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Year 3 diagnosis and management > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

Symptoms and signs of AAA?

A
  • Epigastric pain
  • Radiates to back
  • Severe
  • Syncope
  • Shock

• Grey-Turner’s sign

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2
Q

Investigation for AAA?

A
  1. Aortic ultrasound (doesn’t visualise leak)

2. CT contrast to visualise leak

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3
Q

Symptoms and signs for aortic dissection?

A
  • Sudden tearing pain
  • Radiation to back, between shoulder blades
  • Symptoms of organ hypoperfusion

• Pulsus paradoxus (large decrease in SBP and pulse wave amplitude during inspiration)

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4
Q

Signs for aortic regurgitation?

A
  • Early diastolic murmur
  • Collapsing pulse
  • Wide pulse pressure
  • Displaced and heavy apex beat
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5
Q

Most common cause of aortic stenosis?

A

Worldwide - rheumatic heart disease

UK - calcification

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6
Q

Symptoms and signs of aortic stenosis?

A
  • Angina
  • Syncope
  • Heart failure symptoms (dyspnoea/orthopnoea)
  • Ejection systolic murmur
  • Narrow pulse pressure
  • Slow-rising pulse
  • Aortic thrill
  • Thrusting apex beat
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7
Q

Signs and symptoms of arterial ulcers?

A
  • Punched-out
  • Hairless
  • Nail dystrophy and absent pulses downstream
  • Night pain
  • Symptoms of acute limb ischaemia (6 Ps)
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8
Q

Investigation for arterial ulcers?

A
  1. Duplex ultrasonography

2. ABPI

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9
Q

What are the causes of AF?

A
  • Thyrotoxicosis
  • HTN
  • Pneumonia
  • Alcohol
  • IHD
  • Cardiomyopathy
  • Pericarditis
  • Atrial myxoma
  • Bronchial carcinoma
  • PE
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10
Q

Management for AF and how do you manage stroke risk (low and high risk)?

A

Rhythm control if haemodynamically unstable e.g. angina
• < 48 hours (acute) - cardioversion : DC or chemical (flecainide, or amiodarone if IHD)
• > 48 hours (chronic) - anticoagulate with DOAC for 3-4 weeks, then cardioversion

Then rate control

  1. Bisoprolol or verapamil
  2. Digoxin or amiodarone

Paroxysmal AF - pill in pocket (flecainide)

Manage stroke risk
• Low risk - aspirin
• High risk - warfarin

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11
Q

What is used to assess the risk of stroke in AF patients? What does each score mean?

A

CHADS-vasc score
0 - low
1 - moderate
> 1 - high

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12
Q

What are the 8 reversible causes of cardiac arrest?

A
  • Hypokalaemia
  • Hypothermia
  • Hypovolaemia
  • Hypoxia
  • Tamponade
  • Tension pneumothorax
  • Thromboembolic
  • Toxins
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13
Q

Management for cardiac arrest (BLS)?

A
  • pre-cordial thump

* 2 rescue breaths, 30 chest compressions

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14
Q

Management for cardiac arrest (ALS)?

A

Pulseless VT / VF (shockable)
• shock + CPR
• adrenaline
• amiodarone

Pulseless electrical activity / asystole (non-shockable)
• Above, but just adrenaline

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15
Q

Which electrolytes do you measure in AF? When is there a risk of digoxin toxicity?

A
  • Potassium
  • Magnesium
  • Calcium

Risk of digoxin toxicity if potassium/ magnesium is low, or calcium is high

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16
Q

What are the symptoms and signs of left and right cardiac failure?

A

Left heart
• dyspnoea
• orthopnoea
• paroxysmal nocturnal dyspnoea

• tachycardia, tachypnoea
• displaced apex
• bi-basal crackles
• S3 gallop
• pan-systolic murmur
(• acute: + pulsus alternans)

Right heart
• swollen ankles
• fatigue, difficulty exercising
• anorexia, nausea

  • raised JVP, kussmaul sign
  • hepatomegaly, ascites
  • ankle/sacral oedema
  • tricuspid regurgitation
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17
Q

What is used to measure pressure in vessels (cardiac failure)?

