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Cardiovascular Flashcards

1
Q

Atrial Fibrillation

Definition (3)

A

Chaotic, irregular atrial rhythm at 300-600bpm
AV node responds intermittently, hence irregular ventricular rate
Cardiac output drops by 10-20%

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2
Q

Atrial Fibrillation

Aetiology (9)

A 
Heart Failure
Hypertension 
MI 
PE 
Mitral valve disease 
Pneumonia 
Hyperthyroidism 
Caffeine/alcohol 
Low potassium/magnesium
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3
Q

Atrial Fibrillation

Signs + symptoms (5)

A 
Mostly asymptomatic 
Chest pain 
Palpitations 
Dyspnoea 
Irregularly irregular pulse
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4
Q

Atrial Fibrillation

Investigations (3)

A

ECG: absent P waves, irregular QRS
Bloods: U&Es, cardiac enzymes, TFTs
Echo: left atrial enlargement, mitral valve disease, poor LV function

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5
Q

Atrial Fibrillation

Acute treatment <48 hours (4)

A

Emergency cardioversion (amiodarone/flecainide)
Treat associated illness
Control ventricular reate: 1st verapamil/bisoprolol, 2nd digoxin/amiodarone
Anticoagulation: LMWH

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6
Q 
Atrial Fibrillation 
Chronic treatment (3)
A

Rate control: B-blocker/rate-limiting CCB 1st, then add digoxin, then add amiodarone
Anticoagulation: warfarin (INR aim 2-3), or aspirin if contraindicated
Rhythm control: only if symptomatic, do cardioversion

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7
Q

Atrial Fibrillation

CHA2DS2-VASc Score (4)

A

Quantifies risk of stroke
Consider anticoagulation
1 point for: part failure, diabetes, hypertension, vascular disease, age >65, female
2 points for: age >75, prior TIA/stroke

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8
Q

Atrial Flutter

Definition (2)

A

Small group of ectopics

Continuous atrial depolarisation (regular rhythm but faster than waves)

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9
Q

Atrial Flutter

Investigations (1)

A

ECG: sawtooth baseline +/- 2:1 AV block

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10
Q

Atrial Flutter

Treatment (2)

A

Anticoagulation then cardioversion

Amiodarone to restore sinus rhythm

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11
Q

Heart Failure

Aetiology (5)

A 
Previous MI 
Hypertension 
Heart valve disease 
Cardiomyopathy 
Arrhythmias
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12
Q

Heart Failure

Definition (1)

A

Cardiac output is inadequate for the body’s requirements

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13
Q 
Heart Failure 
Systolic Failure (3)
A

Inability of ventricle to contract normally
Reduced cardiac output
Caused by ischaemic heart disease, MI, cardiomyopathy

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14
Q 
Heart Failure 
Diastolic Failure (2)
A

Inability of ventricle to relax and fill normally

Caused by constrictive pericarditis, tamponade, hypertension, restrictive cardiomyopathy

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15
Q

Heart Failure

Left ventricular failure (6)

A

Body doesn’t get enough oxygenated blood, blood backs up into lungs causing SOB + fluid build up
Dyspnoea
Fatigue
Orthopnoea
Paroxysmal nocturnal dyspnoea and nocturnal cough
Weight loss + muscle wasting

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16
Q

Heart Failure

Right ventricular failure (4)

A

Usually triggered by left-sided heart failure or lung disease as the right ventricle has to work harder
Peripheral oedema
Ascites
Nausea

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17
Q

Heart Failure

Investigations (3)

A

CXR: cardiomegaly, prominent upper lobe vessels, pleural effusion
Echo: valvular disease, LV dysfunction
BNP: elevated

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18
Q

Heart Failure

Treatment of acute heart failure (6)

A

O2
Diamorphine
Furosemide
GTN spray
If systolic BP >100 start nitrate infusion
If worsening give more furosemide, consider CPAP

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19
Q

Heart Failure

Treatment of chronic heart failure (4)

A

Diuretics: furosemide, bumetanide (these lower K so may need to add K-sparing diuretic- spironolactone)
ACE-i: improves symptoms
B-blockers: start low and go slow
Digoxin: strengthens force of contractions

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20
Q 
Arrhythmias 
Cardiac causes (5)
A 
MI 
Coronary artery disease 
LV aneurysm 
Mitral valve disease 
Cardiomyopathy
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21
Q

Arrhythmias

Non-cardiac causes (4)

A

Caffeine/smoking/alcohol
Pneumonia
Drugs (B2 agonists, digoxin)
Metabolic imbalance (K, Ca, Mg, hypoxia)

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22
Q

Arrhythmias

Presentation (5)

A 
Some asymptomatic + incidental, eg. AF 
palpitation 
Chest pain 
Syncope 
Hypotension
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23
Q

Arrhythmias

Investigations (3)

A

Bloods: FBC, U+E, glucose, Ca, Mg
ECG: short PR interval (WPW syndrome), long QT interval (drugs, metabolic imbalance, congenital), U waves (hypokalaemia)
Echo: structural disease

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24
Q

Arrhythmias

Bradycardia (4)

