Cardiovascular

Question 1

Myocardial Infarction

Answer 1

Death of heart muscle cells due to a lack of blood flow from the coronary circulation.
Atherosclerotic plaques become thrombogenic due to endothelial dysfunction.
NSTEMI - Subendocardial infarct, ST depression
STEMI - Transmural infarct, ST elevation
S: crushing central chest pain, nausea, pain in left arm/jaw, dyspnoea, diaphoresis, fatigue
D: Trop I and Trop T, CK-MB (reinfarction)
T: Morphine, Oxygen, Nitrates, Aspirin
Fibrinolytic agents, angioplasty, PCI (stent)

Question 2

Heart failure

Answer 2

Syndrome that results from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump and maintain sufficient cardiac output.
C: Ischaemic heart disease, Cardiomyopathy, Hypertension
Types: LVSD, RVSD (secondary), diastolic
S: Exertional dyspnoea, Orthopnoea, Paroxysmal nocturnal dyspnoea, fatigue, rasied JVP, oedema, tachycardia, pleural effusion.
D: CXR, ECG, echocardiogram, BNP, FBC, LFTs, TFTs, glucose, U&Es
T: lifestyle changes, ACEi, ARBs if not tolerated, Isosorbide mononitrate, β-Blockers, Diuretics, Digoxin if also have AF, Cardiac resynchronization therapy, Implantable cardioverter–defibrillator

Question 3

Hypertension

Answer 3

Persistently elevated blood pressure
Stage 1: more than 140/90mmHg
Stage 2: more than 160/100mmHg
Stage 3: more than 180/110mmHg
C: essential (unknown), chronic kidney disease, adrenal cortical adenoma, coarctation of the aorta, OCP
S: asymptomatic, headaches, visual disturbance, end organ damaged caused by hypertension
D: cardiovascular exam, blood tests, ECG, QRISK
T: Lifestyle changes
1) Under 55 who are not A/AC - ACEi/ARB
Over 55 or A/AC - CCB/TLD
2) Under 55 who are not A/AC - add CCB/TLD
Over 55 or A/AC - ACEi/ARB or TLD
3) Combination of ACEi/ARB, CCB, TLD
4) Resistant hypertension

Question 4

Tetralogy of Fallot

Answer 4

Four heart abnormalities: Pulmonary stenosis (narrowing), Right ventricular hypertrophy, Ventricular septal defect (shunting between ventricles), aorta override the septal defect
Usually in VSD, blood shunts from left to right, in TOF, blood shunts from right to left.
S: cyanosis, clubbing, failure to feed, gain weight and develop normally, squatting during a ‘tet spell’ to increase vascular resistance and encourage shunting left to right
D: Echocardiography
T: keep calm, give oxygen and fluids, cardiac repair surgery within the first year to close VSD and enlarge the RV outflow tract

Question 5

Cor Pulmonale

Answer 5

Cor pulmonale occurs when a lung disorder causes right-sided heart dysfunction which can lead to right-sided heart failure.
Hypoxic vasocontriction occurs (when an alveoli is poorly ventilated, the blood surrounding it vasoconstricts to divert blood away. If this occurs in lots of alveoli, all blood vessels vasoconstrict, increasing resistance and cause pulmonary hypertension.)
C: damage to lung tissue, damage to pulmonary vessels, defect of spine/ribcage e.g. kyphoscoliosis
S: Dyspnoea, fatigue, fainting, hepatomegaly, oedema
D: Echocardiogram, spirometry, right heart catherisation
T: Treat lung condition, supplemental oxygen

Question 6

Acute rheumatic fever

Answer 6

Inflammatory disease that can damage the heart tissue. Develops after streptococcal pharyngitis, antibodies against strep attack cells in the heart, skin, joints and brain.
S: Migratory polyarthritis, Pancarditis, Endocarditis, Myocarditis, Pericarditis, Subcutaneous nodules, Erythema marginatum (rings on skin), Sydenham chorea (rapid movements in face and arms), fever
D: FBC, ESR
T: Rest, Penicillin (or erythromycin or a cephalosporin), aspirin for joint pain, diazepam for chorea, diuretics, ACEi, digoxin for heart failure.