A

Swan-Ganz catheter

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18
Q

Investigation for heart failure? What is systolic and diastolic HF?

A
  1. BNP
  2. Best diagnostic - Transthoracic echocardiogram (TTE) coupled with doppler
    • EF < 40% - systolic HF
    • EF > 50% - diastolic HF
  • ECG
  • CXR
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19
Q

Management for acute LV failure?

A 
1. Treat pulmonary oedema
• Sit up
• 60-100% O2
• IV furosemide
• Diamorphine
• GTN infusion
  1. Treat cardiogenic shock (SBP < 90)
    • inotropes e.g. dobutamine
  2. Monitor essential stats
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20
Q

Management for chronic LV failure? What should you avoid?

A
  1. Lifestyle changes
  2. ACEi (ARB if contraindicated) + beta blocker + furosemide
  3. Hydrazaline + isosorbide dinitrate, if 1. contraindicated
  4. Severe symptoms or EF <35%, consider cardiac resynchronisation

Avoid NSAIDs and non-dihydropiridine CCB

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21
Q

Causes of dilated, hypertrophic and restrictive cardiomyopathy?

A

Dilated - alcohol, drugs, post-viral, thyrotoxicosis
Hypertrophic - genetic
Restrictive - amyloidosis, sarcoidosis

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22
Q

Symptoms/presentation of dilated, hypertrophic and restrictive cardiomyopathy?

A

Dilated - HF symptoms, arrhythmias, FHx sudden death
Hypertrophic - asymptomatic, syncope, FHx sudden death
Restrictive - Kussmaul sign (paradoxical JVP rise), S3

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23
Q

Investigations for cardiomyopathy?

A

Diagnostic: echo
• CXR
• ECG

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24
Q

Symptoms and signs of constrictive pericarditis?

