Cardiovascular Flashcards

Question

Comparing different types of vascular ulcers: * Hx * Location * Characteristics - ulcer & surrounding skin * Tx

Answer 1

Venous: * Hx: **varicose veins, previous DVT**, obesity, preg, recurrent phlebitis * Location: lower calf-medial malleolus * Characteristics: mild pain * Ulcer - **shallow/flat margins, exudate,** sloughing @base, granulation tissue * Surrounding skin - **haemosiderin staining, eczematous, oedematous**, thickening skin, (normal CRT) * Tx: **compression bandaging**, leg elevation, surgical Mx Arterial: * Hx: **HTN**, DM, smoking, prev vascular disease * Location: **pressure points**, toes/feet, lateral malleolus, tibia * Characteristics: painful * Ulcer - **punched-out/deep**, irreg shape, necrosis, no exudate (unless inf) * Surrounding skin: thin, shiny, reduced hair, **6Ps** (pallor, pain, perishingly cold, pulselessness, _paraesthesia, paralysis_) * Tx: revascularization (e.g. bypass), anti-platelet, manage RFs Neuropathic: * Hx: **DM** (peripheral neuropathy), trauma, prolonged pressure * Location: plantar foot, tip of toe, lateral-fifth metatarsal * Characteristics: no pain * Ulcer - **deep, surrounded by callus, insensate** (no feeling) * Surrounding skin - dry, cracked, callus, insensate * Tx: off-loading pressure, topical GF Pressure: * Hx: limited mobility * Location: bony prominence, heel * Characteristics: * Ulcer - deep, macerated (moist, wrinkly) * Surrounding skin - atrophic skin, lost muscle mass * Tx: off-loading pressure, reduced moisture, increased nutrition

Answer 2

BP targets: * \<140/90 * \<150/95 for over 80yrs * Causes of hypertensive crisis ≥180/120: pregnancy, scleroderma, vasculitis, renovascular, endo, cocaine --\> reduce BP slowly Ix: * Bedside - ECG, urine dip * Bloods - FBC, U&E, lipids, BM, TFTs Drug treatment: * Conservative management - diet (low salt), exercise, reduce alcohol * 1. a) \<55yrs/DM --\> ACEi (ramipril)/ANG-II receptor antagonist (Losartan) * 1. b) ≥55yrs/black --\> CCB (amlodipine)/thiazide diuretic (bendroflumethiazide) * 2. _ACEi + CCB_ OR _ACEi + thiazide diuretic_ * 3. ACEi + CCB + thiazide diuretic * 4. Add: * Spironolactone (or other diuretic) * Alpha-blocker * Beta-blocker * Specialist advice

Answer 3

Def: occlusion of deep vein in lower limb RFs: SICC - Surgery, Immobility, Cancer, COCP Presentation: pain, swelling (if extends proximally to iliacs --\> bilateral swelling), pitting oedema, warmth, erythema Scoring & Ix: Well's score * 0-1= D-Dimer --sign raised--\> as below * ≥2 = proximal leg vein USS + D-Dimer * Obtain baseline before starting anti-coag: FBC, U&E, LFTs, clotting screen Mx: * Ongoing anticoagulation - DOAC/Warfarin * Provoked - 3 months (SICC) * Unprovoked - \>6 months + thrombophilia testing

