Cardiovascular COPY Flashcards
1
Q
Define atherosclerosis.
A
A hardened plaque in the intima of an artery. It is an inflammatory process.
2
Q
What can an atherosclerotic plaque cause?
A
- Heart attack.
- Stroke.
- Gangrene.
3
Q
What are the constituents of an atheromatous plaque?
A
- Lipids.
- Necrotic core.
- Connective tissue.
- Fibrous cap.
- Lymphocytes
- Foam cell
4
Q
Give 5 risk factors for atherosclerosis.
A
- Family history.
- Increasing age.
- Smoking.
- High levels of LDL’s.
- Obesity.
- Diabetes.
- Hypertension.
5
Q
In which arteries would you be most likely to find atheromatous plaques?
A
In the peripheral and coronary arteries.
6
Q
Which histological layer of the artery may be thinned by an atheromatous plaque?
A
The tunica media due to migration of smooth muscle cells into the plaque
7
Q
What is the precursor for atherosclerosis.
A
Fatty streaks.
8
Q
What can cause chemoattractant release?
A
A stimulus such as endothelial cell injury.
9
Q
How does injury to endothelial cells cause atherosclerosis
A
- Injury ➡️ endothelial dysfunction ➡️ chemoattractants released from endothelial cells signal circulating leukocytes
- chemoattractants are released from the site of injury ➡️ conc. gradient which the leukocytes follow.
- this causes leukocytes accumulation and they migrate into the vessel wall ➡️ inflammation
10
Q
Describe the process of leukocyte recruitment.
A
- Capture.
- Rolling.
- Slow rolling.
- Adhesion.
- Trans-migration.
11
Q
Describe in 5 steps the progression of atherosclerosis.
A
- Fatty streaks.
- consist of lipid-laden macrophages [foam cells] + T-lymphocytes within the intima layer
- Intermediate lesions.
- made of layers of foam cells, vascular smooth muscles cells + T-lymphocytes
- Fibrous plaque.
- covered by fibrous cap that is made of collagen and elastin for strength and flexibility.
- Plaque rupture.
- the fibrous cap is resorbed and redeposited in order to be maintained
- Plaque erosion.
- Second most prevalent cause of coronary thrombosis
12
Q
Progression of atherosclerosis: what are the constituents of fatty streaks?
A
Foam cells and T-lymphocytes. Fatty streaks can develop in anyone from about 10 years old.
13
Q
Progression of atherosclerosis: what are constituents of intermediate lesions?
A
- Foam cells.
- Smooth muscle cells.
- T lymphocytes.
- Platelet adhesion.
- Extracellular lipid pools.
14
Q
Progression of atherosclerosis: what are the constituents of fibrous plaques?
A
- Fibrous cap overlies lipid core and necrotic debris.
- Smooth muscle cells.
- Macrophages.
- Foam cells.
- T lymphocytes.
Fibrous plaques can impede blood flow and are prone to rupture.
15
Q
Progression of atherosclerosis: why might plaque rupture occur?
A
- Fibrous plaques are constantly growing and receding.
- The fibrous cap has to be resorbed and redeposited in order to be maintained.
- If balance shifted in favour of inflammatory conditions, the cap becomes weak and the plaque ruptures –> Thrombus formation and vessel occlusion.
- e.g. infection tips the balance
16
Q
What is the treatment for atherosclerosis?
A
Percutaneous coronary intervention (PCI).
17
Q
What is the major limitation of PCI?
A
Restenosis.
reduction in lumen diameter again
18
Q
How can restenosis be avoided following PCI?
A
Drug eluting stents: anti-proliferative and prevent scar formation.
drugs that inhibit healing.
19
Q
What is the key principle behind the pathogenesis of atherosclerosis?
A
It is an inflammatory process!
20
Q
Define atherogenesis.
A
The development of an atherosclerotic plaque.
21
Q
Define angina.
A
- Angina is a type of IHD.
- It is a symptom of O2 supply/demand mismatch to the heart experienced on exertion.
- narrowed lumen of coronary arteries reduces blood flow to the cardiomyocytes –> ischaemia.
22
Q
What is the most common cause of angina?
A
Narrowing of the coronary arteries due to atherosclerosis.
23
Q
Give 5 possible causes of angina.
A
- Narrowed coronary artery = impairment of blood flow e.g. atherosclerosis.
- LV hypertrophy –> increased O2 demands.
- Reduced O2 carrying capacity e.g. anaemia.
- Coronary artery spasm.
- Thrombosis.
24
Q
Give 5 modifiable risk factors for angina.
A
- Smoking.
- Diabetes.
- High cholesterol (LDL).
- Obesity/sedentary lifestyle.
- Hypertension.
25
Give 3 non-modifiable risk factors for angina.
1. Increasing age.
2. Gender, male bias.
3. Family history/genetics.
26
Briefly describe the pathophysiology of angina that results from atherosclerosis.
On exertion there is increased O2 demand. Coronary blood flow is obstructed by an atherosclerotic plaque -> myocardial ischaemia -> angina.
27
Briefly describe the pathophysiology of angina that results from anaemia.
On exertion there is increased O2 demand. In someone with anaemia there is reduced O2 transport -> myocardial ischaemia -> angina.
28
How do blood vessels try and compensate for increased myocardial demand during exercise.
When myocardial demand increases e.g. during exercise, microvascular resistance drops and flow increases, due to vasodilation!
29
Why are blood vessels unable to compensate for increased myocardial demand in someone with CV disease?
In CV disease, epicardial resistance is high meaning microvascular resistance has to fall at rest to supply myocardial demand at rest. When this person exercises, the microvascular resistance can't drop anymore and flow can't increase to meet metabolic demand = angina!
