forward and on exhalation)

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37
Q

Aortic Regurgitation: Investigations (4)

A
  1. ECG
  2. CXR
  3. Echo
  4. Cardiac Catheterisation
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38
Q

Aortic Regurgitation: ECG findings (1)

A

LVH (left axis deviation)

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39
Q

Aortic Regurgitation: CXR findings (3)

A
  1. Cardiomegaly
  2. Dilated ascending aorta
  3. Pulmonary Oedema
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40
Q

Aortic Regurgitation: Cardiac Catheterisation findings (4)

A
  1. Severity of AR
  2. Valve movement
  3. LV size, function and pressures
  4. Aortic Root dimensions
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41
Q

Aortic Regurgitation: Moderate AR (2)

A
  1. ACEi to reduce systolic hypertension
  2. Follow up with serial echocardiography
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42
Q

Aortic Regurgitation: Indications for surgery (5)

A
  1. Severe AR
  2. Increasing symptoms
  3. Declining LV function or enlarging LV
  4. Enlarged ascending aorta
  5. Infective endocarditis refractory to treatment
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43
Q

Aortic Regurgitation: Surgical Intervention (2)

A

Aortic valve replacement (tissue or mechanical)
Aortic root/ascending aorta surgery

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44
Q

Aortic Regurgitation: Management of acute AR

A
  1. ABCDE
  2. Positive ionotropes (dopamine) and vasodilator (sodium nitroprusside) for haemodynamic support
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45
Q

Infective Endocarditis: When to suspect IE? (2)

A

Fever + New Murmur
Temperature >1 week in the at-risk patient

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46
Q

Infective Endocarditis: Acute infective endocarditis presentation and where does it occur? (3)

A

Occurs on Normal valves
Acute heart failure
Emboli

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47
Q

Infective Endocarditis: Most common cause of acute IE

A

Staph. Aureus

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48
Q

Infective Endocarditis: Acute IE risk factors (3)

A
  1. Skin Breach (IV lines, wounds)
  2. Renal failure
  3. Immunosuppression
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49
Q

Infective Endocarditis: Where does subacute IE present?

A

Abnormal valves

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50
Q

Infective Endocarditis: Risk factors for IE

A
  1. Valve disease (aortic mitral)
  2. IV drug users (tricuspid)
  3. Coarctation or PDA
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51
Q

Infective Endocarditis: Most common cause of prosthetic valve IE

A

Staph. Epidermis

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52
Q

Infective Endocarditis: Most common organisms (3)

A
  1. Strep viridans
  2. Staph Aureus
  3. Strep Bovis
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53
Q

Infective Endocarditis: Rare Gram Negative causes

A

HACEK
1. Haemophilus
2. Actinobacilus
3. Cardiobacterium
4. Eikenella
5. Kingella

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54
Q

Infective Endocarditis: Most common fungal causes

A
  1. Candida
  2. Aspergillus
  3. Histoplasma
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55
Q

Infective Endocarditis: Systemic septic signs (4)

A
  1. Fever
  2. Night sweats
  3. Rigors
  4. Weight loss
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56
Q

Infective Endocarditis: Septic signs on examination (3)

A

Anaemia
Splenomegaly
Clubbing

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57
Q

Infective Endocarditis: Facial stigmata (1)

A

Roth spots

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58
Q

Infective Endocarditis: Hand stigmata (3)

A
  1. Osler Nodes
  2. Jane Way lesions
  3. Splinter haemorrhages
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59
Q

Infective Endocarditis: Cardiac lesions observed on examination (2)

A
  1. New murmur
  2. Regurgitation or valve obstruction
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60
Q

Infective Endocarditis: Key ECG findings (2)

A
  1. PR interval prolongation (aortic root abscess)
  2. AV block
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61
Q

Infective Endocarditis: Co-morbid conditions which increase risk (2)

A
  1. Heart disease
  2. (congenital or acquired)
    Prosthetic valves
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62
Q

Infective Endocarditis: Duke’s Criteria (Major: Blood Culture positive for IE) (3)

A
  1. Typical culture in 2 separate cultures
  2. Persistently positive cultures (3 drawn 12 hours apart)
  3. Single positive blood culture for coxiella burnetii
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63
Q

Infective Endocarditis: Duke’s Criteria (Major: Imaging positive for IE) (3)