Answer 4

RFs: HTN, DM, Smoking, FHx IHD, Hypercholesterolaemia **Stable angina** - chest pain on exertion relieved by rest * Path - mismatch in O2 supply and demand to the myocardium * Ix: CT-angiogram * Mx: * B-blocker/CCB (e.g. verapamil) - reduces HR req for activity --\> reduced likelihood of mismatch in O2 supply & demand * GTN spray - reduce myocardial preload + reduces strain * RF modification --\> reduced risk of progression **Acute coronary syndrome** - Sx caused by sudden reduced BF to the myocardium * Dx: * _ST-elevation_ = STEMI * _Troponin raised_ = NSTEMI (+ dynamic T-wave inversion, ST depression) * Unstable angina pectoris (pain at rest) = ischemia NOT infarct * Generic ACS Mx - MONA BASH * ALL immediate: * 5-10mg Morphine IV + Nitrates (GTN spray) * Dual antiplatelet therapy (DAPT) - 300mg Aspirin STAT + 300mg Clopidogrel STAT (or 180mg PO Ticagrelor) * ALL long-term: * Continue DAPT * 1 year: _75mg_ OD Aspirin + _75mg_ OD Clopidogrel (or 90mg BD Ticagrelor) * \>1yr - **_75_**mg OD Aspirin * B-blocker (1.25-10mg Bisoprolol OD) * ACEi (1.25-10mg Ramipril OD) * Statin (80mg Atorvastatin OD) * STEMI Mx: establish coronary reperfusion ASAP * Sx under 12hrs for PCI, BUT if no PCI within 2hrs Dx > thrombolysis (e.g. tPA - tissue plasminogen activator) * Sx >12hrs: invasive coronary angiography ± PCI if needed * PCI: * If having PCI give **_Prasugrel_** (instead of Clopi/Ticagrelor) * PCI accessed via radial (or femoral) artery, guidewire passed via X-ray guidance into the affected coronary artery AND **_IV unfractionated heparin_** during the procedure --\> stent inserted impregnated with an anti-proliferative agent (e.g. Tacrolimus - to prevent adverse tissue reaction) --\> takes longer for endothelialization of stent so DAPT needed for 1yr * If PCI with stents inserted --\> DAPT 12 months * NSTEMI Mx: * 2.5mg SC Fondaparinux (direct factor 10a inhibitor) * Risk stratify - GRACE criteria (& others) * High risk = invasive coronary angiography (within 48-72hrs) Complications: **FAP** (failure, arrhythmias, pericarditis) * Heart failure, arrhythmias (incl. VF) * Pericarditis * _Early_ - positional chest pain day after MI --\> give NSAIDs * _Late_ - **Dressler's syndrome** - immune response @6wks (fever, pleuritic chest pain, pericarditis/pericardial effusion)

Answer 5

**Def:** pumping of blood by heart insufficient to meet the demands of the body Causes: * RVF: * Acute: MI, inf endocarditis, PE * Chr: Cor pulmonale, LVF * LVF: * Acute: ischaemic/hypertensive CMO, valvular HD * Chr: MI, inf endocarditis **Pathophysiology:** * **RHF** - right side of the heart pumps deoxygenated blood from the body to the lungs to be reperfused - if the RH is not pumping effectively you get the fluid collection in the peripheries = _PERIPHERAL OEDEMA_ * **LHF** - left side of the heart pumps oxygenated blood from the lungs to the body - if the LH is not pumping effectively you pooling of blood in the lungs = _PULMONARY OEDEMA_ * Reduced CO --\> shock, tachycardia, AKI * CO = SV\*HR * Ejection fraction = SV/End-diastolic Volume **Categories:** * HF w/ _preserved ejection fraction_ (left ventricular \>50%) = inadequate filling of ventricles during diastole (from ventricular stiffness) * Causes of ventricular stiffness: * Volume overload (valve regurg) * Pressure overload (HTN) * Decreased distensibility (constrictive pericarditis) * HF w/ _reduced ejection fraction_ (left ventricular \<40%) = inadequate emptying of ventricles during systoles (from outflow obstruction/impaired contractility) * Causes of outflow obstruction/impaired contractility: * MI, Cardiomyopathy, Arrythmia NYHA classification: * 1 - no limitation on activity * 2 - comfortable at rest but dyspnoea on ordinary activity * 3 - marked limitation on ordinary activity * 4 - dyspnoea at rest **Ix:** * Bedside: _ECG_ - detects if anything precipitating HF (arrhythmia/ischaemic event) * Bloods: _ABG_ (if resp compromise from pul oedema), _troponin_ (ACS), _BNP_ (HF screening) * Imaging: _CXR_ (visualise pul oedema, cardiomegaly), _ECHO_ (valvular abn/regional wall mov abn) **Mx:** MON BA (out of MONA BASH) * Immediate: * Sit the patient up (reduce venous return to heart --\> less strain) * O2 15L/min NRM * Medical: * **IV furosemide** (loop diuretic) - remove excess fluid + venous dilation (reduce preload) * _Nitrates_ (GTN/Isosobide Mononitrate) AND _Morphine_ - reduce preload on the heart * Long-term: * Reduced ejection fraction - prognostic benefit: * **B-blocker** (bisoprolol) - reduce strain on heart, do not give acutely if severe HF as will kill them * **ACEi** - reduce strain on heart * After the above if LVEF \<35% & Sx --\> mineralocorticoid antagonist e.g. _spironolactone_ * 3rd line - by specialist: Sacubitril/Valsartan (entresto), Ivabradine & CRT * **SGLT2 inhibitors** (dapagliflozin) * RF modification - poor glycaemic control/high cholesterol * Sx (diuretics) Complications: * Reduced CO (SV\*HR) --\> shock, tachycardia, AKI * Congestion --\> pulmonary oedema + peripheral oedema