A
  • Gradual onset
  • Advanced - jaundice, cachexia, muscle wasting
  • RHF signs e.g. dyspnoea, peripheral oedema, Kussmaul’s sign S3
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25
Causes of constrictive pericarditis?
* TB * Virus * Post-surgical
26
What is the diagnostic investigation for constrictive pericarditis and what would you would you see in other investigations?
Diagnostic: echo (distinguish from restrictive cardiomyopathy) • CXR (calcification) • CT / MRI (thickness) • Pericardial biopsy
27
Management for constrictive or normal pericarditis? Management if acute/purulent?
1. NSAIDs + PPI (consider colchicine if idiopathic/viral) 2. Corticosteroids 3. Immunosuppression e.g. azathioprine 4. Surgical pericardiectomy acute: pericardiocentesis - ABx if purulent
28
How the risk for DVT is calculated?
Wells criteria | • 2 or more = high risk
29
Investigations for DVT?
Wells score < 2 1. D-dimer 2. if normal: DVT excluded. if elevated: do duplex USS (gold standard) Wells score 2 or more 1. duplex USS Pregnant 1. duplex USS PE suspected - also do ECG, CXR, ABG
30
Management for DVT?
1. Anticoagulation • Warfarin • LMWH whilst waiting for Warfarin to get to INR target (2-3), as it's prothrombotic for first 48 hours Below knee DVT - 3 months of anti-coag + obs Above knee DVT - 6 months of anti-coag + obs 2. IVC filter - if anti-coag contraindicated / high risk of PE 3. Prevention • Graduated compression stockings • Mobilisation • Prophylactic heparin in high risk patients
31
Management for dyslipidaemia?
1. Lifestyle advice 2. Medication ... 1. Statins ... 2. Cholesterol absorption inhibitors e.g. ezetimibe, or fibrates (best for hypertriglyceridaemia)
32
Is gangrene and necrotising fasciitis common or rare?
Gangrene - common | • Necrotising Fasciitis - rare
33
Investigation for gangrene and necrotising fasciitis?
Diagnostic: MC+S tissue swab • Blood test for infection (FBC, CRP) • Blood culture • X-ray (gas gangrene)
34
Compare the different types of gangrene + NF
* Dry gangrene - necrosis, no infection * Wet gangrene - necrosis and infection, pus and strong odour * Gas gangrene - necrosis, crepitus, oedema * NF - erythema, oedema, haemorrhagic blisters, signs of sepsis
35
Describe the different types of heart block on ECG
* 1st degree - prolonged PR interval * 2nd degree MT1 - PR gradually increases, then no QRS after p wave, repeats * 2nd degree MT2 - PR fixed in duration, not every p wave has a QRS after * 3rd degree / complete - no relationship between p wave and QRS complexes
36
Presentation of heart block? Which ones actually have symptoms?
Only MB2 and 3rd degree usually have symptoms • Stokes-Adams attack - syncope from ventricular asystole • Dizziness, palpitations, chest pain, HF • Large volume pulse • Cannon A waves
37
Investigations for heart block?
1. ECG (gold standard) 2. Bloods - troponin, potassium, calcium, digoxin, cardiac enzymes 3. Echo
38
Management for heart block?
Asymptomatic (1st degree, MT1?) 1. monitor Symptomatic 1. discontinue AV nodal blocking meds e.g. beta blockers 2. consider permanent pacemaker or cardiac resynchronisation (atropine no longer indicated?)
39
What causes isolated systolic hypertension?
Stiffening of large arteries | most common form in UK
40
What is malignant hypertension?
Rapid rise in BP leading to vascular damage Bilateral retinal haemorrhages + exudates Hallmark: fibrinoid necrosis
41
Outline the Keith-Wagner classification of hypertensive retinopathy?
Grade I - Silver wiring Grade II - Silver wiring + AV nipping Grade III - flame haemorrhage, cotton wool spots Grade IV - papilloedema - requires admission
42
Diagnosis and investigations for hypertension?
Diagnosis: if BP 140/90 - 180/120, ABPM used to confirm • ECG - left ventricular hypertrophy • Bloods - U&Es, cholesterol, blood glucose • Urinalysis
43
Management for hypertension?
Conservative Medical if symptomatic with end organ damage, or BP over 160/100 1. Type 2 diabetes/under 55 - ACEi or ARB 1. Afrocaribbean/over 55 - CCB 2. (ACEi or ARB) + (CCB or thiazide) 3. (ACEi or ARB) + CCB + thiazide 4. Consider low-dose spirinolactone if K+ ≤ 4.5, consider α/β-blocker if K+ > 4.5