A
  1. Echo positive for IE
  2. Abnormal activity around site of valve implantation on PET-CT
  3. Paravalvular lesions on cardiac CT
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64
Q

Infective Endocarditis: Duke’s Criteria (Minor) (5)

A
  1. Predisposition (heart pathology, IV drug use)
  2. Fever (>38)
  3. Vascular phenomena (aneurysm, infarct)
  4. Immunological phenomena (glomerulonephritis, Osler’s nodes)
  5. Positive blood culture not meeting major criteria
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65
Q

Infective Endocarditis: Duke’s Criteria Interpretation

A

Definite IE if:
1. 2 major criteria
2. 1 Major and 3 minor
3. All 5 minor criteria

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66
Q

Infective Endocarditis: 3 key test

A
  1. Transthoracic/transoesophageal echo echocardiogram
  2. CXR
  3. Bloods (Tests and cultures)
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67
Q

Infective Endocarditis: How to take blood cultures

A

Take 3 samples from 3 different places at height of fever

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68
Q

Infective Endocarditis: Key blood tests (3)

A
  1. Anaemia
  2. White cell count
  3. Rheumatoid factor
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69
Q

Infective Endocarditis: Urinanalysis finding (1)

A

Microscopic haematuria

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70
Q

Infective Endocarditis: CXR findings (2)

A
  1. Cardiomegaly
  2. Pulmonary oedema
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71
Q

Infective Endocarditis: ECG findings (1)

A

Heart block

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72
Q

Infective Endocarditis: Echo (transoesophageal findings)

A
  1. Mitral lesions
  2. Aortic root abscess
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73
Q

Infective Endocarditis: CT findings

A

Emboli

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74
Q

Infective Endocarditis: Management

A
  1. Long term IV antibiotics (6 weeks minimum)
  2. Potentially surgery (Heart failure, bacteraemia, valve obstruction etc.)
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75
Q

Infective Endocarditis: Staphylococcus antibiotics

A

Flucloxacillin + gentamicin + rifampicin (Vancomycin if allergic)

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76
Q

Infective Endocarditis: Streptococcus antibiotics

A

Benzylpenicillin + gentamicin (Vancomycin if allergic)

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77
Q

Infective Endocarditis: ECG sign which is an indication for surgery

A

PR prolongation - can be caused by aortic root abscess

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78
Q

Infective Endocarditis: Hand stigmata

A
  1. Osler Nodes
  2. Jane Way lesions
  3. Splinter haemorrhages
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79
Q

Mitral regurgitation: Definition

A

Backflow through the mitral valve during systole

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80
Q

Mitral regurgitation: Causes

A
  1. Functional (LV dilatation, calcification, prolapse)
  2. Infective (rheumatic, endocarditis)
  3. Genetic (congenital, connective tissue disorders)
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81
Q

Mitral regurgitation: Symptoms (4)

A
  1. Dyspnoea
  2. Palpitations
  3. Fatigue
  4. Symptoms of causative factor
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82
Q

Mitral regurgitation: Signs on palpation (2)

A

Palpitations
Displaced hyperdynamic, apex beat

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83
Q

Mitral regurgitation: Signs on ECG (3)

A

AF
P-mitrale
LVH

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84
Q

Mitral regurgitation: Signs on Auscultation (2)

A

Pansystolic murmur at apex which radiates to axilla
Soft (S1) Split (S2) Loud (P2)

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85
Q

Mitral regurgitation: Key investigations (4)

A

ECG
CXR
Echo
Cardiac catheterisation (confirms diagnosis)

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86
Q

Mitral regurgitation: CXR findings (3)

A

Big LA and LV
Mitral valve calcification
Pulmonary oedema

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87
Q

Mitral regurgitation: Use of an Echo (3)

A

Assess LV function, MR severity and aetiology

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88
Q

Mitral regurgitation: Use of cardiac catheterisation

A

Confirms diagnosis
Excludes other valve disease
Assesses coronary artery disease

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89
Q

Mitral regurgitation: 4 key points of management

A
  1. Rate control (fast AF)
  2. Anti-coagulate (if risk)
  3. Diuretics (symptoms)
  4. Surgery if symptoms deteriorate
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90
Q

Mitral valve prolapse: Epidemiology

A

Most common valvular abnormality

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91
Q

Mitral valve prolapse: Aetiology (2)