Answer 6

**Def:** rapid, chaotic, and ineffective atrial electrical conduction * ECG def: irregularly irregular narrow complex tachycardia with no p waves **Causes:** idiopathic, cardio (**IHD**, valvular disease, cardiomyopathy), resp (PE, pneumonia), hyperthyroidism, alcohol **Ix:** ECG (absence of p-waves, irregularly irreg rhythm) **Mx:** * Haemodynamically unstable (≤90 BP, chest pain, acute HF) --\> DC Cardioversion OR * Rate control --\> **B-blocker** (bisoprolol) OR rate-limiting CCB (verapamil - asthma) OR * Rhythm control - ONLY if clear reversible cause * Sx onset **\<48hrs** --\> **DC/chemical cardioversion** (amiodarone/flecanide) * NOTE: IV heparin started prior to cardioversion * Sx onset \>48hrs --\> _anticoagulate for 3wks_ --\> elective cardioversion (also anticoag for 4wks after) AND * Stroke risk - CHADS-Vasc Vs Orbit/HAS-BLED score --\> DOAC (Apixaban) * If metallic heart valve --\> warfarin INR 3-3.5 * Otherwise DOAC * NOTE: if incidental non-symptomatic AF - normal rate, no other RFs, CHA2DS2-VASc 0 --\> anticoagulation not recommended * **C**HF, **H**TN, **A**ge ≥75rs (2), **D**M, **S**troke (2), **V**ascular disease, **A**ge 65-74, **S**ex - female * Score 1 - consider; ≥2 - DOAC/Warfarin needed * Lifetime risk = annual risk x estimated years of life left (up to 80 yrs e.g. if 60 then x annual risk by 20)

Answer 7

**Def:** _regular_ narrow-complex tachycardia with no p-waves + supraventricular origin **Junctional types:** * AVNRT - local re-entry circuit within AV node * AVRT - re-entry circuit between atria and ventricles --\> after SVT **termination = _delta wave_ = WPW syndrome:** * Assoc w/ HOCM * Avoid _digoxin, verapamil, amiodarone_ (reduce conduction down SAN --\> worsen retrograde conduction --\> risk of VT) * Can use B-blocker/flecainide instead **Case example:** 23yrs, 1-hr palpitations + SoB, 2 similar episodes prev following alcohol, this time severe chest pain **Mx:** * Unstable tachycardia (\<90 BP/chest pain/acute heart failure) --\> synchronised DC Cardioversion * _Vagal manoeuvres_ (increase parasympathetic stim via vagus nerve to slow conduction via AV node) * Valsalva manoeuvre (blow out through nose while pinching + shut mouth) - breath through 50ml syringe * **Adenosine** 6mg --\> 12 mg --\> 12mg * NOTE: if adenosine CI (e.g. asthma) --\> _VERAPAMIL_ (rate-limiting CCB) * Other: * IV B-blocker/amiodarone/digoxin * Synchronised DC Cardioversion

