Cardiovascular Flashcards
1
Q
What are some key differentials for acute chest pain?
A
MI PE Aortic Dissection Pericarditis Pneumothorax Trauma Panic attack
2
Q
What are some differentials for subacute chest pain?
A
Sick cell crisis Cardiac tamponade Aortic aneurysm HOCM Myocarditis
3
Q
What are some chronic causes of chest pain?
A
Angina Pneumonia Aortic stenosis Referred pain from GI tract Neoplasms Congenital heart defects Arrhythmia
4
Q
What can cause palpitations?
A
Arrhythmia Septal defects Cardiomyopathy Congestive heart failure Mitral valve prolapse Valvular Disease
Anaemia Electrolyte imbalance Hyperthyroid Hypoglycaemia Hypovolaemia Phaeochromocytoma
Drugs - alcohol, caffeine, tobacco, prescription etc.
Anxiety
5
Q
What is syncope? (what 3 things must it be)
A
Transient
Loss of consciousness
Due to global cerebral hypoperfusion (typically hypotension)
6
Q
What key things do you want to know in a syncope history
A
5P’s and 5C’s
Prodrome Precipitant Palpitation Position Post event
Colour Convulsions Continence Cardiac hx Cardiac FH of sudden death
7
Q
What are the types of syncope?
A
Neurally mediated
Postural
Arrhythmia induced
Structural
8
Q
What is neurally mediated syncope and what are the types?
A
Inappropriate autonomic response to a trigger
Vasovagal
Situational
Carotid sinus hypersensitivity
9
Q
What is postural syncope?
A
Happen due to insufficient barereceptor response to standing up. Due to:
- Autonomic failure secondary to drugs
- Hypovolaemia
- Primary autonomic failure - Parkinson’s/lewy body
- Secondary autonomic failure - diabetes, uraemia, spinal cord lesions
10
Q
What is structural syncope?
A
Mechanical obstruction to LV inflow or outflow meaning systemic vasculature can’t compensate to exercise. Causes include:
- Valvular - aortic stenosis
- Mass - atrial myxoma
- HOCM
- Constrictive pericarditis
- Non-cardiac - PE/aortic dissection
11
Q
Give some causes for limb pain and swelling? (VITAMIN D)
A
Vascular - DVT, varicose veins, IVC obstruction, PVD, congestive heart failure
Infection/inflammation - cellulitis, septic arthritis, osteomyelitis
Trauma - compartment syndrome, rhabdo,
Autoimmune - rheumatoid
Metabolic - gout, vit D deficiency, hypoproteinaemia
Multiple - lymphoedema, bakers cyst, AKI/CKD
Neoplasms
Drugs - statins, calcium blockers, NSAIDs
Degenerative - Osteoarthritis
12
Q
What is type 1 heart block
A
PR >0.2s Regular Not dangerous itself but can indicate pathology: - coronary artery disease - digoxin poisoning - electrolyte disturbance
13
Q
What are the types of 2nd degree heart block?
A
Mobitz type 1:
- PR interval progressively increase until one is dropped
- cyclical
- Not dangerous but can indicate pathology
Mobitz type 2:
- Normal PR constant
- Cyclically drop QRS
- Can lead to complete heart block
14
Q
What is type 3 heart block?
A
Atrial contraction normal but not conducted to ventricles
Can occur acutely after MI or also due to bundle of his fibrosis
15
Q
What are the features of a complete heart block?
A
- QRS rate slow 36bpm - bradycardia
- p wave rate normal
- no relationship between p and QRS
- Wide QRS
- Syncope
- Heart failure
- Wide pulse pressure
- JVP - cannon wave
16
Q
What are some indications for temporary pacemakers?
A
Symptomatic/haemodynamically unstable bradycardia not responding to atropine
Post anterior MI - type 2 or complete heart block
Trifascicular block prior to surgery
17
Q
What is a bi/trifascicular heart block?
A
Bifascicular block:
- RBBB + Left anterior or posterior fascicle block
= RBBB + Left/Right axis deviation
Trifascicular block:
- RBBB + left/right axis deviation + first degree heart block
18
Q
What happens in a bundle branch block?
A
Depolarisation reach inter ventricular septum but spread across septum is altered:
- Normal PR
- Wide QRS
19
Q
How do left and right bundle branch blocks appear?
A
WilliaM MarroW
Left = W in V1, M in V6 Right = M in V1 W in V6
Newfound LBBB with chest pain may indicate MI or aortic stenosis
20
Q
Which factors would make rate control more appropriate for AF?
A
Older than 65
Hx of ischaemic heart disease
21
Q
Which factors would make rhythm control appropriate for AF?
A
<65yo Symptomatic First presentation Lone AF or secondary to corrected precipitant Congestive heart failure
22
Q
How long should a patient be anti coagulated for before treatment for AF?
A
4 weeks
Can do treatment immediately if echo done to confirm no thrombus present (emergency)
23
Q
Give some key complications of catheter ablation in AF?
A
Cardiac tamponade
Stroke
Pulmonary valve stenosis
24
Q
When is cardioversion considered in AF?
A
Haemodynamically unstable
Haemodynamically stable but rhythm control preferred
Anticoagulate for 4 weeks after cardioversion
25
What time period is used to determine whether cardioversion is considered?
