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Medicine Y6 > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

AF thromboembolic risk: scoring system

A

CHA2DS2-VASc

CCF

HTN

Age <65, 65-74 (1), 75+ (2)

DM

Stroke (2), TIA (1)

Vascular dx

Female

Score: 0=low risk 1=intermediate risk (anticoagulate if male) 2+=high risk (anticoagulate if female)

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2
Q

Anticoagulation major bleeding risk in AF: scoring system

A

HAS-BLED

HTN sBP>160

Abnormal renal function (Cr>200, dialysis, transplant)

Abnormal liver function (LFTs >3x normal, bili>2x)

Age >65

Stroke hx

Bleeding hx

Labile INR (<60% time in normal range)

EToH hx

Drug hx (NSAIDs, antiplatelets)

Score 3+ is high risk and indictes regular r/v if on oral anticoagulation

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3
Q

Infective endocarditis: diagnostic criteria

A

Duke’s Modified Criteria

Pathological: intracardiac or embolized vegetations/abscess on micro/histo

Major:

Blood cultures +ve (2+, 12h apart, typicals)

Endocardial involvement (echo showing abscess, new valve disease, regurg)

minor:

IVDU or predisposing heart disease

Fever >38

Vascular phenomena (Janeway lesions, spetic emboli)

Immunological phenomena (GN, Osler, Roth, RF+ve)

Blood culture +ve (not matching major criteria)

Score:

Definite = 1P, 2M, 1M3m, 5m

Possible = 1M1m, 3m

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4
Q

Identify the possible complications of myocardial infarction

A

Complications of MI: ‘MAP’

Mechanical:

  • Contractile dysfunction –> cardiogenic shock, CCF
  • Papillary muscle damage –> mitral regurgitation (+ or other murmurs)
  • Rupture –> haemopericardium, L-to-R shunt (depending on location of rupture)

Arrhythmias: occur in first 24h, 90% pts, can cause sudden death

Pericardial:

Pericarditis (dusky haemorrhagic tissue). Fibrous pericarditis if infarct in epicardium

Effusion –> cardiac tamponade

Dressler’s syndrome

(Path)

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5
Q

What features allow you to differentiate aortic sclerosis from aortic stenosis on examination?

A

Aortic sclerosis features:

  • No radiation
  • Normal pulse
  • Normal in elderly

(Mirza)

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6
Q

Raised JVP: differentials

A
  • Right sided HF (or CCF)
  • Complete heart block (R atrium contracting agaist closed tricuspid valve)
  • Tricuspid regurgitation
  • Pericardial effusion
  • SVC obstruction
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7
Q

Identify the possible complications of valve replacement

A

FIBAT

Failure (valve, operation)

Infection (IE)

Bleeding (warfarin)

Anaemia (haemolytic from valve, anaemia of chronic disease)

Thromboembolism

(Mirza)

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8
Q

Summarise the indications for valve replacement in aortic stenosis

A

American Heart Association recommendations for valve replacement in aortic stenosis:

  • Strongly indicated when
    • severe high-gradient (50mmHg) AS + sx or +ve exercise test
    • severe AS + LV ejection fraction <50%
    • severe AS undergoing other cardiac surgery
  • May be indicated when
    • severe AS + low surgical risk pt
    • severe AS + low exercise tolerance
    • severe low-gradient AS + sx

There is also a Society of Thoracic Surgeons risk calculator

(UpToDate)

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9
Q

Hypertension: diagnostic criteria

A
  • Stage 1: hypertensionClinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
  • Stage 2 hypertensionClinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg
  • Severe hypertensionClinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 110 mmHg

(NICE)

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10
Q

Hypertension: what other investigations are available in pts with ?white coat HTN

A

NICE suggest offering ABPM or HBPM to any patient with a BP >= 140/90 mmHg.

  • Ambulatory blood pressure monitoring (ABPM): at least 2 measurements per hour during the person’s usual waking hours (for example, between 08:00 and 22:00). Use the average value of at least 14 measurements
  • Home blood pressure monitoring (HBPM): offered if ABPM not tolerated. For each BP recording, two consecutive measurements need to be taken, at least 1 minute apart and with the person seated. BP should be recorded twice daily, ideally in the morning and evening. BP should be recorded for at least 4 days, ideally for 7 days. Discard the measurements taken on the first day and use the average value of all the remaining measurements.

(Passmedicine, NICE)

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11
Q

Hypertension: what factors indicate antihypertensive therapy in pts with stage 1 hypertension?

