Cardiovascular Conditions Flashcards
1
Q
Describe stable angina
A
Narrowing of the coronary arteries results in insufficient blood flow to the myocardium.
During time of high demand (exercise), unable to meet demand = symptoms.
2
Q
Name 3 reasons why stable angina occurs
A
- Impairment of blood flow by proximal arterial stenosis
- Increased distal resistance e.g. left ventricular hypertrophy
- Reduced oxygen-carrying capacity of blood e.g. anaemia
3
Q
Define coronary flow reserve
A
A ratio of the maximal flow down a coronary vessel to the resting flow.
4
Q
Name 5 non modifiable risk factors of cardiovascular
A
- Older age (1)
- Male
- Ethnic background
- Family history (2)
- Kidney disease
5
Q
Name 7 risk factors of cardiovascular disease
A
- Smoking (1)
- High blood level of non-lipoprotein cholesterol
- Lack of physical activity
- Unhealthy diet
- Alcohol intake above recommended levels
- Obesity/overweight
- Stress
6
Q
In CVD how should pain be describe
A
OPQRST
Onset
Position
Quality - character
Relationship
Radiation
Relieving or aggravating factors
Severity
Timing
Treatment
7
Q
Name the GS investigations for stable angina
A
CT coronary angiography
8
Q
Describe RAMP as a management for stable angina
A
RAMP
Refer to cardiology
Advice about the diagnosis, management and when to call an ambulance.
Medical treatment.
Procedural or surgical interventions.
9
Q
Describe the medication pathway for stable angina
A
- Immediate symptom relief
- GTN spray - Long term symptomatic relief
- Beta blocker
- Calcium channel blockers
- Long-term acting nitrates - Secondary prevention (4As)
Aspirin - 75mg once daily
Atorvastatin - 80mg once daily
ACE inhibitor
Already on beta blocker
10
Q
Describe the surgical interventions for stable angina
A
PCI with coronary angioplasty
Coronary artery bypass graft (CABG)
11
Q
Describe the clinical features of stable angina
A
Central chest pain
Tightness of exertion
Pain - radiates to one or both arms, neck or jaw.
Dyspnoea
Sweating
Nausea
12
Q
What is the cause of stable angina
A
Atherosclerosis - leads to narrowing of coronary arteries that results in ischaemia
13
Q
In stable angina what would an ECG show
A
Normal or ST depression
14
Q
What must stable angina be relived by
A
Rest or a dose of subinguinal GTN
15
Q
Name 5 differential diagnosis for stable angina
A
Unstable angina
ACS
Peptic ulcer
Oesophageal spasm
Reflux
Oesophagitis
16
Q
Define unstable angina
A
Myocardial ischemia at rest or on minimal exertion in the absence of acute cardiomyocyte injury/necrosis.
17
Q
When would angina be classed as unstable angina
A
Prolonged > 20 minutes
New onset of severe angina
Angina that is increasing in frequency
Longer duration
Lower in threshold
Angina that occurs after a recent myocardial infarction
18
Q
Name the 3 types of acute coronary syndromes
A
- ST elevation myocardial infarction = STEMI
- Non-St elevation myocardial infarction = NSTEMI
- Unstable angina
19
Q
Name the clinical features of acute coronary syndromes
A
Central constricting chest pain, associated with
- Nausea and vomiting
- Sweating and clamminess
- Feelings of impending doom
- Shortness of breath
- Palpitations
- Pain radiating to the jaw or arms
Longer than 20 minutes
20
Q
What type of patient may have a silent MI
A
Diabetic patients
21
Q
Describe an ECG of a STEMI
A
ST segment elevation in lead consistent with area of ischemia.
New left bundle branch block.
22
Q
Describe the ECG and troponin levels of an NSTEMI
A
ST segment depression in a specific region (possible T wave inversion or pathological waves).
Pathological Q waves may be a late sign.
Raised troponin
23
Q
Describe the ECG and troponin levels of unstable angina
A
ECG - may be normal or show ST-depression, transient ST-segment elevation or T wave inversion
Normal troponin
24
Q
Left coronary artery
Which ECG leads show this area?
What is the view of the heart?
A
I, aVL, V3-6
Anterolateral
25
LAD
What ECG leads show this area?
What area of the heart is this?
V1-4
Anterior
26
Circumflex
What ECG leads show this area?
What heart area is this?
I, aVL, V5-6
Lateral
27
Right coronary artery
Which leads show this area?
What heart area is this?
II, III, aVF
Inferior
28
Describe the treatment of an acute STEMI which presents within 12 hours of onset
1. Within 12 hours + can be done in 2 hours = PCI + prasugrel + aspirin
2. PCI not possible + presenting in 12 hours = Fibrinolysis + ticagrelor + aspirin. ECG 60-90 mins after fibrinolysis
29
Describe the BATMAN approach to a STEMI
- B – Beta blocker unless contraindicated.
- A – Aspirin 300mg stat dose.
- T – Ticagrelor 180mg stat dose – clopidogrel 300mg is an alternative.
- M – Morphine – titrated to control pain.
- A – Anticoagulant – low molecular weight heparin (LMWH).
- N – Nitrates (e.g. GTN) to relieve coronary artery spasm.
- Give oxygen only if their oxygen saturations are dropping, < 95%.
30
Describe the treatment for an NSTEMI
GRACE score to assess for PCI
31
Describe the treatment for unstable angina
Acute management - antiplatelet and anticoagulation therapy
Long term - reduce risk factors
Treatment the same as NSTEMI
32
Describe Dressler's syndrome
Post-myocardial syndrome
Occurs 2-3 weeks after MI
Causes by localised immune response causing pericarditis
NSAIDs - in severe cases steroids
33
Describe the complications of an acute coronary syndrome
DREAD
Death
Rupture of heart septum or papillary muscles
oEdema - heart failure
Arrythmias and Aneurysm
34
Define Heart Failure
Inability of the heart to deliver blood (and O2) at a rate commensurate with the requirements of the metabolising tissue, despite normal or increase cardiac filling pressures.
35
Name 5 symptoms of heart failure
Breathlessness
Tiredness
Cold peripheries
Leg swelling
Increased weight
36
Name 7 signs of heart failure
Tachycardia
Displaced apex beat
Raised JVP
Added heart sounds and murmurs
Hepatomegaly
Peripheral and sacral oedema
Ascites
37
What is the 1st line investigation in heart failure
NT pro-BNP
38
Describe the ECG of a patient who has heart failure
Usually, abnormal
- Arrythmias
- Ischemic ST- and T- wave changes
39
Describe the management of heart failure (HFrEF)
Mainly in HFREF
ACEi + BB
MRA if symptoms persist
Diuretics for fluid retention
40
Describe right sided heart failure
Occurs due to left-sided heart failure
- Results in increased fluid pressure transferred into the lungs
- Results in damage to heart's right side
- Right side loses pumping power - blood backs up into the veins
41
Name the two types of left sided heart failure
1. Systolic failure HFrEF - heart failure with reduced ejection
2. Diastolic failure HFpEF - heart failure with preserved ejection
42
Describe HFrEF
Left ventricle loses ability to contract normally
Reduced ejection
EF < 40%
43
Describe HFpEF
Ventricle loses ability to relax - muscle becomes stuff
Heart cannot properly fill with blood during rest period
EF greater than or equal to 50%
44
Describe hypertensive heart failure
Heart is unable to pump blood properly due to high blood pressure.
Heart walls can become thickened and/or stiff and the blood vessels become narrow and constrict
45
Describe cor pulmonale heart failure
Right sided heart failure secondary to a pulmonary condition
Lung disorder produces pulmonary hypertension
46
Define abdominal aortic aneurysm
Permanent pathological dilation of the aorta with diameter >1.5x the expected anterior posterior diameter, given the patients sex and size.
47
Describe the aetiology of an AAA
Threshold 3cm or more
> 90% of aneurysms originate below the renal arteries
Cause unknown?
