Cardiovascular

Question 1

what is the main reason for loss of consciousness in a young person

Answer 1

vasovagal syncope

Question 2

what is the main cause for loss of consciousness in a middle aged person

Answer 2

vasovagal syncope and also cardiac arrhythmia

Question 3

In elderly patients what is the common cause of loss of consciousness?

Answer 3

orthostatic hypo tension secondary to meds

look at duiretics, ARB, B blockers, calcium channel blockers.

Question 4

B blockers

Answer 4

decrease the heart rate and are negative ionotropes.

Question 5

differentiate between epilepsy, vasovagal, and arrythmias in their presentation.

Answer 5

Epilepsy: there can be a warning aura before (partial) or no warning (general)
During the can have tongue biting, defectation or urination, tonic clonic movements.
after post ictal phase of confusion for 5-30min
vasovagal: before: vagal symptoms (sweating palp, nausea)
lasts only seconds and have rapid recovery afterward.
arrthymias there are no warning it may lasts seconds and maybe incontinant.
but have rapid spontaneous recovery.

Question 6

Aortic stenosis cause

Answer 6

young- congenital bicuspid valve
elderly- calcification pf the valve leads to stenosis
Rheumatic fever (rare)

Question 7

aortic stenosis on examination

Answer 7

slow rising carotid pulse

loud ejection systolic murmer

Question 8

what is a stokes adams attack

Answer 8

sudden loos of consciousness induced by a slow or absent pulse and subsequent loss of cardiac output. caused by complete heart block or a sinoatrial disease.
attacks are not associated with change in posture or trigger. afterwards the patient appears flushed.

Question 9

Heart block

Answer 9

first degree
second degree: mobitz type 1 and mobitz type 2
third degree or complete heart block

Question 10

first degree heart block

Answer 10

every atrial contraction is transmitted to the ventricles
but conduction is slower than normal. it can be caused by damage to the AV node (IHD, fibrosis, and inflammation). On the electrocardiogram, there is a prolongation of the gap between the p wave and the QRS complex, making the PR interval greater than 200 ms. Normally is asymptomatic.

Question 11

second degree heart block: Mobitz type I

Answer 11

each heart beat shows a progressively increased PR interval until a QRS (ventricular contraction) is missed entirely. This can be normal in ultrafit athletes.

Question 12

second degree heart block: Mobitz type 2

Answer 12

QRs complexes are found to be missing after the P waves without a prolonged PR intervbal prior to the proceeding QRS complex. There is often a pattern with QRS complexes missed every third or second P wave. hig risk of progressing to 3rd heart block.

Question 13

complete heart block

Answer 13

no conduction between the SA node and the AV node. On the ECG there are broad QRS complexes that are out of sync with the P waves or atrial contraction.

Question 14

table tilt test is contraindicated in

Answer 14

those with orthostatic hypotension

Question 15

what must you do before attempting a carotid artery message?

Answer 15

doppler on both carotid esp. if history of stroke, TIA, or carotid bruit on auscultation. Need to be done with resus trolley at hand.

Question 16

wells score

Answer 16

clinical signs of a DVT 3
PE is the most likely diagnosis 3
HR greater than 100 (1.5)
immobilisation greater than 3 days or surgery in the last 4 weeks (1.5)
DVT or PE in past 1.5
heamoptysis 1
malignancy in the last 6 months 1
greater than 4 CTPA 
less than 4 D dimer to exclude DVT

Question 17

characteristics of aortic dissection

Answer 17

sudden onset tearing pain radiating to the back
absent pulses in one arm
hypertension or hypotension
a difference in blood pressure greater than 20 mmHg (1/3 of AD)
new onset aortic regurgitation
pleural effusion
RF other than normal CVD is aortic valve replacement

Question 18

troponin when it is elevated? how is it excreted? what is it specific to?

Answer 18

elevated 3-12 hours after the onset of chest pain
excreted renally
it is specific for cardiac damage but not ACS
therefore think about coronary artery spasm, aortic dissection, myopericarditis
HOCM, heart failure cardiac contusion from trauma, and PE

Question 19

what is the management for a myocardial infarct

Answer 19

Morphine
Oxygen 100%
Nitrates (triglycerol)
Antiplatelets (dual antiplatelet therapy aspirin and cloplidogrel)
beta blockers C.I if the patietn is in heart block, has asthma, or signs of acute heart failure
ACE inh preventing cardiac remodelling improve cardiac blood flow and also the after load
statins reduce stain levels and help with endothelial function reduce CRP and mainstina plaque stability
Heparin LMWH

Question 20

STEMI patient specific considerations for management

Answer 20

primary angioplasty or thrombolysis within 12 hours of onset of pain
angioplasty is superior but should not be the reason for withholding tx if not able to preform intervention within one hour

Question 21

NSTEMI receive angioplasty when

Answer 21

if heamodynamtically unstable, severe LV dysfunction, ongoing chest pain despite medical mgx, new mitral regurg, VSD, sustained ventricular arrhythmias.