A

Occurs alone or with congenital conditions (ASD, PDA, Marfan’s, Turner’s)

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92
Q

Mitral valve prolapse: Symptoms (4)

A

Usually asymptomatic
May develop:
Chest pain
Palpitations
Autonomic dysfunction

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93
Q

Mitral valve prolapse: Complications (4)

A

MR
Cerebral emboli
Arrythmias
Sudden death

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94
Q

Mitral valve prolapse: Signs on auscultation (2)

A

Mid-systolic click and/or late systolic murmur

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95
Q

Mitral valve prolapse: Tests (2)

A
  1. Echo for diagnosis
  2. ECG
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96
Q

Mitral valve prolapse: ECG findings (1)

A

May show inferior T-wave inversion

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97
Q

Mitral valve prolapse: Two steps of treatment

A
  1. Beta-blockers (palpitations, chest pain)
  2. Surgery if severe
98
Q

Mitral Stenosis: Causes (3)

A

Rheumatic Fever
Congenital
Mucopolysaccharidosis

99
Q

Mitral Stenosis: When do symptoms begin?

A

When mitral orifice becomes <2cm2

100
Q

Mitral Stenosis: Two key causes of symptoms

A

Pulmonary Hypertension
Pressure from large left atrium on local structures

101
Q

Mitral Stenosis: Effects of pulmonary hypertension (3)

A

Dyspnoea
Haemoptysis
Chronic bronchitis picture

102
Q

Mitral Stenosis: ECG findings (4)

A

AF (enlarged LA)
P-mitrale
RVH
Progressive right axis deviation

103
Q

Mitral Stenosis: Effects of large left atrium (3)

A

Hoarseness (RLN)
Dysphagia (Oesophagus)
Bronchial obstruction

104
Q

Mitral Stenosis: Signs on general examination (2)

A

Malar flush on cheeks (Low CO)
Low-volume pulse

105
Q

Mitral Stenosis: Signs on palpation (2)

A

Non-displaced apex beat
RV heave

106
Q

Mitral Stenosis: Signs on auscultation (4)

A
  1. Loud S1
  2. Opening snap (pliable valve)
  3. Rumbling mid-diastolic murmur
    Graham Steel murmur may occur
107
Q

Mitral Stenosis: When is best to hear this murmur?

A

In expiration with patient on their side

108
Q

Mitral Stenosis: Signs denoting severity (2)

A

Longer diastolic murmur
And closer the opening snap is to S2

109
Q

Mitral Stenosis: Investigations (4)

A
  1. ECG
  2. CXR
  3. Echo
  4. Potential cardiac catheterisation
110
Q

Mitral Stenosis: CXR findings (3)

A

Left atrial enlargement
Pulmonary oedema
Mitral valve calcification

111
Q

Mitral Stenosis: Echo interpretation - When is significant stenosis diagnosed? (2)

A
  1. This is diagnostic
  2. Significant stenosis occurs if valve is <1cm2
112
Q

Mitral Stenosis: Management if initial 3 stages fail

A
  1. Balloon valvuloplasty
  2. Valve replacement
113
Q

Mitral Stenosis: 3 steps of management

A
  1. Rate control and anticoagulation if AF
  2. Diuretics (reduce pre-load and venous congestion)
114
Q

Heart Failure: Definition

A

Cardiac output is inadequate for heart’s requirements

115
Q

Heart failure: Prevalence amongst the elderly population

A

10%

116
Q

Heart failure: Systolic failure pathophysiology

A

Ventricules unable to contract normally - decreased cardiac output

117
Q

Heart failure: Systolic failure Ejection fraction

A

<40%

118
Q

Heart failure: Causes of systolic failure (3)

A

IHD
MI
Cardiomyopathy

119
Q

Heart failure: Diastolic failure pathophysiology

A

Inability of ventricles to relax and fill properly - increased filling pressures (Also known as heart failure with preserved ejection fraction, HEFpEF)

120
Q

Heart failure: Diastolic failure ejection fraction

A

> 50%

121
Q

Heart failure: Diastolic failure causes (4)

