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year 3 conditions > cardiovascular > Flashcards

cardiovascular Flashcards

1
Q

3 types of cardiac ischaemia

A

STEMI - complete blockage of coronary artery
NSTEMI - supply and demand mismatch
unstable angina - supply and demand mismatch (ischaemia not infarction)

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2
Q

signs of chest pain caused by ischaemia

A

worse with exertion
doesn’t change with body positioning
not relieved with rest
radiates to
- epigastrium
- left shoulder/arm
- neck
- lower jaw

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3
Q

what is orthopnea

A

shortness of breath that occurs while lying flat and is relieved by sitting or standing

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4
Q

diaphoresis

A

abnormally excessive sweating

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5
Q

treatment for ACS

A

MONA
- morphine
- O2
- nitrate
- high dose aspirin

high dose statin

beta blocker eg metroprolol

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6
Q

first line of action when someone arrives with chest pain

A
  1. ECG
  2. history + physical
  3. if show signs of ischaemia eg chest discomfort., pressure, tightness, burning, syncope, dyspnea, diaphoresis, nausea/vomiting
    –> measure troponin
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7
Q

signs of cardiogenic shock

A

pale skin
tachycardia
hypotension
cool extremities
diaphoresis

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8
Q

signs of acute heart failure

A

jugular venous distension
crackles on lung auscultation
new S3 gallop
murmur
orthopnea
edema

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9
Q

if a man with stable angina presents with change in baseline gain, new onset pain at rest, what is a likely diagnosis

A

ACS

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10
Q

how may women or older patients with stable angina present with ACS

A

dyspnea instead of new onset chest pain

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11
Q

signs of ongoing ischaemia >12 hours after symptom onset in ACS

A

refractory chest pain
haemodynamic instability
ventricular arrythmias
dynamic ECG changes

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12
Q

stable angina vs ACS

A

stable angina:
- during exertion, blood flow demand to heart increases, but narrowed coronary arteries cannot meet this increased demand leading to myocardial ischaemia and pain

ACS
- sudden plaque rupture and clot formation in the narrowed coronary arteries –> can cause partial or full occlusion

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13
Q

treatment for STEMI

A
  • medical therapy: DAPT + anticoagulants

if <12 hrs since symptom start
- PCI
or
- fibrinolytic

if >12 hrs since symptom start
- assess for ongoing ischaemia
- PCI
or
- medical therapy

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14
Q

how to differentiate between NSTEMI and unstable angin

A

measure troponin

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15
Q

treatment for NSTEMI

A
  • DAPT
  • anticoagulants

+

  • ongoing ischaemia –> PCI or CABG (multiple vessels / left main coronary artery affected)
  • no ongoing ischameia –> medial therapy
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16
Q

what is never indicated for NSTEMI and unstable angina

A

fibrinolysis

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17
Q

unstable angina treatment

A

early risk stratification

  • high risk –> DAPT + anticoagulant
    + PCI / CABG
  • low risk –> non invasive stress testing
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18
Q

what is fondaparineux

A

anticoagulant

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19
Q

what is tricagelor

A

antiplatelet

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20
Q

What are the signs and symptoms of ACS?

A

Signs: distress, anxiety, pallor, sweatiness, low grade fever, signs of heart failure (raised JVP, basal crepitations, 3rd heart sound)

Symptoms: acute central crushing chest pain lasting >20 minutes, nausea, sweating, dyspnoea, palpitations

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21
Q

What is a silent ACS and what patients does this occur in

A

ACS without the chest pain. May have syncope, pulmonary oedema, epigastric pain, bomiting, post op hypotension, oliguria, diabetic hyperglycaemia

Seen in the elderly and diabetics often

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22
Q

How are each of the three acute coronary syndromes diagnosed based on their investigation findings?

A

Triad of symptoms, ECG changes and hs-TnI levels

All will have cardiac sounding chest pain

STEMI:

ST elevation (>1mm in limb leads and 2mm in chest leads) or new LBBB
hs-TNI >100ng/L
CK often raised over 400
NSTEMI

ST depression, T-wave inversion or normal
hs-TnI>100ng/L
Unstable Angina

ST depression, T wave inversion or normal
hs-TnI is normal

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23
Q

what are type 2 myocardial infarctions

A

myocardial infarctions due to cardiac hypoperfusion for other reasons (e.g. severe sepsis, hypotension, hypovolaemia or coronary artery spasm)

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24
Q

what type of infarct causes a stemi vs nstemi

A

stemi - transmural infarct
nstemi - subendocardial infarct

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25
Q

what 3 substances can be measured in the blood to test for myocardial infarct, and which one can be used to measure reinfarction

A

Troponin I, Troponin T, CK-MB

CK-MB can be used to measure reinfarction as it returns to normal after 48 hours, but troponin levels remain high for days after the initial infarct

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26
Q

a patient presents with central pleuritic chest pain worse on inspiration, pain worse lying flat but relieved by sitting forward, and a fever
what’s the most likely diagnosis

A

pericarditis

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27
Q

what is a pericardial friction rub and what is it pathognomonic of

A

high pitched scratching noise, best heard over left sternal border during expiration

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28
Q

signs of pericarditis

A
  • pericardial friction rub
  • Beck’s triad (raised JVP, muffled heart sound, hypotension) –> bc pericarditis can cause pericardial effusion and cardiac tamponade
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29
Q

difference between pericarditis and GORD pain

A

pericarditic pain is often described as sharp

GORD discomfort may be described as a burning sensation that is worse with certain foods and bending over

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30
Q

difference between pericarditis and ACS pain

A

pericarditic chest pain is often described as sharp, pleuritic in nature, and relieved on sitting forward. In ACS, the chest pain is often described as a squeezing pressure that is not positional

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31
Q

difference between MSK and pericarditis pain

A

MSK pain is reproducible with palpation or certain movements.

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32
Q

what treatment is done for pericarditis pts who develop pericardial effusion d cardiac tamponade

A

pericardiocentesis - a procedure done to remove fluid that has built up in the sac around the heart (pericardium)

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33
Q

PR segment depression
+ multilead ST elevation
+ aVR ST depression
are characteristic of…

A

acute pericarditis

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34
Q

which investigations to do to distinguish between pericarditis and MI

A
  1. the pain is different - not affected by position in MI/ACS, worse lying down in pericarditis
  2. echocardiogram - ooking for the absence of regional wall motion abnormalities
  3. angiogram - checks for affected coronary arteries suggesting MI
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35
Q

what is the most common causative agent of acute IE

A

staph aureus

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36
Q

what is the most common causative agent of IE due to drug use

A

staph aureus

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37
Q

what is the most common causative agent of IE less than 2 month post valve surgery

A

staph epidermis

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38
Q

what is the most common causative agent of subacute IE following dental procedures

A

strep viridans

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39
Q

which causative agent predisposes to IE and colorectal cancer

A

strep bovis

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40
Q

strep vs staph shape

A

staph = clusters
strep = chain

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41
Q

which valve is most likely affected by IE due to IV drug use

A

tricuspid

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42
Q

clinical features of IE

A

SOB lying down (heart failure)
weakness
fatigue
weight loss
fever/chills
night sweats
tachycardia
headache
anorexia
janeway lesions
oslers nodes
splinter haemorrhages
Roth spots
clubbing
new heart murmur

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43
Q

what valve pathology are pink cheeks associated with

A

mitral stenosis - pink cheeks = “mitral facies”

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44
Q

what does a slow rising pulse indicate

A

aortic stenosis

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45
Q

what output type of heart failure does hypertension cause

A

low output heart failure (bc the hypertension causes excessive after load)