A

Fewer than 60bpm
If >40bpm + asymptomatic, no treatment needed
Causes: drugs, sick sinus syndrome, hypothyroidism, B-blocker, digoxin
If rate <40bpm or symptomatic then give atropine, if no response insert temporary pacing wire

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25
Arrhythmias | Supra ventricular tachycardia (3)
P wave absent/inverted after QRS Narrow complex tachycardia (rate >100bpm, QRS width <120ms) Treatment: 1st line vagal manoeuvres, 2nd line IV adenosine, 3rd line verapamil
26
Arrhythmias | Wolff-Parkinson White Syndrome
Congenital accessory conduction pathway between atria and ventricles ECG: short PR interval, wide QRS complex Present with SVT Treatment: ablation of accessory pathway
27
``` Arrhythmias Ventricular Tachycardia (4) ```
Broad complex tachycardia (rate >100bpm, QRS >120ms) Acute management: IV amiodarone or IV lidocaine Maintenance anti arrhythmic: oral amiodarone Prevention of recurrent VTs: implantation of automatic defibrillators (ICD)
28
``` Acute Coronary Syndromes Risk Factors (8) ```
``` Age Male Family history of IHD Smoking Hypertension Diabetes Hyperlipidaemia Obesity ```
29
Acute Coronary Syndromes | Diagnostic Criteria of Acute MI (4)
Increase followed by decrease in cardiac biomarkers Symptoms of ischaemia ECG changes Loss of myocardium on imaging
30
Acute Coronary Syndromes | Symptoms (5)
``` Central chest pain lasting >20 mins Nausea Sweatiness Dyspnoea Palpitations ```
31
Acute Coronary Syndromes | Signs (6)
``` Pallor Sweatiness Pulse high or low BP high or low 4th heart sound May have signs of heart failure (increased JVP, 3rd heart sound, basal crepitations ```
32
Acute Coronary Syndromes | Investigations (4)
ECG: tall T waves, ST elevation or new LBBB over hors, T wave inversion and pathological Q waves, over hours- days CXR: cardiomegaly, pulmonary oedema, widened mediastinum Bloods: FBC, U+E, glucose, lipids Cardiac enzymes: cardiac troponin (T + I) levels rise within 3-12 hours and peak at 24-48 hours and creatinine kinase
33
``` Acute Coronary Syndromes Differential Diagnosis (6) ```
``` Angina Pericarditis Myocarditis Aortic dissection Pulmonary embolism Oesophageal reflux ```
34
Acute Coronary Syndromes | Pre-hospital management (3)
Aspirin 300mg Sublingual GTN analgesia
35
Acute Coronary Syndromes | Hospital management of STEMI (4)
Primary angioplasty or thrombolysis B-blocker ACE-i if normotensive CClopidogrel for 30 days
36
Acute Coronary Syndromes | Hospital management of NSTEMI (3)
B-blocker Antithrombotic fondaparinux if low risk Consider clopidogrel
37
``` Acute Coronary Syndromes Subsequent Management (8) ```
``` Bed rest 48h Aspirin Thomboprophylaxis B-blocker ACE-i Statin Address modifiable risk factors Work after 2 months, sex after 1 month, flying after 2 months ```
38
Acute Coronary Syndromes | Complications of MI (9)
``` Cardiac arrest Bradycardia (give atropine/temporary cardiac pacing) AV block Tachycardias RV failure Pericarditis Embolism Cardiac tamponade Mitral regurgitation ```
39
Angina | Definition (1)
Due to myocardial iscahemia and presents as central chest tightness, which is brought on by exertion and relieved by rest
40
Angina | Aetiology (6)
``` Atheroma (reduced coronary blood flow, reduced O2 transport, increased myocardial O2 demand) Age Male Smoking Hypertension Tachyarrhythmias ```
41
Angina | Stable vs Unstable (2)
Stable- induced by effort, relieved by rest | Unstable- increasing frequency/severity, occurring at minimal exertion or at rest
42
Angina | Investigations (4)
ECG: mostly normal but may have ST depression or flat/inverted T waves Angiography Exercise tolerance test Functional imaging (stress echo or MRI)
43
Angina | Canadian Classification of Severity (4)
I- only significant exertion II- moderate exertion III- mild exertion IV- at rest
44
Angina | Treatment (8)
Modify risk factors: smoking, exercise, weight loss, cholesterol, hypertension Aspirin: reduces mortality B-blocker: reduces symptoms and prevent attacks CCBs: relax arteries Nitrates: GTN spray/sublingual tablets for symptoms and regular oral nitrate (isosorbide mononitrate) for prophylaxis Refer if sudden onset, uncontrollable post MI/CABG, unstable CABG: reroutes blood around affected artery PCI: widening of artery with stent
45
Pulmonary Oedema | Definition (2)
Excess fluid in the lungs | Leads to impaired gas exchange and may cause respiratory failure
46
Pulmonary Oedema | Aetiology (2)
Left ventricular failure | Injury to lung parenchyma/vasculature
47
Pulmonary Oedema | Signs and symptoms (4)
Difficulty breathing Haemoptysis Sweating End-inspiratory crackles
48
Pulmonary Oedema | Investigations (2)
CXR: fluid in alveolar walls, Kerley B lines Echo: heart failure
49
Pulmonary Oedema | Treatment (2)
Oxygen if hypoxic | Treat underlying cause eg. heart failure, infection
50
``` Hypertension Risk factors (10) ```
``` Smoking Diabetes Renal disease Male Hyperlipidaemia Previous MI/stroke Genetics Race Age Sodium intake ```
51
Hypertension | Stages of Disease (4)
Prehypertension: 120/80mmHg Stage 1: 140/90mmHg (mild) Stage 2: 160/100mmHg (moderate) Stage 3: 180/110mmHg (severe)
