cardiovascular Flashcards
3 types of cardiac ischaemia
STEMI - complete blockage of coronary artery
NSTEMI - supply and demand mismatch
unstable angina - supply and demand mismatch (ischaemia not infarction)
signs of chest pain caused by ischaemia
worse with exertion
doesn’t change with body positioning
not relieved with rest
radiates to
- epigastrium
- left shoulder/arm
- neck
- lower jaw
what is orthopnea
shortness of breath that occurs while lying flat and is relieved by sitting or standing
diaphoresis
abnormally excessive sweating
treatment for ACS
MONA
- morphine
- O2
- nitrate
- high dose aspirin
high dose statin
beta blocker eg metroprolol
first line of action when someone arrives with chest pain
- ECG
- history + physical
- if show signs of ischaemia eg chest discomfort., pressure, tightness, burning, syncope, dyspnea, diaphoresis, nausea/vomiting
–> measure troponin
signs of cardiogenic shock
pale skin
tachycardia
hypotension
cool extremities
diaphoresis
signs of acute heart failure
jugular venous distension
crackles on lung auscultation
new S3 gallop
murmur
orthopnea
edema
if a man with stable angina presents with change in baseline gain, new onset pain at rest, what is a likely diagnosis
ACS
how may women or older patients with stable angina present with ACS
dyspnea instead of new onset chest pain
signs of ongoing ischaemia >12 hours after symptom onset in ACS
refractory chest pain
haemodynamic instability
ventricular arrythmias
dynamic ECG changes
stable angina vs ACS
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
treatment for STEMI
- 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
how to differentiate between NSTEMI and unstable angin
measure troponin
treatment for NSTEMI
- DAPT
- anticoagulants
+
- ongoing ischaemia –> PCI or CABG (multiple vessels / left main coronary artery affected)
- no ongoing ischameia –> medial therapy
what is never indicated for NSTEMI and unstable angina
fibrinolysis
unstable angina treatment
early risk stratification
- high risk –> DAPT + anticoagulant
+ PCI / CABG - low risk –> non invasive stress testing
what is fondaparineux
anticoagulant
what is tricagelor
antiplatelet
What are the signs and symptoms of ACS?
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
What is a silent ACS and what patients does this occur in
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
How are each of the three acute coronary syndromes diagnosed based on their investigation findings?
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
what are type 2 myocardial infarctions
myocardial infarctions due to cardiac hypoperfusion for other reasons (e.g. severe sepsis, hypotension, hypovolaemia or coronary artery spasm)
what type of infarct causes a stemi vs nstemi
stemi - transmural infarct
nstemi - subendocardial infarct
what 3 substances can be measured in the blood to test for myocardial infarct, and which one can be used to measure reinfarction
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
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
pericarditis
what is a pericardial friction rub and what is it pathognomonic of
high pitched scratching noise, best heard over left sternal border during expiration
signs of pericarditis
- pericardial friction rub
- Beck’s triad (raised JVP, muffled heart sound, hypotension) –> bc pericarditis can cause pericardial effusion and cardiac tamponade
difference between pericarditis and GORD pain
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
difference between pericarditis and ACS pain
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
difference between MSK and pericarditis pain
MSK pain is reproducible with palpation or certain movements.
what treatment is done for pericarditis pts who develop pericardial effusion d cardiac tamponade
pericardiocentesis - a procedure done to remove fluid that has built up in the sac around the heart (pericardium)
PR segment depression
+ multilead ST elevation
+ aVR ST depression
are characteristic of…
acute pericarditis
which investigations to do to distinguish between pericarditis and MI
- the pain is different - not affected by position in MI/ACS, worse lying down in pericarditis
- echocardiogram - ooking for the absence of regional wall motion abnormalities
- angiogram - checks for affected coronary arteries suggesting MI
what is the most common causative agent of acute IE
staph aureus
what is the most common causative agent of IE due to drug use
staph aureus
what is the most common causative agent of IE less than 2 month post valve surgery
staph epidermis
what is the most common causative agent of subacute IE following dental procedures
strep viridans
which causative agent predisposes to IE and colorectal cancer
strep bovis
strep vs staph shape
staph = clusters
strep = chain
which valve is most likely affected by IE due to IV drug use
tricuspid
clinical features of IE
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
what valve pathology are pink cheeks associated with
mitral stenosis - pink cheeks = “mitral facies”
what does a slow rising pulse indicate
aortic stenosis
what output type of heart failure does hypertension cause
low output heart failure (bc the hypertension causes excessive after load)
what would be the first line management in a patient with heart failure and pEF, fluid overload and hypertension
lifestyle advice
low dose diuretic eg furosemide
ACE inhibitor / ARB
which condition are BB’s eg bisoprolol contraindicated in
asthma
symptom management for acute HF
furosemide
sit upright
morphine
oxygen
what is sacubitril/valsartan and what HF is it indicated in
a new ACE inhibitor/ARB combination drug
indicated in pts with reduced EF
what normally presents with haemoptysis, sharp and pleuritic chest pain
pulmonary embolism
what condition is Prominent central pulmonary artery (Fleischner sign) seen in
pulmonary embolism
what condition is Water-bottle-shaped enlarged cardiac silhouette seen in
pericarditis
which heart failure does displaced apex beat indicate and why
left sided heart failure
due to left ventricular hypertrophy
where is BNP secreted from
cardiac ventricles
how does diastolic heart failure affect ejection fraction
EF is usually preserved
what kind of patients does HOCM present in
younger pts with breathlessness, particularly on exertion, palpitations and syncope
what kind of heart failure does HOCM cause
diastolic HF
what kind of heart failure does cardiac tamponade cause
diastolic HF
what kind of heart failure does ischaemic heart disease cause
systolic HF
why does spironolactone increase risk of hyperkalaemia?
