Cardiovascular Flashcards
1
Q
How long should the PR interval be and where is it between?
A
0.12-0.2 seconds (start of p wave to start of r wave)
2
Q
How long should QRS be?
A
0.08-0.12 seconds
3
Q
How long should QT be and where is it between?
A
0.35-0.45 seconds (start of QRS to end of T)
4
Q
Which leads provide a view of the anterior and septal heart (LAD)
A
V1-4
5
Q
Which leads provide a view of the lateral heart (Cx)
A
V5,6 + aVL, aVR + lead 1
6
Q
Which lead provides an inferior view of the heart (RCA)
A
Lead 2, 3 + aVF
7
Q
How long is a little square
A
0.04 seconds
8
Q
How many milivolts is a little square
A
0.1mv
9
Q
How long and many milivolts is a big square
A
0.2 seconds
0.5 mv
10
Q
What does S1 sound represent
A
Mitral/ tricuspid valve closing
11
Q
What does S2 sound represent
A
Aortic/ pulmonary valve close
12
Q
What does S3 sound represent
A
Rapid ventricular filling - cordae tendonae twang like string as they reach their full length, opening the valve quickly (before S2). either…
1. strong healthy heart
2. heart failure/ mitral regurg
13
Q
What does S4 sound represent
A
Turbulent flow of blood into vent due to uncomplient stiff ventricles (before S1)
14
Q
What is cardiovascular disease
A
The development of athersclerotic arteries
15
Q
What two affects on arteries does atherosclerosis have?
A
- stenosis (narrowing)
- Stiffening –> hypertension
16
Q
What are the three major risk factors for atherosclerosis?
A
- Old age
- Family history
- Hypertension
17
Q
What are some other risk factors for atherosclerosis (7)?
A
- Hyperlipidaemia
- Male
- Obesity
- Lack of exercise
- Diabetes
- Smoking
- Alcohol consumption
18
Q
Complications of atherosclerosis
A
- Stroke
- IHD
- TIAs
- Peripheral ischemia
19
Q
What tool can calculate the risk of stroke or MI in next 10 years, what does it ask about?
A
QRISK
Age, Gender, Family history, BP …etc
20
Q
What 4 drugs can be used as secondary prevention of athersclerosis?
A
- Aspirin (antiplatelet)
- Atorvastatin
- Atenolol (beta blocker)
- ACE inhibitors (e.g. ramipril)
21
Q
3 side effects of statins
A
- Myopathy
- Type 2 diabetes (less fat for energy)
- Hemorrhagic stroke (rare)
22
Q
What is ACS
A
Reduction of blood flow through the coronary arteries –> reduced O2 to myocardium
23
Q
What are the 3 types of ACS
A
- Unstable angina
- NSTEMI
- STEMI
24
Q
What is the difference between stable and unstable angina?
A
Unstable = symptoms present at rest
25
Symptoms of angina (5)
* **Central crushing chest pain/ tightness**
* Nausea
* Fatigue
* Sweating
* Dyspnoea
26
Diagnosis of Angina (2)
* ECG
* Coronary artery CT angiogram
27
What would an ecg show in angina (stable Vs unstable)
Stable = normal when resting but may show changes when exercising
Unstable = abnormal during a resting attack
28
What changes may be seen in an angina ECG (3)
* ST depression
* Inverted T wave
* T wave tall
29
Causes of angina (2)
* Atherosclerotic coronary heart disease
* Prinzmetal's angina (artery spasm)
30
What are 3 non invasive treatments for stable angina?
* Lifestyle changes
* Glyceryl trinitrate (GTN) spray
* Other medications
31
What other medications are given for angina itself
* Beta blocker
* CCB
* other - ivabradine, long acting nitrates
32
Medications for secondary prevention of CVD in angina (3)
* Aspirin
* Atorvastatin
* ACE - inhibitor
33
What is a contrindication for beta blockers
asthma
34
What is a contraindication for CCBs in angina
Heart failure
35
What 2 invasive procedures can be carried out for angina
* Percutaneous coronary intervention
* CABG
36
What 2 vessels are often used in CABG
* Internal mamory artery
* Great saphenous vein (leg)
37
What can be used to guide Tx in angina
Grace score (predicts chance of MI)
38
How is NSTEMI diagnosed
Troponin blood levels (due to death of heart tissue)
39
How is STEMI diagnosed
ECG - ST elevation in 2 or more leads
40
How is NSTEMI/ unstable angina treated initially (5)
* Morphine
* Oxygen (If low sats <94%)
* Nitrates
* Aspirin/ anticoagulant
* Clopidogrel/ other anti-platelet
**MONAC**
41
What will be carried out after initial treatment of NSTEMI/ unstable angina
Angiogram if high risk GRACE score --> PCI
42
How is STEMI treated
* MONAC
* then agiogram + PCI
... if not available --> thrombolysis
43
Preventative treatment after MI (3)
* Aspirin
* Atorvastatin
* ACE - inhibitor
44
What is the difference between STEMI / NSTEMI in terms of heart tissue
STEMI = transmural - more tissue affected and disrupts electrical conduction more
45
Complications of MI
* Heart failure - tissue death (valve, muscle...)