A

Age < 80 + any of the following:

  • target organ damage
  • established cardiovascular disease
  • renal disease
  • Q-score >20%

(Antihypertensives indicated in all Stage 2 and Severe HTN pts)

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12
Q

Hypertension: outline the choice of antihypertensive

A
  • Stage 3: NICE recommend clorthalidone or indapamide as D (thiazide-diuretic) of choice
  • (Passmedicine)*
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13
Q

Generate a management plan for angina pectoris (stable)

A
  • Conservative: pt education (can be triggered by exercise, stress, heavy meals, cold), lifestyle advice, safety netting
  • Medical
    • Sx relief - r/v at 2-4w
      • GTN PRN - on pain stop activity, take GTN, if no improvement on 5mins take 2nd dose, if no improvement call 999
      • 1st line: beta-blocker or CCB
      • 2nd line: combine BB + CCB (remember verapamil CI with BBs)
      • 3nd line: if BB or CCB is CI or not tolerated, consider monotherapy of
        • Isosorbide mononitrate
        • Nicorandil
        • Ivabradine or Ranolazine (specialist, Na blocker)
    • Risk modification
      • Antiplatelet: low dose aspirin (or continue clopidogrel if previous CVD / PVD)
      • ACE-inhibitor: if angina + T2DM/HF/CKD/HTN
      • Statin

(NICE)

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14
Q

Reynauld’s phenomenon: mx

A

Medical:

  • 1st line: CCB (nifedipine)
  • 2nd line: IV prsotacyclin (lasts for weeks/months)

(Passmedicine)

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15
Q

Generate a management plan for supraventricular tachycardia

A

Acute management

  • Conservative: vagal manoeuvres: e.g. Valsalva manoeuvre
  • Medical
    • 1st line: intravenous adenosine 6mg → 12mg → 12mg: contraindicated in asthmatics - verapamil is a preferable option
    • 2nd line: electrical DC cardioversion

Prevention

  • Beta-blockers
  • Radiofrequency ablation

(Passmedicine, Resuscitation Council)

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16
Q

Outline the managment of sinus bradycardia

A

(UK Resuscitation Council)

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17
Q

Generate a management plan for NSTEMI or unstable angina

A
  • Immediate:
    • Medical (ABCDE): MONAC
      • Morphine
      • Oxygen: if sats <94%
      • Nitrates
      • Aspirin 300mg
      • Clopidogrel 300mg (if GRACE score >1.5% + no CI). Consider stopping 5d before CABG if low CV risk
        • antithrombin therapy: fondaparinux (if low bleeding risk, no angiography in 24h), unfractionated heparin if due for angiography
        • eptifibatide/tirofiban IV (glycoprotein IIa/IIIb inhib) if GRACE score >3%)
    • Interventional cardiology:
      • Coronary angiography: if GRACE score >3.0% (or recurrent ischaemia, or +ve ischaemia testing), w/i 96h
        • abciximab as adjunct to PCI
        • PCI or CABG if indicated
  • Long-term (if NSTEMI):
    • Conservative: risk factor modification, cardiac rehabilitation
    • Medical: ABDS
      • ACE-inhibitor (once haemodynamically stable)
      • Beta-blocker (once haemodynamically stable –> 12m, or indefinitely if LVF)
      • Dual anitplatelet therapy (aspirin indefinitely + 12m clopidogrel/ticagrelor)
          • gut protection
      • Statin
        • aldosterone antagonist if HF 3-14d post MI

(NICE)

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18
Q

How is aortic dissection classified?

A

Stanford classification

type A - ascending aorta, 2/3 of cases

type B - descending aorta, distal to left subclavian origin, 1/3 of cases

DeBakey classification

type I - originates in ascending aorta, propagates to at least the aortic arch and possibly beyond it distally

type II - originates in and is confined to the ascending aorta

type III - originates in descending aorta, rarely extends proximally but will extend distally

(Passmedicine)

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19
Q

Generate a management plan for STEMI

A
  • Immediate:
    • Coronary reperfusion therapy ASAP
      • Coronary angiography + PCI: if <12h since onset + can be done w/i 2h of when fibrinolysis could have been given (or >12h since onset but ongoing ischaemia/shock)
      • Fibrinolysis (if not suitable for PCI) + antithrombin
        • Do ECG 1h later: if continued ischemia do PCI
    • Medical: MONAC if ineligible for coronary reperfusion therapy
  • Long-term:
    • Conservative: risk factor modification (T2DM, HTN, cholesterol, smoking, diet), cardiac rehabilitation
    • Medical: ABDS
      • ACE-inhibitor (once haemodynamically stable)
      • Beta-blocker (once haemodynamically stable –> 12m, or indefinitely if LVF)
      • Dual anitplatelet therapy (aspirin indefinitely + 12m clopidogrel/ticagrelor)
          • gut protection
      • Statin
        • aldosterone antagonist if HF 3-14d post MI

(NICE)

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20
Q

What are the characteristic of Wolff-Parkinson-White Syndrome on ECG?