52
Hypertension | Pathology (2)
Increased reactivity of resistance vessels and resultant increase in peripheral resistance Kidneys unable to secrete appropriate amounts of sodium for any given BP
53
Hypertension | Types (3)
Essential hypertension: cause unknown Malignant hypertension: rapid rise in BP leading to vascular damage, severe hypertension and bilateral retinal haemorrhage and exudates, may have papilloedema Secondary hypertension: renal disease- glomerulitis, systemic sclerosis, PCKD, chronic pyelonephritis OR endocrine disease- Cushing's, Conn's, pheochromocytoma OR pregnancy OR steroids
54
Hypertension | Treatment step 1 (3)
Over 55 or Afro-Caribbeans: CCB CCB intolerant or heart failure risk: thiazide type diuretic Under 55: ACE-i or ARB if ACE-i intolerant
55
Hypertension | Treatment step 2 (1)
Add thiazide type diuretic to CCB or ACE-i
56
Hypertension | Treatment step 3 (1)
CCB + ACE-i + diuretic
57
Hypertension | Treatment step 4 (2)
Add spironolactone if serum K+ <4.5mmol/l | Higher dose thiazide type diuretic if K+ >4.5mmol/l
58
Hypertension | Treatment in pregnancy (2)
Never ACE-i | Thiazide type diuretic and/or amlodipine
59
Aortic Stenosis | Aetiology (3)
Degeneration (old age calcification) Rheumatic heart disease Congenital bicuspid valve
60
Aortic Stenosis | Signs + symptoms (8)
``` Triad of angina, syncope and heart failure Dyspnoea Dizziness/syncope Slow rising pulse Heaving, non-displaced apex beat LV heave Aortic thrill Ejection systolic murmur, radiating to carotids ```
61
Aortic Stenosis | Investigations (3)
ECG: left bundle branch block or complete AV block may be present CXR: left ventricular hypertrophy, calcified aortic valve Echo: diagnostic +/- doppler echo to assess severity
62
Aortic Stenosis | Treatment (2)
Aortic valve repair/replacement | TAVI if unfit for surgery
63
``` Aortic Regurgitation Acute causes (3) ```
Infective endocarditis Ascending aortic dissection Chest trauma
64
``` Aortic Regurgitation Chronic causes (4) ```
Congenital: bicuspid aortic valve Connective tissue disorders: Marfan's, Ehlers-Dalos Rheumatic fever Rheumatoid arthritis
65
Aortic Regurgitation | Signs + symptoms (6)
``` Exertion dyspnoea Orthopnoea Paroxysmal nocturnal dyspnoea Collapsing pulse Displaced apex beat Early diastolic murmur (heard best in expiration sat forward) ```
66
Aortic Regurgitation | Investigations (4)
ECG: LVH CXR: cardiomegaly, pulmonary oedema, dilated ascending aorta Echo: diagnostic Cardiac catheterisation: assess severity
67
Aortic Regurgitation | Treatment (2)
Aortic valve replacement/repair | Medical therapy to reduce systolic hypertension: ACE-i
68
Mitral Stenosis | Aetiology (3)
Rheumatic Congenital Prosthetic valve
69
Mitral Stenosis | Signs + symptoms (12)
``` Begin when valve orifice <2cm Dyspnoea Fatigue Palpitations Chest pain Systemic emboli Haemoptysis Malar flush (reduced cardiac output) Low-volume pulse AF Tapping non-displaced apex beat Loud S1, rumbling mid-diastolic murmur, best heard in expiration lying on side ```
70
Mitral Stenosis | Investigations (3)
ECG: AF CXR: left atrial enlargement, pulmonary oedema, mitral valve calcification Echo: diagnostic
71
Mitral Stenosis | Treatment (4)
Rate control and anticoagulation if in AF Diuretics: reduced preload and pulmonary venous congestion Balloon valvuloplasty if non-calcified Open mitral valvotomy or replacement
72
Mitral Stenosis | Complications (3)
Pulmonary hypertension Emboli Pressure from large LA on local structures (eg. hoarseness, dysphagia)
73
Mitral Regurgitation | Aetiology (5)
``` Degenerative calcification and thickening of valve Rheumatic heart disease Mitral valve proplapse Infective endocarditis LV dilatation ```
74
Mitral Regurgitation | Signs + symptoms (8)
``` Soft S1, split S2 with radiation to axilla, low pitch (bell) Dyspnoea Fatigue Palpitations Infective endocarditis AF Displaced apex beat RV heave ```
75
Mitral Regurgitation | Investigations (4)
CXR: enlarged LA + LV, mitral valve calcification, pulmonary oedema ECG: AF Cardiac catheterisation Echocardiography
76
Mitral Regurgitation | Treatment (3)
Rate control and anticoagulation if AF Diuretics: improve symptoms Surgical repair/replacement
77
Pulmonary Stenosis | Aetiology (2)
Congenital (Turner's, Noonan's, William's, Fallot's tetralogy) Rheumatic fever
78
Pulmonary Stenosis | Signs + symptoms (6)
``` Dyspnoea Fatigue Oedema Ascites RV heave Ejection systolic murmur radiating to left shoulder ```
79
Pulmonary Stenosis | Investigations (3)
ECG: right bundle ranch block CXR: prominent pulmonary arteries Cardiac catheterisation
80
Pulmonary Stenosis | Treatment (1)
Valvuloplasty/valvotomy
81
Pulmonary Regurgitation | Aetiology (1)
Pulmonary hypertension
82
Pulmonary Regurgitation | Signs + symptoms (1)
Decrescendo murmur in early diastolic at left sternal edge
83
Tricuspid Stenosis | Aetiology (3)
Mainly rheumatic fever Congenital Infective endocarditis
84
Tricuspid Stenosis | Signs + symptoms (5)
``` Fatigue Ascites Oedema AF Early diastolic murmur heard at left sternal edge in inspiration ```