Question 7

Myocarditis

Answer 7

Inflammation of myocardium - the muscular middle layer of the heart wall, reduces cells’ ability to contract.
Can lead to heart failure.
C: viral infection (Coxsackie B), Trichinella, Lyme disease, Toxoplasma gondi, SLE, drugs, Giant-cell myocarditis
S: Chest pain, arrhythmias, fatigue, fever, dyspnoea.
D: Trop, CK, ECG (sinus tachycardia, T-wave inversion, saddle-shaped ST elevation), CXR, echocardiogram.
T: Rest, analgesia, antibiotics if bacterial, pacemaker for arrhythmias, steroids if giant cell.

Question 8

Dilated cardiomyopathy

Answer 8

New sarcomeres are added into the walls of the myocardium, giving chambers with thin walls and a larger volume.
Weak contractions, less blood pumped, lowered stroke volume. This can lead to biventricular systolic congestive heart failure.
C: Idiopathic, genetic, infection, alcohol abuse, drugs, vitamin D deficiency
S: Dyspnoea, peripheral oedema, fatigue, palpitations
D: ECG, echocardiogram, CXR
T: Lifestyle changes, ACEi, diuretics, b-blockers, left ventricular assist device (LVAD), cardioversion, pacemakers, heart transplant.

Question 9

Hypertrophic cardiomyopathy

Answer 9

Myocardial walls get thick, heavy and hypercontractile.
New sarcomeres are added in parallel to existing sarcomeres. Less blood can fill and become less compliant.
C: Autosomal dominant trait due to a missense mutation in B-myosin heavy chain, myosin binding protein C or Troponin T, Friedreich’s ataxia
S: Dyspnoea, syncope, arrhythmias, crescendo-decrescendo murmur, bifid pulse
D: ECG, CXR, echocardiogram, catherisation, doppler ultrasound scan
T: lifestyle changes, anti-arrhythmics like amiodarone, anticoag, B-blockers, CCB like verapamil or diltiazem, surgery, heart transplant.

Question 10

Restrictive cardiomyopathy

Answer 10

Myocardium becomes stiffer and less compliant.
Muscles remain the same size, or only slightly larger.
Ventricles cannot expand, meaning less blood fills, less blood is pumped out. Can lead to diastolic HF.
C: Amyloidosis, Sarcoidosis, Endocardial fibroelastosis, Loffler endocarditis, haemochromatosis, radiation
S: dyspnoea, fatigue, loud third heart sound, pulmonary oedema, murmurs due to valve incompetence, oedema, ascites, hepatomegaly.
D: ECG, CXR, blood tests, echocardiogram, cardiac catherisation, cardiac magnetic resonance, biopsy.
T: treat underlying cause, diuretics and ACEi for HF, anticoag, b-blockers and CCB for rate control, implantable cardioverter defibrillator, heart transplant.

Question 11

Atrial fibrillation

Answer 11

A heart condition that causes an irregular and often abnormally fast heart rate.
Can be paroxysmal, persistent (more than 7 days), long-standing (more than 12 months), permanent.
C: CAD, MI, HT, abnormal heart valves, congenital heart defects, sick sinus syndrome, hyperthyroidism.
S: Palpitations, fatigue, chest pain, dyspnoea, feeling dizzy.
D: ECG, 24-hour ambulatory ECG, blood tests, CXR, echocardiogram, transoesophageal echocardiography.
T: emergency electrical cardioversion if haemodynamically unstable, lifestyle changes, CHA2DS2-VASc, HAS-BLED, anticoag, b-blockers, cardioversion, catheter ablation, pacemaker.

Question 12

Cardiac sarcoma

Answer 12

Cardiac sarcoma is a rare primary malignant tumour.
C: Unknown
S: Peripheral oedema, raised JVP, chest pain, fatigue, dyspnoea, palpitations, haemopytosis, heart rhythm problems, upper facial congestion.
D: ECG, echocardiogram, CT/MRI, CXR, cardiac catherisation, biopsy.
T: surgery, heart transplantation, autotransplantation.

Question 13

Raynauld’s disease

Answer 13

Overstimulation causes vasoconstriction of arteries near the skin causing an area of the body to turn white, blue and then red in response to a trigger with no associated disease.
Triggers include cold, caffeine, stress, nicotine, medications that affect the sympathetic NS.
Seconday is associated with SLE, scleroderma and vasculitis.
S: colour changes in fingers and toes, numbness, tingling and pain.
D: symptoms, Nailfold capillary microscopy.
T: Avoid triggers, CCB, surgery to cut sympathetic nerve supply.