<48 hr - heparinise and DC cardiovert or chemical cardiovert
>48h - >3wk anticoagulation or TOE to confirm no thrombus
26
What would make a patient a high risk of cardioversion failure? What should be done?
Previous failure
AF recurrence
>4 wks amiodarone or sotalol before DC cardioversion
27
What is Wolf Parkinson White?
Accessory bundles form a direct connection from the atria to the ventricles
There is no AVN to delate condition meaning there is early pre-excitation of the ventricles
28
How does WPW appear on ECG?
```
Sinus rhythm
Short PR
Delta wave on QRS - slurred upstroke
Short QRS
Right/Left axis deviation
```
29
What is WPW associated with?
```
HOCM
Mitral valve prolapse
Ebsteins anomoly
Thyrotoxicosis
Secundum ASD
Paroxysmal tachycardia - can lead to VT and VF
```
30
How is WPW managed
Ablation of accessory pathway
| Medical - Sotalol, amiodarone, flecainide
31
Why should sotalol be avoided in WPW if a patient also has AF?
Increased risk of VF
32
How is angina managed?
Aspirin + statin + GTN for all
1. CCB (diltiazem or verapamil) or BB
2. CCB (MR nifedipine) and BB
3. add isosorbide nitrate or ivabradine or nicorandil
4. CABG or PCI
33
What nitrate free time is recommended for patients with nitrate tolerance?
10-14 hours a day
34
What are the signs and symptoms of ACS?
```
Central crushing chest pain
SOB
sweating, pale and clammy
Palpitations and tachycardia
N&V
pulmonary oedema = lung crepitations
```
35
What ECG changes define STEMI?
| What are the timings for some other ECG changes?
ST elevation:
>2mm in 2 contiguous chest leads
<1mm in 2 contiguous limb leads
New LBBB
within minutes: hyperacute T (tall)
within 12 hours: Pathological Q waves (>25% height of R)
within days: T wave inversion
36
What complications are associated with STEMI's? State the timings of these if they are significant
Heart block (particularly after inferior)
Arrest - VF/pVT
Cardiogenic shock
HF
Pericarditis (48hrs)
Dressler's syndrome (4 weeks)
LV aneurysm can lead to stroke
LV wall rupture leading to tamponade (1 week)
VSD
Mitral regurgitation leading to flash pulmonary oedema
37
What immediate management is required for ?ACS
```
Morphine - 10mg IV
Oxygen (if sats <94% on air)
Nitrates (if no bradycardia/BP<90)
Aspirin 300mg
Clopidogrel 300/600mg
```
Anti-emetic - 10mg IV Metoclopramide
38
What is the long term management for an MI?
Lifestyle: stop smoking, drinking, good diet, exercise
```
Aspirin 75mg daily
Clopidogrel/Ticagrelor/Prasugrel
Statin
Beta blocker
ACEi
```
+ eplerenone if HF or LV dysfunction
39
What are poor prognostic indicators for ACS?
Arrest at presentation
Hypotensive
Raised cardiac markers
Raised creatinine
```
High Killip class:
I - No signs of heart failure
II - Lung crackles, S3
III - Frank pulmonary oedema
IV - Cardiogenic shock
```
40
What are the main causes of mitral regurgitation?
PRIMARY: degenerative, rheumatic fever, infective endocarditis, Marfans
SECONDARY (valve incompetent due to heart disortion): dilated cardiomyopathy, post MI ischaemic cardiomyopathy, HF
41
What are the causes of acute mitral regurgitation and how does it present?
Infective endocarditis and post MI ischaemic cardiomyopathy
| Flash pulmonary oedema causing dyspnoea and shock
This is because no time for remodelling so blood backs up
42
What are the signs and symptoms of mitral regurgitation?
```
Pansystolic murmur radiating to the axilla
Soft blowing
Quite S1 (not shutting)
Split S2 (severe)
S3 (blood rush in to dilated ventricle)
Displaced apex beat + heave
```
LV failure: fatigue, orthopnoea, pulmonary oedema
43
What investigations would you request for mitral regurgitation and what may they show?
ECG - bifid, broad p - enlarged atria
CXR - cardiomegaly, double R heart border, pulmonary oedema
Transoesophageal echo - diagnose/determine severity
44
How is mitral regurgitation managed?
Acute - nitrates, diuretics, positive inotropes and balloon pump
HF - ACEi +- B Blockers and spironolactone
Acute severe - surgical valvuloplasty/valve replacement
45
What are the common causes of aortic regurgitation?
Valve disease:
- Rheumatic fever
- Infective endocarditis
- Connective tissue disorders
- Bicuspid aortic valve
Aortic root disease:
- Aortic dissection
- Marfans
- Ank spond
- Syphilis
46
What are the signs associated with aortic regurgitation?
```
Early diastolic murmur (sitting forward, on expiration)
Collapsing pulse - corrigan's
Wide pulse pressure
Quincke's sign - nailed pulsing
De Musset's sign - head bobbing
Traube's sign - pistol shot femoral
Gerhardt - splenic pulsation
```
Mid diastolic Austin flint murmur in severe AR
47
How is aortic regurgitation investigated?