* Dressler syndrome - pericarditis due to immune responce to tissue death
46
Who is at risk of 'silent' MI
* **Diabetics** - diabetic neuropathy
* Females more at risk
47
What is heart failure
Inability for heart to deliver oxygenated blood to tissues at the required rate
48
What is the most common cause of heart failure?
Ischemic heart disease - MI
49
What are some other causes of heart failure (4)?
* Cardiomyopathy
* Valvular disease
* Hypertension/ cor pulmonale
* Arhythmias
50
Risk factors for heart failure (6)
* Age (65+)
* Smoking
* Obesity
* Previous MI
* Male
* Genetics/ family history
51
Pathophysiology of heart failure
Decreased cardiac output for whatever reason --> increased SNS and RAAS --> heart works harder, remodels and fails
52
What 3 hormonal mechanisms initially compensate for the effects of heart failure
* RAAS
* ADH
* Adrenaline/ NAd
53
What is conjestive heart failure?
Heart failure in left and right side
54
What is reduced ejection fraction heart failure
The heart is pumping a smaller fraction of blood into the body with each stroke (can indicate worse prognosis)
55
Is reduced or preserved ejection fraction heart failure systolic or diastolic failure
Reduced = systolic
Preserved = diastolic
56
How is heart failure time classified
Chronic
Acute - life threatning
57
What is normal ejection fraction of the heart?
50-70%
58
What is classed as reduced ejection fraction heart failure?
<40%
59
Which sided heart failure results in pulmonary and which systemic oedema?
Left = pulmonary oedema
Right = systemic oedema
60
3 cardianal signs of heart failure
* Breathlessness
* Peripheral oedema
* Faitigue
61
What are some other signs of heart failure (5)
* Orthopnoea (breathless when lying)
* Paroxysmal nocturnal dysponea
* Increased jugular pressure
* Bibasal crackles (pul oedema)
* Tachy/ hypotensive
62
What is paroxysmal nocturnal dysponea?
Waking at night with severe shortness of breath
63
What 3 mechanisms cause paroxysmal nocturnal dysponea?
* Lying flat --> fluid settles on large area of lungs --> can't breathe
* Repiratory center in pons less active when asleep
* Less adrenaline during sleep
64
How does the NY heart association classify heart heart failure
* 1 - no limit on exercise
* 2 - slight limit on exercise
* 3 - marked limit on exercise
* 4 - symptoms even at rest
65
Heart failure diagnostic tests (4)
* Blood test for B-type natriuretic peptide
* Echo
* Chest X-ray
* ECG
66
Why is B-type natiuretic peptide released in heart failure?
Stressed ventricular myocytes
Higher BNP levels = worse heart failure
67
What is indicitive of heart failure on CXR (5)
* **A**lveolar bat wing oedema (fluid around heart)
* Kerley **B**-lines
* **C**ardiomegaly
* **D**ilated upper lobe vessels
* Pleural **E**ffusion (fluid in pleural space)
| ABCDE
68
How is heart failure treated (3 steps)
* Lifestyle changes
* Medications
* Surgery for underlying cause/ heart transplant
69
What 4 medications and what order are used in heart failure
1. **A**CE inhibitors + **B**eta blockers
2. **A**ldosterone antagonists - *spironolactone*
3. **L**oop diuretics - *furosemide*
| **ABAL**
70
What is an abdominal aortic aneurism
Permanent dilation of the aorta of more than 50%
71
Risk factors for AAA
* Connective tissue disorders - marfans/ EDS
* Smoking
* Obesity
* Hypertension
* Elderly
* Atherosclerotic RFs
72
What point in the aorta do AAA usually occur below?
Renal arteries
73
Which layers of the aorta are affected in an AAA
All 3 layersm - intima, media and adventitia
74
How dilated must the aorta be to be considered an aneurysm
3 cm
75
What are the signs/ symptoms of AAA
None until rupture then...
* sudden epigastric pain raidiating to flank
* Pulsatile mass in abdomen
* Tachy + hypo
76
How is an AAA diagnosed
Abdominal ultrasound
77
How is AAA treated
* Lifestyle changes
* Surgery if bad enough
78
What are the two types of surgery for AAA
* EVAR (endovascular repair) - stent graft put throught femoral artery
* Open surgery
79
How dilated must an AAA be for surgery
>5.5cm or increasing at 1cm/year
80
How is a ruptured AAA treated?
* ABCDE - emergency
* Fluids + transfusion if needed (be carfeul not to displace clots)
* Surgical repair urgently or after angiogram
81
What percent of AAA rupture anteriorly and what percent retroperitoneal
* 20% anteriorly - into peritoneal cavity (worse)
* 80% retroperitoneal
82
Why is atherosclerosis so much less common in venous circulation?
* No smooth muscle cells
* Much lower pressures
83
What is an aortic dissection?
Tear in the intima of the aorta which allows blood to dissect between the intima and media
84
What are 5 risk factors for aortic dissection?
* Hypertension
* Atherosclerosis
* Connective tissue disorders
* Trauma
* Smoking
85
What are the two most common locations for dissection to occur?