48
What are the clinical features of a ruptured AAA
New abdominal pain
And/or
- Back pain
- Cardiovascular collapse
- Loss of consciousness
49
What are the clinical features of an unruptured AAA
Asymptomatic
Minority of patients present with
- Abdominal, back and groin pain
50
What are the 2 main presentations of AAA
Ruptured
Unruptured
51
Describe the 1st line investigations of an AAA
Aortic ultrasound
52
What is the 2nd line investigation in an AAA (unruptured)
CTA or magnetic resonance angiography
- Used for anatomical mapping to assist with operative planning
53
Describe the management of an AAA
Ruptured or symptomatic AAA
- Urgent surgical repair
Unruptured (asymptomatic) if detected on incidental finding
- Surveillance
- No surgery until risk of rupture exceeds risk
54
Define aortic dissection
When a separation has occurred in aortic wall intima, causing blood flow into a new false channel composed of the inner and outer layers of the media
55
Describe the aetiology of an aortic dissection
Most commonly occurs with a discrete intimal tear but can occur without one.
Acute = process is less than 14 days old
56
Describe the clinical features of an aortic dissection
Abrupt onset of chest, back or abdominal pain.
- Severe intensity
- Ripping or tearing
Other features
- Syncope
- Heart/renal failure
- Mesenteric or limb ischemia
57
Describe the GS investigation for an aortic dissection
CT angiogram
58
Describe the CXR of aortic dissection
Widened mediastinum
Double/irregular aortic contour
59
What are the two clinical diagnosis for aortic dissection
Stanford type A and B
60
Define Stanford type A - aortic dissection
Involvement of the ascending aorta and/or arch.
61
Define Stanford type B - Aortic dissection
Dissections of the descending aorta
62
Describe the management of an aortic dissection
Oxygen/advanced life support protocol
Haemodynamic support without delay if suspected
Type A - urgent surgical repair
Type B - managed medically to control HR and BP
63
Name a complication of an aortic dissection
Aortic rupture
64
Name 4 supraventricular tachycardias
1. Atrial Fibrillation
2. Atrial Flutter
3. AVRT
4. AVNRT
65
Define atrial fibrillation
Uncoordinated atrial electrical activity and consequently ineffective atrial contraction.
66
Describe the pathophysiology of supraventricular tachycardias
Atrial ectopics from the pulmonary veins trigger micro re-entry circuits in the atria causing chaotic electrical activity
Activity is intermittently conducted through the AVN which gives rise to the characteristic irregularly irregular ventricular state
67
Describe the clinical features of AF
Irregularly irregular pulse
with or without any one of:
- Palpitations
- Dyspnoea
- Chest pain
- Fatigue
- Dizziness
- Polyuria
- Syncope
68
What is the good standard investigation for atrial fibrillation
12-lead ECG
69
Describe the ECG of acute AF
Irregular R-R intervals - where AV conduction is not impaired
Absence of distinct repeating P waves.
Irregular atrial activation.
70
Describe the ECG of chronic fibrilation
Absent P waves
Presence of fibrillatory waves and irregular QRS complex.
71
What are the 3 categories of AF
1. Paroxysmal
2. Persistent
3. Permanent
72
Describe the GS management of acute AF
DIC cardioversion
73
Define an atrial flutter
Macro re-entrant atrial tachycardia with atrial rates usually 250-320bpm
74
What are the clinical features of atrial flutter
Palpitations
Fatigue or light headiness
Syncope
Chest pain
75
Describe the ECG of atrial flutter
Saw-tooth pattern between QRS complexes
Typically 2:1 AV block
Characteristics ventricular rate is 150 bpm
May fluctuate between atrial flutter and atrial fibrillation.
76
What is the management of atrial flutter
Haemodynamically unstable
- Emergency electrical cardioversion
Same as AF
77
Name 3 Ventricular Tachycardias
1. Ventricular ectopic
2. Prolonged QT syndrome
3. Torsades de Pointes
78
Define ventricular ectopics
Extra heart beat originating in the ventricles
79
How common are ventricular ectopics
Very common - often benign
80
Name the common causes of ventricular ectopics
Usually no clinical significance
Caffeine
Alcohol
Tiredness
Hormonal changes
81
Name 4 more serious causes of ventricular ectopics
1. Infection
2. Muscle disease
3. Channel ion disease
4. Electrolyte imbalance
82
Name 5 clinical features of ventricular ectopics
1. Largely asymptomatic
2. Fluttering chest
3. Dizziness
4. Syncope
5. Pre-syncope
83
What would you seen on an ECG of ventricular ectopics
Diagnosed by accident
'Missed beat'
R on T phenomenon
84
What investigations can be used for ventricular ectopics
1st line - ECG
ECHO
Exercise test
MRI scan
24-hour ECG reading
85
What managment can be given for ventricular ectopics
Beta blocker
Calcium channel blocker
Electrophysiology study - ablation
86
Define prolonged QT syndrome
Characterised by prolonged QT interval on an ECG
>450 ms in males
>460 ms in females
87
Name the risk factors for prolonged QT syndrome
Gene mutations
Drugs
Hypokalaemia/magnesium/calcinemia
Bradyarrhythmia's
Central nervous system lesions
88
Name the clinical features of a prolonged QT syndrome
Dizziness
Syncope
Arrhythmic symptoms postnatal
Palpitations
Angina
Fatigue
89
What investigations would be carried out for prolonged QT syndrome
ECG
Serum
- potassium
- magnesium
- calcium
90
What is the differential diagnosis for prolonged QT syndrome
- Acquired structural heart disease
- Neurocardiogenic (vasovagal) syncope
- Neurological syncope
91
What is the management of prolonged QT syndrome
Usually, identifiable reversible cause
Primary treatment
- lifestyle
- beta-blocker therapy
- implantation of cardioverter-defib
92
Define Torsades de Pointes
Polymorphic VT with a characteristic twisting morphology occurring in the s+etting of a QT interval prolongation
93
What is Torsades de Pointes usually caused by
Drug induced
94
What are the key features of Torsades de Pointes
Episodes are usually self limiting
Frequently recurrent
Can cause impairment or loss of consciousness
95
What would be seen on an ECG of Torsades de Pointes
Long QT syndrome
96
What are the 2nd line investigations for Torsades de Pointes
Transthoracic echocardiogram
Electrolytes
Troponin I
97
What is the gold standard management of Torsades de Pointes
IV magnesium sulfate
98
What are the two types of conduction blocks
Heart Block
- 1st degree
- 2nd degree (Mobitz I and II)
- 3rd Degree
Bundle Branch Block - left and right
99
Define a heart block
Block is cardiac electrical disorder - impaired (delayed or absent) conduction from the atria to the ventricles
100
Describe a 1st degree heart block
Occurs when there is delayed AV conduction through the AV node
101
Describe a 2nd degree heart block
Some of the atrial impulses do not make it through the Av node to the ventricles
102
Describe a Mobitz type 1 heart block
Atrial impulses become gradually weaker - fails to stimulate contraction
PR gradually lengthens
103
Describe Mobitz type 2 heart block
Intermittent failure of interruption of AV block
104
Describe a 2:1 heart block
2 P waves for every QRS complex
105
Describe a 3rd degree heart block
Complete heart block - no communication between atria and ventricles due to complete failure of conduction
No observable relationship between P and QRS waves
106
Describe the clinical features of conduction block
Signs
- HR < 40 bpm
- Syncope
Symptoms
- Chest pain
- Palpitations
- Nausea and vomiting
- High BP
- Fatigue
107
Describe an ECG of 1st degree heart block
Can have 1:1 P and QRS wave
But have longer P-R interval > 0.2 seconds
108
Describe a 3rd degree heart block ECG
No relationship between P and QRS wave
Present P wave but not associated with QRS complex
PR interval absent
QRS complex narrow and broad
109
What is the management for stable heart block (1st degree conduction block, Mobitz type 1)
Observe
110
What is the management for unstable heart block (Mobitz type 2, complete heart block or previous asystole)
1st line - Atropine 400mcg IV
If no improvement
- Repeated Atropine up to 6 doses
- Other inotropes
- Transcutaneous cardiac pacing
111
What is the management for patients with high risk of asystole (Mobitz type 2, complete heart block or previous asystole).
Temporary transvenous cardiac pacing
Permeant implantable pacemaker
112
What are the possible reasons for a left bundle branch block
Always pathological
May be due to conduction system degeneration or myocardial pathologies
May occur after a procedure
113
What are the possible reasons for right bundle branch block
Can be physiological or the result of damage to the right bundle branch
E.g.