Answer 8

Key murmurs: * **AS** = ejection _systolic_ + *radiates to carotids, slow rising pulse*, narrow pulse pressure, heaving apex beat * Sound: Wooooshhh * Severe AS - absent/soft 2nd heart sound, _reversed splitting of 2nd HS_, heaving apex beat * A longer murmur is worse (small space for blood to pass through = takes longer) * **MS** = mid-diastolic + *LLP, malar flush, AF, loud/palpable S1 "tapping" apex*, _pul HTN_ (loud P2 - pul thrill) * Sound: Wooosh de (loud S1) de (early diastolic snap) * **AR** = early diastolic + *sitting forward (LLSE), collapsing pulse*, wide pulse pressure, displaced apex * Sound: de woooshhhh * Severe AR --\> **Austin-flint murmur** = 'Rumbling _mid-diastolic_ murmur' * Best heard at apex, caused by blood flowing back through aortic valve and over mitral valve * Shorter murmur is worse (quicker to flow back through large hole) * **MR** = pan-_systolic_ + *radiates to left axilla, AF*, displaced thrusting apex, LVF/pul HTN * Sound: Woooooshhh (holosystolic) * NOTE: same pattern for pulmonary & tricuspid (pul stenosis & tricuspid regurgitation = systolic) * TR - pulsatile liver * PS - radiates to back, assoc w/ Noonan's (AD, webbed neck, wide-spaced eyes etc.) Accentuation manoeuvres: * R-sided murmurs (tricuspid + pulmonary) --\> louder on **_IN_**spiration = blood goes **_IN_** to right-side of heart * L-sided murmurs (aortic + mitral) --\> louder on **_EX_**piration = blood **_EX_**its left-side of heart * **AS** radiates to the carotids + louder on leaning forward + listen on right sternal edge * **MS** louder on turning to the left, **MR** radiates to axilla Causes: * **AS** (stenosis/sclerosis): _senile calcification_ (aortic valve) * **MR**: * Acute: - _IHD_ (papillary-muscle dysfunction post-MI), _Infective endocarditis_, cardiomyopathy, RHD * Chronic - myxomatous degeration * **AR**: * Acute (_infective endocarditis_, aortic dissection) * Chronic (_CTD_, RHD, HTN, congenital) * **MS**: _rheumatic heart disease_ (RHD) Left vs Right valve abn: * Left = more common as higher pressure system, more likely in damaged valves, commonly _Strep Viridans_ * Right = more common in IV drug users --\> tricuspid valve is first valve reached, commonly _S. aureus_ Management: * AS: * C: 6-monthly ECHO, exercise-stress test if asymptomatic * M: RF optimisation (statins, HTN, DM), HF Sx (diuretics, ACEi) * S: Based on severity/comorbid - **STS-PROM** (surgical risk calc) * If severe AS: * Medically fit (req midline sternotomy & cardiopul bypass) = _Surgical aortic valve replacement (SAVR)_ * Not fit = _Transcatheter aortic valve replacement (TAVR)_ * Acutely Sx/cardiogenic shock = _Balloon valvuloplasty_ * M**_R_**: * M: * ACEi ± B-blockers (as HTN worsens MR) * *Tx AF & anti-coagulate* * *Diuretic* (if refractory to surgery) * S: for acute MR (post-MI, chordae tendinae rupture), asymptomatic LVEF \<60%, symptomatic LVEF \>30% * Valve **_R**_epair \> _**R_**eplacement * A**_R_**: * M: asym + **_R_**eassurance (good prog) * Unfit for surgery/waiting - ACEi & vasodilators (e.g. hydralazine) * S: acute/Sx/severe = surgery * Valve **_R**_eplacement \> _**R_**epair * **_M_**S: * C: asymptomatic - **_M_**onitor * M: * *AF Tx, anti-coagulate & diuretics* (if Sx/severe) * S: Sx/severe - can do balloon valvuloplasty/replacement * Valvuloplasty = lateral thoracotomy scar * Do not do percutaneously if persistent left atrial thrombus/rigid calcified valve --\> need open heart surgery (CABG, concurrent severe MS) Complications of prosthetic heart valves: **FIBAT** * Failure * Infection * Bleeding - MAHA * Anaemia * Thromboembolic phenomena