85
Tricuspid Stenosis | Investigations (1)
Echo
86
Tricuspid Stenosis | Treatment (2)
Diuretics | Surgical repair
87
Tricuspid Regurgitation | Aetiology (3)
RV dilatation Rheumatic fever Infective endocarditis
88
Tricuspid Regurgitation | Signs + symptoms (6)
``` Fatigue Ascites Jaundice Oedema RV heave Pan systolic murmur, heard best at lower sternal edge in inspiration ```
89
Tricuspid Regurgitation | Treatment (3)
Treat underlying cause Diuretics, digoxin, ACE-i Valve replacement
90
Infective Endocarditis | Aetiology (4)
Staph. aureus: IVDU Strep. viridans: valvular surgery Strep. mutans: dental procedures Diabetic soft tissue infections
91
``` Infective Endocarditis Risk Factors (4) ```
IVDU Renal failure Organ transplant Diabetes
92
Infective Endocarditis | Signs + Symptoms (7)
Septic signs: fever, riggers, night sweats, weight loss Cardiac lesions: any new murmur/evolving pre-existing murmur Vasculitis Roth spots (retinal haemorrhage) Splinter haemorrhages Osler's nodes (painful pulp infarcts in fingers/toes) Emboli
93
Infective Endocarditis | Investigations (7)
``` Blood cultures: 3 sets at different sites >6 hours between FBC: normochromic normocytic anaemia ESR + CRP: high Urinalysis: microscopic haematuria CXR: cardiomegaly ECG: long PR interval Echo: shows vegetations ```
94
``` Infective Endocarditis Duke Criteria Major criteria (2) Minor criteria (5) Definitive (3) ```
Major: Positive blood culture (typical organism) Endocardium involved (+ve echo or new regurgitation) Minor: Predisposition (eg. IVDU) Fever >38 Vascular/immunological sign Positive blood culture not meeting major criteria Positive echo not meeting major criteria Definitive: 2 major 1 major + 3 minor 5 minor
95
Infective Endocarditis | Treatment (6)
Blind therapy native valve: amoxicillin +/- gentamicin (IV) Blind therapy prosthetic valve: vancomycin + gentamicin + rifampicin (PO/IV) Staph. in native valve: flucloxacillin >4 weeks Staph. in prosthetic valve: flucloxacillin + rifampicin + gentamicin >6 weeks Strep: benzylpenicillin Surgery if heart failure/valvular obstruction/repeated emboli/fungal endocarditis
96
Acute Myocarditis | Definition (1)
Inflammation of myocardium
97
Acute Myocarditis | Aetiology (5)
``` Mostly idiopathic Viral (flu, hepatitis, HIV) Bacterial (Clostridia, TB) Drugs (cyclophosphamide, penicillin) Toxins ```
98
Acute Myocarditis | Signs + Symptoms (6)
``` Fatigue Dyspnoea Chest pain Fever Palpitation Tachycardia ```
99
Acute Myocarditis | Investigation (2)
ECG: ST elevation/depression, T wave inversion, atrial arrhythmias Troponin: positive I or T
100
Acute Myocarditis | Treatment (1)
Treat underlying cause, patients may recover or get heart failure
101
Dilated Cardiomyopathy | Definition (1)
Dilated heart of unknown cause
102
``` Dilated Cardiomyopathy Risk Factors (5) ```
``` Alcohol Hypertension Viral infection Congenital (X-linked) Peri/post partum ```
103
Dilated Cardiomyopathy | Signs + Symptoms (9)
``` Fatigue Dyspnoea Pulmonary Oedema Emboli AF/VT Tachycardia Displaced apex beat Mitral/tricuspid regurgitation Elevated JVP ```
104
Dilated Cardiomyopathy | Investigations (4)
ECG: tachycardia, non-specific T wave changes CXR: cardiomegaly, pulmonary oedema Coronary angiography to rule out coronary artery disease Echocardiography: dilate d heart, low ejection fraction
105
Dilated Cardiomyopathy | Treatment (6)
``` ACE-i Diuretics Anticoagulants as required Digoxin Cardiac transplant ICDs ```
106
Hypertrophic Cardiomyopathy | Aetiology (1)
Genetic
107
Hypertrophic Cardiomyopathy | Definition (2)
LV outflow tract obstruction from asymmetric septal hypertrophy Leading cause of sudden cardiac death in the young
108
Hypertrophic Cardiomyopathy | Signs + Symptoms (7)
``` Sudden death often first manifestation Angina Dyspnoea Palpitations Syncope CCF Harsh ejection systolic murmur ```
109
Hypertrophic Cardiomyopathy | Investigations (2)
ECG: LVH, progressive T wave inversion, deep Q waves, AF Echocardiography: asymmetrical septal hypertrophy
110
Hypertrophic Cardiomyopathy | Treatment (3)
B-blockers or verapamil for symptoms (reducing ventricular contractility) Amiodarone for arrhythmias Implantable defibrillator
111
Restrictive Cardiomyopathy | Definition (1)
Walls of ventricles to rigid to expand as they fill
112
Restrictive Cardiomyopathy | Aetiology (5)
``` Idiopathic Amyloidosis Haemochromatosis Sarcoidosis Scleroderma ```
113
Restrictive Cardiomyopathy | Signs + Symptoms (4)
``` (Signs of RVF): Elevated JVP Hepatomegaly Oedema Ascites ```
114
Restrictive Cardiomyopathy | Investigations (2)
Echo: thickening | Cardiac catheterisation
115
Restrictive Cardiomyopathy | Treatment (4)
Treat cause ACE-i: reduce work B-blockers: reduce rat and force of heart contraction Diuretics: reduce fluid build up
116
Acute Pericarditis | Definition (1)
Inflammation of the pericardium
117
Acute Pericarditis | Aetiology (5)
``` Idiopathic Viruses (flu, HIV, Epstein-Barr) Bacteria (pneumonia, TB, Staphs, Streps) Fungi MI ```
118
Acute Pericarditis | Signs + Symptoms (4)