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46
Q

what would be the first line management in a patient with heart failure and pEF, fluid overload and hypertension

A

lifestyle advice
low dose diuretic eg furosemide
ACE inhibitor / ARB

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47
Q

which condition are BB’s eg bisoprolol contraindicated in

A

asthma

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48
Q

symptom management for acute HF

A

furosemide
sit upright
morphine
oxygen

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49
Q

what is sacubitril/valsartan and what HF is it indicated in

A

a new ACE inhibitor/ARB combination drug
indicated in pts with reduced EF

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50
Q

what normally presents with haemoptysis, sharp and pleuritic chest pain

A

pulmonary embolism

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51
Q

what condition is Prominent central pulmonary artery (Fleischner sign) seen in

A

pulmonary embolism

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52
Q

what condition is Water-bottle-shaped enlarged cardiac silhouette seen in

A

pericarditis

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53
Q

which heart failure does displaced apex beat indicate and why

A

left sided heart failure
due to left ventricular hypertrophy

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54
Q

where is BNP secreted from

A

cardiac ventricles

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55
Q

how does diastolic heart failure affect ejection fraction

A

EF is usually preserved

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56
Q

what kind of patients does HOCM present in

A

younger pts with breathlessness, particularly on exertion, palpitations and syncope

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57
Q

what kind of heart failure does HOCM cause

A

diastolic HF

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58
Q

what kind of heart failure does cardiac tamponade cause

A

diastolic HF

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59
Q

what kind of heart failure does ischaemic heart disease cause

A

systolic HF

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60
Q

why does spironolactone increase risk of hyperkalaemia?

A

It’s a potassium sparing diuretic, so decreases excretion of potassium in urine. Therefore serum potassium increases –> hyperkalaemia

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61
Q

if a pt is on an ACE inhibitor + beta blocker but can’t tolerate spironolactone, what do you give them

A

epleronone

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62
Q

if a pt is on an ACE inhibitor + beta blocker but can’t tolerate spironolactone and is afro-carribean, what do you give them

A

hydralazine

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63
Q

chest x ray findings for congestive heart failure

A

○ A: Alveolar oedema (with ‘batwing’ perihilar shadowing)

○ B: Kerley B lines (caused by interstitial oedema)

○ C: Cardiomegaly (cardiothoracic ratio >0.5)

○ D: upper lobe blood diversion

○ E: Pleural effusions (typically bilateral transudates)

F: Fluid in the horizontal fissure

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64
Q

what does Widespread saddle-shaped ST elevation on ECG indicate

A

acute pericarditis

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65
Q

what does Bilateral hilar lymphadenopathy on chest x-ray indicate

A

sarcoidosis

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66
Q

what does a fourth heart sound indicate and which wave on the ECG is it

A

indicates forceful atrial contraction against a stiff hypertrophic left ventricle
atrial contraction –> P wave

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67
Q

what is U wave on ECG associated with

A

hypokalaemia
hypercalcaemia

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68
Q

what is U wave on ECG associated with

A

hypothermia

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69
Q

what investigation is essential to confirm heart failure diagnosis

A

echocardiogram

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70
Q

what kind of heart failure is associated with orthopnoea

A

left sided heart failure

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71
Q

what do bibasal crepitations indicate

A

pulmonary oedema

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72
Q

what are the criteria for cardiac resynchronisation therapy

A

LBBB on ECG
LVEF < 30%
NYHA class 3/4

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73
Q

what is P pulmonale

A

P pulmonale (right atrial enlargement) is a big, tall, peaked P waves on ECG

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74
Q

what is the diagnosis of a pt with raised JVP, COPD, high Bp, pitting oedema in legs

A

Cor Pulmonale: right sided heart failure secondary to longstanding pulmonary arterial hypertension (in this case it’s as a result of the severe COPD causing the pulmonary arterial hypertension)

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75
Q

which axis deviation do you see on an ECG with cor pulmonale

A

right axis deviation

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76
Q

name the levels of the NYHA Classification (Severity of Cardiac Failure Symptoms)

A

○ Class I → no symptoms, no limitation

	○ Class II → mild symptoms, slight limitation (comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea)
	
	○ Class III → moderate symptoms, marked limitation of physical activity (comfortable at rest but less than ordinary activity results in symptoms)

Class IV → severe symptoms, unable to carry out any physical activity without discomfort (symptoms of heart failure are present even at rest with increased discomfort with any physical activity)

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77
Q

when is DC cardio version indicated

A

tachyarrhythmias (eg atrial fibrillation with fast ventricular response rate) with signs of confusion, heart failure, hypotension, confusion

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78
Q

does Digoxin improve mortality in heart failure

A

no

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79
Q

what counts as a reduced ejection fraction

A

A reduced LV ejection fraction is usually 40% or less

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80
Q

if a pt has HFpEF with ankle odema and no hypertension what is the first line treatment

A

Furosemide
(Lifestyle advice would be first line if pt didn’t have ankle oedema)

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81
Q

what is the treatment for HFpEF

A
  • lifestyle advice
  • low dose diuretic if have signs of fluid retention eg ankle oedema
  • ACE inhibitor/ARB if hypertensive
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82
Q

if a pt is prescribed high dose diuretic eg furosemide for heart failure, what side effects may they experience

A

tinnitus
deafness

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83
Q

if a pt is prescribed spironolcatone for heart failure, what side effects may they experience

A

Gynacomastia

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84
Q

what counts as a jugular venous distension

A

JVP > 4cm

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85
Q

what are Coryzal symptoms

A

hallmark of URTIs that include nasal stuffiness, runny nose, sneezing, sore throat, and cough

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86
Q

what is a patient with alcoholic cirrhosis at risk of if they take diuretics

A

Diuretics can increase the risk of hypomagnesaemia in those with alcoholic cirrhosis - leading to arrhythmias

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87
Q

what are these findings associated with and in which pts: Regional wall motion abnormality, ejection fraction <55%

A

These findings are consistent with congestive cardiac failure caused by coronary artery disease.
This typically presents in older patients with risk factors for coronary artery disease (smoking, diabetes, hyperlipidaemia, hypertension, positive family history)

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88
Q

what are these findings associated with and in which pts: Apical ballooning of the left ventricle

A

These findings are consistent with Takotsubo cardiomyopathy. The condition typically occurs after extreme stress
Is more common in post-menopausal women. Symptoms may mimic a myocardial infarction (except angiography reveals patent coronary arteries)

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89
Q

what are these findings associated with and in which pts: Left ventricular dilation, ejection fraction <55%

A

These findings are consistent with dilated cardiomyopathy. Dilated cardiomyopathy is commonly caused by excess alcohol consumption or is idiopathic.