Question 14

Vasculitis

Answer 14

Inflammation of the blood vessels, most commonly the arteries, typically due to an autoimmune response.
S: fatigue, weight loss, fever, organ-specific symptoms
GIANT CELL ARTERITIS - in carotid arteries (temporal - headaches, ophthalmic - visual disturbance, facial - claudication in jaw)
D: ESR, biopsy
T: corticosteroids
TAKAYASU ARTERITIS - in aortic branches (upper extremities - weakened pulse, head - visual/neuro symptoms)
D: ESR, biopsy
T: corticosteroids
KAWASAKI DISEASE - in coronary arteries
POLYARTERITIS NODOSA - attack endothelium (renal arteries - hypertension, mesenteric arteries - abdo pain and GI bleed, brain arteries - neuro, skin arteries - lesions)
T: corticosteroids
BUERGER’S DISEASE
Causes blood clots in the tiny arteries of the fingers and toes, leads to ulcers and autoamputation.
Caused by ANCAs.
GRANULOMATOSIS WITH POLYANGIITIS
cANCAs attack proteinase 3 in neutrophils which causes them to produce free radicals.
Nasopharynx (chronic pain, bloody mucus, saddle nose deformity), lungs (difficulty breathing, bloody cough), kidneys (hypertension, decreased urine).
T: corticosteroids, cyclophosphamide
MICROSCOPIC POLYANGIITIS
Similar to GPA but pANCA instead, no nasopharynx.
CHURG-STRAUSS SYNDROME
Caused by pANCAs.
Sinusitis, lung, kidney, gastrointestinal, skin, nerve and heart damage.
HENOCH-SCHONLEIN PURPURA
No ANCAs, elevated IgA antibodies.
Palpable purpura on buttocks and legs, abdo pain, haematuria. Resolves on its own.

Question 15

Infective endocarditis

Answer 15

An infection of the endocardium or vascular endothelium of the heart. Can be acute (usually in structurally normal hearts), but is more commonly insidious and known as subacute bacterial endocarditis (usually structurally abnormal hearts).
C: Streptococcus viridans (usually subacute), Staphylococcus aureus (usually acute) and enterococci (usually subacute) through IV drug users, poor dental hygiene, endoscopy, cystoscopy, catherisation.
S: fever, night sweats, malaise, worsening heart failure or new murmur, metastatic abscess formation in the brain, spleen and kidney, splinter haemorrhages, Roth’s spots, arthralgia, acute glomerulonephritis
D: blood cultures, Transthoracic echocardiography, Transoesophageal echocardiography, CXR, ECG
T: Bactericidal antibiotics given IV for 2 weeks and orally for further 2-4 weeks.
Type of antibiotics depends on microorganism.
Surgery may be needed to repair the valve.

Question 16

Mitral Stenosis

Answer 16

A valvular heart disease characterized by the narrowing of the mitral valve of the heart.
Usually due to previous rheumatic heart disease.
Prevents free flow of blood from the left atrium into the left ventricle during ventricular diastole, leads to an increase in left arterial pressure, pulmonary hypertension and right heart dysfunction.
S: exertional dyspnoea, productive cough with blood-tinged sputum, AF, pulmonary oedema, fatigue.
D: a loud first heart sound, an opening snap followed by a rumbling mid diastolic murmur, CXR, ECG, echocardiogram.
T: B-blockers/digoxin for atrial fibrillation, Diuretics for heart failure, Anticoagulation for atrial fibrillation.
If severe, percutaneous balloon valvotomy or mitral valve replacement.

Question 17

Mitral regurgitation

Answer 17

A condition in which the mitral valve does not close completely causing blood to leak back to the left atrium when left ventricle contracts. A rise in left atrial pressure, resulting in an increase in pulmonary venous pressure and pulmonary oedema
C: Rheumatic heart disease, mitral valve prolapse, infective endocarditis, ruptured or dysfunctional chordae tendineae or the papillary muscle, MI, Hypertrophic cardiomyopathy.
S: pulmonary oedema, exertional dyspnoea, fatigue, lethagy, symptoms of RHF.
D: soft first heart sound, pansystolic murmur, CXR, ECG, echocardiography, doppler.
T: Serial echocardiograms every 1–5 years, diuretics, ACEi, surgery, particularly if there is atrial fibrillation and/or pulmonary hypertension.