It’s a potassium sparing diuretic, so decreases excretion of potassium in urine. Therefore serum potassium increases –> hyperkalaemia
if a pt is on an ACE inhibitor + beta blocker but can’t tolerate spironolactone, what do you give them
epleronone
if a pt is on an ACE inhibitor + beta blocker but can’t tolerate spironolactone and is afro-carribean, what do you give them
hydralazine
chest x ray findings for congestive heart failure
○ 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
what does Widespread saddle-shaped ST elevation on ECG indicate
acute pericarditis
what does Bilateral hilar lymphadenopathy on chest x-ray indicate
sarcoidosis
what does a fourth heart sound indicate and which wave on the ECG is it
indicates forceful atrial contraction against a stiff hypertrophic left ventricle
atrial contraction –> P wave
what is U wave on ECG associated with
hypokalaemia
hypercalcaemia
what is U wave on ECG associated with
hypothermia
what investigation is essential to confirm heart failure diagnosis
echocardiogram
what kind of heart failure is associated with orthopnoea
left sided heart failure
what do bibasal crepitations indicate
pulmonary oedema
what are the criteria for cardiac resynchronisation therapy
LBBB on ECG
LVEF < 30%
NYHA class 3/4
what is P pulmonale
P pulmonale (right atrial enlargement) is a big, tall, peaked P waves on ECG
what is the diagnosis of a pt with raised JVP, COPD, high Bp, pitting oedema in legs
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)
which axis deviation do you see on an ECG with cor pulmonale
right axis deviation
name the levels of the NYHA Classification (Severity of Cardiac Failure Symptoms)
○ 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)
when is DC cardio version indicated
tachyarrhythmias (eg atrial fibrillation with fast ventricular response rate) with signs of confusion, heart failure, hypotension, confusion
does Digoxin improve mortality in heart failure
no
what counts as a reduced ejection fraction
A reduced LV ejection fraction is usually 40% or less
if a pt has HFpEF with ankle odema and no hypertension what is the first line treatment
Furosemide
(Lifestyle advice would be first line if pt didn’t have ankle oedema)
what is the treatment for HFpEF
- lifestyle advice
- low dose diuretic if have signs of fluid retention eg ankle oedema
- ACE inhibitor/ARB if hypertensive
if a pt is prescribed high dose diuretic eg furosemide for heart failure, what side effects may they experience
tinnitus
deafness
if a pt is prescribed spironolcatone for heart failure, what side effects may they experience
Gynacomastia
what counts as a jugular venous distension
JVP > 4cm
what are Coryzal symptoms
hallmark of URTIs that include nasal stuffiness, runny nose, sneezing, sore throat, and cough
what is a patient with alcoholic cirrhosis at risk of if they take diuretics
Diuretics can increase the risk of hypomagnesaemia in those with alcoholic cirrhosis - leading to arrhythmias
what are these findings associated with and in which pts: Regional wall motion abnormality, ejection fraction <55%
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)
what are these findings associated with and in which pts: Apical ballooning of the left ventricle
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)
what are these findings associated with and in which pts: Left ventricular dilation, ejection fraction <55%
These findings are consistent with dilated cardiomyopathy. Dilated cardiomyopathy is commonly caused by excess alcohol consumption or is idiopathic.