CXR - cardiomegaly, dilated ascending aorta, pulmonary oedema
ECG - LVH so deep S in V1/2 and tall R in V5/6
Echo - diagnostic
48
How is aortic regurg managed?
Reduce hypertension - ACEi
Regular echo - monitor
Surgery - indications:
- severe AR with enlarged ascending aorta
- increasing symptoms
- deteriorating LV function
- infective endocarditis refractory to medical therapy
49
What symptoms can aortic regurgitation present with?
What could cause an acute presentation and what would be the key symptoms?
```
Exertional dyspnoea
Orthopnoea
PND
Palpitations
Angina
Syncope
```
ACUTE:
- infective endocarditis and aortic dissection
- dyspnoea (pulmonary oedema)
- angina (reduced coronary filling due to regurg during diastole)
50
What is aortic stenosis caused by?
Elderly - calcification of aortic valve - check for corneal arcus
Congenital - bicuspid aortic valve, William's syndrome
51
What signs are associated with aortic stenosis?
Crescendo-decrescendo ejection systolic murmur radiating to carotids
Slow rising pulse
Narrow pulse pressure
Heave
Soft S2 and presence of S4 in severe
52
What investigations would you request for aortic stenosis?
ECG - LVH (deep S in V1/2 and tall R in V5/6) left ventricular strain, LBBB, poor r wave progression
CXR - calcifications, cardiomegaly
Echo - estimate pressures and assess degree of disease
53
What are the main symptoms of aortic stenosis?
SAD:
- syncope
- angina (hypertrophies muscle has high O2 demand)
- dyspnoea (L HF due to hypertrophy eventually causing impaired relaxation and diastolic dysfunction)
54
How is aortic stenosis managed?
Asymptomatic - observe
Symptomatic - valve replacement
Can consider surgery in asymptomatic + >40mmHg valvular gradient
Balloon valvuloplasty for those with critical AS but not fit for replacement
55
What are the main complications associated with aortic stenosis?
Congestive heart failure
Infective endocarditis
Emboli
56
What are the advantages of each valve type?
Bioprosthetic - req. replacing but don't need anticoagulant
Metallic - last lifetime but anticoag and make loud clicking noise
57
How can mitral stenosis present? What is the pathophysiology behind this?
Increased LA pressure means it dilates:
- AF
- Stroke due to thrombi
Increased pressure within the pulmonary system:
- RV failure (peripheral oedema, ascites, hepatomegaly, raised JVP, dyspnoea, reduced exercise tolerance)
Enlarged LA can compress with L recurrent laryngeal nerve
- hoarse voice
58
What are the examination findings in mitral stenosis?
Mid to late diastolic murmur - expiration, left side, with bell
Loud S1 - opening snap
Low volume pulse
Malar flush
59
What causes mitral stenosis?
RHEUMATIC FEVER
Others:
- calcification
- congenital
- carcinoid disease
- SLE
- infective endocarditis
- Rheumatoid arthritis
60
What investigations are done for mitral stenosis?
CXR - Cardiomegaly with double R heart border, prominent pulmonary vessels, valve calcification
ECG - AF, broad bifid P due to LA enlargement
Echo - assess level of stenosis
61
How is mitral stenosis managed?
Percutaneous mitral commissurotomy (PMC) which is balloon dilation
Manage medical symptoms with diuretics, nitrates, B blockers, Ca channel blockers
Anticoagulate for AF
62
Which murmurs are systolic?
ASMR
Aortic Stenosis
Mitral Regurg
63
What are the most common causes of acute vs chronic heart failure?
ACUTE: ACS, arrhythmia, valve pathology, tamponade
CHRONIC: HTN, IHD, cardiomyopathy (dilated/hypertrophic) valve (stenosis/regurg), AF, CHD
64
What are the key signs and symptoms of acute Heart Failure?
Breathlessness
Oedema
Fatigue
Reduced exercise tolerance
```
Cyanosis
Tachycardia
Raised JVP
Displaced apex beat
Chest signs - wheeze and bibasal crackles
S3 heart sound
```
65
What is high output heart failure and what are some causes?
Cardiac output sufficient but increased metabolic demand, reduced O2 carrying ability, or reduced TPR
- anaemia
- thyrotoxicosis
- sepsis
66
What physiological responses cause heart failure to worsen?
Increased total peripheral resistance - this increases afterload and strain on heart
Increased HR - increased workload of heart - higher O2 demand
Increased blood volume - ventricles dilate, decrease contractility, increase oedema
67
What is the New York heart failure classification?
1 - No symptoms at rest or limitations to daily activities
2 - slight limitation to physical activity
3 - considerable limitation to physical activity
4 - symptoms at rest
68
What are the key signs and symptoms of chronic heart failure?
* Dyspnoea
* Fatigue with reduced exercise tolerance
* Oedema
Pink frothy sputum, wheeze and bibasal crepitations
Orthopnoea and PND
Displaced apex beat
Tachycardic
Right side/congestive - peripheral oedema, raised JVP, hepatomegaly, ascites, nocturia
69
How is heart failure managed acutely?
1. IV furosemide - 40mg
2. If this fails try CPAP
+ oxygen
+ opioids to reduce anxiety and help dyspnoea
+/- Vasodilators
+/- Inotropic agents
+/- Ultrafiltration
+/- Intra-aortic balloon pump
Consider short term stopping of beta blockers
70
How is HF-REF managed?