* Sinotubular junction - just after root of aorta, near valve
* Just distal to left subclavian artery origin
86
How does the stanford classification classify 2 types of dissection?
Type A - proximal to origin of left subclavian (more common)
Type B - distal to left subclavian
87
Where can blood in the false lumen flow to?
* Back up the aorta into the pericardial space
* Puncture out of artery into media stinum
* Puncture back into the lumen
* Down the aorta and compress branching arteries
88
What are the signs/ symptoms of aortic dissection
* Sudden onset tearing chest pain
* Tachy/ hypo
* Aortic regurg murmur
* Weak radial pulse
* Cardiac tamponade - blood collects around pericardium
89
How is aortic dissection diagnosed?
* Ultrasound - can be transoesophageal
* CT angiogram
* Chest x-ray
90
How would an aortic dissection present in a chest x-ray
Widened media stinum > 8cm
91
How is aortic dissection treated?
* Surgery
* Medication if less severe
92
What two types of surgery treat aortic dissection?
* Open surgical repair
* EVSR - endovascular repair
93
What medications are used to treat less serious aortic dissections
* Beta blockers - to treat hypertension e.g. *esmolol*
* Vasodilators - e.g. *sodium nitroprusside*
94
What is hypertension and what are the required readings for diagnosis?
High blood pressure
140/90 in clinic or...
135/85 home readings
95
What percentage of cases is primary/ essential hypertension?
95%
96
What can cause secondary hypertension (4)
* **R**enal disease (most common) e.g. CKD
* **O**besity
* **P**regnancy
* **E**ndocrine e.g. hyperaldosteronism
| **ROPE**
97
What are 6 risk factors for hypertension
* Older age
* Ethnicity - black
* Overweight
* Sedentary
* High salt intake
* Family history
98
What are the stages of hypertension?
1. 140/90 or 135/85 (home)
2. 160/100 or 150/95 (home)
3. 180/120
99
What are signs/ symptoms of severe hypertension?
* Headache
* Blurred vision
* Heart failure
100
How is hypertension diagnosed?
Reading of 140/90 recorded in clinic --> 24 hour ambulatory BP device (above 135/85 = diagnostic)
101
What hypertension treatment is started for those under 55 or with diabetes?
ACE inhibitor
102
What hypertension treatment is started for those over 55 or black
Calcium channel blocker
103
What drugs are used next in the treatment of hypertension?
* Add one of CCB or ACE inhibitor
* Add thioside like diuretic
* Add beta blocker/ K+ sparing diuretic depending on K+ blood levels
104
What drug can be used in replacement of ACE inhibitor
Angiotensin 2 receptor blocker
105
This flashcard is an overview of hypertension treatment... draw out the pathway if you like for treatment
106
What is an example of ACE-i and dose used for hypertension
Ramipril - up to 1.25-10 mg per day
107
What is an example of a CCB and the dose for hypertension
Amlodipine - 5-10mg
108
What are 2 examples of Thiazide like diuretic and dose for hypertension
* Indapamide - more potent
* Bendroflumothiazide - less potent
109
What is an example of a beta blocker and dose for hypertension
Bisoprolol - 5-20mg
110
What is an example of a K+ sparing diuretic and dose for hypertension
Spironolactone - 25mg
111
What is an example of an Angiotensin 2 receptor blocker and dose for hypertension
Candesartan - 8-32mg
112
Why might ARB be used instead of ACE-i
ACE-i can cause a dry cough
113
How do ACE-i cause a dry cough?
ACE breaks down bradykinin --> bradykinin contracts airway smooth muscle
114
What are 4 complications of hypertension?
* Heart failure
* CKD
* IHD
* Cerebrovascular accident
115
What are the treatment targets for hypertension?
<140/90 if under 80
<150/90 if over 80 (prevent falls)
116
What other test are important to do in those with hypertension?
Assess end organ damage:
* Fundoscopy (look for papilloedema)
* Urine dipstick (creatinine, albumnin)
* ECG
117
What is a deep vein thrombosis?
A clot that forms in a deep vein (can be anywhere in the body)
118
Where are DVTs most common and which vessels are often affected?
Below the calf (anterior and posterior tibial veins)
119
What is a pulmonary embolism?
A foreign body that mobilises and blocks a pulmonary artery (usually the result of a DVT that mobilises)
120
What are the three factors in virchows triad and what might cause them?
Venous stasis (immobility)
Endothelial injury (smoking, trauma/injury)
Hypercoagulability (sepsis, pregnancy, the pill)
121
What does a PE result in? (2)
* Cor pulmonale
* VQ mismatch
122
Signs/ symptoms of PE (7)
* Cough + haemoptysis
* Shortness of breath
* Sudden pleuritic chest pain
* Evidence of DVT
* Tachycardic
* Hypoxic
* Tachypnea
123
What score can acess the likelihood of having a PE
Wells score
124
What Wells score is suggestive of a PE?
4<
(evidence of DVT = 3; tachycardic = 1.5)
125
How is a pulmonary embolism diagnosed?
* D-dimer (suggests PE)
* CT pulmonary angiogram (diagnostic)
* ECG - S1Q3T3 and RBBB (suggestive - occurs with cor pulmonale)
126
What is a D-dimer test?