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90
Q

what are these findings associated with: Asymmetric septal hypertrophy, diastolic dysfunction

A

Hypertrophic ostructive cardiomyopathy (HOCM). HOCM typically causes diastolic dysfunction due to impaired relaxation of the thickened left ventricle during diastole. This results in impaired filling of the left ventricle

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91
Q

what is pulsus paradoxus and what conditions is it associated with

A

abnormally large decrease in bp during inspiration
associated with
- constrictive pericarditis
- cardiac tamponade
- pericardial effusion

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92
Q

what is pulsus alternans and what conditions is it associated with

A

alternating strong and weak pulses
associated with severe left heart failure

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93
Q

what type of heart failure is prolonged capillary time associated with

A

left heart failure

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94
Q

what is left heart failure commonly caused by in central/South America

A

Chaga’s disease

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95
Q

what are the 2 output states of heart failure

A

Low output state - low cardiac output
High output state - normal cardiac output, higher metabolic needs (anaemia, Beri-beri “thiamine deficiency”, hyperthyroidism, pregnancy)

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96
Q

what are the 2 types o left heart failure and their common causes

A

systolic LHF (HErEF <40%, unable to pump)

ischaemic heart disease,
dilated cardiomyopathy,
myocarditis,
arrhythmias
infiltration (haemochromatosis, sarcoidosis)

Diastolic (HFpEF >50%, heart can’t relax and properly fill with blood)
hypertrophic obstructive cardiomyopathy,
restrictive cardiomyopathy,
constrictive pericarditis,
cardiac tamponade
uncontrolled chronic HTN

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97
Q

what is RHF secondary to

A

left heart failure (congestive heart failure),
Infarction,
Pulmonary hypertension,
Tricuspid regurgitation

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98
Q

clinical features of LHF

A

(fluid accumulation in lungs = pulmonary symptoms)

dyspnoea,
orthopnoea,
paroxysmal nocturnal dyspnoea,
fatigue,
wheeze,
bibasal crackles,
cough,
pink frothy sputum (as a result of pulmonary oedema)
S3 gallop rhythm is an early sign of left ventricular failure
pulsus alternans

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99
Q

Clinical features of RHF

A

(fluid accumulates in peripheries = swollen signs)

swollen ankles (peripheral oedema),
increased weight,
reduced exercise tolerance,
raised JVP,
hepatomegaly (pulsatile liver edge on palpation),
Ascites

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100
Q

First line investigations for heart failure presentation

A
  1. BNP - if raised (above 400) then do echo
  2. echocardiogram (definitive)
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101
Q

heart failure symptom management

A

sit up
IV furosemide
o2
morphine

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102
Q

treatment for HFrEF with HTN

A
  1. ACEi + BB
    no ACEi –> ARB
    no ACEi/ARB –> Hydralazine
  2. spironolactone + epleronone
    arfo/carribbean –> hydralazine + nitrate
  3. Ivabradine (only if sinus rhythm and HR >75)
  4. cardiac resynchronisation
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103
Q

treatment for HRpEF

A
  1. lifestyle advice
  2. if fluid overload –> furosemide
  3. if HTN –> ACE inhibitor/ARB
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104
Q

investigations of stable angina for ischaemic heart disease

A
  1. CT coronary angiogram
  2. MRI fir regional wall abnormalities / cardiac stress testing / ecg + troponin
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105
Q

what is the 1st line imaging for stable angina

A

CT coronary angiogram

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106
Q

what are pathological Q waves and what do they indicate

A

negative deflection before R wave
indicates previous infarct

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107
Q

treatment for stable angina / ischaemic heart disease

A

anti platelet (aspirin 75g /clopidogrel) + statin 20g
+ GTN spray (for the angina attacks when they come on)
+ (1st line ) BB (bisoprolol/atenolol) OR non dihydropyridine rate limiting CCB (verapamil/diltiazem)

or (2nd line) BB AND dihydropryidine CCB

or (3rd line) BB AND dihydropyridine CCB AND nitrate

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108
Q

GTN spray side effects

A

headaches, flushing, dizziness

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109
Q

what is the first line treatment for asthmatic pt with ischaemic heart disease

A
  1. rate limiting CCB eg verapamil / diltiazem
    (BBs are contraindicated in asthma)
  2. rate limiting CCB + nitrate
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110
Q

which CCBs cannot be used alongside BBs

A

Verapamil/diltiazem can’t be used alongside beta blocker → causes severe bradycardia and heart block

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111
Q

treatment for ischaemic heart disease can’t be managed medically

A

PCI, CABG

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112
Q

what is the aspirin dose for stable angina

A

75 g

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113
Q

what is the aspirin dose for acute CV events eg MI/stroke

A

300g

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114
Q

difference between angina and pleuritic chest pain

A

Angina: central crushing pain
Pleuritic pain: sharp, worse on inspiration, accompanied by features related to underlying cause: productive cough, fevers, VTE, hot swollen calf

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115
Q

what are the non dihydropryidine rate limiting CCBs

A

verapamil
diltiazem

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116
Q

which CCBS CANNOT be used with BB

A

non dihydropyridine CCBS (veramapil / diltiazem)

the combination will cause bradycardia and AV block

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117
Q

which condition is dual anti platelet therapy indicated in

A

ACS

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118
Q

what to look for when thinking about giving ivabradine

A

make sure the HR is not less than 70, as ivabradine slows down the heart

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119
Q

what are the 4 classes of stable angina

A

class 1: occurs with strenuous physical activity
class 2: slight limitation on physical activity
class 3: marked limitation on physical activity
class 4: occurs with any physical activity and may even occur at rest –> unstable angina

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120
Q

how would Spontaneous coronary artery dissection (SCAD) present and in which pts

A

constant sharp left sided chest pain with radiation
often in young, female, pregnant pts

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121
Q

what is takotsubos cardiomyopathy / broken heart syndrome

A

temporary akinesia of the left ventricle
in response to an intense emotional or physical experience

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122
Q

A 67-year-old man with ischaemic heart disease is on verapamil. The addition of which medication would carry a risk of heart block?

A

BBs

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123
Q

a pt is recently diagnosed with stable angina and reversible ischaemia - indicating coronary artery disease
what is the management

A

GTN spray + BB OR CCB

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124
Q

what investigation is required if clinical assessment reveals non anginas chest pain but a resting ECG shows changes in ST or Q waves

A

CT coronary angiography

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125
Q

what is an indication for a CABG

A

multi vessel coronary artery disease with poor response to medical therapy

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126
Q

when does CABG have a survival advantage over PCI

A

in pts who are
- over 65
- diabetic
- have complex 3 vessel disease

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127
Q

what are the clinical signs off cardiac tamponade

A

raised JVP
muffled heart sounds
hypotension

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128
Q

what ECG change does pericarditis involve

A

widespread ST elevation

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129
Q

A 23 year old man with a past medical history of cocaine abuse presents to the ED with sudden, central tearing chest pain. On examination, his vitals are: RR 24, SpO2 97% RA, BP 190/100 mmHg, HR 120 bpm, T 36.9 degrees Celsius. A CT thorax showed a widened mediastinum.

What is the next best step in management?

A

labetolol

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130
Q

High arched palate and lens dislocation indicate which condition

A

marfans syndrome

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131
Q

when would you do a TTE instead of a CT angiogram for suspected aortic dissection

A

when the pt is unstable and proximal dissection is suspected

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132
Q

difference between pain presentation of acute pancreatitis vs aortic dissection

A

aortic dissection - sudden onset, tearing, central chest pain which radiates to the back
acute pancreatitis - epigastric pain which radiates to back but is relieved by sitting forwards, is also associated iwth vomiting

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133
Q

what is Takayasu’s arteritis and in which patients does it normally present, and what is the main sign

A

vasculitis of the major arteries in the body
presents in young women
main sign is absent arm pulses

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134
Q

how to differentiate Takayusu’s arteritis and aortic dissection

A

both can have absent arm pulses
aortic dissection presents with chest pain but takayusu’s arteritis does not

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135
Q

what does the presence of a radio-radial delay indicate

A

Type A aortic dissection

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136
Q

what does expansile pulsatile mass in the abdomen indicate

A

ruptured aortic aneurysm

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137
Q

what does the presence of a radio-femoral delay indicate

A

Type B aortic dissection

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138
Q

a pt with blood pressure 190/117mmHg has sharp central tearing pain radiating to the back and a history of marinas syndrome.
what is the initial management