Question 18

Aortic regurgitation

Answer 18

The leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole, from the aorta into the left ventricle.
C: disease of the valve cusps or dilatation of the aortic root and valve ring, infective endocarditis, rheumatic fever.
S: Left ventricular heart failure - dyspnoea, orthopnoea, fatigue, collapsing pulse, displaced apex beat, diastolic early decrescendo murmur.
D: CXR, ECG, Echocardiography with Doppler examination, cardiac catherisation
T: Vasodilators and diuretics can be used to reduce the afterload
ACEIs are used in patients with left ventricular dysfunction
Surgery and aortic valve replacement if needed

Question 19

Aortic stenosis

Answer 19

A narrowing of theaorticvalve opening causing restriction of the blood flow from the left ventricle to theaortaand consequent effects on the pressure in the left atrium.
C: Degeneration and calcification of a normal valve, Calcification of a congenital bicuspid valve, rheumatic heart disease
S: Asymptomatic, angina, exertional syncope, and dyspnoea, ventricular arrythmias.
D: Harsh systolic ejection murmur and soft and inaudible second heart sound, CXR, ECG, echocardiogram, cardiac catheterization.
T: Aortic valve replacement, If patients cannot have open valve replacement, transcatheter aortic valve implantation (TAVI) with a balloon expandable stent valve.

Question 20

Pericardial effusion and tamponade

Answer 20

Pericardial effusion is an accumulation of fluid in the pericardial sac which may result from any of the causes of pericarditis.
C: viral infection (Coxsackie B, echovirus, HIV infection), MI, uraemia, autoimmune rheumatic diseases, trauma, infection (bacterial, tuberculosis, fungal) and malignancy (breast, lung, leukaemia and lymphoma).
S: Obsured apex beat, soft heart sounds, tamponade - hypotension, tachycardia and an elevated JVP, which paradoxically rises with inspiration (Kussmaul’s sign).
D: CXR, ECG, echocardiography.
T: Most resolve spontaneously, Pericardiocentesis (aspiration of fluid under echocardiographic guidance using a needle into the pericardial sac). If recurrent, excision of a pericardial segment allows fluid to be absorbed through the pleural and mediastinal lymphatics

Question 21

Pericarditis

Answer 21

Inflammation of the pericardial sac and often can cause fluid accumulation. Influx of neutrophils & inflammatory mediators change the permeability of pericardium causing inflammation.
C: enterovirus, herpesvirus (EBV, CMV), adenoviruses, Sjogren syndrome, rheumatoid arthritis, scleroderma, mycobacterium tuberculosis, secondary metastasis tumors.
S: left-sided severe sharp pleuritic chest pain relieved with sitting forward, dyspnoea, coughing, fever, malaise, Pericardial rub (crunching snow), effusion
D: ECG (diffuse ST elevation & PR depression), FBC
T: NSAID (ibuprofen/aspirin) for 1-2 weeks, Colchicine to reduce risk of reoccurrence

Question 22

Ventricular tachycardia

Answer 22

SVTs arise from the atrium or the atrioventricular junction.
Atrioventricular nodal re-entry tachycardia - circus movement due to different conduction times and refractory periods
Atrioventricular reciprocating tachycardia - presence of accessory pathway that allows for antegrade or retrograde conduction e.g. WPW
S: rapid regular palpitations, dizziness, dyspnoea, central chest pain, syncope
D: ECG
T: Unstable patient - cardioversion
Haemodynamically stable - increase vagal stimulation using the Valsalva manoeuvre or right carotid massage, adenosine or IV verapamil or B-blockers.
LT…
Radiofrequency ablation via a cardiac catheter
Flecainide, verapamil, sotalol and amiodarone are the most commonly used drugs

Question 23

Aneurysm

Answer 23

Aneurysm - abnormal bulge in the blood vessel (usually arteries)
If this occurs symmetrically, they are known as fusiform aneurysms.
If this occurs asymmetrically, they are known as saccular or berry aneurysms.
C: weakness in the wall due to atherosclerosis, infection, genetic conditions which affect the body’s use of fibrillin or collagen.
S: AAA - severe left flank pain, pulsating mass, hypotension, TAA - asymptomatic, severe back/abdo pain
D: Incidental, ultrasound, CT/MRI
T: Surgery