Measures a protein released when clot is fibrinolysed
127
What does S1Q3T3 refer to?
Large S wave in lead I
Big Q wave in lead III
Inverted T wave in lead III
128
How does the Wells score affect the investigations done for a PE
If 4> then D-dimer done first, if raised --> CTPA
If 4< then CTPA done
129
What is a massive PE usually defined as?
Systolic BP of <90
130
How is a pulmonary embolism treated?
* If massive PE - thrombolysis
* Non-massive PE - anticoagulation
131
What are 2 examples of thrombolytic drugs?
* streptokinase
* alteplase
132
What is an exmple of anticoagulants used for PE and DVT
* First line = Apixaban/ Rivaroxiban
* LMWH (If CI e.g. renal failure)
133
What class of drug are apixaban and rivaroxiban and what do they inhibit?
DOACs
They inhibit factor Xa
134
How do LMWH work
Bind to and activate antithrombin
135
What is an example of a LMWH
Dalteparin
136
What is a complication of untreated pulmonary embolism?
cor pulmonale --> increased pulmonary resistance --> increased right ventricle strain --> right ventricle hypertrophy --> RV failure
137
What are the symptoms of a deep vein thrombosis (3)
Unilateral leg:
* Swelling
* Redness
* Oedema
138
What does a complete occlusion of a large vein cause?
Clotting backs up into cappilaries causing arterial ischemia (**phlegmasia cerulea dolens**)
139
What are the signs/ symptoms of Phlegmasia cerulea dolens (2)
* Blue leg
* Painful
140
How is DVT investigated?
* D-dimer (raised)
* Duplex sonography - diagnostic (allows flow of blood to be seen)
141
What wells score is suggestive of DVT?
1<
142
How is DVT treated?
Same as non massive PE:
* Apixaban/ rivaroxaban = first line
* LMWH if CI (e.g. renal failure)
143
What is a differential diagnosis for DVT?
Cellulitis - red swollen leg
* Confirm with D-dimer (-ve) and should have high WBC count
144
What is peripheral vascular disease?
Reduction of blood flow through peripheral arteries (IHD of limbs)
145
What are risk factors for PVD (8)
Basically atherosclerotic RFs:
* Smoking
* Age
* Hyperlipidemia
* Male
* Age
* Hypertension
* T2DM
* Obesitiy
* Ethnicity?
146
What is Acute limb ischemia
Sudden decrease in perfusion of the limb = emergency
147
What is a severe form of chronic limb ischemia?
Critical limb threatning ischemia
148
What are the symptoms of PVD (8)
* **P**ain
* **P**allor (pale)
* **P**ulsetiless
* **P**aresthesia (pins and needles)
* **P**ereshingly cold
* **P**aralysis
6 **P**s
Also:
- Ulcers;
- Bruits (pulsatile areas due to turbulent blood flow)
149
How long do nerve and muscle damage take to occur after infarction?
* nerve = 6 hours
* muscle = 6-10 hours
150
What are the stages of PVD
1. Assymptomatic
2. Brought on with exercise (stable angina)
3. Occurs at rest (unstable angina)
4. Infarction (MI)
151
How is PVD investigated?
* Ankle brachial pressure index
* Duplex ultrasound
* CT angiogram
152
What is Ankle brachial pressure index (ABPI)
Compares the blood pressure at ankle (anterior and posterior tibial arteries) to the brachial pressure. Ankle/brachial
153
What ABPI values suggest intermittent claudication and then chronic ischemia
Intermittent claudication = 0.5-0.9
Chronic ischemia = <0.5
154
How is intermittent claudication treated?
* Adress risk factors
* Treat HT
* statins, antiplatelets
155
How is chronic limb ischemia treated?
Revascularisation surgery:
* PCI
* Bypass
156
How is acute limb threatening ischemia treated
Revascularisation quickly within 4-6 hours
157
What are some complications of PVD
* Amputation
* Loss of function/ weakness
* Rhabdomyolysis
158
What are some further complications of rhabdomyolysis?
Release of K+ and Ca2+ into blood --> AKI + arrhythmias
159
What is pericarditis?
Inflammation of the pericardium with or without effusion
160
What are the two types of effusion that can occur in the pericardium?
* Exudate
* Hemorrhagic (blood)
161
What are the causes of pericarditis (6)?
* Idiopathic
* Infectious
* Dressler's syndrome (after MI)
* Autoimmune (e.g. SLE, RA, Sjogren's)
* Tumours (lung/ breast)
* Drug induced
162
What are the 3 layers of the pericardium?
* Outer fibrous pericardium
* Parietal serous pericardium
* Visceral serous pericardium
Layers can rub together in pericarditis and exacerbate inflammation
163
What are the symptoms of pericarditis?
* Sharp pleuritic chest pain --> left shoulder (phrenic nerve)
* Dyspnoea
* Pericardial friction rub on oscultation
164
What position is pericardial frication rub best heard in pericarditis?
Leaning forward
165
When is pericarditis chest pain worst?
Lying down
166
How is pericarditis investigated?