A

IV labetolol
(the pt is very hypertensive so bp needs to be controlled so it doesn’t worsen the dissection)
THEN surgical aortic repair

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139
Q

when is giving a red cell transfusion indicated

A

pt has Hb level < 70 g/L
or pt has ACS and Hb level < 80 g/L

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140
Q

what are the types of aortic dissection under Stanford classification

A

type A - involving ascending aorta
type B - involving descending aorta

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141
Q

what are the types of aortic dissection under Debakey’s classification

A

Type I - involving ascending + descending aorta
Type II - involving ascending aorta
Type III - involving descending aorta

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142
Q

what are the clinical signs of aortic dissection

A

central tearing chest pain which radiates to the back
absent or weak pulses in arms
radio-radial delay - type A
radio-femoral delay - type B
aortic regurgitation (early diastolic murmur)
severe aortic regurgitation (mid diastolic murmur/Austin flint murmur)
hypertension
focal neurological deficits eg Horner’s syndrome

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143
Q

first line investigations for aortic dissection

A

CT angiogram chest/abdo/pelvis
or Transoesophageal echocardiography if pt is to unstable to get CT

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144
Q

what ECG show ion aortic dissection

A

widened mediastinum

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145
Q

treatment for type A vs B aortic dissection

A

A - surgical repair, open or endovascular (but IV labetolol as initial management before surgery if pt is very hypertensive)
B - IV labetolol

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146
Q

71 yr old man, no past medial history, bp 155/95. first line management?

A

amlodipine

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147
Q

pt has bp 210/142 and has a headache. initial management?

A

IV labetolol
(headache raises suspicion of end organ damage, if didn’t have headache would give oral treatment instead)

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148
Q

pt has a high bp of 145/95 despite being on ACEi, what’s the next step

A

add CCB

(if monotherapy doesn’t work, add another medication)

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149
Q

what is doxazosin

A

an alpha blocker used for hypertension

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150
Q

what does S4 heart sound indicate

A

reduced ventricular compliance due to ventricular hypertrophy

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151
Q

a pt has high bp, high sodium and low potassium, what is a possible diagnosis

A

conn’s syndrome

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152
Q

What are the criteria for hypertension referral for same day specialist assessment

A

Clinical bp of 180/120 mmHg with
- retinal haemorrhage or papillodoema
Or
- life threatening symptoms eg confusion, chest pain, AKI, heart failure

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153
Q

If someone is allergic to ACEi and is on a CB but it’s not working what do you add

A

Thiazide like diuretic
(Some ppl allergic to ACEi are also allergic to ARB)

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154
Q

An Afro Carribean with HTN and T2DM is on ramipril but it’s not working. What do you add

A

CCB
(Can’t be on ACEi and ARB at the same time)

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155
Q

If a patient with Turner’s syndrome has radio-radial delay what is the likely diagnosis

A

Coarctation of the aorta proximal to the left subclavian artery

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156
Q

If a patient with Turner’s syndrome has radio-femoral delay what is the likely diagnosis

A

Coarctation of the aorta distal to the left subclavian artery

157
Q

What side effects does hydralazine cause

A

Tachycardia, palpitations, flushing, angina if have underlying heart disease

158
Q

A pt with hypertension has an ecg with tall tented T waves, which of her meds is likely to have caused this and why

A

ACEi eg ramipril
Bc they can cause hyperkalaemia

159
Q

What is a dangerous side effect of bisoprolol for older pts

A

Can cause postural hypotension which can lead to falls

160
Q

What is fludrocortisone used to treat

A

Adrenal insufficiency
Postural Hypotension

161
Q

How long is clodinine given for

A

It is used for the rapid reduction of blood pressure, so only given for a few hours

162
Q

With which patients should you be cautious concerning rapid and aggressive anti hypertensive medications and why

A

Elderly and those with history of stroke
As the medications can cause cerebral infarction or MI

163
Q

If a pt has very high bp but no end organ damage how aggressively do u treat them

A

Over a few days
(If there’s no end organ damage you don’t need to do the aggressive “within a few hours” treatment)

164
Q

When is IV hypertonic saline the drug of choice

A

In the treatment of raised intracranial pressure which can cause raised bp

165
Q

Should sublingual nifedipine be used for very high bp requiring urgent intervention

A

No as it causes uncontrollable decrease in bp

166
Q

When can IV hydrocortisone be used to decrease bp

A

When decreasing raised intracranial pressure

167
Q

Most appropriate treatment for malignant hypotension with signs of encephalopathy and papillodoema

A

IV labetolol

168
Q

Which strokes is prothrombin complex concentrate IV used for

A

It can be used to reverse haemorrhage in pts on warfarin or factor Xa

169
Q

What is the gold standard investigation for phaechromocytoma

A

Urine and plasma metanephrines

170
Q

What is the gold standard investigation for conns syndrome

A

Serum aldosterone

171
Q

What is the gold standard investigation for cushings

A

Urinary free cortisol

172
Q

What is the gold standard investigation for addisons

A

Short ACTH stimulation (synacthen) test

173
Q

What is the gold standard investigation for a carcinoid (serotonin producing) tumour

A

Urine 5-HIAA

174
Q

If pt is on ACEi for hypertension but can’t tolerate the dry cough, what should be done

A

Stop ACEians switch them to ARB

175
Q

What is the treatment if a pts AMBP comes back as below 135/85

A

No medication, just lifestyle interventions and bp monitoring once every 5 years

176
Q

What are the stages of hypertensive retinopathy

A

Stage 1: arteriolar narrowing and tortuosity. Silver wiring.
Stage 2: AV nipping
Stage 3: flame haemorrhages and cotton wool exudates
Stage 4: papillodoema

177
Q

Stages of hypertensive retinopathy

A

Stage 1: arteriolar narrowing and tortuosity, sliver wiring
Stage 2: AV nipping
Stage 3: flame haemorrhages and cotton wool exudates

178
Q

Stages of hypertensive retinopathy

A

Stage 1: arteriolar narrowing and tortuosity, sliver wiring
Stage 2: AV nipping
Stage 3: flame haemorrhages and cotton wool exudates

179
Q

Levels of HTN

A

Level 1: clinical >= 140/90, abpm >= 135/85
Level 2: clinical >= 160/100, abpm >= 150/95
Level 3: clinical systolic >= 180 or diastolic >= 120

180
Q

What is the first step of management if the bp is >= 180/120

A

Investigate for end organ damage

181
Q

ACEi’s used in hypertension

A

Enalapril
Lisinopril

182
Q

ARBs used in hypertension

A

Losartan

183
Q

CCBs used in hypertension

A

Amlodipine

184
Q

Side effects of ACEi

A

Hyperkalaemia
Cough
Angioedema

185
Q

ACEis are contraindicated in what

A

Renal artery stenosis

186
Q

Side effects of CCBs

A

Ankle swelling - peripheral oedema

187
Q

What type of CCBs are used for hypertension and why

A

Dihydropyridine CCBs - less likely to exacerbate heart failure than verapamil

188
Q

Which thiazide like diuretics are used for hypertension

A

Indapamide
Hydrochlorothiazide
Chlorthalidone

189
Q

What are the side effects for thiazide like diuretics used for hypertension

A

Hypercalcaemia
Hyponatraemia
Hypokalaemia
Impaired glucose tolerance
Erectile dysfunction