Answer 9

Def: infection of heart valves (typically mitral/aortic or _tricuspid in IVDU_) RFs: bacteraemia (long-term lines, IVDU, dental work), abn valves (prosthetic, RHD), prev endocarditis, VSD, piercings Presentation: low-grade fevers, night sweats * Exam: * Splenomegaly * _Splinter haemorrhages_, osler's nodes, Janeway lesions, petechiae, Roth spots (eyes) * Chronic = clubbing (rare, mostly acute now) **Ix:** * Urine dip - haematuria * _Serial BCs_ (x3 but start empirical abx), ESR * _Transoesophageal Echo_ (TOE - vegetations) **Dx: _DUKE’S CRITERIA_** (2 major OR 1 major + 3 minor OR 5 minor): * Major**: +ve BC** (typical organism), **new regurg murmur/veg on echo** * Minor: RF, fever (\>38), embolic (vascular) phenomena, immune phenomena, +ve BC (another organism) * **Mx**: IV abx for 6wks – fluclox/vanc/gent **Acute** in structurally normal heart – In IV drug user the first valve met is tricuspid valve, commonly _S. aureus_ (also most common cause in _prosthetic valve endocarditis_) **Subacute** in structurally abn heart – mitral & aortic valves more commonly affected as high pressure system, more likely damaged valves, commonly _Strep Viridans_ (overall most common cause of endocarditis)

Answer 10

3rd = rapid ventricular filling = _volume overload_ e.g. **HF** (reduced EF/systolic) * KEN...TU.CKY (deee. de.de) 4th = atrial contraction against stiff ventricles = _pressure overload_ e.g. **longstanding AS** & other causes of left ventricular hypertrophy (HTN heart disease**,** HOCM, HF with preserved EF/diastolic) * TE.NE..SSEE (de.de.deee)

Answer 11

Pericarditis Causes: * Viral (most common) * MI (can be Dressler's syndrome) * TB (constrictive) * Uraemia (CKD where urea high --\> pericarditis) = indication for haemodialysis (HUMP) * Hydralazine (AI pericarditis) * NOTE: also causes _drug-induced lupus_ * SLE, RF, radiation Presentation: * Pleuritic chest pain, worse lying flat * Exam: pericardial rub - "creaking/scratching" * Tip - put on all-fours, put stethoscope on sternal edge, hold inspiration Ix: * ECG: ST elevation widespread * Only slightly raised/normal troponin Mx: **_colchicine (3 months)_** + NSAIDs (ibuprofen, max 2wks)

Answer 12

JVP + hepatojugular pressure (RUQ), rockstar hand **PQRST:** * **P**ul HTN/PE/Pericarditis/Pericardial effusion/PS * **Q**uantity of fluid (fluid overloaded) * **R**HF * **S**VC obstruction * **T**amponade/TR

Answer 13

Presentation: swollen face and neck and distended veins on her chest in background of cancer Mx: dexamethasone to reduce tumour swelling * Insert EV stent if stridor (after intubation and steroids)

Answer 14

Innitial: A-E * If unstable - 500mcg IV atropine (/5mins up to 3mg) * Also considered unstable if: * Recent asystole \>3s/Mobitz T2 AV block/3rd degree heart block * Caution in acute MI, C/I if heart transplant * If persistent --\> transcutaneous pacing + analgesia/sedation (very painful) * If can't be achieved properly --\> IV isoprenaline/adrenaline (specialist help) * Arrange transvenous pacing (temporary if recent asystole \>3s/Mobitz T2 AV block/3rd degree heart block)