what are these findings associated with: Asymmetric septal hypertrophy, diastolic dysfunction
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
what is pulsus paradoxus and what conditions is it associated with
abnormally large decrease in bp during inspiration
associated with
- constrictive pericarditis
- cardiac tamponade
- pericardial effusion
what is pulsus alternans and what conditions is it associated with
alternating strong and weak pulses
associated with severe left heart failure
what type of heart failure is prolonged capillary time associated with
left heart failure
what is left heart failure commonly caused by in central/South America
Chaga’s disease
what are the 2 output states of heart failure
Low output state - low cardiac output
High output state - normal cardiac output, higher metabolic needs (anaemia, Beri-beri “thiamine deficiency”, hyperthyroidism, pregnancy)
what are the 2 types o left heart failure and their common causes
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
what is RHF secondary to
left heart failure (congestive heart failure),
Infarction,
Pulmonary hypertension,
Tricuspid regurgitation
clinical features of LHF
(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
Clinical features of RHF
(fluid accumulates in peripheries = swollen signs)
swollen ankles (peripheral oedema),
increased weight,
reduced exercise tolerance,
raised JVP,
hepatomegaly (pulsatile liver edge on palpation),
Ascites
First line investigations for heart failure presentation
- BNP - if raised (above 400) then do echo
- echocardiogram (definitive)
heart failure symptom management
sit up
IV furosemide
o2
morphine
treatment for HFrEF with HTN
- ACEi + BB
no ACEi –> ARB
no ACEi/ARB –> Hydralazine - spironolactone + epleronone
arfo/carribbean –> hydralazine + nitrate - Ivabradine (only if sinus rhythm and HR >75)
- cardiac resynchronisation
treatment for HRpEF
- lifestyle advice
- if fluid overload –> furosemide
- if HTN –> ACE inhibitor/ARB
investigations of stable angina for ischaemic heart disease
- CT coronary angiogram
- MRI fir regional wall abnormalities / cardiac stress testing / ecg + troponin
what is the 1st line imaging for stable angina
CT coronary angiogram
what are pathological Q waves and what do they indicate
negative deflection before R wave
indicates previous infarct
treatment for stable angina / ischaemic heart disease
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
GTN spray side effects
headaches, flushing, dizziness
what is the first line treatment for asthmatic pt with ischaemic heart disease
- rate limiting CCB eg verapamil / diltiazem
(BBs are contraindicated in asthma) - rate limiting CCB + nitrate
which CCBs cannot be used alongside BBs
Verapamil/diltiazem can’t be used alongside beta blocker → causes severe bradycardia and heart block
treatment for ischaemic heart disease can’t be managed medically
PCI, CABG
what is the aspirin dose for stable angina
75 g
what is the aspirin dose for acute CV events eg MI/stroke
300g
difference between angina and pleuritic chest pain
Angina: central crushing pain
Pleuritic pain: sharp, worse on inspiration, accompanied by features related to underlying cause: productive cough, fevers, VTE, hot swollen calf
what are the non dihydropryidine rate limiting CCBs
verapamil
diltiazem
which CCBS CANNOT be used with BB
non dihydropyridine CCBS (veramapil / diltiazem)
the combination will cause bradycardia and AV block
which condition is dual anti platelet therapy indicated in
ACS
what to look for when thinking about giving ivabradine
make sure the HR is not less than 70, as ivabradine slows down the heart
what are the 4 classes of stable angina
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
how would Spontaneous coronary artery dissection (SCAD) present and in which pts
constant sharp left sided chest pain with radiation
often in young, female, pregnant pts
what is takotsubos cardiomyopathy / broken heart syndrome
temporary akinesia of the left ventricle
in response to an intense emotional or physical experience
A 67-year-old man with ischaemic heart disease is on verapamil. The addition of which medication would carry a risk of heart block?
BBs
a pt is recently diagnosed with stable angina and reversible ischaemia - indicating coronary artery disease
what is the management
GTN spray + BB OR CCB
what investigation is required if clinical assessment reveals non anginas chest pain but a resting ECG shows changes in ST or Q waves
CT coronary angiography
what is an indication for a CABG
multi vessel coronary artery disease with poor response to medical therapy
when does CABG have a survival advantage over PCI
in pts who are
- over 65
- diabetic
- have complex 3 vessel disease
what are the clinical signs off cardiac tamponade
raised JVP
muffled heart sounds
hypotension
what ECG change does pericarditis involve
widespread ST elevation
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?
labetolol
High arched palate and lens dislocation indicate which condition
marfans syndrome
when would you do a TTE instead of a CT angiogram for suspected aortic dissection
when the pt is unstable and proximal dissection is suspected
difference between pain presentation of acute pancreatitis vs aortic dissection
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
what is Takayasu’s arteritis and in which patients does it normally present, and what is the main sign
vasculitis of the major arteries in the body
presents in young women
main sign is absent arm pulses
how to differentiate Takayusu’s arteritis and aortic dissection
both can have absent arm pulses
aortic dissection presents with chest pain but takayusu’s arteritis does not
what does the presence of a radio-radial delay indicate
Type A aortic dissection
what does expansile pulsatile mass in the abdomen indicate
ruptured aortic aneurysm
what does the presence of a radio-femoral delay indicate
Type B aortic dissection
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
IV labetolol
(the pt is very hypertensive so bp needs to be controlled so it doesn’t worsen the dissection)
THEN surgical aortic repair
when is giving a red cell transfusion indicated
pt has Hb level < 70 g/L
or pt has ACS and Hb level < 80 g/L
what are the types of aortic dissection under Stanford classification
type A - involving ascending aorta
type B - involving descending aorta
what are the types of aortic dissection under Debakey’s classification
Type I - involving ascending + descending aorta
Type II - involving ascending aorta
Type III - involving descending aorta
what are the clinical signs of aortic dissection
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
first line investigations for aortic dissection
CT angiogram chest/abdo/pelvis
or Transoesophageal echocardiography if pt is to unstable to get CT
what ECG show ion aortic dissection
widened mediastinum
treatment for type A vs B aortic dissection
A - surgical repair, open or endovascular (but IV labetolol as initial management before surgery if pt is very hypertensive)
B - IV labetolol
71 yr old man, no past medial history, bp 155/95. first line management?
amlodipine
pt has bp 210/142 and has a headache. initial management?