190
Q

What are the thiazide like diuretics used for hypertension contraindicated in

A

Gout

191
Q

Bp targets for < and > 80

A

> 80 : clinical 140/90, abpm 135/85
< 80 : clincal 150/90, abpm 145/85

192
Q

1st to 4th line treatment for HTN

A

1st
Diabetic : ACEi or ARB
Non diabetic + less than 55 / not black : ACEi or ARB
Non diabetic + over 55 / black : CCB

2nd
Option 1 + option 2 OR thiazide like diuretic

3rd
Option 1 + option 2 + thiazide like diuretic

4th
Option 1 + option 2 + thiazide like diuretic + low dose diuretic (K+ <= 4.5 : spironolactone, K+ > 4.5 : alpha/beta blocker)

193
Q

What is the first step if there is a clinical suspicion of aortic aneurysm (expansive pulsation mass)

A

Refer for ultra sound
If it is shown to be > 5.5 cm the do 2WW referral to vascular surgeons for open surgery or EVAR (endo vascular aneurysm repair)

194
Q

What is the strongest risk factor for developing AAA

A

smoking

195
Q

Who is AAA screening offered to

A

Males 65 years and over

196
Q

What is Saphena varix

A

A dilated saccular varicose swelling from end of long saphenous vein
Presents as painless lump in the groin
Disappears when pt lies down
Non pulsatile
Cough impulse

197
Q

How does femoral artery aneurysm present differently to inguinal/femoral hernia or lymphadenopathy

A

All present as painless lumps
But only aneurysm is a pulsatile lump

198
Q

If a pt has an AAA of over 5.5 cm what is the next step in management

A

Open repair
Unless this is contraindicated - then EVAR

199
Q

Who is EVAR offered to

A

Those who can’t undergo open AAA repair - have medical comorbidities, structural pathology, anaesthetic risk

200
Q

What is the presentation of a ruptured AAA

A

Severe central abdo pain radiating to the back
Expansive and pulsatile mass
Tachycardia
Hypotension

201
Q

If a pt is tachycardic and hypotensive, with severe central abdo pain radiating to the back and a pulsatile mass, what’s the first step of management

A

Fluid resuscitation to raise the bp to 90mmHg systolic
This is to keep the organs preserved until definitive management can be done - open repair

202
Q

What is the most important risk factor for the development of TAAs

A

Connective tissue disorders eg Marfan syndrome

203
Q

What kind of aneurysm(s) does hypertension cause the enlargement of

A

Cerebral aneurysms

204
Q

How to mitigate the risk of AAA rupture

A

Smoking cessation and good bp control

205
Q

What is the most common location for abdominal aortic aneurysms

A

Infrarenal

206
Q

What is permissive hypotension

A

Marinating lower bp in pts with haemorrhagic blood loss eg ruptured AAA

207
Q

What is severe sudden onset back pain most indicative of

A

Ruptured AAA

208
Q

What is an aneurysm

A

Dilation of an artery of more than 50% of its usual diameter

209
Q

Risk factors for AAA

A

SMOKING
Male
Increased age
Atherosclerosis
Hypercholestrolaemia
Connective tissue disorders eg. Marfans syndrome
Family history

210
Q

Risk factors for AAA

A

SMOKING
Male
Increased age
Atherosclerosis
Hypercholestrolaemia
Connective tissue disorders eg. Marfans syndrome
Family history

211
Q

Hat are the steps of management depending on the diameter of the AAA

A

Less than 3cm - discharge
3 - 4.4 cm - annual screening
4.5 - 5.4 cm - 3 monthly screening
5.5+ cm - 2WW referral
Grown more than 1cm/year - 2WW referral
But if is ruptured or pt is symptomatic - urgent surgical repair

(Open surgery unless contraindicated - the do EVAR)

212
Q

investigations for AAA

A

Abdomen ultrasound - first line investigation

CT angiogram - for deciding the surgery method or for visualising a ruptured AAA
MRA (magnetic resonance angiography) if cannot do CT angiogram

213
Q

Signs of aneurysm of the upper limb or popliteal arteries

A

Ischaemia distal to site of occlusion
Pain
Pallor
Pulselessness
Paraesthesia
Paralysis

214
Q

What are the signs of ACI

A

6 Ps
Pain
Pallor
Pulseless
Paraesthesia
Paralysis
Perishingly cold

215
Q

Signs of ALI

A

6 Ps
Pain
Pallor
Pulseless
Paraesthesia
Paralysis
Perishing cold

216
Q

Signs of ALI

A

6 Ps
Pain
Pallor
Pulseless
Paraesthesia
Paralysis
Perishing cold

217
Q

4 causes of ALI and treatment

A

Thrombosis
- due to rupture of atherosclerotic plaque
- if incomplete ischaemia: angiography, then angioplasty / thrombectomy / intra-arterial thrombolysis
- if complete ischaemia: urgent bypass surgery

Embolism
- due to AF
- treat by immediate embolectomy
- if embolectomy can’t be done: on table thrombolsyis

Vasospasm - eg Raynauds

External vascular compromise - eg Trauma, Compartment syndrome

218
Q

Describe what should be done to prepare for amputation surgery in ALI

A

Nil by mouth
Give IV heparin: to prevent further thrombosis

219
Q

Contrast ALI due to thrombosis vs embolism

A

Thrombosis
- sub acute presentation
- features of PVD in contralateral limb
- due to rupture of atherosclerotic plaque
- treatment: angioplasty/thrombectomy/thrombolysis (incomplete ischaemia) OR urgent bypass (complete ischaemia)

Embolism
- acute presentation
- due to AF
- treatment: immediate embolectomy OR on table thrombolysis

220
Q

What is ALI

A

Symptomatic hypo perfusion of limb for less than 2 weeks

221
Q

Define ALI

A

Symptomatic hypo perfusion of limb for less than 2 weeks

222
Q

Intitial Investigations and management for ALI

A

Urgent Doppler ultrasound
Give analgesia and low molecular weight heparin

ECG
FBC
u&Es
Clotting profile
Blood group and save

Refer for vascular surgery !!!!

223
Q

Differential diagnoses for ALI

A

PAD/PVD
DVT
raynauds
Compartment syndrome

224
Q

Initial steps for ALI

A

Urgent Doppler ultrasound
Give anaelgesia and low molecular weight heparin

ECG
FBC
U&Es
Blood group and save
Clotting profile

REFER FOR VASCULAR SURGERY!!!

225
Q

What is cilostazol used for

A

Symptomatic relief for Claudication that causes lifestyle limitation

226
Q

What is used to treat claudication that doesn’t cause lifestyle limitation

A

Clopidogrel

227
Q

What do absent dorsalis pedis / posterior tibial pulses indicate

A

Vascular disease
- limb ischaemia due to thrombosis or embolism/AF

228
Q

If a pt presents with a cold left leg with absent pulses, why would this not indicate heart failure

A

The leg is ischaemic, but heart failure would causes bilateral ischaemia, this is more due to thrombosis or embolism

229
Q

When is myoglobin released

A

In severe muscle damage / ischaemia

230
Q

What does red brown urine indicate

A

Myoglobinuria

231
Q

Why would a pt have oliguria being treated for ALI

A

The ALI caused muscle damage
Damaged muscle cells release myoglobin into blood (causes urine to become red brown)
This causes acute kidney injury
This causes oliguria

232
Q

How would acute limb ischaemia cause more cardiac arrhythmias

A

Causes muscle damage
Damaged muscle cells release K+
Hyperkalaemia causes cardiac arrhythmias

233
Q

How would acute limb ischaemia affect the ph of the body

A

Causes muscle damage
Damaged muscle cells release H+
Causes metabolic acidosis
Causes weakness, confusion, rapid breathing