Question 24

Deep vein thrombosis

Answer 24

Blood clot in a deep vein that runs between the muscles, commonly in the lower leg below the knee.
C: Virchow’s triad - stasis, hypercoagulation (genetics, birth control, damage in surgery), damage to endothelial lining (chronic inflammation, infections or toxins)
S: pain, swelling, redness and warmth, dyspnoea and chest pain if there is a PE
D: Ultrasound, venography
T: Small clots will resolve on their own, large clots require thrombolytic enzymes or thrombectomy (surgically remove the clot), anticoagulant medications like Warfarin or Heparin, a filter can be placed in the inferior vena cava to prevent pulmonary embolism

Question 25

Angina

Answer 25

Reduced blood flow to the heart - ischaemia.
Stable (on exertion), Unstable (at rest) - emergency, Vasospastic angina (aka Prinzmetal) (any time)
C: Atherosclerosis of one or more of the coronary arteries, hypertrophic cardiomyopathy, aortic stenosis, hypertension.
S: pressure or squeezing and it can radiate to the left arm, jaw, shoulder and back, dyspnoea and diaphoresis. Usually subside within 20 mins.
D: ECG (ST depression), BP, cholesterol, coronary angiography,
T: Nitroglycerin (vasodilator), calcium channel blockers, b blockers, statins and aspirin to reduce risk of MI. Surgery includes CABG and PCI.

Question 26

Venticular septal defect

Answer 26

Gap in the ventricular septum after development due to inadequate fusing. Causes a left to right shunt (Oxygenated blood takes an extra trip to the lungs)
C: Spontaneous, associated with foetal alcoholic syndrome, Down’s syndrome and other cardiac deformities.
S: asymptomatic, holosystolic murmur, pulmonary hypertension on the right side, if there is a major pressure change and the right sided pressure is greater than the left there may be a right to left shunt (Eisenmenger syndrome) - cyanosis
D: heart sounds, echocardiogram, ECG, O2 sats
T: May resolve spontaneously, surgery if symptomatic

Question 27

Atrial septal defect

Answer 27

The foetus receives oxygen from the placenta, which travels through the umbilical vein to the right atrium and heads straight to the left atrium to the lung via foramen ovale. ASD occurs when FO doesn’t close.
C: Spontaneous, associated with foetal alcoholic syndrome, Down’s syndrome and other cardiac deformities.
S: Left to right shunt (acyanotic), asymptomatic, shortness of breath, fatigue, heart palpitations.
D: Echocardiogram, ECG, cardiac catherisation, CXR, heart sounds (ejection systolic murmur and a fixed split of S2)
T: May resolve spontaneously, surgery if symptomatic

Question 28

Patent ductus arteriosus

Answer 28

DA connects the pulmonary artery and the aorta during development. Supposed to close and become the ligamentum arterisus, sometimes it doesn’t. Causes a left to right shunt (Oxygenated blood takes an extra trip to the lungs).
C: Spontaneous or Congenital Rubella syndrome.
S: asymptomatic, pulmonary hypertension on the right side, if there is a major pressure change and the right sided pressure is greater than the left there may be a right to left shunt (Eisenmenger syndrome) - cyanosis.
D: heart sounds (systolic ejection murmur), echocardiogram, ECG, CXR
T: Indomethacin can be used to close the ductus arteriosus because it inhibits Prostaglandin E2.
Surgical ligation.

Question 29

Coarctation of the Aorta

Answer 29

Narrowing of the aorta. Infant and adult form.
C: Spontaneous or associated with Turners Syndrome and other congenital heart changes.
S: Infants - causes pressure changes which pushes blood hrough the PDA to the systemic circulation and eventually the lower extremities (cyanosis), Adults - increased blood flow to the aortic branches which means there is increased pressure in the head and upper extremities and low pressure in the lower extremities (risk of berry aneurysms and aortic dissection, weak pulse and claudication in legs, activation of RAAS - hypertension, rib notching in ribs 3 and 4).
D: echocardiogram, ECG, CXR, cardiac catherisation
T: Balloon dilation - used to widen the aorta or narrow area surgically removed

Question 30

Varicose veins

Answer 30

Leakage in a valve causes retrograde flow back into the vein, increasing pressure, causing veins to become tortuous and dilated.
C: Genetic predisposition, pregnancy, DVT, tumours, cirrhotic liver
S: Itching, discomfort and heaviness of the legs, night cramps, oedema, burning sensations, paraesthesia, exercise intolerance, or restless legs.
D: Duplex ultrasound (doppler and ultrasound)
T: Lifestyle changes, compression stockings, Endothermal ablation, Ultrasound-guided foam sclerotherapy, Avulsion, Stripping of the vein, Ambulatory phlebectomy