A

Possible ECG features include:

  • short PR interval
  • wide QRS complexes with a slurred upstroke - ‘delta wave’
  • left axis deviation if right-sided accessory pathway
  • right axis deviation if left-sided accessory pathway

(passmedicine)

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21
Q

What pathologies are associated with Wolff-Parkinson-White Syndrome?

A

Associations of WPW

  • HOCM
  • mitral valve prolapse
  • Ebstein’s anomaly (tricuspid valve malformation, causing atrialisation of the right ventricle)
  • thyrotoxicosis
  • secundum ASD

(passmedicine)

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22
Q

Generate a management plan for Wolff–Parkinson–White syndrome

A

Medical (ABCDE):

  • Manage SVT / VT as per UK Resusitaton Council guidelines (amiodarone / flecainide)
    • sotalol (CI in AF as may –> VF)
  • Definitive treatment: radiofrequency ablation of the accessory pathway

(Passmedicine)

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23
Q

What is the target INR for anticoagulation with warfarin in chronic AF (post TIA)?

A

INR 2-3

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24
Q

Identify the possible complications of varicose veins

A

7 complications:

  • oedema
  • bleeding
  • varicose eczema + pruritus
  • thrombophlebitis
  • haemosiderin deposition
  • lipodermatosclerosis
  • venous ulceration

(lecture)