Chest pain (worse on inspiration or lying flat) Pericardial friction rub may be heard Fever Elevated JVP
119
Acute Pericarditis | Investigations (2)
ECG: concave ST elevation Bloods: FBC, ESR, U+E, troponin may be raised
120
Acute Pericarditis | Treatment (3)
Analgesia Treat cause Colchicine
121
Pericardial Effusion | Pathology (3)
Collection of fluid within pericardial sac Commonly accompanies acute pericarditis When a large volume collects there is compromised ventricular filling- cardiac tamponade
122
Pericardial Effusion | Aetiology (5)
``` Idiopathic Viruses (flu, HIV, Epstein-Barr) Bacteria (pneumonia, TB, Staphs, Streps) Fungi MI ```
123
Pericardial Effusion | Signs + Symptoms (4)
Raised JVP Fatigue SOB Bronchial breathing at left base
124
Pericardial Effusion | Investigations (2)
CXR: enlarged heart ECG: alternating QRS morphologies
125
Pericardial Effusion | Treatment (2)
Treat cause | Pericardiocentesis
126
Constrictive Pericarditis | Definition (1)
Heart encased in a rigid pericardium
127
Constrictive Pericarditis | Aetiology (2)
Often unknown | After pericarditis
128
Constrictive Pericarditis | Signs + Symptoms (4)
Right heart failure Elevated JVP S3 Soft heart sounds
129
Constrictive Pericarditis | Investigations (1)
CXR: small heart +/- pericardial calcification
130
Constrictive Pericarditis | Treatment (1)
Surgical excision
131
Cardiac Tamponade | Definition (1)
Accumulation of pericardial fluid raises intrapericardial pressure, hence poor ventricular filling and fall in cardiac output
132
Cardiac Tamponade | Aetiology (4)
Any pericarditis Aortic dissection Haemodialysis Warfarin
133
Cardiac Tamponade | Signs + Symptoms (4)
High pulse Low BP High JVP Muffled heart sounds
134
Cardiac Tamponade | Investigations (3)
Beck's triad: falling BP, rising JVP, muffled heart sounds CXR: big globular heart Echo: diagnostic echo-free zone around heart
135
Cardiac Tamponade | Treatment (1)
Urgent drainage
136
Atrial Septal Defect | Definition (4)
Hole connecting the atria Osmium primum defects (opposing endocardial cushions) are associated with AV valve anomalies Osmium secundum defects (high in septum) are commonest Primum ASDs present early, secundum are often asymptomatic until adulthood as compliance of the ventricles decreases leading to early heart failure
137
Atrial Septal Defect | Signs + Symptoms (5)
``` AF High JVP Wide, fixed split S2 Pulmonary ejection systolic murmur Pulmonary hypertension ```
138
Atrial Septal Defect | Investigations (3)
ECG: right bundle branch block and prolonged PR interval CXR: small aortic knuckle, progressive atrial enlargement Echo: diagnostic
139
Atrial Septal Defect | Treatment (2)
In children- closure | In adults- transcatheter closure or surgical closure if asymptomatic
140
Ventricular Septal Defect | Definition (1)
Hole connecting ventricles
141
Ventricular Septal Defect | Signs + Symptoms (3)
Severe heart failure/asymptomatic in infancy Harsh pan systolic murmur at left sternal edge with a systolic thrill (smaller holes give louder murmurs) Pulmonary hypertension (typically larger holes)
142
Ventricular Septal Defect | Complications (3)
Aortic regurgitation Infective endocarditis Pulmonary hypertension
143
Ventricular Septal Defect | Investigations (3)
ECG CXR Cardiac catheter
144
Ventricular Septal Defect | Treatment (2)
Medical at first, as many close spontaneously | Indications for surgical closure: failed medical therapy, symptomatic
145
Coarctation of the Aorta | Definition (2)
Congenital narrowing of the descending aorta | Usually occurs just distal to the origin of the left subclavian artery
146
Coarctation of the Aorta | Associations (2)
Bicuspid aortic valve | Turner's syndrome
147
Coarctation of the Aorta | Signs + Symptoms (4)
Radio femoral delay Weak femoral pulse Hypertension Systolic murmur (best heard over left scapula)
148
Coarctation of the Aorta | Complications (2)
Heart failure | Infective endocarditis
149
Coarctation of the Aorta | Investigations (2)
CT/MRI aortogram | CXR
150
Coarctation of the Aorta | Treatment (2)
Surgery | Balloon dilatation +/- stenting
151
Fallot's Tetralogy | Embryology (1)
Abnormalities in separation of the trunks arterioles into the aorta and pulmonary arteries that occur early in gestation
152
Fallot's Tetralogy | Features (4)
Ventricular septal defect Pulmonary stenosis Right ventricular hypertrophy Aorta overriding the VSD
153
Fallot's Tetralogy | Signs + Symptoms (3)
Severity depends on degree of pulmonary stenosis Infants gradually become cyanotic (after closure of ductus arteriosus) During hypoxic spell, child becomes restless and agitated
154
Fallot's Tetralogy | Investigations (3)
Echo: shows anatomy and degree of stenosis CXR: boot-shaped heart Cardiac CT/MRI
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Fallot's Tetralogy | Treatment (3)
Give O2 Morphine to sedate and relax pulmonary outflow Surgery
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Marfan's Syndrome | Definition (1)
Connective tissue disorder (autosomal dominant fibrillar gene)
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``` Marfan's Syndrome Major Criteria (5) ```