Question 31

Peripheral vascular disease

Answer 31

Progressive disease with diverse pathophysiology but centres on damage, inflammation and structural defects of the blood vessels.
C: Atherosclerosis and conditions such as degenerative disorders, vascular inflammation and thrombosis.
S: Intermittent claudication, critical leg ischemia, acute limb ischemia, carotid artery disease, abdominal artery disease, weak pulses, cold pale skin, punched out ulcers.
D: Fontaine Classification, FBC, U&E and ECG, Duplex Ultrasound, Ankle Brachial Pressure Index (ABPI)
T: Lifestyle modification, hypertension treatment and antiplatelet prophylaxis, claudication managed with supervised exercise programmes, consider percutaneous transluminal angioplasty, surgical reconstruction or amputations.

Question 32

Hypotension

Answer 32

Systolic BP less than 90 mm Hg or diastolic BP less than 60 mm Hg.
Types include postural (common in elderly) - a drop in BP (usually >20/10 mm Hg) within three minutes of standing, acute, chronic, postprandial (a decline in systolic arterial pressure of 20 mm Hg or a systolic arterial pressure less than 90 mm Hg, within two hours)
C: Acute (septic, cardiogenic, hypovolaemic, anaphylactic or neurogenic shock), Chronic (primary or second adrenal insuffficency)
S: dizziness, light-headedness, blurred vision, weakness, fatigue, nausea, palpitations and headache.
D: FBC, U&Es, Fasting glucose, pregnancy test, ECG, echocardiogram.
T: Postural - avoid triggers, review medication, positioning advice, increase salt intake, Midodrine, fludrocortisone, droxidopa, octreotide and pyridostigmine.
Acute - Airways, O2, IV fluids, treat underlying cause

Question 33

Phlebitis/thrombophlebitis

Answer 33

Superficial vein (usually the long saphenous vein of the leg or its tributaries) becomes inflamed and the blood within it clots.
C: Risk factors include obesity, thrombophilia, smoking, oral contraceptives, pregnancy, IV drug abuse, IV infusion, injury
S: Redness and tenderness along the vein with swelling
D: Ultrasound, blood tests (D dimer)
T: Elastic support, warm compresses, exercise, topical analgesia, Heparin gel or heparinoid cream, Low molecular weight heparin, Fondaparinux to reduce the risk of PE/DVT

Question 34

Arterial thrombosis

Answer 34

Blood clot in an artery.
C: Usually the result of atheroma, which forms particularly in areas of turbulent blood flow, such as the bifurcation of arteries. Arterial emboli may also form in the left ventricle after myocardial infarction, in the left atrium in mitral valve disease, or on the surface of prosthetic valves.
S: Asymptomatic until MI, stroke, TIA, critical limb ischemia.
D: Blood tests (trop), ECG, CT/MRI
T: Aspirin, Dipyridamole, Clopidogrel,
Antibodies (e.g. abciximab), peptides (e.g. eptifibatide) and non-peptide antagonists (e.g. tirofiban), Statins, Lifestyle advice, Epoprostenol

Question 35

Acute limb ischaemia

Answer 35

Acute thrombotic occlusion of a previously partially occluded, thrombosed arterial segment, or to embolus from a distant site.
C: Embolism, Acute/Chronic thrombosis, Trauma, Raynauld’s syndrome, Compartment syndrome, Congential
S: Pale, Pulseless, Painful, Paralysed, Paraesthetic, Perishing with cold
D: Doppler ultrasound, Blood tests, ECG, Echocardiogram, Aortic ultrasound, Popliteal and femoral artery ultrasound
T: Open surgery, Angioplasty, Heparinisation. If the occlusion is embolic, surgical embolectomy or local intra-arterial is needed. If the occlusion is thrombotic,intra-arterial thrombolysis, angioplasty or bypass surgery is needed., Systemic anticoag, Lifestyle changes. If irreversible - amputation.

Question 36

Trifasicular block

Answer 36

Conducting disease in Right bundle branch (RBB), Left anterior fascicle (LAF) and Left posterior fascicle (LPF).
C: Ischaemic heart disease, Hypertension, Aortic stenosis, Anterior MI, Lenègre-Lev disease, Congenital heart disease, Hyperkalaemia, Digoxin toxicity
S: palpitations, presyncope and syncope, heart failure symptoms, and sudden cardiac death.
D: ECG (complete AV block with a slow ventricular escape rhythm with a wide, bizarre QRS; (2) alternating RBBB and LBBB; and (3) fixed RBBB with alternating LAF and LPF block.)
T: Usually no treatment. But 50% lifetime need for a permanent pacemaker in the setting of atrifascicular block.