44
Management for severe hypertension (Diastolic >140)
* Atenolol | * Nifedipine
45
Management for acute malignant hypertension?
1. IV beta blocker - labetolol 2. Dihydropyridine CCB - nicardipine 3. Fenoldopam (nitroprusside restricted due to thiocynate poisoning risk)
46
Hypertension targets (age 80, diabetes)
under age 80 - 135/85 over age 80 - 145/85 Diabetes without proteinuria = < 130/80 Diabetes with proteinuria = < 125/75
47
Why do you have to be careful of rapidly lowering BP?
Brain ischaemia - constriction from HTN before
48
Symptoms and signs of infective endocarditis?
* Fever with sweats/chills/rigors (can be remitting) * Malaise * Weight loss * Skin lesions * Confusion * Pyrexias * Tachycardia * Clubbing * Murmur: M > A > T > P * Vasculitic lesions (Roth spots, Osler's nodes, petechiae, splinter hameorrhage) * Janeway lesions - painless macules
49
Investigation for infective endocarditis?
Duke's criteria (based on investigations + symptoms/signs)
50
Management for infective endocarditis?
4-6 weeks of ABx * Blind therapy of native valve: amoxicillin +/- gentamicin * Blind therapy of prosthetic valve: vancomycin + gentamycin + rifampicin • Surgery if poor response to antibiotics (valve replacement) Fatal if untreated, quite high mortality even with treatment
51
4 different types of angina?
* Stable - induced by effort * Unstable - occurs during rest or minimal exercise * Decubitus - induced by lying flat * Prinzmetal's - coronary artery spasm, increased myocardial work when lying down
52
Symptoms and signs of angina?
* Chest tightness * Radiation to one/both arms, neck, jaw, teeth * Dyspnoea * Tachycardia
53
Investigation for stable angina?
1. Resting ECG 2. Stress ECG (gold standard) TSH, stress echo, coronary angiogram
54
What does IHD comprise?
* Stable angina * ACS - unstable angina - NSTEMI or STEMI
55
Management for stable angina?
* Manage modifiable risk factors * Acute attack - sublingual GTN 1. beta blockers (CCB in PM) 2. add CCB (nitrates in PM) 3. PCI 4. CABG Syndrome X - CCBs
56
Troponin in unstable angina and STEMI/NSTEMI?
Elevated in STEMI/NSTEMI but not unstable angina
57
ECG in unstable angina and STEMI/NSTEMI?
* Unstable angina + NSTEMI - ST depression or T wave inversion * STEMI - ST elevation, T wave inversion, Q waves
58
Relationship between ECG leads and side of heart
* Anterior (LADA) - V1-V4 * Posterior (PDA) - V1-3 (TALL R WAVE and ST depression) * Lateral (left circumflex) - I, aVL, V5/6 * Inferior (RCA) - II, III, aVF If V1-V3 ST depression without tall R wave = anterior NSTEMI
59
Investigation for ACS?
1. ECG , bloods (troponin, glucose etc.) 2. Consider CXR and TTE (angiography if positive troponin high risk stress test)
60
Management for unstable angina/NSTEMI?
1. O2 2. IV GTN 3. IV morphine 4. Aspirin + clopidogrel (300mg immediately, 75mg a day after) 5. LMWH e.g. enoxaparin 6. Beta blockers (verapamil if contraindicated) 7. GPIIb/IIIa inhibitor - at risk of MI or death 8. Abciximab/eptifibatide - undergoing PCI statins and nitrates?
61
Management for STEMI?
Same as unstable angina + NSTEMI but... Clopidogrel - slight change in dose Primary PCI - goal < 90min Thrombolysis - fibrinolytics a.g. alteplase (within 12 hours). Rescue PCI if it doesn't work.
62
What is the most common cause of mitral regurgitation (and in young women)?
* Most common - rheumatic heart disease | * Young women - mitral valve prolapse
63
Presentation of mitral regurgitation on examination?
* AF pulse * Laterally displaced apex beat * Pan-systolic murmur * Signs of LV failure
64
Investigation for mitral regurgitation?
``` Diagnostic: TTE (with doppler?) • ECG - normal, may show p mitrale or AF • CXR - acute: LVF, chronic: cardiomegaly, calcification, PO, left atrial enlargement • Doppler echo • Cardiac catheterisation ```
65
Main cause of mitral stenosis?
Rheumatic heart disease
66
Presenting signs of mitral stenosis?
* Peripheral cyanosis * Malar flush * AF pulse * Parasternal heaves * Mid-diastolic murmur * Loud S1
67
Investigation for mitral stenosis?
Diagnostic: TOE (better view than TTE) • ECG - normal, may show p mitrale or AF • CXR - left atrial enlargement, calcification, PO • Cardiac catheterisation