* ECG
* Blood tests for sign of infection
* Echo (TTE or TOE)
* Xray (and other imaging)
167
How is pericarditis reflected in an ECG?
* Saddle shaped ST segment
* PR depression
168
What does a blood test test for in suspected pericarditis (2 key things)
* Raised WBC count (infection)
* Erythrocyte sedimentation rate (ESR)/ C reactive protein (CRP)
169
What may be seen on a chest X ray in pericarditis?
Increased cardiothoracic ratio > 0.5
170
How is pericarditis treated (2 medicines)?
* NSAIDs
* Colchicine (anti inflammatory)
171
What are some complications of pericarditis (3)?
* Constrictive pericarditis
* Myocarditis
* Pericardial effusion --> cardiac tamponade
172
Complications of pericarditis
* Cardiac tamponade (due to pericardial effusion)
* Myocarditis
* Heart failure
173
What is cardiac tamponade?
Pericardial effusion which causes impared ventricular filling
174
What can cause cardiac tamponade?
* Pericarditis
* Aortic aneurism
* Trauma
175
What are the symptoms of cardiac tamponade?
* Becks triad
* Pulsus paradoxus
176
What are the three symptoms of Beck's triad
* Hypotension
* Raised JVP
* Muffled heart sounds
177
What is pulsus paradoxus
A fall of more than 10 mmHg in systolic BP on inspiration
178
Investigations for cardiac tamponade
* ECG - varying QRS size as heart bounces around in pericardium
* Chest X-ray - large globular heart
* Ultrasound - **diagnostic**
179
How is cardiac tamponade treated?
Pericardiocentesis (needle aspiration of pericardial sac)
180
What is infective endocarditis?
Infection and inflammation of endocardium (particularly affects valves)
181
What is a vegetation describe how it forms?
Damaged endothelium --> platelet fibrin mesh forms --> pathogen attaches --> more platelets aggregate, pathogens buried
182
What are the two most common bacteria that cause endocarditis?
* Staph aureus (staphylococci)
* Strep viridans (streptococci)
183
What is the most common gram -ve bacteria in endocarditis?
HACEK organisms (anronym for group)
184
What are the 2 most common fungi to cause endocarditis?
* Candida
* Aspergillus
185
What are some risk factors for IE
* Male
* Elderly
* Posthetic valve
* IV drug users
* Congenital heart defects
* Rheumatic heart disease
186
Which valve of heart is more commonly affected
**Tricuspid valve**
*Mitral valve more common in general population, however IVDU make up a large proportion of those affected, and they have their tricuspid valve infected as inject into veins*
187
What can a vegetation on a valve cause?
Regurgitation
188
What are some signs/ symptoms of IE (not hand signs or eye), (3)?
* Tachycardia
* **Fever**
* **New heart murmur**
189
What are 4 main peripheral signs of IE and 2 others
* **Osler nodes** - finger nodules
* **Janeway lesions** - painful marks on palms
* **Splinter haemorrhages** - on nails
* **Roth spots** - retinal haemorrhage
* *Petechiae* - pinpoint round spots due to bleeding
* *Septic emboli*
190
What criteria guide a diagnosis of IE
Duke criteria
191
What are the 2 major Duke criteria
* 2 postitive blood cultures
* Echo shows vegetation
192
What are 5 minor Duke criteria
* Immunological signs (e.g. roth spots)
* Risk factor (e.g. IVDU)
* Septic emboli
* 1 positive blood culture
* Pyrexia >38
193
How many criteria are required for IE to be strongly suspected?
* 2 major
* 1 major; 3 minor
* 5 minor
194
What investigations are done for IE (3)?
* ECG
* Bloods
* Echo
195
What can blood tests show in IE (3)
* High ESR/CRP
* High WBC (neutrophillia)
* +ve cultures
196
What does an ECG somtimes show in IE
Prolonged PR = aortic root abscess
197
How is IE treated (2)
* Antibiotics/ antifungals
* Surgery - remove/ repair valve
198
What antibiotics are used for staph. aureus (2)
* **Vancomycin**
* Rifampicin
199
What antibiotic is used for strep. viridans (2)
* Benzylpenicillin
* Gentamicin
200
What are some complications of IE (4)
* Heart failure
* Septic emboli
* Valve regurgitation
* Aortic root abscess
201
What is the most common valvular disorder?
Aortic stenosis
202
What are the two classes of valve disorder?
* Regurgitation
* Stenosis
203
What affects do regurgitation and stenosis have on the chambers?
* Regurgitation = proximal chamber **dilation**
* Stenosis = proximal chamber **dilation + hypertrophy**
204
When are right and left side defects best heard?
* R**i**ght = on **i**nspiration
* L**e**ft = on **e**xpiration
205
What area is a normal mitral valve and when would symtpoms begin?
4-6 cm^2 = normal
<2 cm^2 = symptoimatic
206
What causes mitral stenosis?
* Rheumatic heart disease = most common
* Valve calcification
* IE
207
How does rheumatic heart disease cause mitral stenosis (simple)?