A

Ventricular hypertrophy
Constrictive pericarditis
Tamponade
Obesity

122
Q

Heart failure: Left Ventricular Failure (LVF) Symptoms

A
  1. Shortness of Breath (Dyspnoea, poor exercise tolerance, Orthopnea, PND)
  2. Cardiac asthma (Wheeze, nocturnal cough)
  3. Systemic (Cold peripheries, weight loss)
123
Q

Heart failure: Right Ventricular Failure (LVF) symptoms

A
  1. Fluid retention (Peripheral oedema, ascites, facial engorgement)
  2. Systemic (Nausea, anorexia)
124
Q

Heart failure: Right Ventricular Failure (RVF) causes (3)

A
  1. LVF
  2. Pulmonary stenosis
  3. Lung Disease (Cor pulmonale)
124
Q

Heart failure: Right Ventricular Failure (LVF) causes (3)

A
  1. LVF
  2. Pulmonary stenosis
  3. Lung Disease (Cor pulmonale)
125
Q

Heart failure: What is congestive cardiac failure?

A

Right and left ventricular failure occur together

126
Q

Heart failure: Acute heart failure definition (2)

A
  1. New-onset acute heart failure
  2. Decompensation of chronic heart failure
127
Q

Heart failure: Acute heart failure - Key signs of decompensation or chronic heart failure (2)

A
  1. Pulmonary and/or peripheral oedema
  2. With/without signs of peripheral hypo perfusion
128
Q

Heart failure: How does chronic heart failure develop?

A

Develops and progresses slowly

129
Q

Heart failure: 2 key symptoms of chronic heart failure

A
  1. Venous congestion
  2. Arterial pressure is maintained until late
130
Q

Low-output heart failure: Definition

A

Cardiac output is decreased and fails to increases normally with exertion

131
Q

Low-output heart failure: 3 causes

A
  1. Excessive preload
  2. Pump failure
  3. Chronic excessive after-load
132
Q

Low-output heart failure: causes of excessive preload (2)

A

Mitral regurgitation or fluid overload

133
Q

Low-output heart failure: Causes of pump failure (3)

A

Systolic or diastolic HF
Decreased HR (beta-blockers)
Negatively inotropic drugs

134
Q

Low-output heart failure: Causes of chronic excessive overload (2)

A

Aortic stenosis or hypertension

135
Q

Low-output Heart failure: Excessive pre-load pathophysiology

A

Can cause ventricular dilatation - exacerbates pump failure

136
Q

Low-output Heart failure: Excessive after-load pathophysiology

A

Leads to ventricular hypertrophy - stiff walls - diastolic dysfunction

137
Q

High-output heart failure: Definition

A

Output is normal or increased in the face of increased needs - failure occurs with a normal heart

138
Q

High-output heart failure: When does this occur?

A

With a normal heart or earlier if there is heart disease

139
Q

High-output heart failure: Causes (3)

A
  1. Anaemia
  2. Pregnancy
  3. Hyperthyroidism
140
Q

High-output heart failure: Consequences (2)

A
  1. Initially features of RVF
  2. Later LVF becomes evident
141
Q

Heart failure: Clinical signs of fluid overload

A
  1. Ankle oedema
  2. Elevated JVP
  3. Basal lung crepitations
  4. Ascites
142
Q

Heart failure: Auscultation findings (2)

A

S3 gallop

143
Q

Heart Failure: Major Framingham Criteria (CXR findings) 2

A
  1. Pulmonary Oedema
  2. Cardiomegaly
144
Q

Heart Failure: Major Framingham Criteria (Signs on examination) 2

A

Hepatojugular Reflex
Neck Vein distention

145
Q

Heart Failure: Major Framingham Criteria (Signs on auscultation) 3

A

S3 gallop
Rales

146
Q

Heart Failure: Major Framingham Criteria (Symptoms) 2

A

Paroxysmal nocturnal dyspnoea and/or orthopnoea

147
Q

Heart Failure: Diagnosis of heart failure (3)

A
  1. Symptoms of heart failure
  2. Evident of cardiac dysfunction at rest
  3. Framingham criteria for CCF
148
Q

Heart Failure: General signs on examination (3)

A

Cyanosis
Decreased BP
Signs of valve disease

149
Q

Heart Failure: Signs on palpation of radial pulse (2)

A
  1. Narrow pulse pressure
  2. Pulsus alterans
150
Q

Heart Failure: Signs on palpation of chest (2)

A

Displaced apex (LV dilatation)
RV heave (Pulmonary hypertension)