ACEi and Beta blockers
Add spironolactone or alpha blocker (K+ <>4.5)
3rd line = specialist
- ivabradine, valsartan, hydralyzine + nitrate, digoxin and cardiac resynchronisation
One off pneumococcal vaccine - booster if asplenic, CKD or splenic dysfunction
Yearly influenze vaccine
Cardiorespiratory rehabilitation exercises
Antiplatelet and statin considered
71
When is ivabradine used in heart failure management?
Sinus rhythm >75 bpm
| Ejection fraction <35%
72
When is sacubitril-valsartan used in heart failure management?
Ejection fraction <35%
Symptomatic on ACEi and Beta blocker
Start after ACEi/ARB washout period
73
When is digoxin used in heart failure management?
Used for symptomatic relief due to inotropic effects
Used in concurrent AF
74
When is Hydralyzine + nitrate used in heart failure management?
Esp. afro-caribbean patients
75
When is cardiac resynchronisation used in heart failure?
Widened QRS on ECG
76
How is heart failure investigated?
1. B type natriuretic peptide and ECG (?cause)
2. Transthoracic Echo
+CXR
+ find cause (BP, coronary angio, FBC, TFT)
77
What are the stages of hypertension?
Stage 1 - clinic >140/90 or ambulatory >135/85
Stage 2 - clinic >160/100 or ambulatory >150/95
Stage 3 - clinic >180/120
78
What is indicative of white coat hypertension?
Drop in systolic BP >20mmHg or diastolic >10
79
How is hypertension investigated?
Clinic BP >140/90 = ABPM (2/hr) or HBPM (2/day)
Glucose ?diabetes
Urine dip ?proteinuria
Bloods ?renal disease ?cholesterol
If age <40 refer for specialist investigation
If BP >180/120 then refer for immediate assessment
80
When should drug treatment be offered for hypertension?
Stage 1 and <80 and 1 of
- end organ damage
- CVS disease
- Renal disease
- QRISK >10%
- diabetes
Stage 2 and above
81
What drug treatment is offered for hypertension?
<55 or T2DM:
1. A
2. A + C/D
>55 or afro-Caribbean:
1. C
2. C + A (ARB if afro-caribbean)
3. A+C+D
4. Spironolactone (if K<4.5) or A/B blocker (if K<4.5)
A - ACEi or Angiotensin 2 antagonist
C - Ca2+ blocker
D - thiazide diuretic
82
What lifestyle advice is given for HTN?
```
Reduce salt intake
Reduce caffeine intake
Stop smoking
Stop drinking alcohol
Exercise
```
83
What is the target blood pressure for those being treated for hypertension?
Age <80:
Clinic <140/90 or ABPM <135/85
Age>80:
Clinic <150/90 or ABPM <145/85
84
What signs do you look for on examination in hyperlipidaemia?
```
Corneal arcus
Tendon xanthoma (often achilles)
Palmar xanthoma
Eruptive xanthoma (red/yellow vesicles on extensors)
Xanthelasma - yellow around eyelids
```
85
How is xanthelasma managed?
Surgical removal
Laser therapy
topical trichloroacetic acid
86
What are the secondary causes of hyperlipidaemia? Which cause predominantly high cholesterol vs high triglycerides
Cholesterol:
- Hypothyroid
- Obstructive jaundice
- Nephrotic syndrome
Triglycerides:
- Diabetes
- Obesity
- Alcohol
- CKD
- Drugs (COCP, thiazides, b-blockers)
87
When is a) primary and b) secondary prevention of hyperlipidaemia required and what is given?
a) 20mg atorvastatin
- 10 year CVS risk >10%, T1DM, CKD with eGFR <60
b) 80mg atorvastatin
- IHD, PAD, cerebrovascular disease
88
What is the spectrum of peripheral vascular disease? What are the signs and symptoms associated?
Intermittent claudication - LL pain on exercise
Critical limb ischaemia - rest pain >2wks/gangrene/ulceration.
Pale and cold leg with lack of hair and skin changes
Weak/absent pulses
89
How is critical limb ischaemia defined?
```
1+ of:
- Pain at rest for >2 weeks
- Gangrene
- Ulceration
ABPI <0.5 indicative
```
90
How would you investigate peripheral vascular disease?
Hx and exam (smoking and diabetes)
CVS assessment - BP, FBC, lipids, BM, ECG
Duplex ultrasound first line
ABPI
MRA before intervention
91
How is peripheral vascular disease managed?
Modify CVS risk factors and exercise training
Atorvastatin 80mg
Clopidogrel
Revascularisation - angiography, stent or bypass
Amputation if others not suitable
Naftidrofuryl oxalate - vasodilator - symptom control if surgery not wanted
92
How can ankle brachial pressure index be interpreted?
```
>1.4 = suspect PAD especially if diabetic
0.9-1 = normal
0.6-0.9 = Claudication
0.3-0.6 = rest pain
<0.3 = impending
```
<0.5 = critical limb ischaemia
93
What are the features of acute limb ischaemia?
6P's
```
Pale
Pulseless
Perishingly cold
Paraesthesia
Pain
Paralysed
```
94
Where can peripheral vascular disease affect in the upper limb?