IV labetolol
(headache raises suspicion of end organ damage, if didn’t have headache would give oral treatment instead)
pt has a high bp of 145/95 despite being on ACEi, what’s the next step
add CCB
(if monotherapy doesn’t work, add another medication)
what is doxazosin
an alpha blocker used for hypertension
what does S4 heart sound indicate
reduced ventricular compliance due to ventricular hypertrophy
a pt has high bp, high sodium and low potassium, what is a possible diagnosis
conn’s syndrome
What are the criteria for hypertension referral for same day specialist assessment
Clinical bp of 180/120 mmHg with
- retinal haemorrhage or papillodoema
Or
- life threatening symptoms eg confusion, chest pain, AKI, heart failure
If someone is allergic to ACEi and is on a CB but it’s not working what do you add
Thiazide like diuretic
(Some ppl allergic to ACEi are also allergic to ARB)
An Afro Carribean with HTN and T2DM is on ramipril but it’s not working. What do you add
CCB
(Can’t be on ACEi and ARB at the same time)
If a patient with Turner’s syndrome has radio-radial delay what is the likely diagnosis
Coarctation of the aorta proximal to the left subclavian artery
If a patient with Turner’s syndrome has radio-femoral delay what is the likely diagnosis
Coarctation of the aorta distal to the left subclavian artery
What side effects does hydralazine cause
Tachycardia, palpitations, flushing, angina if have underlying heart disease
A pt with hypertension has an ecg with tall tented T waves, which of her meds is likely to have caused this and why
ACEi eg ramipril
Bc they can cause hyperkalaemia
What is a dangerous side effect of bisoprolol for older pts
Can cause postural hypotension which can lead to falls
What is fludrocortisone used to treat
Adrenal insufficiency
Postural Hypotension
How long is clodinine given for
It is used for the rapid reduction of blood pressure, so only given for a few hours
With which patients should you be cautious concerning rapid and aggressive anti hypertensive medications and why
Elderly and those with history of stroke
As the medications can cause cerebral infarction or MI
If a pt has very high bp but no end organ damage how aggressively do u treat them
Over a few days
(If there’s no end organ damage you don’t need to do the aggressive “within a few hours” treatment)
When is IV hypertonic saline the drug of choice
In the treatment of raised intracranial pressure which can cause raised bp
Should sublingual nifedipine be used for very high bp requiring urgent intervention
No as it causes uncontrollable decrease in bp
When can IV hydrocortisone be used to decrease bp
When decreasing raised intracranial pressure
Most appropriate treatment for malignant hypotension with signs of encephalopathy and papillodoema
IV labetolol
Which strokes is prothrombin complex concentrate IV used for
It can be used to reverse haemorrhage in pts on warfarin or factor Xa
What is the gold standard investigation for phaechromocytoma
Urine and plasma metanephrines
What is the gold standard investigation for conns syndrome
Serum aldosterone
What is the gold standard investigation for cushings
Urinary free cortisol
What is the gold standard investigation for addisons
Short ACTH stimulation (synacthen) test
What is the gold standard investigation for a carcinoid (serotonin producing) tumour
Urine 5-HIAA
If pt is on ACEi for hypertension but can’t tolerate the dry cough, what should be done
Stop ACEians switch them to ARB
What is the treatment if a pts AMBP comes back as below 135/85
No medication, just lifestyle interventions and bp monitoring once every 5 years
What are the stages of hypertensive retinopathy
Stage 1: arteriolar narrowing and tortuosity. Silver wiring.