Question 37

Ventricular ectopic premature beats

Answer 37

The ectopic electrical activity is not conducted to the ventricles through the normal conducting tissue.
C: Decongestants and antihistamines, Alcohol, Drugs, caffeine, tobacco, exercise or anxiety, injury to the heart muscle from coronary artery disease, congenital heart disease, high blood pressure or heart failure
S: Asymptomatic, fluttering/pounding in the chest, skipped beats or missed beats, increased awareness of heartbeat.
D: ECG (QRS complex is widened with bizarre configuration)
T: Lifestyle changes, Beta-blockers, calcium channel blockers or anti-arrhythmic drugs such as amiodarone or flecainide, Radiofrequency catheter ablation

Question 38

First-degree AV block

Answer 38

This is the result of slight delay in atrioventricular conduction and is reflected by a prolonged PR interval (>0.22 s) on the ECG.
C: Fit people, Myocarditis, Hypokalaemia, Hypomagnesaemia, Antiarrythmics, Ca channel blockers, beta blockers, digoxin
S: Asymptomatic
D: Blood tests, ECG, Echocardiogram
T: No treatment necessary

Question 39

Second-degree AV block

Answer 39

Atrial impulses fail to reach the ventricles.
Mobitz type I (Wenckebach) - AV node block and results in progressive PR interval prolongation until a P wave fails to conduct
Mobitz type II - an infra-nodal level so the QRS is widened and QRS complexes are dropped without PR prolongation
C: MI damage, Lyme disease, Ca channel blockers and beta blockers, Amiodarone, Pentamidine
S: Type I (Light-headedness, dizziness, fainting), Type II (Chest pain, shortness of breath, fatigues easily, dizziness)
D: Blood tests, ECG, Echocardiogram
T: Only needed when symptomatic - Transcutaneous pacing to restore normal heartbeat

Question 40

Third-degree AV block

Answer 40

Complete heart block occurs when there is complete dissociation between atrial and ventricular activity; P waves and QRS complexes occur independently of one another and ventricular contractions.
C: Complication of heart surgery or radiotherapy, Coronary heart disease, Diphtheria or rheumatic fever, poorly controlled hypertension, trauma, metastatic cancer, digoxin, Ca channel blockers, Beta blockers, tricyclic antidepressants, clonidine.
S: Pale and blotchy skin, Lethagry, Dizziness, Fainting (in babies), Lightheadedness, Dizziness, Fainting, Chest pain, Bradycardia
D: Blood tests, ECG, Echocardiogram
T: Only needed when symptomatic - Transcutaneous pacing to restore normal heartbeat

Question 41

Paroxysmal supraventricular tachycardia

Answer 41

Generally refers to atrioventricular nodal re-entry tachycardia (AVNRT), atrioventricular re-entry tachycardia (AVRT) and atrial tachycardia. Abnormalities of impulse conduction (re-entrant tachycardias) or disorders of impulse initiation (automatic tachycardias) causing a narrow complex tachycardia.
C: MI, Mitral valve prolapse, Congenital heart disease, previous cardiac surgery, rheumatic heart disease, pericarditis, pneumonia, chronic lung disease, alcohol, digoxin toxicity.
S: Asymptomatic, syncope, palpitations, lightheadedness, neck pounding, fatigue, chest discomfort, dyspnoea, polyuria, pulse of 145-250 bpm.
D: ECG, FBC, U&Es, TFTs, Digoxin level, CXR, Echocardiogram
T: Direct cardioversion is haemodynamically unstable, if haemodynamically stable, Valsalva manoeuvre, Carotid massage, Facial immersion in cold water
IV adenosine or verapamil.
AVNRT: Radiofrequency catheter ablation, beta-blockers, Valsalva manoeuvre
AVRT: Cardiac electrophysiologist
Review medication and avoid triggers.

Question 42

Ventricular fibrillation

Answer 42

An abnormal heart rhythm in which the ventricles of the heart quiver instead of pumping normally.
C: MI, ischaemia, chronic infarction scar, AF, hypoxia, electrical shock, antiarrthymics, pre-existing heart disease
S: Chest pain, fatigue, palpitations, non-specific complaints
D: Cardiac enzymes, ECG, toxiology screen, electrolytes, CXR, Echocardiogram, Nuclear imaging techniques, Coronary angiogram
T: Cardioversion, B blockers, treatment of background heart conditions, Implantable cardioverter defibrillators
Radiofrequency ablation, CABG if ejection fraction is normal.