Subclavian artery
| Brachiocephalic trunk
95
What are the features of upper limb peripheral vascular disease?
Subclavian steal syndrome: arm claudication and neurological sequalae (syncope)
Can get the 6 P's as per lower limb
96
What are the types of shock?
Hypovolaemic
Distributive - e.g. septic, anaphylactic
Cardiogenic - ventricles unable to empty
Mechanical - ventricles unable to fill
97
What is mitral valve prolapse associated with?
```
Congenital heart disease - PDA, ASD
Turner's
Marfans and Ehler's Danlos
PCKD
WPW and Long QT
```
98
What murmur is heard in mitral valve prolapse?
Mid systolic click (late systolic when patient squatting)
| Late systolic murmur (longer when patient standing)
99
What are the symptoms of mitral valve prolapse?
```
Atypical chest pain
Palpitations
+/- Fatigue
+/- SOB
+/- Dizziness
```
100
What complications are associated with mitral valve prolapse?
Mitral regurg
Arrhythmia (Long QT)
Emboli - stroke
Sudden death
101
How is mitral valve prolapse managed?
Low risk - nothing
High risk of emboli - anticoagulate
Palpitations/symptoms - beta blockers
Risk of mitral regurgitation - replace valve
102
Where does infective endocarditis commonly affect?
Left sided valves - mitral most common
IVDU - tricuspid
103
What are the risk factors for infective endocarditis?
What else can cause endocarditis?
```
Rheumatic fever
IVDU
Prosthetic valves
Poor oral hygiene/dental procedures
New piercing
Congenital heart disease
```
Non-infective (SLE and malignancy)
104
How does infective endocarditis present acutely?
Fever + new murmur = IE unless proven otherwise
```
Heart failure (SOB and orthopnoea)
Stroke/TIA/PE
```
105
What criteria is used for diagnosing infective endocarditis? Briefly overview what is in it
Modified Dukes
Pathological
- +ve microbiology on specimen of tissue
Major
- +ve blood cultures
- echo (oscillating structures, abscess, valve regurg, dehiscence of prosthetic valve)
Minor
- fever >38
- pre-existing heart condition or IVDU
- vascular signs (Janeway, petechiae, splinter haemorrhages, splenomegaly)
- immunological signs (Oslers, Roth spots, glomerulonephritis)
106
Which organisms typically cause infective endocarditis?
Staph aureus in general population and IVDU
Staph epidermidis if <2 months post prosthetic valve surgery
Strep viridian's in developing countries and poor dental hygiene
Strep Bovis in colorectal cancer
107
What are the poor prognostic factors for infective endocarditis?
Staph aureus infection
Early prosthetic valve infection
Culture negative endocarditis
Low complement levels
108
How is infective endocarditis managed immediately? i.e. with no culture results
Blind:
Native: Amoxicillin (vancomycin if allergic) + gent
Prosthetic: Vancomycin + rifampicin + gentamicin
Severe sepsis: Vancomycin and gentamicin
109
How is infective endocarditis managed in native valves once culture results are back?
Staph - fluclox
Strep - Benzylpenicillin (+low dose gent if less sensitive i.e. not viridans)
Vanc+rifampicin if allergic/MRSA
Vanc if strep and allergic
110
How is infective endocarditis managed in prosthetic valves?
Flucloxacillin + Rifampicin + low dose gentamycin
vancomycin if allergic or MRSA
111
What are the indications for surgery in infective endocarditis?
```
Severe valve incompetence
Aortic abscess
Resistant infections/fungal
Cardiac failure
Recurrent emboli
```
112
How would you know someone with infective endocarditis had developed an aortic abscess?
Prolonged PR on ECG
113
When is antibiotic prophylaxis recommended for infective endocarditis?
At risk and already receiving Abx for GI/genitourinary surgery
Not routinely recommended anymore - dental, GI, genitourinary or respiratory tract surgery
114
What can cause pericarditis?
```
Infection - normally viral (coxackie B) or TB
Post MI - Dressler's syndrome
Trauma
!!Malignancy!!
Uraemia
```
115
How does pericarditis present?
Need 2/4 of:
Pleuritic chest pain - Relieved by sitting forward
Pleural effusion
Pericardial friction rub
ECG changes (PR depression and ST elevation)
```
+/-
Fever
Tachycardia and tachypnoea
SOB
Dry cough
```
116
What investigations are done for pericarditis?
ECG - widespread saddle ST elevation, PR depression, t wave invesion
Transoesophageal echo
117
How is pericarditis managed?
NSAID's and Colchicine for idiopathic and viral
Fix the cause
Supportive care
118
What complications are associated with pericarditis?
Pericardial thickening --> constrictive pericarditis
119
What is Dressler's syndrome?
Autoimmune reaction to antigenic proteins formed in myocardial recovery post MI
2-6 weeks post MI --> pericarditis
Fever, pleuritic pain, pericardial effusion, raised ESR
120
What are the signs and investigation results of a pericardial effusion?
Soft distant heart sounds
Apex beat obscured
Friction run which disappear over time
CXR - enlarged heart with precise outlines
ECG - low voltage QRS
Echo - shows the effusion
121
What commonly causes constrictive pericarditis?
TB induced pericarditis
122
How does constrictive pericarditis present?
What is seen on CXR?