30
How can angina be reversed?
- Resting - reducing myocardial demand.
- Nitrates - vasodilation to reduce resistance and increase blood flow/O2 to myocardial cells
31
How would you describe the chest pain in angina?
- Crushing central chest pain.
- Heavy and tight.
- The patient will often make a fist shape to describe the pain.
32
Give 5 symptoms of angina.
1. Crushing central chest pain.
2. The pain is relieved with rest or using a GTN spray.
3. The pain is provoked by physical exertion.
4. The pain might radiate to the arms, neck or jaw.
5. Breathlessness.
33
What tool can you use to determine the best investigations and treatment in someone you suspect to have angina?
Pre-test probability of CAD.
- It takes into account gender, age and typicality of pain.
34
What investigations might you do in someone you suspect to have angina?
1. ECG - usually normal, there are no markers of angina.
2. Echocardiography.
3. CT angiography - has a high NPV and is good at excluding the disease.
4. Exercise tolerance test - induces ischaemia.
5. Invasive angiogram - tells you FFR (pressure gradient across stenosis).
35
A young, healthy, female patient presents to you with what appears to be the signs and symptoms of angina. Would it be good to do CT angiography on this patient?
Yes. CT angiography has a high NPV and so is ideal for excluding CAD in
younger, low risk individuals.
36
Describe the treatment for stable angina.
1. All pts receive
- antiplatelet therapy - aspirin or clopidogrel
- statins to lower cholesterol
- GTN spray for acute attacks
2. 1st line treatment =
- **Beta Blockers or CCBs**
- if intolerant ➡️ **switch**
- if not controlled ➡️ **combine**
3. If pt still uncontrolled or intolerant consider mono therapy or combinations with:
- Long acting nitrate
- Ivabradine (inhibits If current)
- Nicorandil (K channel activator)
- Ranolazine (inhibits late inward sodium current)
37
Describe the secondary prevention of CVD.
statins, aspirin + clopidogrel, BB, ACEi in diabetics
38
Name 3 pharmacological therapies that might be used in someone with angina.
1. Beta blockers.
2. Nitrates e.g. GTN spray.
3. Calcium channel blockers.
39
Describe the action of beta blockers.
- Beta blockers are beta 1 specific.
- They antagonise sympathetic activation and so are negatively chronotropic [rate] and inotropic [contractility].
- Myocardial work is reduced and so is myocardial demand = symptom relief.
40
Give 3 side effects of beta blockers.
1. Bradycardia.
2. Tiredness.
3. Erectile dysfunction.
4. Cold peripheries.
5. nightmares
41
When might beta blockers be contraindicated?
- asthmatics
- pts with bradycardia
42
Describe the action of nitrates.
- Nitrates are vasodilators that act on the arteries and veins.
- arterial vasodilation -> reduced resistance and increased blood flow in the coronary arteries.
- Venodilation -> reduced venous return -> reduced pre-load -> reduced myocardial work and myocardial demand.
43
Describe the action of CCBs.
CCBs are arterial vasodilators -> reduced peripheral BP -> reduced afterload -> reduced myocardial demand.
44
Name 2 drugs that might be used in someone with angina or in someone at risk of angina to improve prognosis.
1. Aspirin.
2. Statins.
45
How does aspirin work?
- Aspirin irreversibly inhibits COX1, which is needed for conversion of arachidonic acid into TXA2 [a potent inducer of platelet aggregation].
- thus, you get reduced TXA2 synthesis and so platelet aggregation is reduced.
Caution: Gastric ulcers!
46
What are statins used for?
They reduce the amount of LDL in the blood.
47
What is revascularisation?
- restoration of patency in an artery so it is patent again + blood flow increases.
- Revascularisation might be used in someone with peripheral artery disease of MI = PCI
48
Name 2 types of revascularisation.
1. PCI.
2. CABG.
49
Give 2 advantages and 1 disadvantage of PCI.
1. Less invasive.
2. Convenient and acceptable.
3. High risk of restenosis.
50
Give 1 advantage and 2 disadvantages of CABG.
1. Good prognosis after surgery.
2. Very invasive.
3. Long recovery time.
51
What are acute coronary syndromes (ACS)?
- unstable angina
- NSTEMI
- STEMI.
52
What is the common cause of ACS?
Rupture of an atherosclerotic plaque and subsequent arterial thrombosis.
53
What are uncommon causes of ACS?
1. Coronary vasospasm.
2. Drug abuse.
3. Coronary artery dissection.
54
Briefly describe the pathophysiology of ACS?
Atherosclerosis -> plaque rupture -> platelet aggregation -> thrombosis formation -> ischaemia and infarction -> necrosis of cells -> permanent heart muscle damage and ACS.
55
Describe type 1 MI.
Spontaneous MI with ischaemia due to plaque rupture.
56
Describe type 2 MI.
MI secondary to ischaemia due to increased O2 demand.
57
Why do you see increased serum troponin in NSTEMI and STEMI?
- The occluding thrombus causes necrosis of cells and so myocardial damage.
- Troponin is a sensitive marker for cardiac muscle injury therefore rises in MI.
58
Give 3 signs of unstable angina.
1. Cardiac chest pain at rest.
2. Cardiac chest pain with crescendo patterns; pain becomes more frequent and easier provoked.
3. No significant rise in troponin.
59
Give 6 signs/symptoms of MI.
1. Unremitting and usually severe central cardiac chest pain.
2. palpitations + pallor.
3. Sweating
4. Breathlessness.
5. Nausea/vomiting.
6. dyspnoea.
Pain occurs at rest
60
Give 5 potential complications of MI.