``` Diagnostic if >2 Lens dislocation Aortic dissection Dural ectasia Skeletal features: long fingers, arm span > height, pectus deformity, scoliosis ```
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``` Marfan's Syndrome Minor Signs (3) ```
Mitral valve prolapse High-arches palate Joint hypermobility
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Marfan's Syndrome | Treatment (2)
B-blockers: slow dilatation of aortic root | Annual echoes with elective surgical repair when aortic diameter >5cm
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Noonan's Syndrome | Inheritance (1)
Autosomal dominant
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Noonan's Syndrome | Signs + Symptoms (5)
Short stature Characteristic facial features (ptosis, down-slanting eyes, low-set ears) Congenital heart defects (hypertrophic cardiomyopathy + pulmonary stenosis) Webbed neck Learning disability
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Turner's Syndrome | Inheritance (1)
45XO
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Turner's Syndrome | Signs + Symptoms (7)
``` Coarctation of aorta Absent kidney Short stature Webbed neck Behavioural difficulties Hearing loss Gonadal dysgenesis resulting in absent puberty and impaired growth ```
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Turner's Syndrome | Treatment (2)
Human growth factor for short stature | Supplemental oestrogen to initiate puberty
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William's Syndrome | Inheritance (1)
Random deletion of chromosome 7 and genes
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William's Syndrome | Signs + Symptoms (5)
Cardiac defects (aortic stenosis) GI problems Characteristic facial features (broad forehead, short nose, full cheeks, 'elfin') Hypercalcaemia Intellectual disability (particularly visuospatial)
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22q11 Deletion Syndrome | Inheritance (1)
Random deletion of genes on chromosome 22
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``` 22q11 Deletion Syndrome CATCH 22 (6) ```
``` Cardiac abnormality (interrupted aortic arch, tetralogy of Fallot) Abnormal facies Thyme hypoplasiai (frequent infections) Cleft palate Hypoparathyroidism + hypocalcaemia 22q11 deletion ```
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Ehlers-Dalos Syndrome | Definition (1)
Group of rare inherited conditions that affect connective tissue
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Ehlers-Dalos Syndrome | Signs + Symptoms (4)
Hyper mobility Mitral valve prolapse Fatigue Easy bruising
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Acute Limb Ischaemia | Definitions (2)
Acute: ischaemia <14 days | Acute on chronic: worsening signs + symptoms <14 days
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Acute Limb Ischaemia | Aetiology (5)
Thrombosis in situ (60%): stenosed vessel plaque rupture Embolism (30%): atrial fibrillation, valve disease, iatrogenic from surgery Graft/stent occlusion Trauma Aortic dissection
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Acute Limb Ischaemia | Signs + Symptoms ( 6)
``` Pain Pallor Perishingly cold Paraesthesia Paralysis Pulseless ```
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Acute Limb Ischaemia | Thrombosis vs Embolus
Onset: hrs-days vs sudden Severity: less vs profound ischaemia History of claudication: present vs absent Contralateral pulses: absent vs present Diagnosis: angiography vs clinical Treatment: thrombolysis/bypass surgery vs embolectomy + warfarin
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Acute Limb Ischaemia | Investigations (5)
``` ECG FBC, U+E, INR CXR Doppler Angiography ```
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Acute Limb Ischaemia | Treatment (4)
Embolectomy Thrombolysis Amputation Emergency reconstruction
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Chronic Limb Ischaemia | Definition (2)
Ischaemia stable for >14 days | Ankle artery pressure <50mmHg
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Chronic Limb Ischaemia | Aetiology (1)
Atherosclerosis
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``` Chronic Limb Ischaemia Risk Factors (7) ```
``` Male Age Genetic Smoking Hypertension Hyperlipidaemia Diabetes ```
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Chronic Limb Ischaemia | Signs + Symptoms (4)
Intermittent claudication: cramping pain after walking and rapidly relieved by rest Critical limb ischaemia: rest pain (especially at night, usually in foot and patient hangs foot out of bed), ulceration, gangrene Skin: cold, white, absent hair Buerger's Angle decreased (20-30 = ischaemia): angle to which leg has to be raised before it becomes pale whilst lying down
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Chronic Limb Ischaemia | Fontaine Classification for Peripheral Artery Disease (4)
1 asymptomatic 2 intermittent claudication 3 ischaemic rest pain 4 ulceration/gangrene (critical ischaemia)
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Chronic Limb Ischaemia | Investigations (5)