Dyspnoea
Right heart failure - raised JVP, ascites, oedema, hepatomegaly
Loud S3
Kussmaul's sign - paradoxical JVP rise on inspiration
Pericardial calcification
123
Compare the JVP waveform in constrictive pericarditis vs tamponade
X and Y descent are both present in constrictive pericarditis however in tamponade there is no Y descent (Y descent represents ventricle filling in diastole)
124
What is cardiac tamponade caused by?
Trauma
Pericarditis
Malignancy
Iatrogenic
125
What should be done if you suspect cardiac tamponade?
FAST scan and bedside echo ASAP
- ECG
- Transthoracic echo
- CXR
- FBC
- ESR
- Troponin
126
How is a cardiac tamponade managed? (Stable vs unstable)
If haemodynamically stable/pre-tamponade - NSAIDs + gastroprotection
Haemodynamically unstable:
Needle pericardiocentesis - rarely works
Clamshell thoracotomy
127
Where is the needle inserted in a pericardiocentesis?
Angle of xiphisternum with L rib border
| Aim towards left scapula
128
What are the classical triad of features of cardiac tamponade?
Beck's Triad:
- Hypotension
- Raised JVP
- Muffled heart sounds
129
What other features are seen in cardiac tamponade? Including ECG findings
Pulsus paradoxus - BP drop on inspiration
Dysnpnoea
Tachycardia
Electrical alternans on ECG - alternating QRS amplitude
130
What happens in an aortic dissection?
Tear in the tunica intima of the wall of the aorta
131
How does an aortic dissection present?
Tearing pain that goes through to the back
Pulse deficit - weak/absent carotid, radial or femoral
Aortic regurg
Hypertension
132
What are the types of aortic dissection?
Stanford Classification
A - Ascending aorta
B - Descending aorta
DeBakey classification
I - Ascending aorta --> arch and slightly distal
II - Originate and confined to ascending aorta
III - Originate descending, extend distally
133
How can aortic dissections be investigated?
Guided by presentation - often acute
CT CAP ideal - stable and awaiting surgery
TOE - For unstable
CXR - widened mediastinum
134
How are aortic dissections managed?
Type A - Surgery
BP <100-120 whilst waiting
Type B - Conservative/bed rest
IV labetalol
135
What are the complications associated with an aortic dissection?
Backward tear:
- Aortic regurg/incompetence
- MI - typically inferior
Forward tear:
- Unequal arm pulses
- Renal failure
- Stroke
136
What is arrhythmogenic right ventricular cardiomyopathy?
Inherited condition presenting with syncope, palpitations or sudden cardiac death
Autosomal dominant
RV myometrium replaced with fatty/fibrofatty tissue
137
How is arrhythmogenic right ventricular cardiomyopathy investigated?
ECG - V1-3 t wave inversion. Epsilon wave on QRS
Echo - subtle to start. Enlarged hypo kinetic RV
MRI - show fibrofatty tissue
138
How is arrhythmogenic right ventricular cardiomyopathy managed?
Sotalol
Catheter ablation - prevent ventricular tachy
ICD
139
What is Naxos disease?
Autosomal recessive variant of arrhythmogenic RV cardiomyopathy
Triad: ARVC, palmoplantar keratosis, woolly hair
140
How is atrial fibrillation managed post stroke?
Warfarin or direct thrombin/factor Xa inhibitor
2 weeks post if no haemorrhage
141
What is an atrial myxoma?
Cardiac tumour in LA
Common in females
- Dyspnoea, fatigue, weight loss, pyrexia of unknown -origin, clubbing
- Emboli
- AF
- Mid diastolic murmur
Echo show pedunculate heterogenous mass in fossa ovalis region
142
What are the features of an atrial septal defect?
Ejection systolic murmur
Fixed splitting of S2
Mostly in ostium secundum - RBBB and right axis deviation
If in ostium primum - RBBB and left axis deviation, prolonged PR
143
What is brugada syndrome?
Autosomal dominant condition
More common in asians
Cause sudden cardiac death
144
What ECG changes are seen in brugada syndrome?
Coved ST elevation followed by negative t wave
Partial RBBB
More obviously seen when given flecainade
145
How do you managed brugada syndrome?
Implantable ICD
146
What is Burgers disease?
Small and medium vessel vasculitis associated with smoking
- Extremity ischaemia - claudication and ulcers
- Superficial thrombophlebitis
- Raynaud's
147
What echo findings are associated with hypertrophic cardiomyopathy?
Mitral regurg
Systolic anterior motion of anterior mitral valve
Asymmetrical septal hypertrophy
148
What commonly causes dilated cardiomyopathy?
Alcohol
Coxackie B
Wet beri beri
Doxorubicin
149
What causes restrictive cardiomyopathy?
Amyloidosis
Post-radiotherapy
Loefflers endocarditis
150
What are the types of acquired cardiomyopathy?
Peripartum
| Takotsubo
151
What is permpartum cardiomyopathy?
Develop between last month of pregnancy and 5 months post partum
More common in older women, greater parity or multiple gestation
152
What is takotsubo's cardiomyopathy?
Stress induced
Transient apical ballooning of myocardium
Supportive treatment
Broken heart
153
What is coarctation of the aorta?