DARTHVADER –
1. * Death,
1. * Arrythmia,
1. * Rupture of septum or papillary muscles,
1. * Tamponade,
1. * Heart failure,
1. * Valvular disease,
1. * Aneurysm,
1. * Dressler’s syndrome,
1. * Embolism,
1. * Recurrence, regurgitation. + repeat infarct
61
What investigations would you do on someone you suspect to have ACS?
1. ECG.
2. Blood tests; look at serum troponin.
3. Coronary angiography.
4. Cardiac monitoring for arrhythmias.
62
What might the ECG of someone with unstable angina show?
The ECG from someone with unstable angina may be normal or might show T wave inversion and ST depression.
63
What might the ECG of someone with NSTEMI show?
The ECG from someone with NSTEMI may be normal or might show T wave inversion and ST depression. There also might be R wave regression, ST elevation and biphasic T wave in lead V3.
64
What might the ECG of someone with STEMI show?
The ECG from someone with STEMI will show ST elevation in the anterolateral leads. After a few hours, T waves invert and deep, broad, pathological Q waves develop.
65
What would the serum troponin level be like in someone with unstable angina?
Normal.
66
What would the serum troponin level be like in someone with NSTEMI/STEMI?
Significantly raised.
67
- T/F
High troponin is always a marker of ACS
False troponin is non-selective
**troponin is also positive in**
- gram negative sepsis
- pulmonary embolism
- myocarditis
- heart failure
- arrhythmias
- chronic renal failure
- aortic dissection
- cytotoxic drugs
68
what might a raised toponin level indicate besides MI
**troponin is also positive in**
- gram negative sepsis
- pulmonary embolism
- myocarditis
- heart failure
- arrhythmias
- chronic renal failure
- aortic dissection
- cytotoxic drugs
69
Describe the initial management for ACS.
1. Get into hospital ASAP - call 999.
2. If STEMI, paramedics should call PCI centre for transfer.
MOAN
3. Aspirin 300mg.
4. Pain relief e.g. morphine.
5. Oxygen if hypoxic.
6. Nitrates.
70
What is the treatment of choice for STEMI?
PCI.
71
What is the function of P2Y12?
It amplifies platelet activation.
72
Give 3 potential side effects of P2Y12 inhibitors.
1. Bleeding.
2. Rash.
3. GI disturbances.
73
Describe the secondary prevention therapy for people after having a STEMI.
1. dual anti platelet: Aspirin + clopidogrel.
3. Statins.
4. beta blocker
5. ACE inhibitor.
6. Modification of risk factors.
74
ECG: what is the J point?
Where the QRS complex becomes the ST segment.
75
ECG: what is the normal axis of the QRS complex?
-30° -> +90°
76
ECG: what does the P wave represent?
Atrial depolarisation.
77
ECG: how long should the PR interval be?
120 - 200ms.
78
ECG: what might a long PR interval indicate?
Heart block.
79
ECG: how long should the QT interval be?
0.35 - 0.45s.
80
ECG: what does the QRS complex represent?
- firing of AVN
- Ventricular depolarisation.
81
ECG: what does the T wave represent?
Ventricular repolarisation.
82
ECG: where would you place lead 1?
From the right arm to the left arm with the positive electrode being at the left arm. At 0°.
83
ECG: where would you place lead 2?
From the right arm to the left leg with the positive electrode being at the left leg. At 60°.
84
ECG: where would you place lead 3?
From the left arm to the left leg with the positive electrode being at the left leg. At 120°.
85
ECG: where would you place lead avF?
From halfway between the left arm and right arm to the left leg with the positive electrode being at the left leg. At 90°.
86
ECG: where would you place lead avL?
From halfway between the right arm and left leg to the left arm with the positive electrode being at the left arm. At -30°.
87
ECG: where would you place lead avR?
From halfway between the left arm and left leg to the right arm with the positive electrode being at the right arm. At -150°.
88
What is the dominant pacemaker of the heart?
The SA node. 60-100 beats/min.
89
How many seconds do the following represent on ECG paper?
a) small squares.
b) large squares.
a) 0.04s.
| b) 0.2s.
90
How long should the QRS complex be?
Less than 110 ms.
91
In which leads would you expect the QRS complex to be upright in?
Leads 1 and 2.
92
In which lead are all waves negative?
aVR.
93
In which leads must the R wave grow?
From chest leads V1 to V4.
94
In which leads must the S wave grow?
From chest leads V1 to V3. It must also disappear in V6.
95
In which leads should T waves and P waves be upright?
Leads 1, 2, V2 -> V6.
96
What might tall pointed P waves on an ECG suggest?
Right atrial enlargement.
97
What might notched, 'm shaped' P waves on an ECG suggest?
Left atrial enlargement.
98
Give 3 signs of abnormal T waves.
1. Symmetrical.
2. Tall and peaked.
3. Biphasic or inverted.
99
What happens to the QT interval when HR increases?
The QT interval decreases.
100
What part of the ECG does the plateau phase of the cardiac action potential coincide with?
QT interval.
101
What are the symptoms of DVT?
Non-specific symptoms, pain and swelling. Tenderness, warmth and slight discolouration.
102
Briefly describe the investigations might be done in order to diagnose a DVT.
1. D-dimer; looks for fibrin breakdown products. If normal, you can exclude DVT. Abnormal does not confirm diagnosis however.
2. Ultrasound compression scan; if you can't squash the vein = clot.
103
What is the treatment for DVT?
1. LMWH.
2. Oral warfarin or DOAC.
3. Compression stockings.
4. Treat the underlying cause e.g. malignancy or thrombophilia.
104
Give 5 risk factors for DVT.
1. Surgery, immobility, leg fracture.
2. OCP, HRT.
3. Long haul flights.
4. Genetic predisposition.
5. Pregnancy.
105
How can DVT's be prevented?