Answer 15

Causes: * MI/IHD (MOST COMMON) * Inf (RHD, IE) * Drugs (digoxin) * Metabolic (hyperkalaemia) * Infiltration of conducting system (e.g. sarcoidosis) * Degeneration of conducting system Types: * First Degree AV block - fixed prolonged PR interval (\> 0.2 s) - _ASYMPTOMATIC_ * Second degree AV block: * Mobitz TI (Wenckebach) - progressively prolonged PR interval --\> P-wave NOT followed by a QRS complex = 'going, going, gone' * _Normally asymptomatic_ * Mobitz Type II - intermittently P wave NOT followed by a QRS * May be regular pattern of P waves not followed by QRS (e.g. 2:1 or 3:1) * Can cause: * Stokes-Adams Attacks (syncope caused by ventricular asystole) * Dizziness, palps, chest pain, HF * Complete AV heart block - no relationship between P waves and QRS complexes * Presentation as in Mobitz T2 Ix: ECG * Bloods: TFTs, Digoxin, cardiac enzymes (troponin, CK, BNP) * CXR (cardiac enlargement, pulmonary oedema) * Echo (wall motion abn, aortic valve disease, vegitations) Mx: * Acute block - if clinical deterioration: * IV atropine * Consider temporary transcutaneous pacing * Chronic block: * 1st degree monitored * Permanent pacemaker in: * Symptomatic Mobitz T1 * Advanced Mobitz T2 * Complete heart block Complications: asystole, cardiac arrest, HF, surgical complications of pacemaker insertion

Answer 16

Types: * Implantable Cardioverter Defibrillator (ICD, has a thicker end) * Single-chamber pacemaker (right ventricle) * Used in permanent AF (no organised atrial contraction so atrial lead not required to sense contraction) * Rarely can have atrial lead only - if SA disease in young with good AV conduction * Dual-chamber pacemaker (right atrium & ventricle) * Can have ICD dual-chamber pacemaker * Used in paroxysmal AF/all other scenarios (there is sometimes organised atrial contraction - this is sensed by the atrial lead) * Cardiac Resynchronisation Therapy/Biventricular pacemaker (right ventricle, left ventricle ± right atrial lead) * Can have ICD biventricular pacemaker When to use each type: * Atrial lead only → Sino-atrial disease in young people with good AV node conduction * RV lead only → Pacing whilst in _permanent atrial fibrillation_ * Dual-lead → All other scenarios (paroxysmal AF, bradycardia) * CRT → LV dysfunction + broad QRS --\> _end-stage HF_ * Indications for ICD: * Primary prevention = **@risk of serious ventricular arrhythmia** * Familial cardiac conditions (hypertrophic cardiomyopathy, long QT) * Previous surgical repair of congenital HD * Previous MI + LVEF \<35% + HF Sx * Secondary prevention = **had previous serious ventricular arrhythmia _wo/ treatable cause_** * Cardiac arrest from VT/VT * Spontaneous sustained VT AND: * Syncope/haemodynamic compromise OR * LVEF \<35% + sign HF Sx (NYHA 3+) * NOTE: VT/VF from STEMI has treatable cause (open occluded vessel) Complications: * Surgical complications - infection, bleeding, damage to underlying structures * Displacement (of lead) * Pacemaker syndrome (if ventricular lead with no atrial) --\> AV node conducts in retrograde direction = mitral/tricuspid regurge + HF Sx

Answer 17

**Pulsus paradoxus** - greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration * severe asthma, cardiac tamponade **Slow-rising/plateau** * AS **Collapsing** * AR, PDA * hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy) **Pulsus alternans** - regular alternation of the force of the arterial pulse * severe LVF **Bisferiens pulse** - 'double pulse' - two systolic peaks * Mixed aortic valve disease * HOCM (also causes 'Jerky' pulse)

Answer 18

**VT** or SVT w/ aberrancy * SVT \>200bpm, also often irregular * VT more likely if LAD * Acutely treat any broad complex tachy as VT until proven otherwise Presentation: _palpitations, light-headed, chest pain_, syncope, seizure * Tachycardia, LVF * ACS most common cause * **_NEVER IGNORE palpitations & light-headedness_** Ix: ECG - regular broad complex tachycardia * U&E (Mg, Ca, K), TFTs, Troponins Mx: * Unstable tachycardia (BP \<90, chest pain, acute cardiac failure) = _DC cardioversion_ * Stable: * IV amiodarone, b-blocker --\> prepare for DC cardioversion

Answer 19

Pulsus paradoxus - BP variation between inspiration & expiration (≥10) Beck's triad (50%): * Raised JVP * Muffled heart sounds * Hypotension Mx: * IV fluids (RV filling depends on venous pressure & effusion is constricting) * Echo --\> refer to cardiology for pericardiocentesis * Coagulation profile (to prep for pericardiocentesis)