Stage 2: AV nipping
Stage 3: flame haemorrhages and cotton wool exudates
Stage 4: papillodoema
Stages of hypertensive retinopathy
Stage 1: arteriolar narrowing and tortuosity, sliver wiring
Stage 2: AV nipping
Stage 3: flame haemorrhages and cotton wool exudates
Stages of hypertensive retinopathy
Stage 1: arteriolar narrowing and tortuosity, sliver wiring
Stage 2: AV nipping
Stage 3: flame haemorrhages and cotton wool exudates
Levels of HTN
Level 1: clinical >= 140/90, abpm >= 135/85
Level 2: clinical >= 160/100, abpm >= 150/95
Level 3: clinical systolic >= 180 or diastolic >= 120
What is the first step of management if the bp is >= 180/120
Investigate for end organ damage
ACEi’s used in hypertension
Enalapril
Lisinopril
ARBs used in hypertension
Losartan
CCBs used in hypertension
Amlodipine
Side effects of ACEi
Hyperkalaemia
Cough
Angioedema
ACEis are contraindicated in what
Renal artery stenosis
Side effects of CCBs
Ankle swelling - peripheral oedema
What type of CCBs are used for hypertension and why
Dihydropyridine CCBs - less likely to exacerbate heart failure than verapamil
Which thiazide like diuretics are used for hypertension
Indapamide
Hydrochlorothiazide
Chlorthalidone
What are the side effects for thiazide like diuretics used for hypertension
Hypercalcaemia
Hyponatraemia
Hypokalaemia
Impaired glucose tolerance
Erectile dysfunction
What are the thiazide like diuretics used for hypertension contraindicated in
Gout
Bp targets for < and > 80
> 80 : clinical 140/90, abpm 135/85
< 80 : clincal 150/90, abpm 145/85
1st to 4th line treatment for HTN
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)
What is the first step if there is a clinical suspicion of aortic aneurysm (expansive pulsation mass)
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)
What is the strongest risk factor for developing AAA
smoking
Who is AAA screening offered to
Males 65 years and over
What is Saphena varix
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
How does femoral artery aneurysm present differently to inguinal/femoral hernia or lymphadenopathy
All present as painless lumps
But only aneurysm is a pulsatile lump
If a pt has an AAA of over 5.5 cm what is the next step in management
Open repair
Unless this is contraindicated - then EVAR
Who is EVAR offered to
Those who can’t undergo open AAA repair - have medical comorbidities, structural pathology, anaesthetic risk
What is the presentation of a ruptured AAA
Severe central abdo pain radiating to the back
Expansive and pulsatile mass
Tachycardia
Hypotension
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
Fluid resuscitation to raise the bp to 90mmHg systolic
This is to keep the organs preserved until definitive management can be done - open repair
What is the most important risk factor for the development of TAAs
Connective tissue disorders eg Marfan syndrome
What kind of aneurysm(s) does hypertension cause the enlargement of
Cerebral aneurysms
How to mitigate the risk of AAA rupture
Smoking cessation and good bp control
What is the most common location for abdominal aortic aneurysms
Infrarenal
What is permissive hypotension
Marinating lower bp in pts with haemorrhagic blood loss eg ruptured AAA
What is severe sudden onset back pain most indicative of
Ruptured AAA
What is an aneurysm
Dilation of an artery of more than 50% of its usual diameter
Risk factors for AAA
SMOKING
Male
Increased age
Atherosclerosis
Hypercholestrolaemia
Connective tissue disorders eg. Marfans syndrome
Family history
Risk factors for AAA
SMOKING
Male
Increased age
Atherosclerosis
Hypercholestrolaemia
Connective tissue disorders eg. Marfans syndrome
Family history
Hat are the steps of management depending on the diameter of the AAA
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)
investigations for AAA
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
Signs of aneurysm of the upper limb or popliteal arteries
Ischaemia distal to site of occlusion
Pain
Pallor
Pulselessness
Paraesthesia
Paralysis
What are the signs of ACI
6 Ps
Pain
Pallor
Pulseless
Paraesthesia
Paralysis
Perishingly cold
Signs of ALI
6 Ps
Pain
Pallor
Pulseless
Paraesthesia
Paralysis
Perishing cold
Signs of ALI
6 Ps
Pain
Pallor
Pulseless
Paraesthesia
Paralysis
Perishing cold
4 causes of ALI and treatment
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
Describe what should be done to prepare for amputation surgery in ALI
Nil by mouth
Give IV heparin: to prevent further thrombosis
Contrast ALI due to thrombosis vs embolism
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
What is ALI
Symptomatic hypo perfusion of limb for less than 2 weeks
Define ALI
Symptomatic hypo perfusion of limb for less than 2 weeks
Intitial Investigations and management for ALI
Urgent Doppler ultrasound
Give analgesia and low molecular weight heparin
ECG
FBC
u&Es
Clotting profile
Blood group and save
Refer for vascular surgery !!!!
Differential diagnoses for ALI
PAD/PVD
DVT
raynauds
Compartment syndrome
Initial steps for ALI
Urgent Doppler ultrasound
Give anaelgesia and low molecular weight heparin
ECG
FBC
U&Es
Blood group and save
Clotting profile
REFER FOR VASCULAR SURGERY!!!