1. Hydration.
2. Mobilisation.
3. Compression stockings.
4. Low does LMWH.
106
What might be the consequence of a dislodged DVT?
Pulmonary embolism.
107
How would you describe an arterial thrombosis?
Platelet rich - a 'white thrombosis'.
108
How would you describe a venous thrombosis?
Fibrin rich - a 'red thrombosis'.
109
What are the potential consequences of arterial thrombosis?
1. MI.
2. Stroke.
3. Peripheral vascular disease e.g. gangrene
110
What are the potential consequences of venous thrombosis?
Pulmonary embolism.
111
What is the treatment for arterial thrombosis?
1. Aspirin.
2. LMWH.
3. Thrombolytic therapy.
112
How does warfarin work?
It produces NON-functional clotting factors 2, 7, 9 and 10.
113
What is warfarin the antagonist of?
Vitamin K.
114
Why is warfarin difficult to use?
1. Lots of interactions!
2. Teratogenic.
3. Needs almost constant monitoring.
115
What is infective endocarditis?
Infection of the heart valves.
116
What is the clinical diagnosis of hypertension?
BP ≥ 140/90mmHg.
117
How can hypertension be treated?
1. Lifestyle modification e.g. reduce salt intake.
| 2. Anti-hypertensive drugs.
118
Write an equation for BP.
BP = CO X TPR.
119
Name 2 systems that are targeted pharmacologically in the treatment of hypertension.
1. RAAS.
| 2. Sympathetic nervous system (NAd).
120
Give 4 functions of angiotensin 2.
1. Potent vasoconstrictor.
2. Activates sympathetic nervous system; increased NAd.
3. Activates aldosterone = Na+ retention.
4. Vascular growth, hyperplasia and hypertrophy.
121
Give 3 ways in which the sympathetic nervous system (NAd) lead to increased BP.
1. Noradrenaline is a vasoconstrictor = increased TPR.
2. NAd has positive chronotropic and inotropic effects.
3. It can cause increased renin release.
122
Name 3 ACE inhibitors.
1. Ramapril.
2. Enalapril.
3. Perindopril.
123
In what diseases are ACE inhibitors clinically indicated?
1. Hypertension.
2. Heart failure.
3. Diabetic nephropathy.
124
Give 4 potential side effects of ACE inhibitors.
1. Hypotension.
2. Hyperkalaemia.
3. Acute renal failure.
4. Teratogenic.
125
Why do ACE inhibitors lead to increased kinin production?
ACE also converts bradykinin to inactive peptides. Therefore ACE inhibitors lead to a build up of kinin.
126
ACE inhibitors: give 3 potential side effects that are due to increased kinin production.
1. Dry chronic cough.
2. Rash.
3. Anaphylactoid reaction.
127
You see a patient who is taking ramipril. They say that since starting the medication they have had a dry and persistent cough. What might have caused this?
ACE inhibitors lead to a build up of kinin. One of the side effects of this is a dry and chronic cough.
128
What are ARBs?
Angiotensin 2 receptor blockers.
129
At which receptor do ARB's work?
AT-1 receptor.
130
Name 3 ARBs?
1. Candesartan.
2. Valsartan.
3. Losartan.
131
In what diseases are ARBs clinically indicated?
1. Hypertension.
2. Heart failure.
3. Diabetic nephropathy.
132
A patient with hypertension has come to see you about their medication. You see in their notes that ACE inhibitors are contraindicated. What might you prescribe them instead?
An ARB e.g. candesartan.
133
Give 4 potential side effects of ARBs.
ARBs have similar side effects to ACEi:
1. Hypotension.
2. Hyperkalaemia.
3. Renal dysfunction.
4. Rash.
Contraindicated in pregnancy.
134
Name 4 Calcium channel blockers.
1. Amlodipine.
2. Felodipine.
3. Diltiazem.
4. Verapamil.
135
Name 2 dihydropyridines and briefly explain how they work.
Dihydropyridines are a class of calcium channel blockers. Amlodipine and felodipine are examples of dihydropyridines. They are arterial vasodilators.
136
Name a calcium channel blocker that acts primarily on the heart.
Verapamil - it is negatively chronotropic and inotropic.
137
Name a calcium channel blocker that acts on the heart and on blood vessels.
Diltiazem - acts on the heart and the vasculature.
138
In what diseases are calcium channel blockers clinically indicated?
1. Hypertension.
2. IHD.
3. Arrhythmia.
139
On what channels do calcium channel blockers work?
L type Ca2+ channels.
140
Give 3 potential side effects that are due to the vasodilatory ability of calcium channel blockers.
1. Flushing.
2. Headache.
3. Oedema.
141
Give a potential side effect that is due to the negatively inotropic ability of calcium channel blockers.
Worsening caridac failure.
142
Give 2 potential side effects that are due to the negatively chronotropic ability of calcium channel blockers.
1. Bradycardia.
| 2. Atrioventricular block.
143
Give 4 potential side effects of verapamil.
1. Worsening cardiac failure (-ve inotrope).
2. Bradycardia (-ve chronotrope).
3. Atrioventricular block (-ve chronotrope).
4. Constipation!
144
A patient comes to see you who has recently started taking calcium channel blockers for their hypertension. They complain of constipation. What calcium channel blocker might they be taking?
Verapamil.
145
Name 3 beta blockers.
1. Bisoprolol (beta 1 selective).
2. Atenolol.
3. Propanolol (beta 1/2 non selective).
146
In what diseases are beta blockers clinically indicated?
1. IHD.
2. Heart failure.
3. Arrhythmia.
4. Hypertension.
147
Give 5 potential side effects of beta blockers.