Question 43

Tricuspid valve disease

Answer 43

Tricuspid stenosis is almost always the result of rheumatic fever and is frequently associated with mitral and aortic valve disease, which tends to dominate the clinical picture.
Tricuspid regurgitation is usually functional and secondary to dilatation of the right ventricle in right ventricular failure.
C: rheumatic heart disease, infective endocarditis or carcinoid syndrome
S: elevated JVP, pansystolic murmur heard at the lower left sternal edge, the liver is enlarged and pulsates in systole, peripheral oedema, ascites.
D: Heart sounds, ECG
T: Diuretics

Question 44

Pulmonary valve disease

Answer 44

Pulmonary stenosis is usually a congenital lesion but may present in adult life with fatigue, syncope and right ventricular failure.
Pulmonary regurgitation results from pulmonary hypertension and dilatation of the valve ring.
C: endocarditis (usually in IV drug users)
S: early diastolic murmur heard at the upper left sternal edge, asymptomatic
D: Heart sounds, ECG
T: Rarely required

Question 45

Angiosarcoma

Answer 45

Aggressive malignant tumour of a blood or lymphatic vessel. Arise from the endothelium when they proliferate abnormally. Commonly occurs in skin, bone, soft tissue, breast, liver and lungs.
C: Chronic lymphedema - when lymph nodes have been removed or damaged (cancer, infection, genetic, Vinyl chloride gas found in PVC manufacturing and arsenic insecticide.
S: Purple raised area (skin), pain and swelling, prickling or numbness if affecting veins, palpable masses, fatigue, abdominal pain (liver), chest pain and difficulty breathing (lungs).
D: Biopsy of the mass, MRI/CT scan
T: Surgery, Chemotherapy, Radiotherapy

Question 46

Bundle Branch Block

Answer 46

WILLIAM MARROW
Right bundle branch block: sequential spread of an impulse resulting in a large terminal R wave in V1 (M) and a slurred S wave in V5 and V6 (W)
Left bundle branch block: the opposite occurs with an QS (no R) or rS (small R) complex in V1 (W) and a notched wave in V6 (M).
C: pulmonary embolus, right ventricular hypertrophy, ischaemic heart disease and congenital heart disease (right), aortic stenosis, hypertension, severe coronary artery disease and following cardiac surgery (left).
S: Asymptomic or syncope.
D: ECG (wide QRS >120 msec)
T: If present since birth, usually no treatment. If acquired through heart failure, you can implant a cardiac resynchronisation pacemaker with electrical leads to both the left and the right ventricles, pacing them at the same time.

Question 47

Mitral valve prolapse

Answer 47

An abnormal bulging of one or both of the mitral valve leaflets into the left atrium.
C: Marfan’s syndrome, Ehlers-Danlos syndrome, Osteogenesis imperfecta, Small left ventricular capacity, Unrepaired atrial defects, Adult polycystic kidney disease, Genetic factors
S: Asymptomatic but can cause mitral regurg. Dynamic mid-to-late systolic click, often followed by a late systolic mitral regurgitant murmur.
D: Echocardiography, heart sounds, ECG
T: Low risk - a trial of beta-blockers and abstinence from caffeine, alcohol and cigarettes. High risk - monitoring and surgical repair or replacement of the valve may be needed.

Question 48

Abdominal aortic aneurysm

Answer 48

An aneurysm is a permanent and irreversible dilatation of a blood vessel by at least 50% of the normal expected diameter. Aortic aneurysms can be thoracic or abdominal.
C: trauma, infection, inflammatory disease, connective tissue disorders, non-specific (lifestyle choices, hypertension, COPD, hyperlipidaemia, diabetes)
S: Unruptured (usually asymptomatic), Ruptured (Pain in the back, abdomen, loin or groin, syncope, shock or collapse, pulsatile abdominal swelling).
D: FBC, clotting, CRP, renal and liver function, cross-match
T: Uncomplicated (regular ultrasound, treat underlying conditions, lifestyle changes, consider surgical repair if fit for surgery)
Ruptured (IV access, group and save, emergency endovascular aneurysm repair)