What is cilostazol used for
Symptomatic relief for Claudication that causes lifestyle limitation
What is used to treat claudication that doesn’t cause lifestyle limitation
Clopidogrel
What do absent dorsalis pedis / posterior tibial pulses indicate
Vascular disease
- limb ischaemia due to thrombosis or embolism/AF
If a pt presents with a cold left leg with absent pulses, why would this not indicate heart failure
The leg is ischaemic, but heart failure would causes bilateral ischaemia, this is more due to thrombosis or embolism
When is myoglobin released
In severe muscle damage / ischaemia
What does red brown urine indicate
Myoglobinuria
Why would a pt have oliguria being treated for ALI
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
How would acute limb ischaemia cause more cardiac arrhythmias
Causes muscle damage
Damaged muscle cells release K+
Hyperkalaemia causes cardiac arrhythmias
How would acute limb ischaemia affect the ph of the body
Causes muscle damage
Damaged muscle cells release H+
Causes metabolic acidosis
Causes weakness, confusion, rapid breathing
What cause of ALI does previous intermittent claudication indicate
Thrombosis
History indicates atherosclerotic disease in peripheral arteries of limb
How to treat ALI with sensory loss but no motor loss (Rutherford 2a)
Can attempt conservative management: prolonged course of heparin
If you have sensory and motor loss (Rutherford 2b+): urgent surgery eg embolectomy
What is considered gold standard investigation for ALI
Digital subtraction angiography
What is the treatment for peripheral odeoma secondary to fluid overload
Furosemide PO
What is the treatment for cellulitis
Flucoxacillin PO
What does a “woody and tense” limb with palpable pulses and pain on passive stretching indicate
Compartment syndrome
Are pulses palpable in compartment syndrome
Yes
Describe compartment syndrome
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
Contrast acute, critical and chronic limb ischaemia
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
What is the ABPI for critical limb ischaemia
< 0.5
what is the typical location for a diabetic ulcer vs venous ulcer vs arterial ulcer
diabetic - plantar aspect of foot
venous - medial malleolus
arterial - lateral malleolus, heel, tips of toes
which is more beneficial in managing venous ulcers, weight loss or compression bandaging
compression bandaging
what type of leg ulcer is associated with mild cold pain when walking long distances
arterial ulcer
- pt suffers from intermittent claudication which is a symptom of PAD
give signs of chronic venous insufficiency
pruritis
oedema
prominent superficial veins
lipodermatosclerosis
venus ulcer
what is a Marjolin’s ulcer
an ulcerating squamous cell tumour that arises in an area of previously traumatised or chronically inflamed skin
what is a pyoderma gangrenous
a large, painful ulcer associated with autoimmune diseases
what type of ulcer cause pain at rest
arterial
what is the name of the area at which venous ulcers are found
gaiter area (from mid calf to the malleoli)
what does an ulcer with a rolled edge indicate
basal cell carcinoma
contrast the bases of venous and arterial ulcers
venous - pink granulating base
arterial - dark necrotic base
what is the Waterlow score
screening tool measuring a pt’s risk of developing pressure ulcers
what must be done before applying compression bandaging to an ulcer and why
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)
what does ‘inverted champagne bottle leg’ indicate
severe lipodermatosclerosis - indicates progression towards venous leg ulcers
risk factors for arterial ulcers
coronary artery disease
PAD
obesity
diabetes
smoking
hypercholestrolaemia
stroke/TIA
describe the clinical features of arterial ulcers
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
investigations for arterial ulcers
duplex US
ABPI - arterial ulcer will give low abpi (less than 0.9 ish)
capillary refill time
management for arterial ulcers
lifestyle modifications - diet and smoking cessation
wound care
skin graft
surgical revascularisation - bypass or angioplasty
risk factors for venous ulcers
DVT
varicose veins
obesity
immobility
leg injury/surgery
age
clinical features of venous ulcers
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
investigations for venous ulcers
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
management for venous ulcers
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
Pt presents with varicose veins around medial malleolus, which venous system is affected?
Great/long saphenous system
Pt presented with varicose veins around lateral malleolus and back of calf, which venous system is affected
Short saphenous system
What is superficial thrombophlebitis
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
A pt presents with varicose veins, ABPIs of 0.9 and 0.7 and BMI of 32. What’s the initial management
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
A pt presents with varicose veins that are asymptomatic but she finds them unsightly. What’s the management
Lifestyle advice , compression stockings
what is a varicocele and how does it present
dilation of the pampiniform plexus
presents as a distention of the scrotal sac
if a pt presents with a lump under the inguinal ligament, what are the 2 man differential diagnosis and how do you differentiate them
fermoral hernia vs saphena varix
differentiate via Duplex US
(femoral hernia also predominantly occurs in women, and is often irreducible)
what is a saphena varix and describe how it presents
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
what are hydroceles and how do they present
fluid accumulation in tunica vaginalis
present as scrotal masses
Risk factors for varicose veins
Female
Family history
Increased number of births
Occupation which involves long periods of standing
DVT
increased age
Clinical features of varicose veins
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