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25
Give 3 cause of thoracic outflow obstruction + What are the 3 types of thoracic outflow obstruction?
3 causes: * extra cervical rib * overgrowth of scalenus anterior muscle (body builders) * occupation where arms raised (musicians) 3 types: depends on which structures impinged * venous: upper limb DVT, long-term oedema * arterial: Raynauld's, claudication, embolisation * neurological: pain, radiculopathy *(lecture)*
26
What are the main investigations in thoracic outflow obstruction?
* Depends on type (venous, arterial or neurological) * Imaging: MRI, MRA or MRV * Duplex in abduction * Nerve conduction studies
27
What is the classification system for chronic heart failure?
New York Heart Association (NYHA) classification is used to grade the severity of functional limitations: * Class I: no limitation of physical activity (includes asymptomatic left ventricular dysfunction) * Class II: slight limitation of physical activity (comfortable at rest). Ordinary physical activity results in fatigue, palpitation, breathlessness or angina pectoris (symptomatically 'mild' heart failure). * Class III: marked limitation of physical activity (comfortable at rest, symptomatically 'moderate' heart failure) * Class IV: inability to carry out any physical activity without discomfort(sx present even at rest, increased discomfort with any physical activity, symptomatically 'severe' heart failure) *(GPNotebook)*
28
Outline which coronary territories correspond to which leads on an ECG
*(passmedicine)*
29
Outline the ALS algorithm for cardiac arrest
*(UK Resusitation Council)*
30
Generate a management plan for acute atrial fibrillation
_Acute AF mx_ * Medical (ABCDE) * If haemodynamically unstable: short-acting GA + DC cardioversion (synchronised, 200J-400J) (UK Resuscitation Council) * Haemodynamically stable: depends on onset * \<48h * Rate control: beta-blocker (metoprolol) and/or CCB (diltiazem) * Rhythm control: after TTE confirms no intracardiac thrombus * amiodarone (if structural heart dx, older pts), flecainide (younger pts) or DC cardioversion * Heparin IV (continue until starting oral anticoagulation. Keep with warfarin until INR 2-3, CI to use with NOAC) * \>48h or uncertain * Rate control: beta-blocker and/or CCB * Anticoagulation 3w (warfarin): * Then rhythm control: amiodarone or flecainide * Oral anticoagulation therapy: Start when sinus rhythm achieved, if CHA2DS2-VASc 1(male) or 2(female). HAS BLED to assess bleeding risk. Continue OAC for 4+ weeks after cardioversion * Warfarin (target INR 2.5, esp use w mechanical valves) * NOAC (apixaban, rivaroxaban, dabigatran etexilate). Only requires yearly r/v. Indicated if 75+, CVA, HTN, DM, HF. CI in ESRF *(NICE, BMJ)*
31
Define atrial fibrillation
Atrial fibrillation: supraventricular tachycardia characterised by uncoordinated atrial activity on ECG, with an irregularly irregular ventricular response when AV conduction is intact *(BMJ)*
32
Give common causes of acute atrial fibrillation
_Acute_ Intracardiac: think myocardium, pericardium, valves * IHD (CAD or MI) * Valvular dx (mitral, often rheumatic HD) * CCF (or dilated cardiomyopathy) * Inflammation + infiltrative (pericarditis, myocarditis, amyloidosis) Extracardiac: THE APPE * Thyrotoxicosis * HTN * Electrolyte (esp hypokalaemia) * Alcohol / caffeine * Pneumonia * Pulmonary Embolism *(AS, OHCM, BMJ)*
33
Give risk factors for acute atrial fibrillation
Strong RFs: age, T2DM, HTN, CCF, CAD, valvular dx, other atrial arrhythmias, hyperthyroidism Weak RFs: obesity, ETOH intoxication, hypoxic pulmonary conditions (COPD) *(BMJ)*
34
Identify appropriate investigations for atrial fibrillation
* Confirm diagnosis: * ECG * Identify cause: * Bloods: Trop, CK-MB, TFTs * Imaging: CXR * Exercise stress echo: if ?structural abnormalities * Plan managment: * Imaging: TTE or TOE *(BMJ)*
35
Identify the possible complications of atrial fibrillation
Early: acute stroke, MI, CCF *(BMJ)*
36
What are the definitions of paroxysmal, persistent and long-standing atrial fibrillation?
_Chronic_ * Paroxysmal AF: recurrent AF (\>1 episode \>=30s duration) that terminates spontaneosly w/i 7d * Persistent AF: sustained AF for \>7d (or \<7d but required cardioversion) * Longstanding AF: sustained AF doe \>1y *(BMJ)*
37
Give common causes of chronic atrial fibrillation
_Chronic_ Intracardiac: acute + ACE * Acute causes (IHD, valvular, CCF, inflammatory) * Age-related fibrosis * Congenital heart disease * Electrophysiological abnormalities (sick sinus syndrome) Extra-cardiac: PHAT * Pulmonary HTN (pulmonary fibrosis etc) * HTN * Alcohol / caffiene * Thyroid dx *(AS, BMJ)*
38
What is the long-term therapy for paroxysmal atrial fibrillation