1. Fatigue.
2. Headache.
3. Nightmares.
4. Bradycardia.
5. Hypotension.
6. Cold peripheries.
7. Erectile dysfunction.
8. Bronchospasm.
148
Diuretics: where do in the kidney do thiazides work?
The distal tubule.
149
Name a thiazide.
Bendroflumethiazide.
150
Name 2 loop diuretics.
1. Furosemide.
| 2. Bumetanide.
151
Name a potassium sparing diuretic.
Spironolactone.
152
Why are potassium sparing diuretics especially effective?
They have anti-aldosterone effects too.
153
In what diseases are diuretics clinically indicated?
1. Heart failure.
| 2. Hypertension.
154
Give 5 potential side effects of diuretics.
1. Hypovolemia.
2. Hypotension.
3. Reduced serum Na+/K+/Mg+/Ca2+.
4. Increased uric acid -> gout.
5. Erectile dysfunction.
6. Impaired glucose tolerance.
155
You see a 45 y/o patient who has recently been diagnosed with hypertension. What is the first line treatment?
ACE inhibitors e.g. ramapril or ARB e.g. candesartan.
156
You see a 65 y/o patient who has recently been diagnosed with hypertension. What is the first line treatment?
Calcium channel blockers (as this patient is over 55) e.g. amlodipine.
157
You see a 45 y/o patient who has recently started taking ACE inhibitors for their hypertension. Unfortunately their hypertension still isn't controlled. What would you do next for this patient?
You would combine ACE inhibitors or ARB with calcium channel blockers.
158
You see a 45 y/o patient who has been taking ACE inhibitors and calcium channel blockers for their hypertension. Following several tests you notice that their blood pressure is still high. What would you do next for this patient?
You would combine the ACEi/ARB and calcium channel blockers with a thiazide diuretic e.g. bendroflumethiazide.
159
What is heart failure?
A complex clinical syndrome of signs and symptoms that suggest the efficiency of the heart as a pump is impaired.
160
What is the most common cause of heart failure?
Ischaemic heart disease.
161
What might you give to someone with hypertension if they are ACE inhibitor intolerant?
ARB.
162
What hormones does the heart produce?
ANP and BNP.
163
What metabolises ANP and BNP?
NEP.
164
Why can NEP inhibitors work for heart failure treatment?
NEP metabolises ANP and BNP. NEP inhibitors can therefore increase levels of ANP and BNP in the serum.
165
What are the functions of ANP and BNP?
1. Increased renal excretion of Na+ and therefore water.
2. Vasodilators.
3. Inhibit aldosterone release.
166
What is the counter regulatory system to RAAS?
ANP/BNP hormones.
167
Name 2 nitrates that are used pharmacologically.
1. Isosorbide mononitrate.
| 2. GTN spray.
168
How do nitrates work in the treatment of heart failure?
They are venodilators. They reduce preload and so BP.
169
Give 3 potential side effects of nitrates.
1. Headache.
2. Syncope.
3. Tolerance.
170
What classification is used to group anti-arrhythmic drugs?
Vaughan Williams classification.
171
Vaughan Williams classification: name 3 class 1 drugs.
Class 1 are Na+ channel blockers. There are 3 sub-divisions in this group.
1a: disopyramide.
1b: lidocaine.
1c: flecainide.
172
Vaughan Williams classification: name 3 class 2 drugs.
Class 2 are beta blockers:
1. Propranolol.
2. Atenolol.
3. Bisoprolol.
173
Vaughan Williams classification: name a class 3 drug.
Class 3 drugs prolong the action potential. E.g. amiodarone. Side effects are very likely with these drugs.
174
Vaughan Williams classification: name 2 class 4 drugs.
Class 4 drugs are calcium channel blockers but NOT dihydropyridines as these don't effect the heart.
1. Verapamil.
2. Diltiazem.
175
How does digoxin work?
It inhibits the Na+/K+ pump therefore making the action potential more positive and ACh is released from parasympathetic nerves.
176
What are the main effects of digoxin?
1. Bradycardia.
2. Reduced atrioventricular conduction.
3. Increased force of contraction (positive inotrope).
177
Give 4 potential side effects of digoxin.
1. Nausea.
2. Vomiting.
3. Diarrhoea.
4. Confusion.
178
In what diseases is digoxin clinically indicated?
Atrial fibrillation and severe heart failure.
179
Name 2 drugs that can prolong the QT interval.
1. Sotalol.
| 2. Amiodarone.
180
Give 5 potential side effects of drugs that prolong the QT interval.
1. Pro-arrythmic effects.
2. Interstitial pneumonitis.
3. Abnormal liver function.
4. Hyper/hypothyroidism.
5. Sun sensitivity.
6. Grey skin discolouration.
7. Corneal micro-deposits.
8. Optic neuropathy.
181
How do sodium channel blockers work in the treatment of ventricular tachycardia?
They block the inactivation gate of the sodium channel.
182
What additional property makes propranolol the most useful beta blocker to help control the arrhythmias which occur immediately following a heart attack ?
It can also block sodium channels.
183
What does furosemide block?
The Na+/K+/2Cl- transporter.
184
Why are beta blockers good in chronic heart failure?
They block reflex sympathetic responses which stress the failing heart.
185
Doxazosin can be used in the treatment of hypertension. How does this drug work?
It is an alpha 1 receptor antagonist.
186
How do beta blockers provide symptom relief in angina?
1. They reduce O2 demand by slowing heart rate (negative chronotrope).
2. They reduce O2 demand by reducing myocardial contractility (negative inotrope).
3. They increase O2 distribution by slowing heart rate.
187
What drug might you give to someone with angina caused by coronary artery vasospasm?
Amlodipine.
188
Define shock.