68
Most common pathogenic cause of myocarditis in EU and USA?
Coxsackie B virus Most commonly idiopathic though
69
Symptoms and signs of myocarditis
* Flu like * Breathlessness * Palpitation * Sharp chest pain (pericarditis suggestion) * Tachycardia * Soft S1 * S4 gallop
70
Investigation for myocarditis?
* Bloods - +ve troponin I or T, antimyosin scintigraphy * ECG - non-specific T/ST changes, pericarditis signs * CXR - may show cardiomegaly * Echo
71
Most common cause of pericarditis?
Idiopathic
72
What is pericarditis occuring weeks/months after acute MI called?
Dressler's syndrome
73
Symptoms and signs of pericarditis?
* Sharp and central chest pain * Pleuritic * Radiation to neck/shoulder * Relieved by sitting forwards * Worse when lying flat ``` • Pericardial friction rub • Cardiac tamponade signs - Beck's triad - Raised JVP - Low BP - Muffled heart sounds • Pulsus paradoxus (>10 drop in SBP and drop in pulse wave amplitude on inspiration) ```
74
Investigation for pericarditis?
Diagnostic: ECG - saddle ST elevation • Echo • Bloods (cardiac enzymes normal|) • CXR (usually normal)
75
What are the 4 types of peripheral vascular disease? Compare them.
* Intermittent claudication - calf pain on exercise * Critical limb ischaemia - pain at rest (develops from inter. claudication - most severe PVD) * Acute limb ischaemia - sudden deterioration due to thrombotic/embolic causes * Arterial ulcers + gangrene Fontaine classification: asymptomatic, i. claud, rest pain, ulceration/gangrene
76
What (arterial) disease causes calf and buttock claudication?
* Calf claudication - femoral disease | * Buttock claudication - iliac disease
77
What is Leriche syndrome?
Arterioiliac occlusive disease • Buttock claudication - build up of plaque in iliac arteries • Importence • Absent/weak distal pulses
78
What are the investigations for peripheral vascular disease?
History + vascular exam 1. ABPI 2. Colour duplex ultrasound (shows site and degree) 3. MRI/CT angiogram (gold standard) 4. Full cardiovascular risk assessment (BP, FBC, ECG, etc.)
79
How do you calculate ABPI and what do the results mean?
* Ankle SBP/Brachial SBP * Normal: 1-1.2 * PAD: 0.5-0.9 * Critical limb ischaemia: <0.5 (< 0.2 with tissue loss) * < 0.8, don't apply pressure bandage
80
Investigation for PE?
Wells' score ≤ 4 1. D-dimer 2. if normal: PE excluded. if elevated: do CTPA (gold standard) Wells' score > 4 1. CTPA and start on LMWH (or V/Q scanning if CT contradindicated e.g. pregnancy) Additional: bloods, ECG, CXR (Get result of D-dimer within 4 hours, or offer interim anticoagulaiton)
81
Management for PE?
Compression stockings, heparin prophylaxis for high risk ABCDE if h. unstable 1. LMWH, NOAC/heparin (h. unstable) 2. IVC filter or embolectomy if recurrent or anti-coagulant contraindicated High risk - thrombolysis Long-term - NOAC or warfarin for 6 months post. LMWH if malignancy present.
82
Signs of pulmonary hypertension?
* Right ventricular heave * Loud pulmonary second heart sound * Tricuspid regurgitation * Raised JVP * Peripheral oedema
83
Investigations for pulmonary hypertension?
``` Diagnostic - right heart catheterisation • Echo • ECG • CXR (exclusion) • LFTs (liver damage from portal hypertension) ```
84
Define rheumatic fever (causative infection)?
Inflammatory multisystem disorder following group A beta-haemolytic strep. (GAS) infection Pharyngeal infection
85
Diagnosis and investigations for rheumatic fever?
Revised Jones criteria - evidence of recent strep infection + 2 major, or 1 major + 2 minor ``` Evidence of infection • Positive throat culture • Rapid strep antigen test • Elevated strep antibody titre • Recent scarlet fever ``` ``` Major criteria (CASES) • Carditis (tachycardia, murmurs etc.) • Arthritis • Subcutaneous nodules • Erythema marginatum (mainly on trunk and proximal limbs) • Sydenham's chorea ``` ``` Minor criteria (PRAPP) • Pyrexia • Raised ESR/CRP • Arthralgia • Prolonged PR interval • Previous rheumatic fever ```
86
Describe the 2 types of SVT?