* Oral anticoagulation therapy: Start when sinus rhythm achieved, if CHA2DS2-VASc 1(male) or 2(female). * Warfarin (target INR 2.5, esp use w mechanical valves) * NOAC (apixaban, rivaroxaban, dabigatran etexilate). Only requires yearly r/v * Indicated if 75+, CVA, HTN, DM, HF * CI in ESRF * Rate control * 1st: beta-blocker * 2nd: CCB (diltiazem, verapamil) or digoxin *(BMJ)*
39
Outline the prognosis in paroxysmal AF
Chronic: 25% paroxysmal AF progress to more sustain form w/i 1.5y 30% higher risk of cardiovascular events *(BMJ)*
40
Identify appropriate investigations for chronic cardiac failure
_Chronic HF_ 1st line ix depends if pt has had previous MI * Previous MI: echo w/i 2w * No previous MI: BNP * If BNP high: echo w/i 2w * If BNP raised: echo w/i 6w Assess RFs and DDx * Bloods: UEs, eGFR, TFTs, LFTs, FBC, lipids, glucose * Urinalysis * Spirometry * Imaging: ECG, CXR *(Passmedicine, NICE)*
41
What factors can alter a B-natriuretic peptide (BNP) reading in ?heart failure?
Factors decreasing BNP * Obesity * HTN medication (diuretics, ACE-Is, ARBs, BBs) * Aldosterone antagonists Factors increasing BNP * \>70 * IHD, COPD, T2DM, sepsis, cirrhosis *(NICE)*
42
Generate a management plan for acute cardiac failure
_Acute HF_ * Medical (ABCDE) * Supportive * Sit up, limit fluids * High flow O2 * + IV morphine (if distressed) * Diuretic * 1st line: loop diuretic (furosemide PO/IV) * 2nd line: spironolactone / eplerenone PO * Additional support (consult senior): * pulmonary oedema + sBP\>90: vasodilator (GTN IV) * sBP\<90: inotrope (dobutamine) / vasopressor * hypertensive crisis: IV beta-blocker + GTN, nitroprusside * Consider escalation * NIV: if severe dyspnoea, acidosis * Consult senior if may require intubation / ventilation (resp failure, reduced GCS, exhaustion) * Tx underlying cause * MI: aspirin +/- revascularisation (PCI / CABG) * Valvular dx: nitroprusside (reduces TPR + venous return) * R-sided HF: eg PE (thrombolysis etc) Ongoing: * Conservative: low salt diet, regular wts, fluid balance * Medical: ABDS * ACE-I / ARB * Beta-blocker * Diuretics (loop +/- thiazide) * Spironolactone (or eplerinone) *(NICE, BMJ)*
43
Identify the possible complications of deep vein thrombosis (DVT)
* Immediate: Pulmonary Embolism * Early: Heparin-related bleeding, thrombocytopenia * Late: Post-thrombotic syndrome: * DVT --\> venous outflow obstruction + venous insufficiency --\> chronic venous hypertension *(passmedicine, BMJ)*
44
Explain the aetiology / risk factors of deep vein thrombosis (DVT)
Virchow's triad * Hypercoagulability: cancer, COCP, pregnancy, syndromes (antiphospholipid syndrome, Factor V Leiden) * Haemodynamics (stasis, turbulence): orthopaedic surgery, long distance * Endothelial injury: smoking, sepsis, obesity, HTN *(path)*
45
Generate a management plan for deep vein thrombosis (DVT)
* Acute * Initial anticoagulation: LWMH or fondaparinux * For 5d or until INR 2+ for 24h * Unfractionated heparin instead in severe renal impairment or bleeding risk * Interventional: * Catheter-directed thrombolytic therapy: if iliofemoral DVT + \<14d sx + low bleeding risk + \>1y life expectancy + good funcitonal status * IVC filter (if ineligible for anticoagulation or recurrent) * Long-term * TED stockings on affected leg (1w after dx, recommend for 2y) * Long-term anticoagulation (BMJ recommends NOACs) * Warfarin - start w/i 24h. 3m if cause known, 3-6m if cause unknown, lifelong if recurrent. * LMWH: if active cancer (3-6m) *(Passmedicine, NICE)*
46
Recognise the signs of infective endocarditis on physical examination
* Hands: clubbing, splinter haemorrhages, Osler's nodes, Janeway's lesions * Arm: injection points * Eyes: Roth spots * Chest: new murmur * Abdo: petechiae, splenomegaly, microscopic haematuria (urine dip part or O/E) * tachycardia, tachypnoea, high temp *(Meeran)*
47
What are the common causative organisms of infective endocarditis? - How do they enter blood stream usally? - Which valves to they affect?
* Strep viridans. Mouth commensal, enters bloodstream in dental work. Settle on mitral valve with pre-existing disease. * Staphylococcus aureus. Skin commensal, enters bloodstream in IVDUs. Settle on first valve it encounters; tricuspid. ## Footnote *(Meeran)*
48
Summarise the diagnostic criteria for acute rheumatic heart disease
Duckett Jones criteria * Major * Carditis * Erythema marginatum * Subcutaneous nodules * Polyarthritis * Syndenham's Chorea * Minor: fever, arthraligia, ESR up, WCC up, PR interval up, previous RF *(Meeran)*
49
Summarise the aetiology of acute rheymatic heart disease
strep throat in child --\> autoAbs against strep --\> Type II HR attacking skin / heart / brain / joints *(Meeran)*
50
What is pulmonary haemosiderosis?
* In mitral stenosis, enlarged L atrium + valve disease causes haemolysis --\> Fe deposition in lung * Rare now due to valve replacement * Appears on CXR as bilateral shadowing + dense opacities + L-atrial enlargement ## Footnote *(Meeran)*