151
Q

Heart Failure: Interpretation of New York classification

A

Severity of HF

152
Q

Heart Failure: New York Classification (4)

A
  1. Heart disease present, no SOB during ordinary activities
  2. Comfortable at rest, SOB during ordinary activities
  3. Less than ordinary actives cause SOB
  4. SOB at rest, all activities cause discomfort
153
Q

Heart Failure: 3 Key investigations

A

ECG
Beta Natiuretic Peptide (BNP)
Echo if these are abnormal

154
Q

Heart Failure: What does an ECG show (2)

A

Structural heart disease
1. Q waves (previous MI)
2. AF or LBB

155
Q

Heart Failure: Echo findings

A
  1. LV dysfunction
  2. Cause of HF (MI, Valvular heart disease)
156
Q

Heart Failure: Prognosis

A

25-50% die within 5 years of prognosis

157
Q

Heart Failure: ABCDE CXR findings

A

A - Alveolar Oedema
B- Kerley B lines (Interstitial oedema)
C - Cardiomegaly (cardiothoracic ratio >50% on film)
D - Dilated upper lobe veins
E - Pleural Effusion

158
Q

Heart Failure: How does acute HF become life-threatening?

A

It can cause severe pulmonary oedema

159
Q

Heart Failure: 3 key symptoms of severe pulmonary oedema

A
  1. Pink frothy sputum
  2. Autonomic (Pale, sweaty, increase pulse and RR)
  3. HF symtoms
160
Q

Heart Failure: Acute Heart failure management (4)

A
  1. A-E
  2. Diamorphine
  3. Furosemide
  4. GTN spray
161
Q

Heart Failure: Acute heart failure if systolic BP fails to respond

A

Nitrate infusion

162
Q

Heart Failure: Mechanical ventilation option in acute heart failure

A

CPAP

163
Q

Chronic Heart Failure: Non-pharmacological treatment (4)

A
  1. Stop smoking
  2. Stop drinking alcohol
  3. Eat less salt
  4. Optimise weight and nutrition
164
Q

Chronic Heart Failure: Two key drugs which may be exacerbating factors

A
  1. NSAID (fluid retention)
  2. Verapamil (Negative ionotrope)
165
Q

Chronic Heart Failure: Two key goals of intervention around CHF

A
  1. Treat cause
  2. Treat exacerbating factors
166
Q

Chronic Heart Failure: 6 stages of treatment

A
  1. Diuretics
  2. ACE-i
  3. Beta-blockers
  4. Mineralocorticoid receptor antagonists
  5. Digoxin
  6. Vasodilators
167
Q

Chronic Heart Failure: Effect of loop diuretics

A

Symptomatic relief

168
Q

Chronic Heart Failure: Example loop diuretic

A

Furosemide, Bumetanide

169
Q

Chronic Heart Failure: Loop Diuretic side effects

A

Hypokalaemia, renal impairment

170
Q

Chronic Heart Failure: What do do if diuretic causes hypokalaemia

A

Switch to K+ sparing diuretic like spironolactone

171
Q

Chronic Heart Failure: What to do if refractory oedema occurs after prescribing loop diuretic?

A

Switch to thiazide diuretic

172
Q

Chronic Heart Failure: When to consider ACEi?

A

Left ventricular systolic dysfunction

173
Q

Chronic Heart Failure: What to do if ACEi causes problematic cough?

A

ARB may be a substitute

174
Q

Chronic Heart Failure: Effect of beta blockers

A

Decrease mortality in HF, and are beneficial when used with ACEi in patient with systolic dysfunction

175
Q

Chronic Heart Failure: Effect of spironolactone

A

Shown to decrease mortality when added to traditional therapies

176
Q

Chronic Heart Failure: When is spironolactone indicated? (2)

A
  1. When patient is still symptomatic despite optimal therapy (ACEi, diuretics and beta-blockers)
  2. Post MI patients with LVSD
177
Q

Chronic Heart Failure: Effect of digoxin

A

Symptomatic relief even in those in sinus rhythm

178
Q

Chronic Heart Failure: When should digoxin be considered? (2)

A

Patients symptomatic despite standard therapy, and patients with AF

179
Q

Chronic Heart Failure: Why is important with measure K+ with digoxin?