Repeated RHD = reactive inflammation of mitral valve
208
What are the signs/ symptoms of mitral stenosis (4)
* Malar cheek flush
* Dyspnoea
* Pulmonary oedema (crckling lungs)
* Pulmonary hypertension - high JVP, etc
209
What causes malar cheek flush?
Back pressure of blood into pulmonary circulation--> retention of CO2 --> CO2 is a vasodilator, red cheeks
210
What condition is associated with MS and why?
AFib as LA hypertrophy --> electrical disruption
211
When is MS murmur heard?
Mid diastolic, low pitched
212
How does MS affect S1
Louder as high pressure needed to shut stiff valve
213
How is MS investigated?
* CXR - enlarged RA
* ECG - AFib/ enlarged RA
* Echo = gold standard
214
How is MS treated?
* Medications - for symptoms
* Surgery
215
What 2 surgerys can be done for MS?
* Valve replacement
* Percutaneous balloon valvotomy (opens valve opening)
216
What causes mitral regurgitation (3)?
* Myxomatous degeneration
* Marfans/ EDS
* IE/ RHD/ MI
217
What is the main symptom of MR
Exertion dyspnoea
218
When is a MR murmur heard?
Pan systolic radiating to axilla
219
What extra heart sound is heard in MR
S3
220
How does MR affect S1
Softer
221
How is MR investigated?
* ECG - LA enlargement + AFib
* CXR - LA enlargement
* Echo = gold standard
222
How is MR treated?
* Medication
* Surgery - replacement or repair
223
What is the normal area and symptomatic area of aortic valve
normal = 3-4 cm^2
symptomatic = 1/4 of size
224
What causes AS
* Calcification (age related)
* Congenital (bicuspid valve)
225
What are the signs/ symptoms of aortic stenosis (3)?
* **S**yncope (exertional)
* **A**ngina
* **D**yspnoea
**SAD**
226
What sort of murmur is an AS murmur?
Ejection systolic crescendo decrescendo @right sternal border 2nd space, radiating to carotids
227
What other heart sound can be heard?
S4
228
What other features are common with AS (2)?
* Narrow pulse pressure
* Slow rising pulse
229
How is aortic stenosis investigated?
* ECG
* CXR
* Echo = gold standard (LV size + function)
230
How is AS treated surgically (2)?
* Healthy patient = open repair/ replacement
* At risk patient = transoesophageal aortic valve implant (TAVI)
231
What causes AR (3)
* Congenital bicuspid valve
* RHD/ IE
* Marfans/ EDS
232
What are the signs/ symptoms of AR
* Wide pulse pressure
* Collapsing pulse @carotid
233
What sort of murmur is heard in AR
Early diastolic murmur @left sternal border 3rd space
234
What is a more severe murmur heard in AR?
Austin flint murmur - mid diastolic murmur (blood bounces of mitral valve cusps)
235
How is AR investigated?
* ECG
* CXR
* Echo = gold standard
236
How is AR treated?
* Medications for symptoms
* Surgery if severe
237
What is bradycardia defined as?
<60
238
What is tachycardia defined as?
>100
239
What is the pathway of electrical impulses through the heart?
SA node --> Bachmann's bundle --> AV node --> Bundle of His --> Right/ left bundle --> Purkinje fibres
240
What is the most common arrhythmia?
Atrial fibrillation
241
What is the rhythm of atrial fibrillation?
Irregularly irregular (QRS complexes)
242
What can cause AF (6)?
* Heart failure
* Htn
* Mitral valve pathology
* IHD / MI
* Hyperthyroidism
* Congenital defects
243
What is happening to the electrical activity for AF to occur?
Completely disorganised activity around both atria, with electrical activity re-entering
244
What is the difference between AFib and flutter?
* AFib is more disorganised
* AFlutter has electrical signals moving in a circle, re-entering in an organised more regular way
245
What are the symptoms/ signs of AF
* Irregularly irregular pulse
* Palpitations
* Stroke
* Syncope
* Hypotensive
246
Investivgations for AF
ECG = no P wave; irregularly irregular pulse; narrow QRS
247
How is AF treated?
* **Rate** control first line...
* ... then **rhythm** control
Acute attack = cardioversion
248
What medication is used for rate control (3)?
* Beta blockers
* CCBs
* Cardiac glycoside
249
What beta blocker might be used?
Atenolol
250
What are the two classes of CCBs?
* Dihydropyridines - peripheral vasodilators
* Non-dihydropyridines - affect SA + AV nodes
251
Which CCB is used in AF and what class?
Non-dihydropyridines (diltiazem)
252
What cardiac glycoside is used in AF?
Digoxin
253
How does digoxin work?
Inhibit Na+/K+ ATPase pump in heart
254
What medications are used for rhythm control in AF (3)?
* Beta blockers
* Dronedarone
* Amiodarone
255
What are the two types of cardioversion?
* Electrical cardioversion
* Pharmacological cardioversion
256
What medication is used for pharmacological cardioversion?
* 1st line = **Flecanide**
* 2nd line = amiodarone
257
What medication can be used to treat AF that comes in attacks?
Flecanide
258
What medications are used in AF to prevent strokes?
Anticoagulants
259
What anticoagulants are used in AF?
* Warfarin
* N/DOACs
260
How does warfarin work?