51
Recognise the signs of mitral stenosis on physical examination
Malar flush , AF, tapping apex, non-displaced apex, R ventricular heave Blowing soft mid diastolic murmur + loud S1 *(Meeran)*
52
Generate a management plan for mitral stenosis
* Mild/moderate stenosis: no tx required * Severe stenosis (gradient \>5mmHg): * diuretics (frusomide): reduce LV pressure * balloon valvotomy (percutaneous) * valve replacement surgery ## Footnote *(BMJ)*
53
Identify the possible complications of mitral stenosis
Long term: * L-sided HF (--\> CCF) * AF (--\> CVA) * Complications of replacement (FIBAT) * Failure (heart, valve) * Infection (IE) * Bleeding (warfarin) * Anaemia (haemolysis, of chronic disease) * Thromboembolic *(BMJ, Mirza)*
54
Recognise the signs of mitral regurgitation on physical examination
Pansystolic murmur radiating to axilla Displaced apex, apical thrill, S1 quiet, S3 (rapid ventrilucar filling) Look for valvotomy scar (under breast, old procedure to turn MS into MR) *(Meeran)*
55
Give causes of mitral regurgitation
* Ischaemic damage to papillary muscle (MI) * Infective (IE) * Cardiac dilatation (R-sided HF) * Acute rheumatic fever * Congenital * Degenerative ## Footnote *(BMJ)*
56
Generate a management plan for mitral regurgitation
* Acute (or ejection fraction \<60%): * Surgical: valvuloplasty or valve replacement * +/- medical ((ACE-Is + beta blocker) * Chronic: * Ejection fraction \>60%: medical (ACE-Is + beta blocker) ## Footnote *(BMJ)*
57
Identify the possible complications of mitral regurgitation
* L-sided HF (--\> CCF) * AF (--\> CVA) * Complications of replacement (FIBAT) * Failure (heart, valve) * Infection (IE) * Bleeding (warfarin) * Anaemia (haemolysis, of chronic disease) * Thromboembolic ## Footnote *(BMJ, Mirza)*
58
Summarise the prognosis for patients with mitral regurgitation
L-ventricular dysfunction 6-10y 1% reoperation risk for valve replacement *(BMJ)*
59
Recognise the signs of aortic regurgitation on physical examination
* End diastolic murmur at left sternal edge, systolic flow murmur * Wide pulse pressure * Collapsing pulse, dynamic apex * ALL the signs eg * Corrigans - visible neck pulses * De musset's - head nodding w heartbeat * Quincke's - capillary pulsation in nail bed ## Footnote *(Meeran)*
60
Explain the aetiology of aortic regurgitation
* Congenital (biscuspid valve) * Valve damage * Infective: endocarditis, post-rheumatic fever * Aortic root dilatation * Marfan's * Inflammatory: ankylosing spondyltiis, Behcet's * Infective: secondary syphilis * Aortic root dissection - acute ## Footnote *(BMJ)*
61
Generate a management plan for aortic regurgitation
* Mild/moderate: monitor * Severe:if symptomatic or outflow \<50%:Aortic valve replacement * Surgical (mechanic vs bioprosthetic) * Transcatheteric aortic valve implantation (TAVI) * +/- vasodilator (nifedipine) * +/- Ace-Inhibitor ## Footnote *(BMJ)*
62
Identify the possible complications of aortic regurgitation
* R-sided HF (--\> CCF) * AF (--\> CVA) * Complications of valve replacement (FIBAT) * Failure (heart, valve) * Infective endocarditis * Bleeding (warfarin) * Anaemia (haemolysis, of chronic disease) * Thromboembolic ## Footnote *(BMJ, Mirza)*
63
Generate a management plan for varicose veins
* Conservative * Risk factor modification: wt loss, light exercise, stop smoking, elevate legs when possible, warn to watch for complications * Compression stockings may help with symptoms * Medical (in secondary care, refer if complications) * Foam sclerotherapy --\> irritant foam --\> inflammation --\> vein closure * Endothermal methods: radiofrequency or laser ablation * Surgery: stripping or ligation ## Footnote *(NICE)*
64
Give risk factors for varicose veins
Causative factors: previous DVT, genetic Risk factors: pregnancy, female, age, obesity
65
Summarise the prognosis for patients with varicose veins
treatment leads to resolution of symptoms in 95% cases ## Footnote *(BMJ)*
66
Generate a management plan for HOCM
HOCM * Conservative: reduce strenuous exercise * Medical * Asymptomatic: monitor * Symptomatic: * 1st line: beta-blocker * 2nd line: CCB * High risk sudden death (including asymptomatic): implantable cardioverter-defibrillator * Manage complications: * AF: eg add warfarin * CCF: eg add ABDS *(BMJ)*
67
Identify the possible complications of hypertrophich obstructive cardiomyopathy
Immediate: sudden death (if undetected) Early: AF (--\> CVA), WPW, ventricular ectopics Late: L-sided heart failure (--\> CCF) *(BMJ)*
68
Give common drugs that cause hyperlipidaemia
Think of the X-men * Corticosteroids (cerebro --\> cerebral cortex --\> cortico) * Ciclosporin (cyclops) * Isotretonoin (iceman) * Protease inhibitors (Professor X) * Antipsychotics (any of them) *(passmedicine)*
69
Outline the Vaughan Williams Classification for antiarrhythmic drugs