PE
IHD
ASD
VSD
114
Describe a bundle branch block
Depolarisation only occurs down one side
Abnormally depolarises the septum from one side to the other
Other ventricle wall is depolarised but occurs much slower and less efficient
115
What are the clinical features of a bundle branch block
Usually - asymptomatic
- syncope
RBBB - splitting of the second heart sound
116
Describe an ECG of a left bundle branch block
W in V1 - deep downwards defection
M in V6 - broad notched or 'M' wave
WiLLiaM
117
Describe the ECG of a right bundle branch block
M in V1 - RSR wave
W in V6 - QRS wave
MaRRoW
118
What are the physiological mechanisms involved in the development of hypertension
Cardiac output
Peripheral resistance
RAAS
Autonomic nervous system
119
Define hypertension
> (or equal to) 140/90 mmHg
120
Are hypertension values always the same
Depends on clinical setting
Low/high CVD risk
121
Describe the management of hypertension
Lifelong
- BP response
- Medication
- Lifestyle changes
122
When is hypertension a clinical emergency
Evidence of immediate damage
- Papilledema
- Acute kidney injury
- Acute stroke
- Acute coronary syndrome
- Aortic dissection
123
Define bleeding time
Clinical lab test performed to evaluate platelet function.
124
Describe the pathophysiology of a DVT
Fibrin driven
Venous circulation = low pressure = fibrin rich
Blood does not go back to the heart = swelling
125
What is the main risk factor for a DVT
Virchow's Triangle
Immobilisation
- Long haul flights
- Surgery
- Trauma
Endothelium
- Injury - physical, chemical
126
What are the clinical features of a DVT
Unilateral nature of swelling and assessing risk factors
- Leg pain
- Swelling
- Tenderness
- Warmth
- Redness
127
What is the GS investigations for a DVT
Doppler ultrasound
128
Describe the general management of a DVT
Medication- main = anticoagulant
- Heparin or LMWH
- Warfarin
- DOAC
- Compression stocking
- Underlying cause
- Recannalisation
129
What is the prevention of a DVT
Mechanical
- Hydration
- Early mobilisation
- Compression stocking
- Foot pumps
Chemical
LMW Heparin
130
What are the complications of a DVT
Phlegmasia Alba Dolens/Phlegmasia Cerulae Dolens
Pulmonary Embolism
131
Define a pulmonary embolism
Life-threatening condition resulting from dislodged thrombi occluding the pulmonary vasculature
132
Why does a pulmonary embolism occur
Potentially fatal complication of a DVT
51% DVT develop into PE
Consequence of thrombus formation within a deep vein of the body - normally lower extremities
133
What are the symptoms of a pulmonary embolism
Symptoms
- Breathlessness
- Pleuritic chest pain
134
Name 3 signs of PE
- Tachycardia
- Tachypnoea
- Pleural rub
135
What is the GS investigation for a pulmonary embolism
CTPA
Computerised tomography pulmonary angiography
Detailed visualisation of pulmonary vessels and emboli
Includes radiation
136
Describe the investigation route of PE
1. Wells score
2. If high risk of PE = D-dimer
3. D-dimer raised = CTPA
137
What is the GS investigation in PE if a CTPA is contraindicated
V/Q scan
138
Define peripheral artery vascular disease
Narrowing or occlusion of the peripheral arteries affecting the blood supply to the lower limbs
139
Name 6 reasons for why arterial vascular disease occurs
1. Atherosclerosis
2. Inflammatory
3. Vasospastic
4. Compression
5. Traumatic
6. Pro-thrombotic conditions
140
Describe acute ischaemia in artery vascular disease
6Ps
Pain
Pulselessness
Pallor
Perishingly cold
Paralysis
Pins and needles
141
Describe chronic ischemia in artery vascular disease
Caused by atherosclerosis
Rest pain
Buerger's test
142
Describe the GS investigation for artery vascular disease
ABPI
Ankle Brachial
143
Describe the management of artery vascular disease
Risk factor modification
- Antiplatelets
- Statin
- Stop smoking
- BP
- DM
Exercise programme
144
What are invasive treatments for arterial vascular disease
Carotid endarterectomy
Stenoses
Short occlusion
DEB/DES
Bypass surgery
145
What classification is used to diagnose venous vascular disease
CEAP Classification
146
What clinical assessments for venous peripheral disease
Tap test - Schwartz
Trendelenburg test
Torniquet test
Perthes test
147
What investigations are used for venous vascular disease
Duplex - gold standard
MRV - Pelvic
Venography
148
What is the management for superficial venous disease
Lifestyle
Compression
Sclerotherapy
Endo-venous treatments
Surgical stripping
149
What is the management for deep venous disease
Lifestyle
Compression
Stents
Valves
150
Define Pericarditis
Acute inflammation of pericardium with or without effusion
151
What are the causes of pericarditis
Viral (most common)
Purulent bacterial
Tuberculosis
Dressler's syndrome
Majority = idiopathic
152
What are the risk factors of pericarditis
Male sex
Age 20-50 yrs - most common 41-60
Transmural myocardial infarction
Cardiac surgery
Neoplasm
Viral and bacterial infections
Uraemia or on dialysis
Systemic autoimmune disorders
153
Describe the clinical features of pericarditis
Sharp pleuritic chest pain - worse on inspiration and lying down + relieved by sitting forwards
Dyspnoea
Cough
Hiccups
Fever
Tachycardia
154
Describe the chest pain in pericarditis
Severe
Sharp and pleuritic
Rapid onset
Left anterior chest or epigastrium
Radiates to the arm
Relieved by sitting forward, exacerbated by lying down
155
Describe the clinical examination of pericarditis
Clinical examination
- pericardial rub
- sinus tachycardia
- fever
- signs of effusion
156
What would an ECG of pericarditis look like
Saddle shaped
PR depression
157
How is a clinical diagnosis made in pericarditis
Made with 2 of 4 of them:
- Chest pain
- Friction rub
- ECG changes
- Pericardial effusion
158
What is the management of pericarditis
Sedentary lifestyle
NSAIDs
Colchicine
159
Describe a pericardial effusion
Present when the fluid in the pericardial space exceeds its physiological amount <50mL.
160
How can a pericardial effusion be classified
Onset
Distribution
Haemodynamic impact
Composition
Size based
161
What are the GS investigation for a pericardial effusion
transthoracic echocardiograph
Assess size
Assess the effect on heart function
162
Describe an ECG of pericardial effusion
Low voltage QRS complex
163
Describe the signs of pericardial effusion
Soft and distant heart sounds
Muffled apex beat
Raised (JVP) jugular venous pressure
Dyspnoea
164
What is a complication for pericardial effusion
Cardiac tamponade
165
Describe a cardiac tamponade
Compromised ventricular filling due to pericardial effusion
166
Define infective endocarditis
Infection of heart valve/s or other endocardial lined structures within the heart
167
What increases the risk of infective endocarditis
Have abnormal heart valve, regurgitant or prosthetic valves
Introduce infectious material into the blood stream or directly onto the heart during surgery
Have had a previous IE
IVDU
Poor dental hygiene
168
When should infective endocarditis be suspected
1. New regurgitant heart murmur
2. Embolic events of unknown origin
3. Sepsis of unknown origin
4. Fever (most frequent sign)
169
What are some peripheral signs of infective endocarditis
Splinter haemorrhages
Osler's nodes
Janeway lesions
Retinal infarcts
Finger clubbing
170
Name the 2nd investigation used for infective endocarditis
Blood cultures - 3 different sites over 24 hours
Raised ESR, CRP
CXR - cardiomegaly
ECG - prolonged PR interval
171
What is the criteria used to test for infective endocarditis
Modified Dukes Criteria
172
What are the criteria for the Modified Dukes Criteria
Definite IE - 2 major, 1 major + 1 minor, 5 minor
Possible IE - 1 major + 1 minor, 3 minors
173
Describe the GS investigation in infective endocarditis
ECHO
- TTE (transthoracic)
- TEE (transoesophageal) - more sensitive
174
Describe the management in infective endocarditis caused by staphylococcus
Flucloxacillin + rifampicin + gentamicin
Prolonged cause - 2 weeks IV followed by oral
175
When would operations be chosen in infective endocarditis
Infection cannot be cured with antibiotics
Complications
Remove infected device/replace valve after infection cured
Remove large vegetation before they embolise
176
What are the differential diagnosis for infective endocarditis
Lymphoma
Pulmonary embolism
Deep vein thrombosis
Drug fever
TB
Meningitis
177
Name 4 valvular heart diseases
1. Aortic stenosis
2. Mitral regurgitation
3. Aortic regurgitation
4. Mitral stenosis
178
Define aortic stenosis
Obstruction of blood flow across the aortic valve due to aortic valve fibrosis and calcification
Blood flow out of left atrium
179
What type of problem is aortic stenosis
Pressure problem
180
What are the 3 types of aortic stenosis
1. Supravalvular
2. Subvalvular
3. Valvular
181
Describe the pathophysiology of aortic stenosis
Pressure gradient develops between L. Ventricle and aorta = increased afterload.