When the cardiovascular system is unable to provide adequate substrate for aerobic cellular respiration.
189
Give 7 signs/symptoms of shock.
1. Pale.
2. Sweaty.
3. Cold.
4. Pulse is weak and rapid.
5. Reduced urine output.
6. Confusion.
7. Weakness/collapse.
190
What can cause hypovolemic shock?
1. Loss of blood e.g. acute GI bleeding, trauma, post-op, splenic rupture.
2. Loss of fluid e.g. dehydration, burns, vomiting, pancreatitis.
191
Classification of shock: describe the vital signs in class 1 e.g. blood loss, pulse, blood pressure, pulse pressure, respiratory rate and urine output.
1. 15% blood loss.
2. Pulse < 100 bpm.
3. Blood pressure - normal.
4. Pulse pressure - normal.
5. Respiratory rate: 14 - 20.
6. Urine output > 30ml/h.
192
Classification of shock: describe the vital signs in class 2 e.g. blood loss, pulse, blood pressure, pulse pressure, respiratory rate and urine output.
1. 15-30% blood loss.
2. Pulse > 100 bpm.
3. Blood pressure - normal.
4. Pulse pressure - decreased.
5. Respiratory rate: 20 - 30.
6. Urine output: 20 - 30ml/h.
193
Classification of shock: describe the vital signs in class 3 e.g. blood loss, pulse, blood pressure, pulse pressure, respiratory rate and urine output.
1. 30-40% blood loss.
2. Pulse > 120 bpm.
3. Blood pressure - decreased.
4. Pulse pressure - decreased.
5. Respiratory rate: 30 - 40.
6. Urine output: 5 - 15ml/h.
194
What can cause cardiogenic shock?
1. Cardiac tamponade.
2. Pulmonary embolism.
3. Acute MI.
4. Fluid overload.
195
What is septic shock?
A systemic inflammatory response associated with an infection (bacterial endotoxins).
196
What is anaphylactic shock?
An intense allergic reaction associated with massive histamine release = haemodynamic collapse. The patient may be breathless, wheezy and have a rash.
197
What is the treatment for anaphylactic shock?
Adrenaline and supportive therapy e.g. O2 delivery, fluid replacement.
198
Give 2 signs of ARDS.
1. Impaired oxygenation.
2. Bilateral pulmonary infiltrates.
3. No cardiac failure.
199
Describe the pathophysiology of ARDS in 3 stages.
1. Exudative phase: increased vascular permeability leads to a platelet, fibrin and clotting factor rich exudate.
2. Proliferative phase: fibroblast proliferation.
3. Fibrotic phase.
200
Give 4 extra-pulmonary causes of ARDS.
1. SEPSIS!
2. Trauma.
3. Shock.
4. Drug reaction.
5. Pancreatitis.
201
Give 3 pulmonary causes of ARDS.
1. Pneumonia.
2. Smoke inhalation.
3. Near drowning.
202
How much serous fluid is there between the visceral and parietal pericardium?
50ml.
203
What is the function of the serous fluid between the visceral and parietal pericardium?
It acts as a lubricant and so allows smooth movement of the heart inside the pericardium.
204
What is the function of pericardium?
It restrains the filling volume of the heart.
205
Describe the aetiology of pericarditis.
1. Viral (common) e.g. enteroviruses.
2. Bacterial e.g. mycobacterium tuberculosis.
3. Autoimmune e.g. RA, sjögren syndrome.
4. Neoplastic.
5. Metabolic e.g. uraemia.
6. Traumatic and iatrogenic.
7. 80-90% are idiopathic.
206
What is acute pericarditis?
An inflammatory pericardial syndrome with or without effusion.
207
How can acute pericarditis be clinically diagnosed?
Acute pericarditis can be clinically diagnosed if the patient has at least 2 of the following:
1. Chest pain.
2. Friction rub.
3. ECG changes.
4. Pericardial effusion.
208
Give 5 symptoms of pericarditis.
1. Chest pain! Described as severe, sharp and pleuritic. Rapid onset. Pain can radiate to the arm.
2. Dyspnoea.
3. Cough.
4. Hiccups.
5. Skin rash.
209
Why might someone with pericarditis have hiccups?
Because of irritation to the phrenic nerve.
210
What investigations might you do on someone who you suspect to have pericarditis?
1. ECG.
2. CXR.
3. Bloods.
4. Echocardiogram.
211
What might the ECG look like in someone with acute pericarditis?
1. PR depression seen in most leads.
| 2. 'Saddle shaped' concave ST elevation.
212
What is the major differential diagnosis of acute pericarditis?
MI - it is important to rule this out ASAP!
213
What is the treatment for pericarditis?
1. Patients are advised to avoid strenuous activity until symptom resolution.
2. NSAID or aspirin - high doses.
3. Colchicine (anti-inflammatory).
214
Why does chronic pericardial effusion rarely cause tamponade?
The parietal pericardium is able to adapt when effusions accumulate slowly and so tamponade is prevented.
215
What is haemopericardium?
Direct bleeding from vasculature through the ventricular wall following MI.
216
What can cause myocarditis?
Viral infection.
217
Name 3 cardiomyopathies.
1. Hypertrophic (HCM).
2. Dilated (DCM).
3. Arrhythmogenic right/left ventricular (ARVC/ALVC).
218
What can cause HCM?
Sarcomeric gene mutations e.g. beta myosin, troponin T mutations. About 1 in 500 people are affected.
219
What can cause ARVC/ALVC?
Desmosome gene mutations.
220
What is the usual inheritance pattern for cardiomyopathies?
Autosomal dominant; off-spring have a 50% chance of being affected.
221
Describe the pathophysiology of HCM.