A

Hypokalaemia risks digoxin toxicity

180
Q

Chronic Heart Failure: Combination of vasodilators which should be used

A

Hydralazine and isosorbide dinitrate

181
Q

Chronic Heart Failure: When are vasodilators indicated?

A

If patient is intolerant of ACEi and ARBs

182
Q

Intractable heart failure: Definition

A

Failure which is apparently resistant to further treatment

183
Q

Intractable heart failure: Diuretics recommendation

A

Switch furosemide to bumetanide

184
Q

Intractable heart failure: Other steps to consider (3)

A
  1. Na+ and fluid restriction
  2. DVT prophylaxis
  3. Add thiazide diuretic to spironolactone
185
Q

Intractable heart failure: Example of thiazide diuretic

A

Metolazone

186
Q

Intractable heart failure: Treatment in extremis

A

IV inotropes

187
Q

Intractable heart failure: Surgical interventions to consider (3)

A
  1. Cardiac resynchronisation
  2. LV assist device
  3. Transplant
188
Q

Heart Failure: How does an LVAD work?

A

A pump forces blood through tubing from the LV to aorta

189
Q

Heart Failure: Signs on LVAD on exam (2)

A

No pulse (if continuous flow), Mechanical hum heart on auscultation

190
Q

Heart Failure: Where is BNP released?

A

Ventricular myocardium

191
Q

Heart Failure: What does plasma BNP show?

A

Plasma BNP is closely related to left ventricular pressures

192
Q

Heart Failure: How does BNP change in MI or LV dysfunction?

A

It is released in high quantities

193
Q

Heart Failure: Things apart from MI or HF which lead to BNP secretion (3)

A

Tachycardia, glucocorticoids, thyroid hormones

194
Q

Heart Failure: What level of BNP diagnoses heart failure?

A

> 100bg/L

195
Q

Heart Failure: What level of BNP rules out HF?

A

<50ng/L

196
Q

Acute Coronary Syndrome: Pathophysiology

A

Thrombus from an atherosclerotic plaque blocks a coronary artery (Plaque rupture - thrombosis - inflammation)

197
Q

Acute Coronary Syndrome: What two conditions does it include?

A

Unstable Angina and MI

198
Q

Acute Coronary Syndrome: 3 rarer causes of ACS

A

Vasculitis, emboli and coronary spasm

199
Q

Acute Coronary Syndrome: What is a thrombus in a fast flowing artery mainly formed of?

A

Platelets

200
Q

Acute Coronary Syndrome: What events does Myocardial Infarction mean have occurred?

A

Cell death has occurred, releasing troponin

201
Q

Acute Coronary Syndrome: What does ischaemia signify?

A

A lack of blood supply with or without cell death

202
Q

Acute Coronary Syndrome: What vessels does the left coronary artery form?

A

The circumflex and left anterior descending artery

203
Q

Acute Coronary Syndrome: What does the right coronary artery supply? (4)

A

Right atrium
Right ventricle
Inferior aspect of left ventricle
Posterior septal area

204
Q

Acute Coronary Syndrome: What does the circumflex artery supply? (2)

A

Left atrium
Posterior aspect of left ventricle

205
Q

Acute Coronary Syndrome: What does the left anterior descending artery supply? (2)

A

Anterior aspect of left ventricle
Anterior aspect of septum

206
Q

Acute Coronary Syndrome: Two types of MI

A
  1. STEMI
  2. NSTEMI
207
Q

Acute Coronary Syndrome: STEMI definition

A

ST segment elevation or new left bundle branch block

208
Q

Acute Coronary Syndrome: NSTEMI definition

A

Troponin positive without ST segment elevation

209
Q

Acute Coronary Syndrome: Changes associated with posterior STEMI

A

ST segment elevation in V7-V9

210
Q

Acute Coronary Syndrome: ECG changes associated with NSTEMI (4)

A

ST depression
T-wave inversion
Pathological Q waves
May be normal

211
Q

Acute Coronary Syndrome: What should be diagnosed if troponin levels are normal and ECG does not show pathological changes?