LV function initially maintained by compensatory pressure hypertrophy.
Compensatory mechanisms exhausted = Lv function declines.
182
What are the 2 causes of aortic stenosis
1. Congenital
2. Acquired
183
Name the 4 strong risk factors associated with aortic stenosis
Age > 60 years
Congenitally bicuspid aortic valve
Rheumatic heart disease
Chronic kidney disease
184
Describe the clinical features of aortic stenosis
Syncope
Angina
Dyspnoea
Sudden death
185
What investigations are used for aortic stenosis
ECHO - quantitative doppler echocardiography
Measures
- L, ventricular size and function
- Doppler derived gradient and valve area
186
Describe the medical management for aortic stenosis
Limited as AS is mechanical problem
187
Describe the surgical management for aortic stenosis
1st line - as AS is a medical problem
Aortic valve replacement
Transcatheter aortic valve implantation
188
Define mitral regurgitation
Backflow of the blood from the LV to the LA during systole
189
What type of problem is mitral regurgitation
Volume problem
190
What is the compensatory mechanism of mitral regurgitation
Left atrial enlargement, LVH and increased contractility
191
Describe the main causes of mitral regurgitation
Primary - disease of leaflets e.g. rheumatic fever, infective endocarditis
Secondary - dilated cardiomyopathy. Normal valve architecture but impaired due to abnormal LV/LA dilated cardiomyopathy
192
Describe the clinical features of the murmur of mitral regurgitation
Auscultation - pansystolic murmur at the apex radiating to the axilla
Loudest over the mitral area
Loudest on expiration in the left lateral decubitus position
193
Describe the GS investigations for mitral regurgitation
Echocardiogram
194
Define aortic regurgitation
Leakage of blood from the aorta into LV during diastole due to ineffective coaptation of the aortic cusps.
195
What type of problem is aortic regurgitation
Combined pressure AND volume overload
196
What are the compensatory mechanisms of aortic regurgitation
LV dilation
LVH
Progressive dilation leads to heart failure
197
What are the clinical features of chronic aortic regurgitation
Asymptomatic for years
Initial symptoms
- Palpitations
- Pounding heart when lying on the left side
- Dyspnoea
198
Describe the 2 key investigations of aortic regurgitation
Echocardiogram
CXR
199
Describe the general management of aortic regurgitation
Surgical treatment SAVR
Serial echocardiogram
Vasodilators
200
Define mitral stenosis
Obstruction of LV inflow that prevents proper filling during diastole
201
What is the predominant cause of mitral stenosis
Rhematic heart disease
202
What are the clinical features of mitral stenosis
Progressive dyspnoea (LA dilation)
Increased transmitral pressures
RHF symptoms
Haemoptysis
203
What are the GS investigations of mitral stenosis
Echocardiograph
204
Describe the management of mitral stenosis
Serial echocardiography
205
Define shock
Life-threatening, generalised form of acute circulatory failure with inadequate oxygen delivery to and consequently oxygen utilised by cells
206
What does shock describe
Pathophysiological state with many different causes
207
How is shock characterised
By the release of cytokines and other inflammatory response syndrome mediated by tissue hypoxia
208
Name 3 potential causes of shock
1. Decreased blood perfusion of tissues
2. Inadequate blood oxygen saturation
3. Increased oxygen demand from tissues
209
Define hypovolemic shock
Loss of blood or plasma cause inadequate tissue perfusion.
210
Describe the pathophysiology of hypovolaemic shock
Loss of blood volumes is detected by low-pressure stretch receptors in the atria and arterial baroreceptors in the aorta and carotid artery
211
When does hypovolemic shock occur
After haemorrhage
Systolic BP decrease after 30-40% of blood volume is lost
212
What is the management for hypovolemic shock
Stop bleeding - replace blood if required
Warm all fluids
If needed - give fresh frozen plasma and platelets early
213
Define anaphylactic shock
Sudden onset of life-threatening airway and/or breathing and/or circulation problems (with or without skin changes) after exposure to a trigger (allergen).
214
What is the management of anaphylactic shock
Diagnosis is clinical
Treat with IM adrenaline and secure airways
215
Define septic shock
Life threatening organ dysfunction caused by dysregulated host response to infection
216
What is the score tool used in septic shock
National Early Warning Score 2 (NEWS2)
217
What is the management for septic shock
Within 1 hour of being recognised
- Take 2 sets of blood cultures
- Measure serum lactate on a blood gas
- Assess the patents hourly urine output
- Give IV broad spectrum antibiotics (after taking blood cultures)
- IV fluids if any sign of circulatory insufficiency
- Oxygen if required
218
Define cardiogenic shock
Characterised by low CO state of circulatory failure that results in end-organ hypoperfusion and tissue hypoxia
219
Define neurogenic shock
Characterised by organ tissue hypoperfusion resulting from the disruption of normal sympathetic control over vascular tones due to damage of the nervous system
220
When does neurogenic shock often arise from
Spinal cord (T6)
221
What is the 1st line management for neurogenic shock
1. IV fluid
222
Define hypertrophic cardiomyopathy
Left ventricle muscle becomes thickened
223
Define dilated cardiomyopathy
Heart muscle becomes thin and dilated.
May be genetic or secondary to another condition
224
Define restrictive cardiomyopathy
Heart becomes rigid and stiff with impairment ventricular filling during diastole
225
What are the signs of hypertrophic cardiomyopathy
Ejection systolic murmur at low left sternal border
4th heart sound
Thrill at lower sternal border
226
What is the GS the investigation of hypertrophic cardiomyopathy
Echocardiography - establish diagnosis
227
What is the management of hypertrophic cardiomyopathy
Depends on severity of symptoms
- Beta blockers
- Surgical myectomy
- Alcohol septal ablation
- Implantable cardioverter defib
- Lifestyle factors
228
In hypertrophic cardiomyopathy what medication is avoided
ACE inhibitors and nitrates
229
Define rheumatic fever
Autoimmune disease mostly occurs following a group A streptococcal throat infection
230
What systems can rheumatic fever affect
Multiple systems
- Joints
- Heart - only affects here can lead to permanent damage
- Brain
- Skin
231
What are the 5 major manifestations of rheumatic fever
Carditis (most common)
Arthritis (most common)
Chorea
Erythema marginatum
Subcutaneous nodules
232
What is the diagnosis test for rheumatic fever
No single test to diagnose.