Question 22

choice of blood control medications after MI

Answer 22

less than 55 and white ACE inh

if greater than 55 or black ca channel blocker

Question 23

how to reduce thromboembolic risk after MI

Answer 23

low dose aspirin for life and ADR receptor inhibitor for 1 year

Question 24

what is the GRACE score?

Answer 24

This is for patients who have an NSTEMI on ECG with chest pain. It is a risk stratification tool in order to assess the benefit of angioplasty.
variables are based on age, heart rate, systolic bp, creatinine, congestive heart failure, cardiac arrest on admission, st segment deviation, elevated cardiac enzymes

Question 25

complications fo a MI

Answer 25

death 
arrhythmia
rupture 
tamponade
heart failure
valve disease
aneurysm
dressers syndrome 
embolism 
reinfarction

Question 26

dressler’s syndrome

Answer 26

2-10 weeks after the MI
positional - worse lying down better leaning forward
worse on inspiration 
radiantes to the left shoulder
tx high dose NSAIDS

Question 27

aortic dissection involving the ascending aorta

Answer 27

stanford A class and is a surgical emergency

Question 28

aortic dissection involving the descending aorta

Answer 28

type B and are managed medically

Question 29

patients with diabetes target blood pressure

Answer 29

130/80

Question 30

patients with diabetes and protienuria target blood pressure

Answer 30

less than 125/75

Question 31

approach to the management of heart failure

Answer 31

1. symptomatic relief *too much fluid in lungs and limbs
2. pathological mechanism of heart failure
3. the underlying cause of the problem (atherosclerosis)

Question 32

symptomatic relief in heart failure

Answer 32

1. acute positional- sit upright give oxygen and reduce cardiac preload with vasodilator (nitrates and frusemide)
   CPAP (optional)
2. chronic loop diuretic furosemide which may be combined with a potassium sparing diuretic

Question 33

fixing the pathophysiological mechanism of heart failure

Answer 33

reduced CO activates
1. sympathetic system: increases heart rate and contractility via beta adrenergic receptors *increases metabolic demand and also increases HR leads to decreased CO
can use B blockers but never in acute LV failure. (start low and titrate slow)
2. renin-angiotensin system: increased water retention
ACE inhibitors, ARB spirolactone (aldosterone antagonist can be used in moderate to severe heart failure)

Question 34

fixing the underlying cause of the heart failure

Answer 34

atherosclerosis: angiography (revascularisation if the myocardium is still viable cardiac MRI, thallium scans debutamine stess echo)
stinks to reduce cholesterol levels
asprin to reduce the risk of thrombolysis
medications for diabetes mellitus
advanced heart failure digoxin, cardiac resynchonization, implantable cardioversion device, (biventricular) heart transplantation

Question 35

pyroderma gangrenosum

Answer 35

ibd or heam malignancies has a characteristic purple halo around it

Question 36

In an arterial ulcer what is the pattern of pain?

Answer 36

painful to wake up at night. better when hang foot out of the bed and when the put the blanket off feet. May have claudication.

Question 37

in a venous ulcer what is the pattern of pain?

Answer 37

less painful when elevated and drained of blood.

Question 38

arterial ulcers most often appear after what?

Answer 38

minor trauma

Question 39

a long history of an ulcer should make you suspicious of what?

Answer 39

marjolin ulcer.

Question 40

what should you always ask in a patient where you suspect an arterial ulcer?

Answer 40

other atherosclerotic disease CVD, angina

claudication, and night pain

Question 41

What might you notice when examining a neuropathic ulcer?

Answer 41

secondary infection caused by anaerobes causing smell.

Question 42

What are the risk factors of venous ulcers?

Answer 42

previous DVT, oral contraceptive pill, HRT, varicose veins, immobile, pelvic mass, arteriovenous malformation, joint replacement.,

Question 43

what are the risk factors for arterial vascular disease?

Answer 43

risk factors for atherosclerosis

AAA, CVD, stroke,and peripheral vascular disease

Question 44

Associated symptoms for venous ulceration?

Answer 44

varicose veins, stasis, eczema, heavy legs, swelling around the ulcer.

Question 45

What are the treatment options for AS

Answer 45

open aortic valve replacement
trans catheter valve replacement

tissue valves last 15 years

metal need lifelong anti-coagulation

Question 46

commonest cause of endocarditis

Answer 46

staph aureus

Question 47

what would you choose for dual anti platelet therapy?

Answer 47

aspirin and ticagrelor