Vitamin K antagonist - clotting factors 10,9,7,2
261
What needs to be monitored when using warfarin?
International normalised ratio (INR) - how prothrombin time compares to normal adult
262
What enzyme breaks down warfarin and can be affected by diet and medications?
Cytochrome p450
263
Which NOACS are commonly used for AF?
* Apixaban/ rivaroxaban
* Dabigatran
264
How do apixaban and rivaroxaban work?
Xa inhibitors
265
How does dabigatran work?
Prevents thrombin activating clotting factors
266
What tool can assess whether a patient should be put on anticoagulation?
CHA2Ds2-VASc
267
What does chadvasc stand for?
* **C**ongestive heart failure
* **H**ypertension
* **A**ge > 75 = 2
* **D**iabetes
* **S**troke (previous) = 2
* **V**ascular disease
* **A**ge 65-74 = 1
* **S**ex (female)
268
What tool can assess the likelihood of a bleed?
HAS-BLED
269
What are some complications of AF (2)
* Heart failure
* Stroke
270
What is Atrial flutter?
The atria beating too fast but in a more regular way than AF
271
How fast is atrial flutter generally?
250-350 bpm
272
What are the symptoms of atrial flutter (3)?
* Dyspnoea
* Syncope
* Palpitations
273
What heart block often occurs with atrial flutter?
2:1 heart block
274
What pattern does atrial flutter make on an ECG?
Saw tooth P wave pattern
275
How is atrial flutter treated?
Same as AF
276
How else can AFib/Flut be treated using catheter
Catheter ablation - burn atrial septum so electrical signals cannot pass between the atria
277
What is Wolff-Parkinson white syndrome?
An electrical connection from the atria to ventricles that surpasses the AV node
278
What is this extra connection known as in WPW?
Bundle of Kent
279
What is atrioventricular nodal reentrant tachycardia (AVNRT)
When the electrical activity reenters the atria through the AV node
280
What is atrioventricular reentrant tachycardia (AVRT)
When electrical activity reenters atria through an accessory pathway (not AV node) in WPW
281
How can electrical activity also travel in WPW?
Enter the ventricles through the bundle of Kent, and join the impulse through the AV node. (It does not always reenter the atria)
282
What are some symptoms of WPW (3)?
* Palpitations
* Dizziness
* Dyspnoea
283
Features of WPW in an ECG (3)
* Wide QRS
* Delta wave (slope up early from P wave)
* Short PR interval
284
What heart rhythm can WPW, AFib/flut, AVNRT cause?
Supraventricular tachycardia
285
How is supraventricular tachycardia treated?
1. Vagal manoeuvre
2. Adenosine
3. Syncronised electrical cardioversion
286
What are 2 examples of vagal manoeuvres?
* Valsalva manoeuvre (blowing into a tube)
* Carotid massage
287
How does vagal manoeuvres treat SVT?
Tricks body to think BP is too high --> body works to reduce BP by slowing heart rate
288
How does adenosine work?
Slows electrical conduction for around 10 seconds
289
How does adenosine make someone feel?
Like they're dying!!!!!! hahahahahahah
290
What dose of adenosine is used?
**6**mg... then... **12**mg... then... repeat **12**mg
291
How can WPW be definitively treated?
Catheter ablation of bundle of Kent
292
What is long QT syndrome?
A QT interval of >480ms
293
What causes long QT interval (2)?
* Congenital
* Drugs
294
What electrolyte imbalances cause long QT interval (2)?
* Hypokalaemia
* Hypocalcaemia
295
What causes ventricular ectopic beats?
Pacemaker cells in ventricles becoming stressed and sending action potential before the AP initiating in the SA node reaches it
296
What is Torsades de pointes?
Ventricular depolarisation that rotates around a point in the heart forming QRS with varying heights
297
What causes Torsades de pointes?
Ventricular depolarisation at the wrong point during a T wave (often due to long QT syndrome)
298
What else can happen as a result of a QRS during T wave?
Ventricular tachycardia
299
What can ventricular tachycardia progress to?
VFib
300
How are VFib and V tachy treated?
Electrical defibrillation
301
What causes first degree heart block?
Split second delay in an impulse travelling through the AV node
302
How long should PR be for 1st degree heart block?
>200ms
303
How is 1st degree heart block treated?
It isn't!!!! gotcha
304
What causes 2nd degree heart block?
When some P waves are conducted through AV node and others are not
305
What are the two types of 2nd degree heart block?
Mobitz 1 and 2
306
What is the difference between Mobitz 1 and 2?
1 = PR Prolongation until QRS dropped
2 = No PR prolongation; QRS randomly dropped
307
What is a fixed ratio heart block (e.g. 2:1)?
Ratio of P waves to QRS - occurs in Mobitz type 1 as this has a regular dropping of QRS
308
What is 3rd degree heart block?
Complete block in AV node
309
How does the heart deal with 3rd degree heart block, what happens?
Atria and ventricles beat independently
310
How can heart blocks be treated?
Pacemakers
311
What medication can be used to treat (3rd) degree heart block?
Atropine (speeds conduction through AV node)
312
What can cause heart blocks (2)?