234
Q

What cause of ALI does previous intermittent claudication indicate

A

Thrombosis
History indicates atherosclerotic disease in peripheral arteries of limb

235
Q

How to treat ALI with sensory loss but no motor loss (Rutherford 2a)

A

Can attempt conservative management: prolonged course of heparin

If you have sensory and motor loss (Rutherford 2b+): urgent surgery eg embolectomy

236
Q

What is considered gold standard investigation for ALI

A

Digital subtraction angiography

237
Q

What is the treatment for peripheral odeoma secondary to fluid overload

A

Furosemide PO

238
Q

What is the treatment for cellulitis

A

Flucoxacillin PO

239
Q

What does a “woody and tense” limb with palpable pulses and pain on passive stretching indicate

A

Compartment syndrome

240
Q

Are pulses palpable in compartment syndrome

A

Yes

241
Q

Describe compartment syndrome

A

Typically following crush injuries or fractures
Swelling of the fascia causes compression of the venous system
Causes ischaemia - pain on passive stretching of muscle
Pulses are still palpable
Limb feels woody or tense
Needs urgent fasciotomy

242
Q

Contrast acute, critical and chronic limb ischaemia

A

Acute
- sudden onset, less than 2 weeks
- severe pain
- no pulses
- 6 Ps
- pale and cold
- needs immediate intervention

Critical limb ischaemia
- gradual onset, over 2 weeks
- pain at rest and exertion
- warm and pink
- muted or absent pulses
- ulcers and gangrenes
- no need for immediate intervention, but immediately refer to vascular surgeon

Chronic limb ischaemia
- chronic but reversible ischaemia - pain/ischaemia is only on exertion and is relieved by rest: INTERMITTENT CLAUDICATION
- no ulcers or gangrene

243
Q

What is the ABPI for critical limb ischaemia

A

< 0.5

244
Q

what is the typical location for a diabetic ulcer vs venous ulcer vs arterial ulcer

A

diabetic - plantar aspect of foot
venous - medial malleolus
arterial - lateral malleolus, heel, tips of toes

245
Q

which is more beneficial in managing venous ulcers, weight loss or compression bandaging

A

compression bandaging

246
Q

what type of leg ulcer is associated with mild cold pain when walking long distances

A

arterial ulcer
- pt suffers from intermittent claudication which is a symptom of PAD

247
Q

give signs of chronic venous insufficiency

A

pruritis
oedema
prominent superficial veins
lipodermatosclerosis
venus ulcer

248
Q

what is a Marjolin’s ulcer

A

an ulcerating squamous cell tumour that arises in an area of previously traumatised or chronically inflamed skin

249
Q

what is a pyoderma gangrenous

A

a large, painful ulcer associated with autoimmune diseases

250
Q

what type of ulcer cause pain at rest

A

arterial

251
Q

what is the name of the area at which venous ulcers are found

A

gaiter area (from mid calf to the malleoli)

252
Q

what does an ulcer with a rolled edge indicate

A

basal cell carcinoma

253
Q

contrast the bases of venous and arterial ulcers

A

venous - pink granulating base
arterial - dark necrotic base

254
Q

what is the Waterlow score

A

screening tool measuring a pt’s risk of developing pressure ulcers

255
Q

what must be done before applying compression bandaging to an ulcer and why

A

must do ABPI to rule out material ulcer, as compression bandaging is contraindicated in arterial disease
( if ABPI is normal - 0.9-1.2 - it’s more likely to be venous ulcer not arterial)

256
Q

what does ‘inverted champagne bottle leg’ indicate

A

severe lipodermatosclerosis - indicates progression towards venous leg ulcers

257
Q

risk factors for arterial ulcers

A

coronary artery disease
PAD
obesity
diabetes
smoking
hypercholestrolaemia
stroke/TIA

258
Q

describe the clinical features of arterial ulcers

A

pushed out
well defined borders
dark necrotic base
very painful - worse on lying down, elevating the leg
can also be worse on walking - (PAD)
limb appears cold, pale, shiny, hairless, no pulse
distal location: lateral malleolus, tips of toes, heels

259
Q

investigations for arterial ulcers

A

duplex US
ABPI - arterial ulcer will give low abpi (less than 0.9 ish)
capillary refill time

260
Q

management for arterial ulcers

A

lifestyle modifications - diet and smoking cessation
wound care
skin graft
surgical revascularisation - bypass or angioplasty

261
Q

risk factors for venous ulcers

A

DVT
varicose veins
obesity
immobility
leg injury/surgery
age

262
Q

clinical features of venous ulcers

A

shallow
irregular borders
pink granulating base
itchy
pain is worse on standing
usually only mild pain or painless
usually occur after injury
in gaiter’s region (from mid calf to malleoli), usually above medial malleolus
features of venous insufficiency: oedema, haemosiderin deposition (brown pigmentation), lipodermatosclerosis (had skin), eczema

263
Q

investigations for venous ulcers

A

duplex US
ABPI - to exclude arterial ucler
swab for microbiology culture - if looks infected
biopsy - for any non ischeamic wound that hasn’t healed after 3 months of treatment
measure SA of ulcer to monitor its progression

264
Q

management for venous ulcers

A

1st line: compression bandaging (C/I in arterial ulcers, do do ABPI first to rule arterial ulcer out)

antibiotics if signs of infection
topical steroids - for surrounding dermatitis (but doesn’t treat the actual venous ulcer)
debridement and cleaning
skin graft

265
Q

Pt presents with varicose veins around medial malleolus, which venous system is affected?

A

Great/long saphenous system

266
Q

Pt presented with varicose veins around lateral malleolus and back of calf, which venous system is affected

A

Short saphenous system

267
Q

What is superficial thrombophlebitis

A

Inflammation of a vein just below surface of skin due to blood clot
Vein becomes hard and cord like, and is painful and tender
Presents with erythema and raised temp

268
Q

A pt presents with varicose veins, ABPIs of 0.9 and 0.7 and BMI of 32. What’s the initial management

A

Weight loss (most appropriate as she is obese, always do conservative management first)
Don’t give compression stockings as she has a ABPI less than 0.8, so risk of limb ischaemia

269
Q

A pt presents with varicose veins that are asymptomatic but she finds them unsightly. What’s the management

A

Lifestyle advice , compression stockings

270
Q

what is a varicocele and how does it present

A

dilation of the pampiniform plexus
presents as a distention of the scrotal sac

271
Q

if a pt presents with a lump under the inguinal ligament, what are the 2 man differential diagnosis and how do you differentiate them

A

fermoral hernia vs saphena varix
differentiate via Duplex US
(femoral hernia also predominantly occurs in women, and is often irreducible)

272
Q

what is a saphena varix and describe how it presents

A

dilation of saphenous vein at saphenofemoral junction - below inguinal ligament
- bluish tinge
- reducible
- disappears when lying down
- positive cough impulse test
- likely with a PMH of varicose veins

273
Q

what are hydroceles and how do they present

A

fluid accumulation in tunica vaginalis
present as scrotal masses

274
Q
A
275
Q

Risk factors for varicose veins

A

Female
Family history
Increased number of births
Occupation which involves long periods of standing
DVT
increased age

276
Q

Clinical features of varicose veins

A

Dilated tortuous veins
Itchy
Swelling
Leg fatigue or aching, worse when standing
Leg cramps
Restless legs
Skin changes
- haemosiderin deposition
- varicose eczema
- lipodermatosclerosis —> gives champagne bottle leg
- atrophie Blanche