Narrowing of the descending aorta
More common in males
154
What are the features of co-arctation of the aorta?
Infancy - heart failure
Adult - hypertension
Radiofemoral delay
Midsystolic murmur with apical click
Notching of inferior border of ribs
155
What is coarctation of the aorta associated with?
Turners syndrome
Bicuspid aortic valve
Berry aneurysm
Neurofibromatosis
156
What is DVLA guidance in hypertension?
Can continue
If group 2 - disqualified if consistently above 180/100
157
What is DVLA guidance post angioplasty?
1 week off driving
158
What is DVLA guidance post CABG and ACS?
CABG - 4 weeks off
ACS - 4 weeks off. 1 week if treated successfully by angioplasty
159
What is DVLA guidance in angina?
Must stop if symptoms at rest
160
What is DVLA guidance for pacemakers?
Insertion - 1 week off
If for sustained ventricular arrhythmia - 6 months off
If prophylactic - 1 month off
Can't drive group 2 vehicles
161
What is the driving guidance for successful catheter ablation?
2 days off driving
162
What is the driving guidance for berry aneurysms?
Notify DVLA
License renewal reviewed annually
Diameter >6.5cm disqualify
163
What is the driving guidance post heart transplant?
6 weeks off
Don't need to inform DVLA
164
What is eisenmengers syndrome?
Left to right shunt become right to left stunt because pressure build up in pulmonary system
Features:
- Cyanosis
- Clubbing
- RV failure
- Haemoptysis
- Embolism
May need heart lung transplant
165
What are the features of hypertrophic cardiomyopathy?
Often asymptomatic
- Exertional dyspnoea
- Angina
- Syncope - follow exercise
- Sudden death
- Jerky pulse
- Ejection systolic murmur - increase with valsalva, -decrease with squatting
166
What ECG findings are associated with hypertrophic cardiomyopathy?
LV hypertrophy
Non specific ST and t wave abnormalities
Deep q waves
AF
167
What is long qt syndrome associated with?
Sudden death
Exertional dyspnoea
Syncope
168
How is long QT managed?
Avoid drugs that prolong QT
Beta blockers
ICD in high risk cases
169
What is the diagnostic criteria for postural hypotension?
| What are some causes?
>20mm/Hg drop in systolic BP after 3 minutes of standing
- hypovolaemia (dehydration)
- autonomic dysfunction (diabetes, Parkinsons)
- drugs (diuretics, alpha blockers, anti-HTN, sedatives)
- alcohol
170
How is orthostatic hypotension managed?
Stop precipitating drugs
| Fludrocortisone and midodrine
171
What is pulsus paradoxus and what causes it?
BP drop with inspiration
Asthma and Cardiac Tamponade
172
What causes a slow rising pulse?
Aortic stenosis
173
What causes a collapsing pulse?
Aortic regurgitation
PDA
Hyperkinetic states
174
What is pulsus alterans and what causes it?
Regular alternation of force of pulse
| Severe LV failure
175
What causes a bisferens pulse?
Mixed aortic valve disease
| HOCM* - can be associated
176
What causes a jerky pulse?
HOCM
177
What is rheumatic fever?
Immunological reaction to a recent step pyogenes infection (2-6 weeks prior)
178
How is rheumatic fever diagnosed?
Evidence of strep pyogenes infection
+ 2 major or
+ 1 major and 1 minor
179
What are the major criteria for rheumatic fever?
```
Erythema marginatum
Sydenham's chorea
Polyarthritis
Carditis and valvulitis
Subcutaneous nodules
```
180
What are the minor criteria for rheumatic fever?
Raised ESR
Pyrexia
Arthralgia
Prolonged PR
181
How is rheumatic fever managed?
NSAIDs
PenV oral
treat complications
182
What is takayasu's arteritis?
Large vessel vasculitis occluding aorta leading to missing limb pulse
More common in women and asians
183
What are the features of takayasu's arteritis?
```
Malaise, headache
Unequal pulses in limbs
Carotid bruit
Intermitted claudication
Aortic regurgitation
```
Associated with renal artery stenosis
184
How is takayasu's arteritis managed?
Steroids
185
What is HF-REF?
AKA systolic HF
There is an INABILITY TO PUMP out blood so the ventricle DILATES to compensate. This can lead to the mitral valve being pulled open and then blood backing up to the atria
186
What is HF-PEF?
AKA diastolic HF
There is an INABILITY TO RELAX/FILL so the ventricle HYPERTROPHYS to compensate. The deeper layers of muscle are not perfused so can become fibrotic
187
When does right sided heart failure occur?
Rarely alone
- Pulmonary HTN (Left sided HF or COPD)
- right sided valve disease
- pericardial pathology
188
When else may BNP be raised? How should the result be interpreted in HF diagnosis?
Diabetes
CKD
COPD
Liver cirrhosis
If it is negative it's likely not HF however if +ve do next step of investigations as not diagnostic
189
How is HF-PEF managed?
Furosemide for symptoms
| Refer to specialists
190
A patient is on an ACE-I for HTN, when would you consider switching this and to what?
Intolerable cough = Angiotensin 2 antagonist
| K>5.5 or Creatinine >30% baselines = CCB
191
What defines malignant HTN and how would they present?
s>180 or d>120 + papilledema
- retinal bleeding
- RICP = headache
- epistaxis
- chest pain
- haematuria
192
How is malignant hypertension managed?