Jones Test
- Evidence of a strep A infection
+
2 major criteria
OR
One major criteria and 2 minor criteria
233
What is the management of rheumatic fever
- Initial management
- Antibiotic therapy
- Diazepam
- Long term penicillin
234
Name 5 structural heart defects which results in narrowing
1. Tetralogy of Fallot
2. Ventricular Septal Defect
3. Atrial Septal Defect
4. Atrio-ventricular septal defects (AVSD)
5. Patent Ductus Arteriosus
235
Define tetralogy of fallot
Ventricular septal defect with over-riding aorta and right ventricular outflow tract obstruction and resulting RV hypertrophy
236
Describe the pathophysiology of tetralogy of fallot
Stenosis of the heart RV outflow leads to the RV being at higher pressure than the left
Result = blue blood passes from the RV to LV
Patients = Blue
237
What are the 4 classical findings of tetralogy of fallot
1. A mal-alignment ventricular septal defect
2. Aorta over-riding VSD
3. Right ventricular outflow tract obstruction
4. Secondary right ventricular hypertrophy
238
How is tetralogy of fallot diagnosed
Echocardiography
239
What are the 6T's used to recall the differential diagnosis of cyanotic lesions
Tetralogy of fallot
Transposition of great arteries
Truncus arteriosus
Total anomalous pulmonary venous connection
Tricuspid valve abnormalities
Tons of others
240
What is the management of tetralogy of fallot
Surgical repair
- Complete intracardiac repair
241
Define ventricular septal defect
Congenital or acquired defects in the inter-ventricular septum that allow shunting of blood
242
Describe the pathophysiology of ventricular septal defect
Hold between high pressure LV and low pressure RV
243
What are the investigations of ventricular septal defects
1. Echo
Chest x-ray
ECG
2. Cardiac MRI
Cardiac CT scan
Cardiac catheterisation
244
What is the management of a large ventricular septal defect
Complete repair
PA band
245
What is the management of a small ventricular septal defect
No form of management needed
Small risk of infection
246
Describe Eisenmenger syndrome
High pressure pulmonary blood flow
Damages pulmonary vasculature
Resistance to blood flow through lungs increases
RV pressure increases
Shunt direction reverses
Patient = Blue
247
What is a possible complication of congenital heart conditions
Eisenmenger syndrome
248
Define atrial septal defect
Abnormal connection between two atria
- primum
- secundum
- sinus venosus
249
Describe the pathophysiology of atrial septal defect
Slightly higher pressure in the LA than RA
Shunt L to R
= Not blue
Increased flow into right heart and lungs
Extra volume to the lungs
250
What are the clinical features of an atrial septal defect
Pulmonary flow murmur
Fixed split second heart sound
Big pulmonary arteries on CXR
Big heart on chest x-ray
251
What is the management of atrial septal defect
Surgical
Percutaneous - keyhole technique
252
Describe AVSD
Hole in very centre of the heart
Involves the ventricular septum, the atrial septum, the mitral and tricuspid valves
Can be complete or partial
253
What is the management of AVSD
Medical treatment
- Diuretics and vasodilators to reduce preload and afterload
- Increase calories
Surgical treatment
254
What are the clinical features of patent ductus arteriosus
Continuous 'machinery' murmurs
If large - big heart, breathless
Eisenmenger's syndrome
255
Describe the management of patent ductus arteriosus
Surgical or percutaneous
256
Define coarctation
Narrowing of the aorta at the site of insertion of the ductus arteriosus
257
Describe the clinical features of coarctation
Right arm hypertension
Bruits over the scapula and back from collateral vessels
Murmurs
258
What is the management of coarctation
Surgical vs. percutaneous repair
Subclavian flap repair
End to end repair
259
What is the clinical blood pressure reading and ambulatory/home BP reading of stage 1 hypertension
Clinical
> (or equal to) 140/90 mmHg
Ambulatory/home BP
> (or equal to) 135/85 mmHg
260
What is the clinical blood pressure reading and ambulatory/home BP reading of stage 2 hypertension
Clinical
> (or equal to) 160/100 mmHg
Ambulatory/home BP
> (or equal to) 150/95 mmHg
261
What is the clinical blood pressure reading of stage 3 hypertension
> (or equal to) 180/120 mmHg
262
What is the aims of clinical BP and ambulatory/home BP in < 80
Clinical
< 140/90 mmHg
Ambulatory/home
< 135/85 mmHg
263
What is the aims of clinical BP and ambulatory/home BP in > 80 (or equal to)
Clinical
< 150/90 mmHg
Ambulatory/home
< 145/85 mmHg
264
Name differential diagnosis of ACS
Other ACS
Pericarditis
Aortic dissection
PE
Aortic stenosis
Hypertrophic cardiomyopathy
265
Define an NSTEMI
Partial occlusion of major artery or complete occlusion of minor
266
Describe the clinical features of ACS
Sudden onset of crushing chest pain
Radiating to L arm or jaw
Longer than 20 mins
Diaphoresis
Nausea
SOB
267
What is the GS investigation of NSTEMI
Troponin + ECG
268
What is a 2nd investigation in NSTEMI
Coronary angiogram
If clinically unstable
Within 24 hours
269
What is given after an NSTEMI
Dual therapy
Antiplatelet (aspirin) + clopidogrel (P2Y12 receptor inhibitor)
270
What is the immediate treatment of an NSTEMI
Antiplatelet - 300mg aspirin
Analgesia
GTN or IV opioids
Initial anti-thrombin therapy
Oxygen
271
What is troponin a marker for
Myocardial damage
272
Define STEMI
Complete occlusion of major coronary artery
Full thickness damage of heart
273
What is the 1st line management of a STEMI
MONA
Morphine
Oxygen
Nitrates
Aspirin 300mg
274
What is the GS management of STEMI
PCI in 2 hours
275
ECG - A STEMI of the l. anterior descending artery would show as...
ST elevation in V1-V3
276
ECG - A STEMI of r. coronary artery would show as...
ST changes in inferior leads II, III, aVF
277
ECG - A STEMI of l. circumflex artery would show as...
ST elevation in lateral leads I, aVL, V5-6
278
Define prinz metal angina
Clinical condition characterised by chest discomfort or pain with rest with transient ECG changes in ST segment, with prompt response to nitrates
279
Describe the clinical features of prinz metal angina
Chest pain at rest 5-15 minutes
Midnight to early morning
Pain decreases with short acting nitrates
280
Who is prinz metal angina seen in
Younger patients with less CVD risk scores
281
What are not risk factors for prinz metal angina
Smoking and inflammation by CRP
Other risk factors are same as CVD
282
What is GS investigation for prinz metal angina
Evidence of coronary spasm during coronary angiogram
283
Name the ECG changes seen in prinz metal angina
ST segment elevation or depression
284
What is 1st line management in prinz metal angina
Calcium antagonist due to vasospastic angina
285
Name 2nd line management in prinz metal angina
Smoking cessation
Avoiding medication or drugs that can induce
286
Name 6 differential diagnosis of prinz metal angina
Acute pericarditis
Anxiety
Aortic dissection
MI
GORD
Unstable angina
287
Describe the pathophysiology of prinz metal angina
Spasm in coronary arteries = decrease in blood supply to the myocardium generating symptoms like chest pain
288
Name the risk factors of heart failure
HTN
Diabetes
Obesity
Sleep apnoea
CKD
Thyroid disorders
Anaemia
AF
Lifestyle habits
289
What is heart failure based upon
L. ventricular ejection fraction
290
Describe the 2nd line investigation in heart failure
If NT-pro BNP > 400
= Transthoracic echocardiography
291
Name some signs which would be shown on a clinical exam of heart failure
Displaced apex beat - left ventricular dilation
Dullness on percussion = pleural effusion
292
What is the treatment of heart failure mainly for
HFrEF
293
Describe the management for HFpEF
Manage co-morbidities
294
Name 7 differential diagnosis of heart failure
AKI
ARDs
Pneumonia
COPD
Cirrhosis
MI
Cardiomyopathy
295
Based on frank starling law what does heart failure result in
= optimal myocardial contracility
CO = SV x HR
Co = reduced
HR = reduced
Preload = reduced
Contracility = reduced
Afterload = increased
296
Name the causes of Heart failure
HIGH VIS
Hypertension
Infection/immune
Genetic
Heart attack
Volume overload (organ failure)
Infiltration
Structural
297
What are the 2 most common reasons for heart failure
Hypertension
Heart attack - ischaemic heart disease
298
Describe BNP
Increases when myocardial stress - correlates with severity of disease
299
Describe NT-pro BNP
Helps with diagnosis + informs type and urgency of further investigations
300
Describe the ECG of heart failure
Left tachycardia
AF
L. axis deviation - L. ventricular hypertrophy