Systole is normal but diastole is affected; the heart is unable to relax properly due to thickening of the ventricular walls.
222
Describe the pathophysiology of DCM.
Ventricular dilation and dysfunction = poor contractility.
223
Describe the pathophysiology of ARVC/ALVC.
Desmosomes attach cells via their intermediate filaments. Desmosome mutations lead to myocytes being pulled apart and ventricles are replaced with fatty fibrous tissue. Gap junctions are affected too.
224
Give 3 symptoms of HCM.
1. Angina.
2. Dyspnoea.
3. Syncope.
225
Give 3 symptoms of DCM.
DCM usually presents with symptoms similar to those seen in heart failure:
1. Breathlessness.
2. Tiredness.
3. Oedema.
226
Give a sign of ARVC/ALVC.
Ventricular tachycardia.
227
What might an ECG look like from a person with HCM.
1. Large QRS complexes.
| 2. Large inverted T waves.
228
What might an ECG look like from a person with ARVC/ALVC.
Epsilon waves.
229
What is restrictive cardiomyopathy?
Poor dilation of the heart restricts diastole.
230
What is the commonest cause of restrictive cardiomyopathy?
Amyloidosis (extra-cellular deposition of an insoluble fibrillar protein - amyloid).
231
What are channelopathies?
Mutations in genes coding for ion channels.
232
Name 4 channelopathies.
1. Long QT syndrome.
2. Short QT syndrome.
3. Brugada.
4. CPVT.
233
What ion channel is affected in Brugada?
Sodium channel.
234
What is the commonest symptom of channelopathies?
Recurrent syncope.
235
What might the ECG look like from someone with Brugada?
Characteristic ST elevation in chest leads.
236
What is Brugada?
A channelopathy caused by a mutation in sodium channels.
237
What are the four main features of tetralogy of fallot?
1. Ventricular septal defect.
2. Over-riding aorta.
3. RV hypertrophy.
4. Pulmonary stenosis.
238
Would a baby born with tetralogy of fallot be cyanotic?
YES! There is a greater pressure in the RV than the LV and so blood is shunted into the LV -> CYANOSIS!
239
What is VSD?
An abnormal connection between the two ventricles.
240
Would a baby born with VSD be cyanotic?
No. There is a higher pressure in the LV than the RV and so blood is shunted from the left to right meaning there is an increased amount of blood going to the lungs; not cyanotic.
241
Give 4 clinical signs of a large VSD.
1. High pulmonary blood flow.
2. Breathless, poor feeding, failure to thrive.
3. Increased respiratory rate,
4. Tachycardia.
5. Requires surgical repair.
242
What syndrome might VSD lead on to?
Eisenmengers syndrome.
243
Briefly describe the physiology of Eisenmengers syndrome.
High pressure pulmonary blood flow damages pulmonary vasculature -> there is increased resistance to blood flow (pulmonary hypertension) -> RV pressure increases -> shunt direction reverses (RV to LV) -> CYANOSIS!
244
What are the risks associated with Eisenmengers syndrome?
1. Risk of death.
2. Endocarditis.
3. Stroke.
245
What is ASD?
An abnormal connection between the two atria; it is fairly common.
246
Would a baby born with ASD be cyanotic?
No. There is a higher pressure in the LA than the RA and so blood is shunted from the left to right, therefore not cyanotic.
247
Give 5 clinical signs of a large ASD.
1. Significant increase in blood flow through the right heart and lungs - pulmonary flow murmur.
2. Enlarged pulmonary arteries.
3. Right heart dilatation.
4. SOBOE.
5. Increased chest infection.
248
What is AVSD?
Atrio-ventricular septal defects. Basically a hole in the very centre of the heart.
249
Give 2 clinical signs of AVSD.
1. Breathless.
| 2. Poor feeding and poor weight gain.
250
What is PDA?
Patent ductus arteriosus.
251
Give 4 clinical signs of PDA.
1. Torrential flow from the aorta to the pulmonary arteries can lead to pulmonary hypertension and RHF.
2. Breathless.
3. Poor feeding, failure to thrive.
4. Risk of endocarditis.
252
Describe the pathophysiology behind coarctation of the aorta.
Excessive sclerosing that normally closes the ductus arteriosus extends into the aortic wall leading to narrowing.
253
What is pulmonary stenosis?
Narrowing of the RV outflow tract.
254
Name 3 congenital heart defects that are not cyanotic.
1. VSD.
2. ASD.
3. PDA.
Left to right shunt! This is okay but a bit insufficient and there is a risk of Eisenmengers syndrome.
255
Name a congenital heart defect that is cyanotic.
Tetralogy of Fallot.
Right to left shunt.
256
Define cardiac failure.
A complex clinical syndrome of signs/symptoms that suggest the efficiency of the heart as a pump is impaired; the heart is unable to deliver blood at a rate that meets the metabolic demands.
257
What are the two broad categories of heart failure?
1. Systolic failure: the ability of the heart to pump blood around the body is impaired.
2. Diastolic failure: the heart is pumping blood effectively but is relaxing and filling abnormally.
258
Give 5 causes of heart failure.
1. Commonest cause: IHD.
2. Hypertension.
3. Cardiomyopathy.
4. Excessive alcohol.
5. Obesity.
259
Why are men more commonly effected by heart failure than women?
Women have 'protective hormones' meaning they are less at risk of developing heart failure.
260
Briefly describe the pathophysiology of heart failure.
When the heart fails, compensatory mechanisms attempt to maintain CO. As HF progresses, these mechanisms are exhausted and become pathophysiological.
261
What are the compensatory mechanisms in heart failure?