* Class Ia: increases AP duration (quinidine, procainamide). **Ia** = **I**ncreases **A**P * Class Ib: decreases AP duration, blocks Na channels (lidocaine). **Ib** = **I**s **b**rief * Class Ic: no affect on AP duration, blocks Na channels (flecainide). **Ic** = **I**s **c**onsistent * Class II: beta-blockers (atenolol, bisporolol, propranolol, misoprolol). **II** = -**l**o**l** * Class III: blocks K+ channels (amiodarone, sotalol) * Class IV: blocks Ca2+ channels (verapamil, diltiazem)
70
Give causes of pericarditis
* Infarction: MI (fibrous pericarditis, Dressler's syndrome) * Infection: * Viral: coxsackie, flu, EBV * Bacterial: pneumonia, rheumatic fever, TB * Inflammatory: SLE, RA, sarcoid * Drugs: isoniazid, penicillin, procainamide, hydralazine ## Footnote *(AS)*
71
Identify appropriate investigations for pericarditis
* Confirm diagnosis * ECG: ST elevation widespread, PR depression * Bloods: FBC, ESR, trop, cultures, virology (AS)
72
Generate a management plan for pericarditis
Medical * Manage cause * Analgesia: WHO ladder * Consider steroids / immunosuppression *(AS)*
73
Identify the possible complications of pericarditis
* Constrictive pericarditis: --\> R-sided HF. Kussmaul's sign (JVP raised on inspiration), S3, hepatosplenomegaly, ascites etc * Pericardial effusion--\> cardiac tamponade * Tamponade = Beck's triad (low BP, high JVP, quiet heart sounds), pulsus paradoxus, Kussmauls sign ## Footnote *(AS)*
74
Give potential causes of chronic heart failure
* Low output: PEE * Pump-failure: IHD, cardiomyopathy (dilated, restrictive, HOCM), pericardial (constriction, effusion), arrhythmias * Excessive preload: fluid overload, AR, MR * Excessive afterload: AS, HTN, HOCM * High output: ATP * Anaemia, AVM * Thyrotoxicosis, Thiamine deficiency (beri-beri) * Pregnancy, Paget's ## Footnote *(AS)*
75
What are the complications of having a pacemaker?
* Insertion * Bleeding * Arrhythmia (due to lead displacement) * Pneumothorax * Post-insertion * Erosion of skin * Lead migration * Pocket infection * Malfunction * Pacemaker syndrome: AV asynchrony ## Footnote *(AS)*
76
What are the indications for a permanent pacemaker?
* Heart blocks: * Complete AV block * Mobitz Type 2 * Heart rate: * Symptomatic bradycardia: sick sinus syndrome * Drug resistant tachyarrhythmias * Heart failure, chronic (requires biventricular pacing) ## Footnote *(AS)*
77
What lifestyle advice should be given after implantation of a pacemaker?
* No driving for a week * No arm elevation for 6 weeks * No contact sports * Minimal phone interference * Carry pacemaker card (shop alarms, metal detectors) ## Footnote *(AS, Adam)*
78
What do you check on a CXR after pacemaker insertion?
* Lead position * Lead integrity * Lead tension (coiling) * Apical pneumothorax ## Footnote *(AS, Adam)*
79
What are the different types of pacemaker? When are they indicated?
* Single lead: * Atrial pacemaker: bradycardias * Ventricular pacemaker: AF (featuring bradycardia or ventricular pause) * Dual lead: heart blocks (complete, Mobitz Type II) * Biventricular: chronic heart failure (NYHA II/IV, despite optimal treatment) = cardiac resynchronisation therapy ## Footnote *(AS, Adam)*
80
Which drugs lengthen the QT interval on ECG?
'CAAAT * Ciprofloxacin * Amiodarone * Adenosine * Antipsychotics * TCAs *(passmedicine)*
81
Give the features of aortic stenosis O/E
Features of severe aortic stenosis * narrow pulse pressure * slow rising pulse * delayed ESM * soft/absent S2 * S4 * thrill * duration of murmur * left ventricular hypertrophy or failure *(passmedicine)*
82
What are the causes of aortic stenosis
Calcification (most common) Congenital bicuspid valve Rheumatic heart disease *(OHCM, BMJ)*
83
Identify appropriate investigations for aortic stenosis
* Confirm diagnosis: * Imaging: Echo + doppler * Assess complications * ECG, CXR * Bloods: FBC, UE, BNP, lipids, glucose * consider * cardiac catheterisation: valve gradient * coronary angiography ## Footnote *(AS)*
84
What are the echocardiogram feaures of severe aortic stenosis?
* Valve area \<1cm^2 * Pressure gradient \>40mmHg * Jet velocity \>4m/s ## Footnote *(AS, AHA)*
85
Generate a management plan for aortic stenosis
* Conservative: MDT (cardiologist, GP, cardiothoracic surgeon, specialist nurse), RF modification (optimise CV health), regular r/v + echos * Medical: * RF modification: statins, antihypertensive, DM, anticoagulation * Surgical * Valve replacement (if symptomatic, EF \<50% or having other cardiac surgery) * +/- CABG * + life-long anticoagulation (warfarin, NOAC) if prosthetic * Transcatheteric aortic valve implantation (TAVI) * Balloon valvuloplasty: if not fit for the above ## Footnote *(AS)*
86
Identify the possible complications of aortic stenosis