P wave abnormalities
Prolonged PR interval
Wide QRS complex
301
Describe the chest xray in heart failure
ABCDE
Alveolar oedema
Kerley B lines
Cardiomegaly - thoracic ratio > 50%
Dilated upper lobe vessels
Effusions e.g. pleural effusions
302
Describe the classes of heart failure
1 - asymptomatic
2 - slight limitation = mild
3 - marked limitation
4 - inability to carry out normal activity
303
Name what infections/immune conditions could cause heart failure
HIV (viral)
Bacterial (sepsis)
Autoimmune (lupus, rheumatoid arthiritis)
304
Name the genetic features which could result in heart failure
Hypertrophic obstructive cardiomyopathy
Dilated cardiomyopathy
305
Name the infiltration that could cause heart failure
Sarcoidosis
Amyloidosis
Haemochromatosis
306
Name the structural that could cause heart failure
Valve disease
Septal defects
307
Define ejection fraction
% of blood pumped with each beat
308
What is the normal ejection fraction
55-60%
309
Describe ischaemic heart failure
One or more frequent causes
Obstructive plaques
Determines reduced coronary blood flow
310
Describe myopathic heart failure
Dilated = heart enlarged + weakened = harder to pump blood
Hypertrophic = heart abnormally thick = harder to pump blood
311
Describe hypertensive heart failure
Increase BP = unable to pump blood correctly
Heart walls = thicken + stiffen + blood vessels become narrow and constrict
312
Name the different forms of heart failure
Right sided
Left sided
Ischaemic
Myopathic
Hypertension
Cor-pulmonale
313
Name the key differences in AAA between genders
Men 4-6x more likely than women
Female more likely to rupture
Mortality = higher in women operatively
314
What is a complication of an AAA
Endoleak
315
Name 5 differential diagnosis of AAA
Renal colic
Diverticulosis
Bowel ischaemia
Ovarian torsion
Peptic ulcer
316
Name 3 differential diagnosis of aortic dissection
MI
Aortic aneurysm
Cardiac tamponade
317
Name the risk factors for aortic dissection
Marfan syndrome
Ehler's Danlos syndrome
Bicuspid aortic valve
Cortication
Smoking
Family history
318
Name the 2nd line management in acute AF
If DC cardioversion unsuccessful
Flecainide or amiodarone
319
What should be given > 48 hours before cardioversion
BB or rate limiting CCB
320
Describe the 1st line management in chronic AF
Rate control - BB, rate limiting CCB or diltiazem
Failure = digoxin
Then consider amiodarone
321
What is given for a month post cardioversion
Anticoagulants
322
Name the risk factors of supraventricular tachycardias
Age
HTN
HF
DM
Obesity
Coronary artery disease
Other cardiac conditions
323
Name the differential diagnosis of supraventricular tachycardias
Other supraventricular tachycardias
324
What tools are used in AF
CHA2DS2VASC tool
ORBIT score
325
Define AVRT (atrioventricular re-entrant tachycardia)
Occurs when myocardial fibres connect the atrium to ipsilateral ventricles across mitral or tricuspid annulus, pre-existing ventricles
326
Name the clinical features of AVRT
Dizziness
Syncope
Chest pain
SOB
Palpitations
327
Name the risk factors of AVRT
Ebstein's anatomy
Hypertrophic cardiomyopathy
Mitral valve prolapse
Ventricular septal defects
328
What is the ECG of AVRT
Narrow QRS complex - due to conduction solely by AV node
329
What is the GS investigation of AVRT
12-lead ECG
330
What is a 2nd investigation of supraventricular tachycardias
ECHO
331
What is the management of AVRT if symptomatic
Catheter ablation
332
What is another name for AVRT
Wolff-Parkinson White syndrome
333
Define AVNRT (atrioventricular nodal re-entrant tachycardia)
Caused by re-entry within the AV node while some fibres are still refractor
Impulse will only be the excitable pathway
334
Name the clinical features of AVNRT
Dizziness
Syncope
SOB
Palpitations
Polyuria
HR 140-280 bpm
335
Name 2 risk factors of AVNRT
Coronary artery disease
Heart failure
336
What is the GS investigation of AVNRT
12-lead ECG
337
Describe the ECG of AVNRT
Ventricular rhythm 150-250bpm
P wave not visible - hidden by QRS complex
OR
P wave may be visible before or after QRS complex
Depends on the pathway
338
Describe the ECG of the slow-fast pathway in AVNRT
P wave sometimes seen after QRS.
Pseudo S lead II
Pseudo R lead V1
339
Describe the ECG of fast-slow pathway in AVNRT
P-wave before QRS or P wave on ST-T segment
340
What is the 1st line management of symptomatic AVNRT
Catheter ablation
341
What is the 2nd line management of symptomatic AVNRT
If catheter ablation not possible
BB, diltiazem, verapamil
342
Describe the epidemiology of AVNRT
1/4 of population has 2 pathways that input
One slower and one rapid
343
Describe the pathophysiology of ventricular ectopics
Electrical impulse starts from the ventricles before electrical impulse can be made by the atrium
344
Name the differential diagnosis for ventricular ectopics
LBBB
345
What does prolonged QT syndrome increase the risk of
Syncope
Ventricular arrythmias (torsades de pointes)
Sudden cardiac death
346
Name 4 clinical features of torsades de pointes
Tachycardia
Hypotension
Syncope
Dizziness
347
Name the risk factors for torsades de pointes
Coronary artery disease
MI
Hypertrophic cardiomyopathy
Electrolyte imbalance
348
What is the 2nd line medical management of torsades de pointes
Beta blocker
Atrial pacing
Anti-arrythmia drugs
349
Name 3 differential diagnosis of torsades de pointes
Ventricular tachycardia
Ventricular fibrillation
Drug-toxicity
350
Describe the complications of Torsades de pointes
If not controlled can lead to ventricular fibrillation
Sometimes death
351
Name the causes of 1st degree conduction block
Hypokalaemia
Myocarditis
Inferior MI
AV blocking drugs e.g. BB, CCB, digoxin
352
Name the differential diagnosis of conduction blocks
Congenital heart block
Sinoatrial exit block
1st degree AV block
MI
Medication toxicity
353
What is does a 1st degree conduction block increase the risk of
AF
354
Name the causes of Mobitz type 1 (2nd degree)
Av blocking drugs
Inferior MI
Fit athletes due to vagal toning
355
Describe the ECG of Mobitz type 1
PR lengthens before a QRS complex is dropped
356
Name the causes of Mobitz type 2
Anterior MI
Mitral valve surgery
SLE
Lyme disease
Rheumatic fever
357
Describe the ECG of Mobitz type 2
Normal PR interval with intermittently dropped QRS
QRS broad - if conduction failure located in bundle of his
358
What is there a risk of in Mobitz type 2 and 3rd degree complete block
Asystole
359
What is a complication of 3rd degree conduction block
Sudden cardiac death
360
Define RBBB
Right bundle no longer conducts - do not contract at the same time
Left 1st then right
361
Define LBBB
Left bundle no longer conducts - does not contract at the same time
Right 1st then left
362
Name 4 risk factors of LBBB
Younger children/adults < 35
Hypertension
Coronary artery disease
Left ventricular hypertrophy
363
How are bundle branch blocks diagnosed
ECG
364
Define hypertension
Persistently elevated arterial blood pressure
365
Name the red flags of hypertension
Headache
Visual disturbances
Seizures
N&V
Chest pain
366
Describe hypertension in genders
Women < 65 BP less than men
Women 65-74 = BP higher than men
367
Name risk factors of hypertension
Sex
Black African/Black Caribbean
Increased age
Lifestyle factors
368
Name secondary causes of hypertension
Kidney disease (most common)
Cushing's syndrome
Hypo/hyperthyroidism
Combined oral contraceptive pill
Renal cell carcinoma
Acromegaly
369
What is the single biggest risk factors of CVD
HTN
370
What are the possible causes of hypertension
Primary (90%)
Secondary
White coast syndrome
371
Name 2 2nd investigations of a DVT
D-dimer
Wells score
372
What is the GS management of DVT
Anticoagulant
373
Name the risk factors of DVT
Immobility
Recent surgery
Long haul travel
Pregnancy
Hormone therapy with oestrogen
Malignancy
374
Name 3 differential diagnosis of DVT
Cellulitis
Lymphedema
Asymmetrical oedema due to cardiac or renal failure
375
What type of respiratory failure can PE cause
Type 1
376
Describe the management of an unstable PE
Iv tissue plasminogen activator
Catheter direct thrombolysis
Open pulmonary embolectomy
377
What is used to assess risk of PE/DVT
Wells Score
378
Describe the 1st line management of a stable PE
DOACs e.g. apixaban or rivaroxaban
379
Describe the 2nd line management of stable PE
LMWH followed by warfarin
380
Name the differential diagnosis of PE
Heart attacks
Heart failure
Pericarditis
Cardiac tamponade
Pneumonia
Pneumothorax
381
What is a PE most commonly due to
Thrombus formation in the deep veins of the lower extremities