277
Q

Investigation for varicose legs

A

Duplex US

278
Q

What does the valve closing time shown by Duplex US in varicose veins indicate

A

> 0.5 secs = reflux
1 sec = reflux in deep system

279
Q

Management for varicose veins

A

Lifestyle eg weight loss, elevating legs
Compression stocking
EVLA (endo vascular laser ablation)
Surgery : stripping of long or short saphenous vein

280
Q

most common cause of aortic stenosis in >65 and <65

A

> 65 : aortic valve sclerosis
<65 : bicuspid aortic valve

281
Q

what are the clinics signs (PP, pulse, murmur) and symptoms of aortic stenosis

A

symptoms: SAD
-syncope
-angina
-exertional dyspnea

narrow PP
slow rising pulse
soft S2

harsh crescendo decrescendo
ejection systolic murmur tha radiates bilaterally to carotids

282
Q

what are the clinics signs (PP, pulse, murmur) and symptoms of aortic regurgitation

A

symptoms of left sided heart failure
- rapid cardiac decompensation
- pulmonary oedema
- quinces sign (nailed pulsation)
- de musset’s sign (head bobbing)
- dyspnea

widening PP
collapsing pulse

early decrescendo diastolic murmur
- if severe, Austin Flint murmur (mid diastolic)

283
Q

investigations for aortic valve disease, first line/gold standard

A

first line/gold standard : transthoracic echocardiogram - to see calcification and stenosis

CXR - to see pulmonary oedema

284
Q

treatments for aortic valve disease (aortic regurguctaion/stenosis) for asymptomatic with valve gradient < 40 mmHg

A

no treatment
annual echocardiogram screening

285
Q

treatments for aortic valve disease (aortic regurguctaion/stenosis) for symptomatic OR asymptomatic with valve gradient > 40 mmHg
for low/medium vs high operative risk pts

A

low/medium operative risk pt: surgical valve replacement

high operative risk pt: transcatheter valve replacement (TAVI)

286
Q

if a pt has aortic valve repair with a metallic valve, what medication must they be on to prevent thromboembolic event, and what is the target INR

A

long term anticoagulant and warfarin
target INR = 2.5 - 3.5

287
Q

if a pt with high risk of IE has aortic valve repair, what meds would they be on

A

prophylactic Abx

288
Q

describe the symptoms and clinical signs of mitral stenosis

A

symptoms
- dyspnoea
- malar flush
- hoarseness and dysphagia (as enlarged atrium compressed recurrent laryngeal nerve and oesophagus)
- haemoptysis
- severe causes signs of RHF

  • loud S1
  • opening snap
  • mid diastolic murmur heard on left lateral side during expiration
289
Q

describe investigation for mitral stenosis and what it would show

A

Transthoracic echo - shows reduces SA of mitral valve
CXR - shows LA enlargement
ECG - P mitrale (broad notched P waves due to atrium enlargement)

290
Q

how would you see atrial enlargement on an ECG

A

P mitrale - broad notched P waves

291
Q

Tx for mitral stenosis if symptomatic or valve less than 1.5 cm2

A

ballon valvotomy or valve replacement

292
Q

comp0lications of mitral stenosis

A

atrial fibrillation
stroke
congestive HF

293
Q

what is given to prevent atrial fibrillation as a result of mitral stenosis

A

warfarin - target INR is 2.5

294
Q

symptoms and clinical signs of mitral regurgitation

A

dyspnea
palpitations
fatigue
LHF
pulmonary oedema

quiet S1
ejection systolic murmur
heard loudest over apex beat and radiates to axilla

295
Q

Ix for mitral regurgitation

A

CXR - LA and LV enlargement
ECG - LV enlargement causes larger QRS complex

296
Q

Tx for mitral regurgitation

A

valve replacement
HF meds - nitrates and diuretics (furosemide)

297
Q

complications of mitral regurgitation

A

LHF
pulmonary oedema
cariogenic shock
atrial fibrillation

298
Q

most common cause of primary mitral stenosis

A

rheumatic fever

299
Q

most common cause of primary mitral stenosis in young females

A

mitral valve prolapse

300
Q

most common causes of secondary mitral stenosis

A

coronary artery disease
dilated cardiomyopathy

301
Q

what type of HF do mitral and aortic regurgitation causes

A

LHF

302
Q

what type of HF can mitral stenosis cause

A

RHF

303
Q

what is the main treatment for cariogenic shock

A

ionotropes - dobutamine

304
Q

clinical signs and symptoms of tricuspid regurgitation

A

raised JVP
hepatomegaly
hepatic pain
jaundice
fatigue
oedema
ascites

pansystolic murmur

305
Q

clinical signs and symptoms of tricuspid stenosis

A

fatigue
ascites
oedema

early diastolic murmur

306
Q

clinical signs and symptoms of pulmonary stenosis

A

dsynpoea
fatigue
oedema
ascites

ejection systolic murmur

307
Q

clinical signs and symptoms of pulmonary regurgitation

A

decrescendo early diastolic murmur

308
Q

which sided murmurs are heard best on inspiration vs expiration

A

left side - expiration
right sided - inspiration

309
Q

which valve condition causes a murmur with an opening snap

A

mitral stenosis

310
Q

How to differentiate between ejection systolic murmur due to aortic stenosis vs aortic sclerosis

A

Aortic stenosis
- radiates to carotids
- symptomatic
- slow rising pulse
- narrow PP
- soft S2

Aortic sclerosis
- no radiation
- asymptomatic
- normal S2/PP/pulse

311
Q

which valve conditions causes a pan systolic murmur heard loudest over the apex

A

mitral regurgitation

312
Q

what non valve condition presents similar to mitral regurgitation but is much less common than it, and also causes a panystolic murmur

A

VSD

313
Q

what is heard on auscultation in Dressler’s syndrome

A

pericardial friction rub

314
Q

which valve is heard best over left 2nd intercostal space

A

pulmonary

315
Q

which valve is heard best over right 2nd intercostal space

A

aortic

316
Q

what valve condition causes a quiet S2

A

aortic stenosis

317
Q

which valve condition could cause a loud S2

A

aortic sclerosis

318
Q

how to differentiate ejection systolic murmur caused by aortic stenosis vs aortic sclerosis

A

aortic stenosis
- murmur radiates to carotids
- symptomatic
- slow rising pusle
- narrow PP
- soft S2

aortic sclerosis
- murmur doesn’t radiate to carotids
- asymptomatic
- normla pusle/PP/S2

319
Q

which valve disease is noonans syndrome associated

A

pulmonary stenosis

320
Q

which valve disease is Marfans syndrome associated with

A

aortic regurgitation

321
Q

which heart abnormalities is down syndrome associated with

A

ASD
VSD
AVSD

322
Q

which valve disease is William’s syndrome associated with

A

aortic stenosis

323
Q

which heart murmur is turners syndrome associated with

A

pan systolic murmur in left scapular area
- due to coarctation of aorta

324
Q

when is a cannon A wave seen

A

heart block

325
Q

what does it mean if a pts orthostatics are positive

A

significant decrease in bp when pt goes from sitting down to standing up - identifies those at risk of hypovolaemia

326
Q

which valve condition is rheumatic fever classically associated with

A

mitral stenosis

327
Q

most common cause of aortic stenosis in YOUNG pt

A

bicuspid aortic valve

328
Q

what is soft S1 classical of

A

aortic regurgitation

329
Q

which valve condition can cause chest pain

A

aortic stenosis - reduced blood flow over aortic valve = reduced blood flow through coronary arteries

330
Q

what is the cause of a pan systolic murmur which is loudest at the left sternal edge

A

VSD - NOT mitral regurgitation, that is loudest at the apex

331
Q

high pitched blowing diastolic murmur at left sternal border, cause?