* LVF (--\> CCF) * Ventricular arrhythmias --\> sudden cardiac death * Valve replacement complications: * Failure (valve, heart, restenosis) * Infection (IE) * Bleeding (warfarin) * Anaemia (haemolytic mechanical, of chronic disease) * Thromboembolic ## Footnote *(BMJ, Mirza)*
87
Summarise the prognosis for patients with aortic stenosis
Severe AS: * angina: 50% dead in 5y * syncope: 50% dead in 3y * dyspnoea: 50% dead in 2y *(AS)*
88
Identify the possible complications of chronic cardiac failure
Early: AKI, acute heart failure Late: chronic renal insufficiency, pleural effusion, anaemia *(BMJ)*
89
What are the features of chronic heart failure on CXR?
'ABCDEF' * Alveolar shadowing * Kerley B lines * Cardiomegaly * Upper lobe diversion * Effusions * Fluid in fissures *(AS)*
90
Summarise the prognosis for patients with chronic heart failure
NYHA - annual mortality risk: * Class I: 5% * Class II: 10% * Class IV: 40-60% Higher BNP indicates worse prognosis *(BMJ OHCM)*
91
Identify possible complications of acute heart failure
* End organ hypoperfusion: arrythmias, AKI, MI * pulmonary oedema, pleural effusion --\> Type 1 resp failure * Peripheral oedema
92
Give potential causes of acute heart failure
* New: * Left-ventricular HF (post-MI) * Arrythmias (electrolyte imbalance, post-MI) * Fluid overload * Neurogenic (eg head injury) * Acute exacerbation of CCF (see causes CCF: PEE + ATP) (OHCM)
93
Define peripheral vascular disease
Peripheral vascular disease involves atherosclerosis of the arteries leading to stenosis via a mulitfactorial process ## Footnote *(OHCM)*
94
Give risk factors for peripheral vascular disease
RFs: * Modifiable: smoking, BP, DM, hyperlipidaemia, reduced exercise * Non-modifiable: FHx, PMH, male, age, ethnicity *(OHCM)*
95
What is the classification system for peripheral vacular disease?
_Fontaine Classification_ of peripheral vascular disease * Class 1: asymptomatic * Class 2: intermittent claudication * Class 3: ischaemic rest pain * Class 4: ulceration, gangrene, critical ischaemia *(OHCM)*
96
Identify appropriate investigations for peripheral vascular disease
* Confirm diagnosis * ABPI +/- exercise ABPI (drop \>0.2 = claudication) * \>1.0 = calcified artery * 0.8-1.0 = normal * 0.6-0.8 = claudication (may only drop to this on exercise) * \<0.6 = critical ischaemia * Colour duplex USS (B-mode USS + multidirectional Doppler probe) * Assess cause / complications * Bloods: FBC (anaemia worsens PVD), UEs (renovascular dx), glucose, lipids * ECG * Plan tx: Imaging: * CT/MRI gadolinium contrast * digital subtraction angiography (if therapeutic angioplasty or stenting) ## Footnote *(AS, lecture)*
97
Generate a management plan for peripheral vascular disease
* Conservative: * walk through the pain, supervised exercise programmes * RF modification: smoking cessation, control HTN/lipids/BP, lose wt * Foot care * Medical: * Anticoagulation: clopidogrel (lifelong) * Statin * Interventional: * Percutaneous transluminal angioplasty +/- stenting * Surgical * Endarterectomy (short segment only) * Bypass grafting (artificial dacron vs autologous vein) * Anatomical: fem-pop, fem-distal, aortobifemoral * Extra-anatomical: axillo-(bi)fem, fem-fem crossover * Amputation: unsalvageable limb, below-knee, physiotherapy, gabapentin ## Footnote *(AS)*
98
What are the indications for venous grafting in peripheral vascular disease?
* \<100m claudication distance * Sx impacting QoL * Rest pain ## Footnote *(AS)*
99
Summarise the prognosis for patients with peripheral vascular disease
Morbidity: \<3% pts with intermittent claudication have amputation w/i 5y Vasculopaths: increased risk of IHD, CVA *(OHCM)*
100
Identify the possible complications of peripheral vascular disease
* Early: acute-on-chronic limb ischaemia * ischaemia less bad due to collaterals * Mx: catheter directed thrombolysis * Long: progression, ulcers, tissue loss, gangrene (--\> sepsis) ## Footnote *(lecture)*
101
What is typical and atypical angina?
Typical angina presents with all 3 of: * Constricting discomfort in the front of the chest, in the neck, shoulders, jaw, or arms. * Relieved by rest or glyceryl trinitrate (GTN) within about 5 minutes. * Precipitated by physical exertion. Atypical angina has 2 of these features *(NICE)*
102
Identify appropriate investigations of ischaemic heart disease
* Immediate * Bloods: FBC, Trop-I or T, UEs, glucose, clotting * Imaging: ECG +/- echo * Long-term * If CAD risk \>30%: * Stress echo * Functional imaging: myocardial perfusion scintigraphy or MRI * If CAD risk \>60%: * coronary angiography (if CI, functional imaging) * Monitor: BP, renal function ## Footnote *(OHCM)*
103
Summarise the prognosis in ischaemic heart disease
Morbidity: Aggressive lifestyle modification reduces complications risk Mortality: * ACS: 50% of deaths occur w/i first 2h * Worse prognosis if elderly, LV failure, ST changes *(OHCM)*

Medicine Y6 (14 decks)

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