Bloods: FBC, ESR, CRP (exclude diabetes + arteritis), U+Es ECG: cardiac ischaemia ABPI: normal 1-1.2, peripheral artery disease 0.5-0.9, critical ischaemia <0.5 Colour doppler ultrasound scan 1st line imaging CT/MR angiography
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Chronic Limb Ischaemia | Treatment (5)
Risk factor modification: quit smoking, treat hypertension and hyperlipidaemia, prescribe anti platelet to prevent progression (clopidogrel 1st line) Management of claudication: supervised exercise programmes, vasoactive drugs Percutaneous transluminal angioplasty (PTA) +/- stunting Surgical reconstruction (fem-pop bypass, fem-fem crossover) Amputation
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Carotid Artery Disease | Pathogenesis (3)
Turbulent flow at carotid bifurcation promoting atherosclerosis and plaque formation Plaque rupture causes complete occlusion or distal emboli Cause 20% of strokes and TIAs
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Carotid Artery Disease | Investigations (2)
MR angiography | Duplex carotid doppler
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Carotid Artery Disease | Treatment (3)
Aspirin/clopidogrel Endarterectomy Stunting if there is a concern over increased stroke risk of endarterectomy, especially in patients >70
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Aneurysms | Definition (1)
Abnormal dilatation of a blood vessel >50% of its normal diameter
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Aneurysms | Classification (3)
True aneurysm: involving all layers of the wall, fusiform (AAA) or saccular (Berry) False aneurysms: collection of blood around a vessel wall that communicates with the vessel lumen, usually iatrogenic (eg. cannulation) Dissection: vessel dilatation caused by blood splaying apart the media to form a channel within the vessel wall
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Aneurysms | Complications (4)
Rupture Thrombosis Distal embolism Fistula
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Popliteal Aneurysm | Signs and Symptoms (3)
Palpable popliteal pulse 50% bilateral Thrombosis + distal embolism is main complication leading to acute limb ischaemia
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Popliteal Aneurysm | Treatment (2)
Acute: embolectomy or fem-distal bypass Stable: elective grafting + tie off vessel
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Abdominal Aortic Aneurysm | Definition (1)
Dilatation of abdominal aorta >3cm
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Abdominal Aortic Aneurysm | Aetiology (2)
Degeneration of elastic lamellae and smooth muscle loss | Genetic component
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Abdominal Aortic Aneurysm | Signs + Symptoms (3)
Often asymptomatic Abdominal/back pain Acute rupture: continuous pain, collapse, shock, expansile abdominal mass
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Abdominal Aortic Aneurysm | Investigations (3)
Abdominal X-ray: calcification Abdominal ultrasound: screening + monitoring CT/MRI: gold standard
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Abdominal Aortic Aneurysm | Treatment (4)
Manage cardiovascular risk factors, especially BP Monitoring: <4cm yearly, 4-5.5cm 6 monthly Elective surgery for aneurysms >5.5cm or expanding >1cm per year- open or EVAR Emergency management: O2, cross match, major haemorrhage protocol, analgesia, antibiotic prophylaxis (ceftriaxone and metronidazole), theatre- clamp + insert graft
197
Thoracic Aortic Dissection | Definition (1)
Tear in inner aortic wall causes blood to force walls apart
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Thoracic Aortic Dissection | Aetiology (4)
Hypertension Atherosclerosis Marfan's syndrome Ehlers-Dalos syndrome
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``` Thoracic Aortic Dissection Stanford Classification (2) ```
``` Type A (proximal): 70%, involves ascending aorta +/- descending, higher mortality due to probable cardiac involvement, usually need surgery Type B (distal): 30%, involves descending aorta only, usually conservative management ```
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Thoracic Aortic Dissection | Signs + Symptoms (4)
Sudden onset chest pain radiating to back Unequal arm pulses + BP as dissection extends Hemiplegia (carotid artery), paralysis (ant. spinal artery) as dissection extends If dissection moves proximally- aortic regurgitation, inferior MI, cardiac arrest
201
Thoracic Aortic Dissection | Investigations (3)
ECG: exclude MRI Bloods: crossmatch, FBC, U&E, clotting, amylase CT/MRI or TOE (transoesophagel echocardiography)
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Thoracic Aortic Dissection | Treatment (2)
Type A- surgery | Type B- conservative unless persistent/complicated (keep BP low with B-blocker labetalol/esmolol)
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Gangrene | Definition (1)
Death of tissue from poor vascular supply (sign of critical ischaemia)
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Gangrene | Classification (3)