* Drugs
* MIs
313
What are bundle branch blocks?
A block in one side of the bundle of His
314
What causes LBBB (2)
* MI
* Valvular diseases
315
What causes RBBB (3)
* MI
* Valvular diseases
* Pulmonary embolism
316
How does RBBB present in an ECG
**M**a**RR**o**W**
M shape in V1 (basically 2 R waves)
W shape in V6
317
How does LBBB present in an ECG
**W**i**LL**ia**M**
W shape in v1
M shape in V6 (basically 2 R waves)
318
How are bundle branch blocks treated?
Pacemakers
319
What are the three types of cardiomyopathy?
* Hypertrophic
* Dilated
* Restrictive
320
What is hypertrophic cardiomyopathy?
Thickening of heart muscle, particularly in the septum
321
What is dilated cardiomyopathy?
Heart chambers thin and stretch, growing larger (particularly ventricles)
322
What is restrictive cardiomyopathy?
Walls of heart become stiff and rigid, don't fill well
323
What causes hypertrophic cardiomyopathy (2)?
* Inherited
* Aortic stenosis
324
What mutation sometimes causes hypertrophic cardiomyopathy?
Autosomal dominant mutation of sarcomere proteins
325
How is hypertrophic cardiomyopathy treated (3 medicines)?
* BBs
* CCBs
* Amiodarone
326
What causes dilated cardiomyopathy (2)?
* Inherited
* IHD
327
How is dilated cardiomyopathy treated (2)?
* BBs
* CCBs
etc...
328
What causes restrictive cardiomyopathy (2)?
* Post MI
* Granulomatous disease (e.g. sarcoidosis)
329
How is restrictive cardiomyopathy treated?
Transplant (or they die)
330
How are cardiomyopathies diagnosed (2)?
* ECG
* Echo
331
What are the symptoms of cardiomyopathies (5)?
* Dyspnoea
* Syncope
* Heart failure
* Palpitations
* Chest pain
332
What is shock?
Hypoperfusion --> Tissue hypoxia --> organ dysfunction
333
What are the types of shock?
* Cardiogenic
* Septic
* Hypovolaemic
* Anaphylactic
* Neurogenic
334
What are the symptoms of shock (4)?
* Confusion + reduced GCS
* Weak rapid pulse
* Pale, cold skin
* Hypotension
335
What is a complication of shock?
Prolonged hypotension --> organ damage
336
What organs are most at risk of hypotension (4)?
* Brain
* Kidneys
* Heart
* Lungs
337
Which type of shock is caused by bradycardia?
Neurogenic
338
What is neurogenic shock?
Damage to spinal cord = disrupted SNS but intact PSNS
339
How is each type of shock treated?
ABCDE then...
* Cardiogenic - treat underlying cause
* Septic - Antibiotics
* Hypovolaemic - fluids
* Anaphylactic - adrenaline
* Neurogenic - atropine
340
How does atropine work to treat neurogenic shock?
Blocks vagus nerve (PSNS) --> more chance for SNS to work
341
What is rheumatic fever?
Systemic inflammatory response following infection
342
What bacteria causes rheumatic fever?
Strep pyogenes infection (Lancefield group A beta haemolytic streptococci)
343
What percent of cases of rheumatic fever affect the heart?
50%
344
How does strep pyogenes cause rheumatic fever?
Antibodies against M protein attack heart valves as similar antigens (molecular mimicry)
345
What does rheumatic heart disease often cause?
Mitral stenosis as valve inflamed and thickens
346
What are the symptoms of rheumatic fever (5)?
* Arthritis erythema nodosum
* New mitral murmur
* Sydenham's chorea
* Pyrexia
* Recent strep A infection
347
How is rheumatic fever diagnosed?
* CXR = cardiomegaly
* Echo
* Jones criteria
348
What is diagnostic in the Jone's criteria?
Recent strep pyogens infection + 2 major or 1 major, 2 minor
349
How is rheumatic fever treated?
Benzylpenicillin, then phenoxymethylpenicillin
350
How are Sydenham's symptoms treated?
Diazepam
351
What is the most common inherited heart defect?
Bicuspid aortic valve
352
What 3 inherited conditions affect the septum?
* Atrial septal defect
* Ventricular septal defect
* Atrioventricular septal defect
353
What two conditions result from the failure of tissues to close?
* Patent ductus arteriosus
* Patent foramen ovale
354
What can these septal and patent conditions cause?
Eisenmenger syndrome
355
What is Eisenmenger syndrome?
Left to right shunt --> pulmonary hypertension
356
What 4 things together cause tetralogy of Fallot?
* VSD
* Misplaced aorta
* Pulmonary stenosis
* RV hypertrophy
357
How is tetralogy of Fallot treated?
Full surgical repair
358
What is coarctation of the aorta?
Narrowing of the aorta just after ductus arteriosus
359
What does coarctation of the aorta result in?
More blood to upper limbs and brain than lower body
360
What is the main sign of coarctation of the aorta?
Hypertension in the upper body
361
How is coarctation of the aorta diagnosed?
* CXR
* CT angiogram
362
How is coarctation of the aorta treated?
Surgical repair/ stent