* AVNRT - localised re-entry around AV node - conducts to ventricles faster * AVRT - normal AV conduction, but accessory pathway. Can conduct anteretrograde (towards) or retrograde (both directions) impulses
87
What is Wolff-Parkinson-White Syndrome?
* An AVRT | * Accessory pathway = bundle of Kent
88
Symptoms and signs of SVT?
• Syncope • Palpitations • Polyuria (most common in females, risk factors include nicotine, alcohol, caffeine) * AVNRT - normal except tachycardia * WPW - tachycardia, secondary cardiomyopathy (S3 gallop, RV heave, displaced apex)
89
Investigations and findings for SVT?
``` 1. ECG • Tachycardia • Narrow complex • P waves buried • Shortened PR interval (after correcting tachycardia, delta wave in AVRT, but not AVNRT) • WPW - delta wave (slurred upstroke in QRS) 2. 24 hour ECG monitor ``` * Cardiac enzymes - features of MI * Electrolytes, digoxin * Echo
90
Immediate management for SVT?
H. stable 1. Vagal maneouvres e.g. valsava or carotid massage 2. Adenosine - chemical cardioversion 3. No change => IV beta-blocker/amiodorone (verapamil if asthmatic) 4. DC cardioversion H. unstable 1. DC cardioversion
91
Ongoing management for SVT (AVRT, AVNRT, Sinus Tachycardia)?
* AVRT - Catheter ablation * AVNRT - Catheter ablation + BB (CCB if asthma) * Sinus tachycardia - exclude secondary cause, BB or rate-limiting CCB
92
Most common cause of tricuspid regurgitation?
Infective endocarditis
93
Signs of tricuspid regurgitation?
* Pan-systolic murmur * Louder on inspiration (Carvallo sign) * AF signs * Raised JVP with giant V waves * Giant A waves * Parasternal heave * Ascites, jaundice, palpable liver * Pitting oedema, pleural effusion, PH
94
Investigations for tricuspid regurgitation? (3)
Diagnostic - TTE with doppler USS • ECG - p pulmonale • CXR - right sided enlargment
95
What is the difference between primary and secondary varicose veins?
Primary • Genetic/developmental weakness • Congenital valve absence ``` Secondary • Venous outflow obstruction - pregnancy, DVT, ovarian tumour, ascites etc. • Valve damage • High flow • Constipation ```
96
Signs/tests of varicose veins?
* Oedema, eczema, ulcers, atrophie blanche, lipodermatosclerosis * Cough impulse over saphenofemoral junction * Tap test - sf junction - impulse felt distally * Trendelenburg test allows localisation of site
97
Investigation for varicose veins?
Duplex USS | allows exclusion of DVT too
98
Management for varicose veins (superficial vs deep)?
Symptomatic superficial vein insufficiency 1. Graduated compression stockings 2. • If effective: ablative prodecures +/- phlebectomy/sclerotherapy. • If ineffective: phlebectomy/sclerotherapy Deep vein insufficiency 1. phlebectomy + compression stockings
99
Investigations for vasovagal syncope?
Usually for checking other causes of syncope • ECG - arrhythmia • Echo - outflow obstruction • Lying/standing BP - orthostatic hypotension • Fasting blood glucose - DM
100
Presentation of venous ulcers?
* Large, shallow, painless * Irregular margin * Above medial malleoli
101
Investigations for venous ulcers?
* ABPI (exclude arterial) * Measure surface area and monitor * Swab * Biopsy - possibility of Marjolin's ulcer
102
Management for venous ulcers?
* Graduated compression * Debridement and cleaning * ABx and topical steroids
103
VF investigations?
1. ECG, electrolytes, troponin | 2. Drug levels and toxicology
104
VF management? (Acute and sub-acute)
Acute • defibrillation and cardioversion Sub-acute • ICD (implantable cardioverter defibrillator) • beta blockers • RFA (radiofrequency ablation)
105
Difference between VF and VT?
* VF - irregular, broad-complex tachycardia (can cause cardiac arrest and death) * VT - regular, broad-complex tachycardia (usually >120bpm)
106
VT investigations?
* ECG - > 100bpm, broad QRS, AV dissociation | * Electrolytes, drug levels
107
Management for VT?
``` • Pulseless VT - ALS (CPR/shock=>adrenaline=>amiodarone) • Unstable VT (reduced CO) 1. synchronised DC cardioversion 2. correct electrolytes 3. amiodarone • Stable VT 1. correct electrolytes 2. amiodarone 3. synchronised DC cardioversion (if above unsuccessful) ```

Year 3 diagnosis and management (9 decks)

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