Wet: tissue death and infection (associated with discharge) Dry: necrosis in absence of infection Gas: subset of necrotising myositis (caused by Clostridiol species)
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Gangrene | Treatment (3)
Wet: analgesic, broad-spectrum IV antibiotics, surgical debridement +/- amputation Dry: restoration of blood supply +/- amputation Gas: remove all dead tissue (eg. amputation), benzylpenicillin +/- clindamycin, hyperbaric O2 can reduce number of debridements
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Varicose Veins | Definition (1)
Tortuous, dilated veins of the superficial venous system
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Varicose Veins | Pathology (3)
Valves become incompetent | Venous hypertension develops leading to dilatation
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Varicose Veins | Aetiology (4)
Obstruction: DVT, fetus Valve destruction: DVT Overactive muscle pumps: cyclists Prolonged standing/obesity
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Varicose Veins | Signs + Symptoms (8)
``` Pain, cramping Tingling Bleeding Oedema Eczema Ulcers Haemosiderin (pigment formed due to haemoglobin breakdown- yellow/brown) Phlebitis (inflammation of venous walls, painful) ```
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Varicose Veins | Investigations (1)
Duplex ultrasound scan (doppler)
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``` Varicose Veins Referral criteria (5) ```
``` Bleeding Pain Ulceration Superficial thrombophlebitis Severe impact on QoL (not cosmetic alone) ```
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Varicose Veins | Treatment (6)
Treat any underlying cause Education (avoid prolonged standing, leg elevation, lose weight regular walking as calf muscle action aids venous return, support stockings) Radio frequency ablation: catheter inserted into vein and heated to close vein Endogenous laser ablation Injection + sclerotherapy: liquid/foam Surgery
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Leg Ulcers | Definition (1)
Interruption in the continuity of an epithelial surface
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Leg Ulcers | Aetiology (6)
Venous (most common)- painless, shallow, commonly medial malleolus Arterial- painful, deep, punched out, occur at pressure points Diabetic Vasculitic Malignant Traumatic (pressure)
215
Leg Ulcers | Examination (10)
Site: venous above medial malleolus common Temperature: if cold-ischaemic, warm- local factors Surface area Shape Edge: sloping- healing, punched out- ischaemic, everted- malignant Base: slough- grey/yellow mixture of fibrin and cell breakdown products, granulation tissue- pink base, evidence of healing Depth Discharge: culture before antibiotics Associated lymphadenopathy: infection/malignancy Sensation: decreased around ulcer- neuropathy
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Leg Ulcers | Treatment (4)
Treat cause and focus on prevention Compression bandaging Surgery for deriding sloughy necrotic tissue (desloughing) Antibiotics only if infected
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``` Leg Swelling Bilateral Swelling (3) ```
Increased venous pressure (right heart failure, venous insufficiency, drugs eg. nifedipine) Decreased oncotic pressure (nephrotic syndrome) Lymphoedema
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``` Leg Swelling Unilateral Swelling (4) ```
Venous insufficiency DVT Infection/inflammation Lymphoedema
219
Deep Vein Thrombosis | Aetiology (3)
Stasis eg. bed rest, travel Hyper coagulability eg. pregnancy Vessel damage eg. atherosclerosis
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Deep Vein Thrombosis | Signs + Symptoms (4)
Unilateral limb swelling Pain in calf Warmth in calf Erythema
221
Deep Vein Thrombosis | Long Term Consequences (1)
Post-phlebitic syndrome (swelling, discomfort, pigmentation, ulceration)
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Deep Vein Thrombosis | Investigations (2)
D-dimer: sensitive but not specific | Ultrasound
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``` Deep Vein Thrombosis Wells Score (10) ```
<1 point: DVT unlikely, do D-dimer >2 points: DVT likely, do D-dimer and ultrasound Active cancer: 1 Paralysis/immbolisation of leg: 1 Recently bedridden >3 days/major surgery in past 12 weeks: 1 Local tenderness along distribution of deep venous system: 1 Entire leg swollen: 1 Calf swelling >3cm compared with asymptomatic leg: 1 Pitting oedema: 1 Previous DVT: 1
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Deep Vein Thrombosis | Prevention in Hospital (4)
Early mobilisation Anti-embolism stockings (compression) Daily injections of low molecular weight hearing or fondaparinux if bleeding risk Pill stopped 4 weeks pre-op
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Deep Vein Thrombosis | Treatment (3)
LMWH/fondaparinux Start warfarin simultaneously and continue post-op for 3 months Stop heparin when INR 2-3

Med Student Finals (23 decks)

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