A

Unstable angina or musculoskeletal chest pain

212
Q

Acute Coronary Syndrome: Non-modifiable risk factors (3)

A
  1. Family history of ILD
  2. Male gender
  3. Age
213
Q

Acute Coronary Syndrome: Modifiable risk factors (3)

A
  1. Smoking
  2. Hypertension
  3. DM
214
Q

Acute Coronary Syndrome: Symptoms (2)

A

Central constricting chest pain with autonomic symptoms (nausea, vomiting, sweating, dyspnoea, palpitations)

215
Q

Acute Coronary Syndrome: Where can pain radiate?

A

Jaw or arms

216
Q

Acute Coronary Syndrome: Where are silent MIs seen?

A

Silent MI (do not experience typical chest pain) seen in elderly and diabetic patients

217
Q

Acute Coronary Syndrome: What is diagnosis based on? (4)

A
  1. Rise in troponin
  2. Symptoms of ischaemia
  3. ECG changes - ischaemia, Q waves
  4. Imaging showing loss or myocardium or wall abnormalities
218
Q

Acute Coronary Syndrome: Pulse and blood pressure

A

May be raised or low

219
Q

Acute Coronary Syndrome: Signs on auscultation (2)

A
  1. 4th Heart sound
  2. Pan-systolic murmur (Due to VSD, or papillary muscle dysfunction)
220
Q

Acute Coronary Syndrome: Systemic signs on examination

A
  1. Signs of heart failure (Raised JVP, 3rd heart sound, basal crepitations)
  2. Low grade fever
221
Q

Acute Coronary Syndrome: Signs which may develop later

A
  1. Pericardial friction rub
  2. Peripheral oedema
222
Q

Acute Coronary Syndrome: Does the ECG always look abnormal?

A

In 20% of MIs, the ECG is normal initially

223
Q

Acute Coronary Syndrome: Signs in I, aVL and V3-6

A

Left coronary artery (Anterolateral area)

224
Q

Acute Coronary Syndrome: Signs in V1-4

A

Left Anterior descending artery (Anterior)

225
Q

Acute Coronary Syndrome: Signs in I, aVL, V5-6

A

Circumflex artery, Lateral

226
Q

Acute Coronary Syndrome: Signs in II, III, aVF

A

Right Coronary Artery, Inferior

227
Q

Acute Coronary Syndrome: 3 possible findings on CXR

A
  1. Cardiomegaly
  2. Pulmonary Oedema
  3. Widened mediastinum
228
Q

Acute Coronary Syndrome: How does a diagnosis of ACS require troponin to be measured?

A

Troponin should be measured serially - this is specific to deanery

229
Q

Acute Coronary Syndrome: What does Troponin measure?

A

Myocardial necrosis

230
Q

Acute Coronary Syndrome: Which troponins are most specific to MI?

A

T and I

231
Q

Acute Coronary Syndrome: Other causes of raised troponin (3)

A
  1. Renal failure
  2. Infection (Myocarditis, pericarditis)
  3. Iatrogenic (following CPR, DC cardioversion)
232
Q

Acute Coronary Syndrome: What would an Echo show?

A

Regional wall abnormalities

233
Q

Acute Coronary Syndrome: Acute Treatment of NSTEMI

A

BATMAN
B - Beta-blockers
A - Aspirin
T - Ticagrelor (Anti-platelet)
M - Morphine
A - Anti-coagulant (Fondaparinux)
N - Nitrates (coronary artery spasm)

234
Q

Acute Coronary Syndrome: With which drug are beta-blockers contraindicated?

A

Verapamil - can precipitate systole

235
Q

Acute Coronary Syndrome: Function of GRACE score

A

Gives 6 month risk of death or repeat MI after an NSTEMI

236
Q

Acute Coronary Syndrome: Interpretation of GRACE score

A

<5% Low Risk
5-10% Medium Risk
>10% High Risk

237
Q

Acute Coronary Syndrome: Management based on NSTEMI

A

Medium or high risk refer for early PCI (within 4 days of admission) to treat underlying coronary artery disease.

238
Q

Acute Coronary Syndrome: Secondary Prevention Medical Management (6As)

A
  1. Aspirin 75mg once daily
  2. Another antiplatelet: e.g. clopidogrel or ticagrelor for up to 12 months
  3. Atorvastatin 80mg once daily
  4. ACE inhibitors (e.g. ramipril titrated as tolerated to 10mg once daily)
  5. Atenolol (or other beta blocker titrated as high as tolerated)
  6. Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)
239
Q

Acute Coronary Syndrome:

A

Conditions (4 decks)

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