Investigation for varicose legs
Duplex US
What does the valve closing time shown by Duplex US in varicose veins indicate
> 0.5 secs = reflux
1 sec = reflux in deep system
Management for varicose veins
Lifestyle eg weight loss, elevating legs
Compression stocking
EVLA (endo vascular laser ablation)
Surgery : stripping of long or short saphenous vein
most common cause of aortic stenosis in >65 and <65
> 65 : aortic valve sclerosis
<65 : bicuspid aortic valve
what are the clinics signs (PP, pulse, murmur) and symptoms of aortic stenosis
symptoms: SAD
-syncope
-angina
-exertional dyspnea
narrow PP
slow rising pulse
soft S2
harsh crescendo decrescendo
ejection systolic murmur tha radiates bilaterally to carotids
what are the clinics signs (PP, pulse, murmur) and symptoms of aortic regurgitation
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)
investigations for aortic valve disease, first line/gold standard
first line/gold standard : transthoracic echocardiogram - to see calcification and stenosis
CXR - to see pulmonary oedema
treatments for aortic valve disease (aortic regurguctaion/stenosis) for asymptomatic with valve gradient < 40 mmHg
no treatment
annual echocardiogram screening
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
low/medium operative risk pt: surgical valve replacement
high operative risk pt: transcatheter valve replacement (TAVI)
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
long term anticoagulant and warfarin
target INR = 2.5 - 3.5
if a pt with high risk of IE has aortic valve repair, what meds would they be on
prophylactic Abx
describe the symptoms and clinical signs of mitral stenosis
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
describe investigation for mitral stenosis and what it would show
Transthoracic echo - shows reduces SA of mitral valve
CXR - shows LA enlargement
ECG - P mitrale (broad notched P waves due to atrium enlargement)
how would you see atrial enlargement on an ECG
P mitrale - broad notched P waves
Tx for mitral stenosis if symptomatic or valve less than 1.5 cm2
ballon valvotomy or valve replacement
comp0lications of mitral stenosis
atrial fibrillation
stroke
congestive HF
what is given to prevent atrial fibrillation as a result of mitral stenosis
warfarin - target INR is 2.5
symptoms and clinical signs of mitral regurgitation
dyspnea
palpitations
fatigue
LHF
pulmonary oedema
quiet S1
ejection systolic murmur
heard loudest over apex beat and radiates to axilla
Ix for mitral regurgitation
CXR - LA and LV enlargement
ECG - LV enlargement causes larger QRS complex
Tx for mitral regurgitation
valve replacement
HF meds - nitrates and diuretics (furosemide)
complications of mitral regurgitation
LHF
pulmonary oedema
cariogenic shock
atrial fibrillation
most common cause of primary mitral stenosis
rheumatic fever
most common cause of primary mitral stenosis in young females
mitral valve prolapse
most common causes of secondary mitral stenosis
coronary artery disease
dilated cardiomyopathy
what type of HF do mitral and aortic regurgitation causes
LHF
what type of HF can mitral stenosis cause
RHF
what is the main treatment for cariogenic shock
ionotropes - dobutamine
clinical signs and symptoms of tricuspid regurgitation
raised JVP
hepatomegaly
hepatic pain
jaundice
fatigue
oedema
ascites
pansystolic murmur
clinical signs and symptoms of tricuspid stenosis
fatigue
ascites
oedema
early diastolic murmur
clinical signs and symptoms of pulmonary stenosis
dsynpoea
fatigue
oedema
ascites
ejection systolic murmur
clinical signs and symptoms of pulmonary regurgitation
decrescendo early diastolic murmur
which sided murmurs are heard best on inspiration vs expiration
left side - expiration
right sided - inspiration
which valve condition causes a murmur with an opening snap
mitral stenosis
How to differentiate between ejection systolic murmur due to aortic stenosis vs aortic sclerosis
Aortic stenosis
- radiates to carotids
- symptomatic
- slow rising pulse
- narrow PP
- soft S2
Aortic sclerosis
- no radiation
- asymptomatic
- normal S2/PP/pulse
which valve conditions causes a pan systolic murmur heard loudest over the apex
mitral regurgitation
what non valve condition presents similar to mitral regurgitation but is much less common than it, and also causes a panystolic murmur
VSD
what is heard on auscultation in Dressler’s syndrome
pericardial friction rub
which valve is heard best over left 2nd intercostal space
pulmonary
which valve is heard best over right 2nd intercostal space
aortic
what valve condition causes a quiet S2
aortic stenosis
which valve condition could cause a loud S2
aortic sclerosis
how to differentiate ejection systolic murmur caused by aortic stenosis vs aortic sclerosis
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
which valve disease is noonans syndrome associated
pulmonary stenosis
which valve disease is Marfans syndrome associated with
aortic regurgitation
which heart abnormalities is down syndrome associated with
ASD
VSD
AVSD
which valve disease is William’s syndrome associated with
aortic stenosis
which heart murmur is turners syndrome associated with
pan systolic murmur in left scapular area
- due to coarctation of aorta
when is a cannon A wave seen
heart block
what does it mean if a pts orthostatics are positive
significant decrease in bp when pt goes from sitting down to standing up - identifies those at risk of hypovolaemia
which valve condition is rheumatic fever classically associated with
mitral stenosis
most common cause of aortic stenosis in YOUNG pt
bicuspid aortic valve
what is soft S1 classical of
aortic regurgitation
which valve condition can cause chest pain
aortic stenosis - reduced blood flow over aortic valve = reduced blood flow through coronary arteries
what is the cause of a pan systolic murmur which is loudest at the left sternal edge
VSD - NOT mitral regurgitation, that is loudest at the apex
high pitched blowing diastolic murmur at left sternal border, cause?