382
What is a complication of a PE aggressively treated
R. heart failure
383
What is the main management of arterial vascular disease
Anti-coagulants
384
Name the risk factors of peripheral artery disease
Atherosclerosis
Smoking
Age
Diabetes
Sex
385
Describe intermittent claudication in peripheral artery disease
Muscle pain occurs during activity and subsides with rest
386
What is a complication of peripheral artery disease
Acute limb ischaemia
387
Describe the Buerger's test
1. Patient lies supine (on back) lift patients legs angle of 45 degrees for 1-2 minutes, Look for pallor
2. Sit patient with legs hanging off the side. Blood goes back assisted by gravity. In peripheral artery disease - blue then dark red (rubor)
388
What is the Buerger's test used to assess
Peripheral artery disease
389
What does a Buerger's angle of 30 degrees mean
Legs go pale when lifted to 30 degrees
390
What is the GS investigation in pericarditis
ECG
391
Name the 2nd line investigation in pericarditis
CXR - cardiomegaly (if effusion)
Raised inflammatory markers
392
Why so colchicine prescribed in pericarditis
For 3 weeks
Binds to neutrophil to prevent them migrating to areas of uric accumulation = reduced inflammation and pain
393
Name the differential diagnosis of pericarditis and pericardial effusion
ACS
Pneumonia
PE
GORD
394
Describe the pathophysiology of pericarditis
Acute inflammation of pericardium - fibrous reaction - exudate and adhesions within the pericardial sac
395
Name the risk factors of pericardial effusion
Older age
Hypertension
DM
Coronary artery disease
AF
396
What can be used to find the underlying cause of pericardial effusion
Fluid analysis
397
Describe the main management of pericardial effusion
Most resolve spontaneously
Treat underlying cause if needed
398
When does pericardial effusion occur
Following acute pericarditis
399
What is the clinical presentation of cardiac tamponade
Buck's triad
- raised JVP
- Muffled heart sounds
- low bp
400
What is a risk factor of cardiac tamponade
Pericardial effusion
401
What is the GS investigation of cardiac tamponade
ECHO
402
What does an ECHO of cardiac tamponade show
Late diastolic collapse of r. atrium
403
Name 2 second line investigations of cardiac tamponade
CXR
ECG
404
What does a CXR of cardiac tamponade show
Large globular heart
405
What does an ECG of cardiac tamponade show
Low voltage QRS complex
406
What is the management of cardiac tamponade
Urgent drainage - pericardiocentesis
407
What can cardiac tamponade be caused by
Any disorder that results in pericardial effusion
408
What is a complication of cardiac tamponade
Can be fatal if not treated quickly
409
Describe the pathophysiology of cardiac tamponade
Increased intra-pericardial pressure = restricted cardiac filling = decreased cardiac output
410
What is the management of infective endocarditis of an unknown cause/1st line
FAG
Flucloxacillin + gentamicin + ampicillin
411
What is the management of infective endocarditis caused by MRSA
Vancomycin + rifampicin + gentamicin
412
What is the management of infective endocarditis caused by not staphylococcus
Benzylpenicillin + gentamicin
413
What is the most likely cause of infective endocarditis in IVDU
Staph aureus
414
What is the most likely cause of infective endocarditis in poor dental hygiene/developing countries
Strep viridians
415
What is the most likely cause of infective endocarditis in prosthetic valve surgery
Staphylococcus epidermis
416
Define rheumatic heart disease
Autoimmune disease mostly occurring post strep A throat infection
417
What are the 5 major manifestations of rheumatic heart disease
Carditis
Arthritis
Chorea
Erythema marginatum
Subcutaneous nodules
418
What are the major criteria for rheumatic heart disease
5 major manifestations
Carditis
Arthritis
Chorea
Erythema marginatum
Subcutaneous nodules
419
What does rheumatic heart disease follow
Initial infection typically manifests as pharyngitis
420
Name the risk factors for rheumatic heart disease
Female
Immunocompromised
Genetic
Untreated group A strep
Low socioeconomic status
Overcrowding
421
What is the criteria of rheumatic fever
Jones criteria
422
Describe Jones Criteria
Must be evidence of a recent group A strep infection + 2 major criteria or 1 major + 2 minor criteria
423
What can be used to test for rheumatic fever
Microbiology - throat culture
Rapid antigen group A strep
Anti-strep serology
424
What inflammatory markers would be high in rheumatic fever
CRP
ESR
WCC
425
Describe the 1st line conservative management for rheumatic fever
Bed rest until CRP has returned to normal range
426
Describe the 1st line medical management for rheumatic fever
IV benzylpenicillin single dose + oral penicillin for at least 10 days
Add aspirin - limit inflammatory response
427
Name 3 differential diagnosis for rheumatic fever
Septic arthritis
Juvenile arthiritis
Post-infectious reactive arthropathy
428
Describe the affect on systems by rheumatic fever
Affects multiple systems
Joints, heart (only affects here can lead to permeant damage), brain, skin
429
What hypersensitivity reaction is rheumatic fever
Type 2
430
Describe the medical management of mitral stenosis
Mechanical problem, medical therapy does not prevent progression
431
Define mitral stenosis
Narrowing of the mitral valve, which results in decreased filling of the left ventricle during systole and increased left atrial (due to incompetent left atrial emptying)
432
What are the signs of mitral stenosis
Mitral facies
Vasoconstriction results in pinkish - purple patches on checks
433
Describe the murmur of mitral stenosis
Low-pitched rumbling
Mid-diastolic murmur
434
Name 2 other investigations of mitral stenosis
CXR - LA enlargement
ECG
435
What is the surgical treatment of mitral stenosis
Percutaneous mitral balloon valvotomy
436
What type of problem is mitral stenosis
Mechanical problem
437
Name 5 differential diagnosis of valvular diseases
Hypertrophic obstructive cardiomyopathy
Restrictive cardiomyopathy
Congestive HFrEF
Coronary artery disease
Pulmonary hypertension
438
Name 2 clinical features of mitral regurgitation
Exertion dyspnoea
Heart failure
439
Name 3 risk factors for mitral regurgitation
Mitral valve prolapse
Rheumatic heart disease
Infective endocarditis history
440
What is the surgical management of mitral regurgitation
Mechanical tissue mitral valve
Transcatheter edge to edge repair
441
Describe the murmur of aortic stenosis
Crescendo decrescendo
Ejection systolic murmur
Heard loudest over the aortic area
442
How do you remember valvular diseases
PASS PAID
ASMR ARMS
443
What amount of normal valve space is left in aortic stenosis
1/4
444
Describe the signs of aortic stenosis
Slow rising pulse with narrow pulse pressure
Radiates to carotid arteries
Loudest on expiration and when patient sits forwards
445
What would be shown on a CXR of mitral regurgitation
LA enlargement
446
Name the signs of aortic regurgitation
Corrigan's sign
De Musset's sign
Quinche's sign
Traube's sign
Muller's sign
447
Define De Musset's sign
Aortic regurgitation
Head tremor, in synchrony with the beating of the heart
448
Define Corrigan sign
Aortic regurgitation
Bounding pulse in large arteries - subsequently increases
449
Define Quincke's sign
Aortic regurgitation
Visualisation of capillary pulsations upon light compression applied to tip of fingernail bed
450
Define Traube's sign
Aortic regurgitation
Double sound or murmur heard in auscultations over artery
Particular over femoral head
451
Define Muller's sign
Aortic regurgitation
Pustulation's or bobbing of uvula that occurs during diastole
452
Describe the risk factors of aortic regurgitation
Bicuspid aortic valve
Rheumatic fever
Endocarditis
Marfan syndrome
Related connective tissue disorders
453
Describe the aortic regurgitation murmur
Decrescendo early diastolic murmur
Heart loudest at the left sternal edge
Austin flint murmur
Collapsing pulse
454
What type of event is aortic regurgitation
Medical emergency
Sudden onset of pulmonary oedema + hypertension or cardiogenic shock
455
Describe aortic regurgitation pathophysiology
Leakage of blood flow in LV during diastole due to infective coaptation of aortic cusps - LV dilation, LVH, progressive dilation = HF
456
Name 3 risk factors of mitral stenosis
Rheumatic heart disease = most common
Risk - streptococcal infection
Female
457
What is the 2nd line management in neurogenic shock
If option 1 does not work
Vasopressors and inotropes
Adrenaline
Initial immobilisation of cervical spine.