A

aortic regurgitation

332
Q

what is the cause of a pan systolic murmur in a pt with dyspnea

A

mitral regurgitation

333
Q

what is the cause of a pan systolic murmur which radiates to the axilla

A

mitral regurgitation

334
Q

most common worldwide cause of aortic regurgitation

A

rheumatic heart disease

335
Q

what valve condition is malar rash associated with

A

mitral stenosis

336
Q

what peak trans valvular pressure gradient and valve area indicate severe aortic stenosis

A

peak trans valvular pressure gradient > 40 mmHg
valve area < 1cm

337
Q

which valve condition can carcinoid syndrome cause

A

pulmonary stenosis

338
Q

what valve condition causes a mid systolic click

A

mitral valve prolapse

339
Q

which valve condition has an opening snap

A

mitral stenosis

340
Q

what gcs indicates coma

A

8/15 or less

341
Q

when do you use DC cardioversion instead of amiodarone

A

when you want an immediate effect - pt is deteriorating

342
Q

which arrhythmia does adenosine treat

A

SVT by blocking AV node

343
Q

which arrhythmia does procainamide treat

A

VT

344
Q

what does the A wave on a JVP waveform indicate

A

atrial contraction

345
Q

describe the A wave on a JVP waveform in atrial fibrillation

A

absent A wave

346
Q

what is first line management for symptom control in AF

A

rate control
- BBs (proponalol) or rate limiting CCBs (verapamil, diltiazam)

347
Q

what does the ORBT score measure

A

measures the risk of major bleeding events in pts who are on anticoagulation as a treatment for AF

348
Q

if DC cardio version is unsuccessful in a pt with AF, what do you try next

A

rate control therapy +/- anticoagulation if needed
- don’t try chemical cardio version –> the fact that DC cardio version didn’t work shows you that the AF is permanent and cannot be reverted to a sinus rhythm

349
Q

if a pt with AF presents with a bp of 85/50 and palpitations/malaise, what is the management and why

A

emergency DC cardioversion
bc she’s haemodynamically unstable ( bp <90/60) and symptomatic

350
Q

when is warfarin preferred to DOAC’s as an anticoagulant for AF

A
  • If pt has mechanical heart valves
  • pt has stage 4/5 kidney disease
351
Q

what are the requirements to be put on anticoagulants for an AF pt

A

anyone with valvular disease and AF
or
male with CHADSVASc score 1+
or
female with CHADSVASc score 2+

352
Q

what is acute, paroxysmal, persistent and permanent atrial fibrillation

A

acute - less than 48 hrs onset
paroxysmal - intermittent episodes, last less than 7 days
pertinent - lasts more than 7 days, but subject to cardio version
permanent - lasts more than 7 days and doesn’t respond to cardio version

353
Q

AF symptoms

A

chest pain
dyspnea
dizziness
syncope
palpitations

354
Q

ECG changes in AF

A

no P waves
narrow QRS
irregularly irregular rate

355
Q

what pulse deficit is seen in AF

A

apical to radial pulse deficit

356
Q

give 3 main causes of AF

A

alchohol
sepsis
hyperthyroidism

357
Q

give 2 complications of AF

A

Heart failure
stroke

358
Q

AF vs atrial flutter

A

AF has irregular peripheral pulse and is always a irregularly irregular rate
Atrial flutter is usually regular but can be irregularly ire=regular if the AV block is variable (makes it hard to distinguish from AF)

AF shows fibrillating baseline with no P waves
atrial flutter has sawtooth baseline

Atrial flutter is more likely to occur with pulmonary disease

359
Q

first line treatment for paroxysmal AF

A

flecanide

360
Q

first line management for pt who comes in with asymptomatic AF

A

rate control
assess if they need anticoagulation via CHADSVASc score

361
Q

first line management for pt who comes in with AF that started over 48 hrs ago

A

rate control
give LMWH for 3 weeks or do TOE to exclude mural thrombus –> then do cardioversion

362
Q

rate control for AF 1st and second line

A

1st : BB (bisoprolol) or CCBs (verapamil, diltiazem)

2nd dual therapy or digoxin+bisoprolol

363
Q

which medications for AF rate control should never be given together as they cause heart block

A

verapamil and bisoprlol

364
Q

which conditions are BBs C/I in

A

COPD
Asthma HTN

365
Q

which conditions are CCBs C/I in

A

HF

366
Q

which pts should be given digoxin / which ones should we avoid

A

avoid younger pts
give to sedentary pts

367
Q

first line rhythm control for persistent non-emergency AF

A

amiodarone

368
Q

3 methods of rhythm control for AF

A
  1. DC cardio version (give LMWH before)
  2. chemical cardio version
    - amiodarone (older pts, persistent AF)
    - flecanide (younger pts, C/I in structural heart disease, paroxysmal AF)
    - sotalol (for thsoe who don’t meet above criteria)
  3. catheter ablation (of foci between pulmonary veins and left atrium)
369
Q

options for anticoagulation in AF

A

1st) DOAC eg apixaban or edoxaban
2nd) warfarin –> needs INR monitoring
3rd) LMWH (enoxaparin) - for pt who can’t tolerate oral treatment

370
Q

edoxaban vs apixaban, which one is given to pt with good kidney function

A

apixaban
- edoxaban is cleared too quickly

371
Q

what type of tachycardia is atrial flutter

A

Is a form of SVT

372
Q

Atrial flutter treatment in unstable pts

A

DC cardioversion / amiodarone

373
Q

Atrial flutter for stable pts

A

1st) BBs or CCBs
2nd) cardioversion
3rd) ablation of arrythmogenic foci at cavotricuspid isthmus
(this is the first line for RECURRENT atrial flutter)

374
Q

Atrial flutter ECG features

A

regular rhythm - Unless the AV block is variable - then its irregularly irregular and hard to distinguish from AF

narrow QRS

sawtooth pattern

2:1, 3:1 etc (sawtooths to QRSs) depending on level of block

375
Q

symptoms of atrial flutter

A

same as AF

376
Q

what is the effect that digoxin can ave on an ecg

A

causes a down-sloping St segment “reverse tick”
and reduces QT interval

377
Q

hypokalaemia on ecg

A

inversion of T wave
U wave (small wave after the inverted T wave)

378
Q

which ecg changes indicate previous MI

A

Q waves

379
Q

what is a mid systolic click characteristic of

A

mitral valve prolapse

380
Q

what murmur is heard with coarctation of the aorta

A

pan systolic murmur which radiates to the left scapula

381
Q

which classes of medication can cause prolonged QT interval

A

Anti ABCDE
anti arhythmic
anti biotics
anti chotics
anti depressants
anti emetics

382
Q

what causes digoxin toxicity

A

hypokalaemia

383
Q

best treatment for recurrent episodes of atrial flutter

A

catheter ablation

384
Q

what is dextrocardia

A

heart is on right not left

385
Q

what does left-right arm lead reversal in ecg cause

A

negative complex and P wave in lead 1

386
Q

what does chets lead reversal in ec cause

A

inappropriate R wave progression

387
Q

what does dextrocardia show on ecg

A

no R wave progression in leads V1-V6

388
Q

if a pt is on medication for AF and develops nausea, vommiting and yellow green visual disturbances, what is happening

A

digoxin toxicity

year 3 conditions (17 decks)

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