aortic regurgitation
what is the cause of a pan systolic murmur in a pt with dyspnea
mitral regurgitation
what is the cause of a pan systolic murmur which radiates to the axilla
mitral regurgitation
most common worldwide cause of aortic regurgitation
rheumatic heart disease
what valve condition is malar rash associated with
mitral stenosis
what peak trans valvular pressure gradient and valve area indicate severe aortic stenosis
peak trans valvular pressure gradient > 40 mmHg
valve area < 1cm
which valve condition can carcinoid syndrome cause
pulmonary stenosis
what valve condition causes a mid systolic click
mitral valve prolapse
which valve condition has an opening snap
mitral stenosis
what gcs indicates coma
8/15 or less
when do you use DC cardioversion instead of amiodarone
when you want an immediate effect - pt is deteriorating
which arrhythmia does adenosine treat
SVT by blocking AV node
which arrhythmia does procainamide treat
VT
what does the A wave on a JVP waveform indicate
atrial contraction
describe the A wave on a JVP waveform in atrial fibrillation
absent A wave
what is first line management for symptom control in AF
rate control
- BBs (proponalol) or rate limiting CCBs (verapamil, diltiazam)
what does the ORBT score measure
measures the risk of major bleeding events in pts who are on anticoagulation as a treatment for AF
if DC cardio version is unsuccessful in a pt with AF, what do you try next
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
if a pt with AF presents with a bp of 85/50 and palpitations/malaise, what is the management and why
emergency DC cardioversion
bc she’s haemodynamically unstable ( bp <90/60) and symptomatic
when is warfarin preferred to DOAC’s as an anticoagulant for AF
- If pt has mechanical heart valves
- pt has stage 4/5 kidney disease
what are the requirements to be put on anticoagulants for an AF pt
anyone with valvular disease and AF
or
male with CHADSVASc score 1+
or
female with CHADSVASc score 2+
what is acute, paroxysmal, persistent and permanent atrial fibrillation
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
AF symptoms
chest pain
dyspnea
dizziness
syncope
palpitations
ECG changes in AF
no P waves
narrow QRS
irregularly irregular rate
what pulse deficit is seen in AF
apical to radial pulse deficit
give 3 main causes of AF
alchohol
sepsis
hyperthyroidism
give 2 complications of AF
Heart failure
stroke
AF vs atrial flutter
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
first line treatment for paroxysmal AF
flecanide
first line management for pt who comes in with asymptomatic AF
rate control
assess if they need anticoagulation via CHADSVASc score
first line management for pt who comes in with AF that started over 48 hrs ago
rate control
give LMWH for 3 weeks or do TOE to exclude mural thrombus –> then do cardioversion
rate control for AF 1st and second line
1st : BB (bisoprolol) or CCBs (verapamil, diltiazem)
2nd dual therapy or digoxin+bisoprolol
which medications for AF rate control should never be given together as they cause heart block
verapamil and bisoprlol
which conditions are BBs C/I in
COPD
Asthma HTN
which conditions are CCBs C/I in
HF
which pts should be given digoxin / which ones should we avoid
avoid younger pts
give to sedentary pts
first line rhythm control for persistent non-emergency AF
amiodarone
3 methods of rhythm control for AF
- DC cardio version (give LMWH before)
- 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) - catheter ablation (of foci between pulmonary veins and left atrium)
options for anticoagulation in AF
1st) DOAC eg apixaban or edoxaban
2nd) warfarin –> needs INR monitoring
3rd) LMWH (enoxaparin) - for pt who can’t tolerate oral treatment
edoxaban vs apixaban, which one is given to pt with good kidney function
apixaban
- edoxaban is cleared too quickly
what type of tachycardia is atrial flutter
Is a form of SVT
Atrial flutter treatment in unstable pts
DC cardioversion / amiodarone
Atrial flutter for stable pts
1st) BBs or CCBs
2nd) cardioversion
3rd) ablation of arrythmogenic foci at cavotricuspid isthmus
(this is the first line for RECURRENT atrial flutter)
Atrial flutter ECG features
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
symptoms of atrial flutter
same as AF
what is the effect that digoxin can ave on an ecg
causes a down-sloping St segment “reverse tick”
and reduces QT interval
hypokalaemia on ecg
inversion of T wave
U wave (small wave after the inverted T wave)
which ecg changes indicate previous MI
Q waves
what is a mid systolic click characteristic of
mitral valve prolapse
what murmur is heard with coarctation of the aorta
pan systolic murmur which radiates to the left scapula
which classes of medication can cause prolonged QT interval
Anti ABCDE
anti arhythmic
anti biotics
anti chotics
anti depressants
anti emetics
what causes digoxin toxicity
hypokalaemia
best treatment for recurrent episodes of atrial flutter
catheter ablation
what is dextrocardia
heart is on right not left
what does left-right arm lead reversal in ecg cause
negative complex and P wave in lead 1
what does chets lead reversal in ec cause
inappropriate R wave progression
what does dextrocardia show on ecg
no R wave progression in leads V1-V6
if a pt is on medication for AF and develops nausea, vommiting and yellow green visual disturbances, what is happening
digoxin toxicity