458
What are the symptoms of neurogenic shock
Hypotension
Bradycardia
Warm pink skin
459
What are the risk factors of neurogenic shock
Spinal cord trauma and injury
Car accidents
Sports injuries
Nerve damage
Guillain-Barre syndrome
460
Name a common cause of death after an MI
Cardiogenic shock
461
Name the symptoms of cardiogenic shock
Altered mental state
Cold extremities
Peripheral cyanosis
Urine output < 30mL/hour
462
Name the causes of cardiogenic shock
Acute MI
Mechanical deficit
Contractility defect
PE
R. ventricular failure
463
Describe the diagnosis of cardiogenic shock
Based on diagnostic factors
Blood
ABG
Lactate
464
Describe the 1st line management of cardiogenic shock
Restoration of coronary blood flow
Medication to manage BP
465
What is the management of cardiogenic shock caused by a MI
Urgent coronary bypass
466
What plays a vital role in the prognosis of cardiogenic shock
Underlying cause
467
Describe the pathophysiology of cardiogenic shock
Progressive state of hypoperfusion (systolic < 90mmHg) lasting 30 minutes = leads to systemic hypoperfusion
CO and BP fall = increase sympathetic tone - cardiac and systemic affects
468
Describe the symptoms of septic shock
Symptoms are variable and often non-specific
Low BP
Confusion
Nausea
Cold clammy skin
469
Describe the risk factors of septic shock
Weakened immune system
Autoimmune condition
Cirrhosis of liver
Kidney disease
Cancer
470
What are the signs of anaphylactic shock
Cardinal signs
Skin rash
Wheezing/inspiratory stridor
471
Name the risk factors of anaphylactic shock
Previous anaphylactic reactions
Allergies or asthma
Previous history of anaphylaxis
472
Describe the cause of hypovolaemic shock
Movement of fluid from the interstitium to intravascular space and mobilisation of intracellular fluid
473
Name a sign of hypovolaemic shock
Thirst increase
474
Name a 2 test result of hypovolaemic shock
Reduced eGFR
Lactic acidosis
475
Why are fluids warmed in hypovolaemic shock
Risk of hypothermia - increase mortality
476
What is the treatment of hypovolaemic shock due to massive haemorrhage
Give fresh frozen plasma and platelet early
477
Name the different causes of shock
Distributive
Cardiogenic
Hypovolaemic
Obstructive
478
What are the general symptoms of shock
Unwell
Fever
Chest pain
SOB
Abdominal pain
479
Name the general risk factors of shock
Increasing age
MI
Arrythmias
Trauma
GI bleeding
Ruptured AAA
Burns/heat stroke
Pancreatitis
Sepsis
480
Describe the general signs of shock
Tissue hypoperfusion may be present without hypotension
Arterial hypotension + organ dysfunction
481
What risks is cardiomyopathy associated with
Heart failure
Myocardial infarction
Arrythmias
Sudden cardiac death (on exertion)
482
Describe the symptoms of cardiomyopathy
Asymptomatic
Symptoms - may occur on exertion
Symptoms of heart failure
483
Name the risk factors of hypertrophic cardiomyopathy
Autosomal genetic condition
Results from a defect in the genes for sarcomere family history
484
Name the differential diagnosis for cardiomyopathy
Congestive heart failure
Cerebrovascular accident
Sudden cardiac death
Thromboembolism
485
Define tetralogy of fallot
Ventricular septal defect overriding aorta and RV outflow tract = RV hypertrophy
486
Name the risk factors of tetralogy of fallot
Trisomy 21, 18 or 13
DiGeorge's syndrome - chromosome 22q11 deletion
Alagille's syndrome
Environmental factors
Family history of congenital heart disease
487
Describe the symptoms of tetralogy of fallot
Fallot spells - patient goes blue
Stop feeding
Stop crying
488
What are the 4 clinical findings of tetralogy of fallot
Ventricular septal defect (VSD)
Aorta-over riding VSD
R. ventricular outflow tract obstruction
Secondary r. ventricular hypertrophy
489
What is the GS investigation in tetralogy of fallot
Echocardiogram
490
Name the 1st line management in tetralogy of fallot
Surgical repair
Complete intracardiac repair - before age 2
491
Describe the prognosis of tetralogy of fallot post surgery
Often get pulmonary valve regurgitation in adult life and require re-do surgery
492
Name the differential diagnosis of tetralogy of fallot
6T's of cyanotic congenital heart disease
493
Describe the 6Ts of cyanotic congenital heart disease
Tetralogy of fallot
Transposition of great arteries
Truncus arteriosus
Total anomalous pulmonary venous connection
Tricuspid valve abnormalities
Tons of others
494
Describe the pathophysiology of tetralogy of fallot
Stenosis of RV outflow leads to RV being at high pressure to left = blue blood passes from RV to LV
495
Define coaraction of aorta
Narrowing of aorta at the site of insertion the ductus arteriosus
496
Name the risk factors of ventricular septal defect
Family history of congenital heart disease
Down's syndrome (trisomy 21)
Maternal alcohol consumption on during pregnancy
497
Describe the clinical features of ventricular septal defect
Blood flows from high pressure to low = not blue
Depends if large or small
498
If there is large ventricular septal defect what symptoms would this present in
Large - high pressure pulmonary blood flow
SOB
Poor feeding
Failure to thrive
Skinny baby
499
If there is a small ventricular septal defect what symptoms would this present in
Small increase in pulmonary blood flow
Asymptomatic
500
Describe the diagnosis in coaraction of aorta
Commonly only clinical sign = weak femoral pulse
Ejection systolic murmur
Unequal blood pressure between arms
Cold extremities
501
Name the risk factors of coaraction of aorta
Male gender
Genetic conditions e.g. Turner syndrome
Family history
502
Describe the clinical features of coaraction of aorta
Right arm hypertension
Bruits (buzzes) over scapula and back from collateral vessels
Murmur
503
Describe the ECG in coaraction of aorta
Normal with mild coaraction
504
Describe the chest x-ray in coaraction of aorta
Indentation of aortic shadow or signs of congestive HF
505
Describe the MRI in coaraction of aorta
Determines nature of abnormalities
506
Describe the management of severe coaraction of aorta
Severe urgent repair
507
Describe the management of mild coaraction of aorta
Repair to prevent problems in long term
508
Describe the surgical management in coaraction of aorta
Surgical (mostly children) pr percutaneous repair
509
Name the differential diagnosis of coaraction of aorta
Aortic stenosis
Cardiomyopathies
Primary hypertension
Viral myocarditis
510
Describe the different classifications of coaraction of aorta
Severe - complete/almost obstruction to aortic flow. Collapse with HF
Mild - hypertension. Incidental murmur
511
Define ventricular septal defect
Congenital or acquired defects in the inter ventricular septum allowing shunting of blood
512
Name the 1st line investigations of ventricular septal defect
ECHO
Chest x-ray
ECG
513
Name the 2nd line investigations of ventricular septal defect
Cardiac MRI
Cardiac CT scan
Cardiac catheterisation
514
Describe the management of a large ventricular septal defect
Fixing in infancy - PA band.
Complete repair
515
Describe the management of small ventricular septal defect
No need for intervention
516
Name the differential diagnosis for ventricular septal defect
Eisenmenger syndrome
Endocarditis
Embolization
Aortic insufficiency
517
Describe the pathophysiology of ventricular septal defect
Hole between high pressure LV and low pressure RV
Can result in increased pressure in the lungs
518
Name a complication of large ventricular septal defect
Eisenmenger syndrome
519
Name a complication of small ventricular septal defect
Endocarditis