Labetalol and GTN infusion
193
What are the causes of HTN?
```
90% Primary/idiopathic
10% secondary
- renal disease
- endocrine disease (pheochromocytoma, Cushing's, hyperaldosteronism
- pregnancy
- COCP, steroids, NSAIDs, SSRI
```
194
Although HTN is often asymptomatic, how might it present?
Palpitations
Angina
Headache
Blurred vision
195
What are the stages of hypertensive retinopathy?
1. arteriolar narrowing (silver wiring)
2. arteriovenous nipping
3. blot/flame haemorrhage, cotton wool spots
4. papilledema
196
What are some complications of HTN?
```
HF
Stroke
MI
Retinopathy
CKD
```
197
What is the grading of murmurs?
1: very faint
2: soft
3: easily heard
4: can hear thrill
5: audible with stethoscope partly off chest
6: audible with stethoscope fully of chest
198
What is responsible for the 3rd and 4th heart sounds?
3rd: rush of blood into the ventricle
4th: atrial contraction of blood in to a stiff ventricle
199
What defines typical vs atypical angina?
Typical: all 3
Atypical: 2/3
- Constricting central chest discomfort
- Precipitated by strenuous activity
- Relieved in 10 minutes or after 2 GTN sprays
200
What are the causes of angina?
```
Atheroma (coronary artery disease)
Aortic stenosis
Coronary vasospasm (cocaine)
Vasculitis (Kawasaki)
LV hypertrophy
Tachyarrhythmias
Anaemia
```
201
What advice regarding GTN and calling an ambulance should you give to angina patients?
take 2 sprays 5 minutes apart and if not relived after the second one (i.e. at 10 minutes) then call an ambulance
202
What is the classification of angina?
1. precipitated by strenuous activity
2. precipitated by daily activities done fast paced
3. precipitated by normal daily activities i.e. 1 flight of stairs
4. rest pain
203
What investigations are done at rapid access chest pain clinic? What results would you see?
ECG: pathalogical Q, ST and T wave changes, LBBB
Echo: valve pathology, motion abnormalities, LV dysfunction
Bloods: anaemia exacerbates
204
What is the step wise approach to diagnosing angina?
1. for people at low risk/ have no history of CAD
- CT coronary angio
2. functional testing - if obstruction seen on CT angio or if established CAD
- dobutamine stress echo
- SPECT
- stress contrast MRI
3. if positive functional tests, unresponsive to medical therapy, high risk of ACS or angina at low activity level
- CABG or PCI
205
What is Dressler's syndrome?
Fever + pleuritic chest pain + raised ESR + pleural effusion
Occurs around a month after an MI
206
What is the driving advice post STEMI?
not for 4 weeks
207
What features define myocardial ischaemia?
Elevated troponin + one of:
- Suggestive symptoms
- Pathological Q waves
- ST changes or new LBBB
- Echo evidence of motion abnormality
- Angiography evidence of occlusion
208
What can causes myocardial ischaemia?
```
Atherosclerosis
Vasculitis
Coronary vasospasm
coronary dissection
oxygen demand/delivery missmatch
- anaemia
- tachyarrhythmia
- hyperthyroid
- severe sepsis
```
209
What are some differentials for ST elevation?
Pericarditis
Coronary vasospasm
Ventricular aneurysm
210
What are some differentials for ST depression?
Electrolyte abnormalities
Digoxin effect
BBB
211
What are some differentials for a raised troponin?
```
HF
Tachyarrhythmia
Myocarditis
PE
and lots lots more
```
212
How is NSTEMI/UA managed? What is this determined by?
Do a GRACE risk score and depending on outcome:
- just aspirin
- dual antiplatelet + fondaparinux
- coronary angiography + UFH + dual antiplatelet (aspirin + prasugrel or clopidogrel if on anticoag)
213
What factors contribute towards calculating a GRACE score?
```
BP
HR
ECG changes
cardiac biomarkers
Arrest
Renal function
```
214
When do you do PCI and when do you use fibrinolysis in ACS?
PCI
- presenting within 12 hours and can get to centre within 120 minutes
- presents >12 hours of symptom onset but has continuing ischaemic changes
- ECG does not show resolution of symptoms 90 minutes after fibrinolysis
Fibrinolysis
- PCI not available within 120 minutes
215
What drugs are given to a patient undergoing PCI?
Aspirin
Prasugrel (or clopidogrel if on antiplatelet)
UFH
Bailout GPI
216
What drugs are given to a patient alongside doing fibrinolysis?
```
Aspirin
Ticagrelor (or clopidogrel if ++ bleeding risk)
Antithrombin drug (UFH, fondaparinux etc.)
```
217
What reciprocal changes would you expect in an a) anterolateral or lateral STEMI and b) inferior STEMI?
a) 2, 3, AVF
| b) 1, AVL
218
What ECG changes are seen in a posterior STEMI?
ST depression in V1-3
Dominant R wave in V1 (tall, broad and R/S ration >1)
ST elevation in leads V7-V9
219
What artery occlusion is responsible for
a) inferior MI
b) lateral MI
c) anteroseptal MI?
a) RCA
b) Left circumflex
c) LAD