1. Sympathetic system.
2. RAAS.
3. Natriuretic peptides.
4. Ventricular dilation.
5. Ventricular hypertrophy.
262
Explain how the sympathetic system is compensatory in heart failure and give one disadvantage of sympathetic activation.
The sympathetic system improves ventricular function by increasing HR and contractility = CO maintained.
BUT it also causes arteriolar constriction which increases after load and so myocardial work.
263
Explain how RAAS is compensatory in heart failure and give one disadvantage of RAAS activation.
Reduced CO leads to reduced renal perfusion; this activates RAAS. There is increased fluid retention and so increased preload.
BUT it also causes arteriolar constriction which increases after load and so myocardial work.
264
Give 3 properties of natriuretic peptides that make them compensatory in heart failure.
1. Diuretic.
2. Hypotensive.
3. Vasodilators.
265
What are the 3 cardinal symptoms of HF?
1. Shortness of breath.
2. Fatigue.
3. Peripheral oedema.
266
Give 3 signs of left heart failure.
1. Pulmonary crackles.
2. Added heart sounds (3rd and 4th) and murmurs.
3. Displaced apex beat.
4. Tachycardia.
267
What investigations might you initially do in someone who has the signs/symptoms suggestive of HF?
1. ECG.
2. CXR - might show cardiac enlargement.
3. Natriuretic peptide levels - raised indicate heart failure.
268
You have done an ECG, CXR and blood tests on a patient who you suspect might have HF. These have come back abnormal. What investigation might you do next?
An echocardiogram.
269
What is the first line treatment for heart failure?
Vasodilator therapy (ACEi, beta blockers) via the neurohumoral blockade (RAAS-SNS).
270
Give an example of an ACE inhibitor that is commonly used in HF.
Perindopril.
271
Name 4 beta blockers that are used in the treatment of heart failure.
1. Metoprolol.
2. Bisoprolol.
3. Carvedilol.
4. Nebivolol.
272
What drugs might you give to someone with HF for symptom relief.
Diuretics: thiazides (bendroflumethiazide) and loop diuretics (furosemide). They promote Na and so H2O excretion.
273
What is cor pulmonale?
RV hypertrophy and dilation due to pulmonary hypertension.
274
What is the WHO clasification of hypertension?
140/90mmHg.
275
On average, by how much does having high blood pressure shorten life?
7 years. Although this depends on onset and severity.
276
Give 5 causes of hypertension.
1. Kidney disease.
2. Genetics and family history.
3. Lifestyle factors e.g. high salt diet, excess alcohol, obesity, stress, caffeine.
4. Recreational drug use e.g. cocaine.
5. Drugs such as OCP and NSAIDS.
6. Hyperaldosteronism.
277
Name 3 endocrine diseases that can cause secondary hypertension.
1. Conn's syndrome - hyperaldosteronism.
2. Cushing's syndrome - prolonged cortisol exposure -> raised BP.
3. Phaeochromocytoma - adrenal gland tumour, excess NAd and Ad release -> high BP.
278
Give 3 symptoms of phaeochromocytoma?
1. Pallor.
2. Palpitations.
3. Chest pain.
4. Panic.
279
Why might you examine the eyes of someone with hypertension?
Very high BP can cause immediate damage to small vessels, this can be seen in the eyes where there are small exposed blood vessle.s
280
What investigations might you do in someone with hypertension?
1. 24h ambulatory blood pressure monitoring to confirm a diagnosis.
2. ECG and blood tests may be done to identify secondary causes of hypertension.
281
Name 5 conditions that hypertension is a major risk factor of?
1. MI (IHD).
2. Stroke.
3. Heart failure.
4. Chronic renal disease.
5. Dementia.
282
If you gave someone 1 blood pressure tablet by how much would you expect their blood pressure to decrease?
1 tablet = 10mmHg reduction in BP.
283
What is the threshold BP for giving treatment to the following:
a) high risk individuals.
b) low risk individuals.
a) High risk - 140/90mmHg.
| b) Low risk - 160/100mmHg.
284
What are the NICE treatment targets for the following:
a) People aged <80?
b) People aged >80?
a) Below 140/90mmHg in those aged less than 80.
| b) Below 150/90mmHg in those aged above 80.
285
Will anti-hypertensives make someone feel better?
Anti-hypertensives won't necessarily make someone feel better as there are few symptoms associated with high BP although headache symptoms may improve.
286
What are the two main types of treatment for hypertension?
1. Lifestyle modification: reduce salt intake, lose weight, reduce alcohol.
2. Drug therapy: ABCD.
287
What drugs might you give to someone with hypertension?
A - ACEi e.g. rampiril or ARB e.g. candesartan.
B - beta blockers e.g. bisoprolol.
C - Calcium CB e.g. amlodipine, diltiazem or verapamil.
D - diuretics e.g. bendroflumethiazide or furosemide.
288
Give 5 potential side effects of rampiril.
Side effects of ACE inhibitors:
1. Hypotension.
2. Acute renal failure.
3. Hyperkalaemia.
4. Teratogenic.
5. Cough, rash, anaphylactoid due to increased kinin production.
289
On what receptor does valsartan act?
AT-1, prevents Ang 2 binding.
290
Give 4 side effects of valsartan.
Side effects of valsartan:
1. Hypotension.
2. Renal dysfunction.
3. Hyperkalaemia.
4. Rash.
5. Contraindicated in pregnancy.
291
Give 5 side effects of bisoprolol.
Side effects of beta blockers:
1. Hypotension.
2. Fatigue.
3. Headaches.
4. Nightmares.
5. Bradycardia.
6. Hypotension.
7. Erectile dysfunction.
8. Cold peripheries.
292
Give 3 side effects of amlodipine.
Side effects of dihydropyridines (CCB):
1. Flushing.
2. Headache.
3. Oedema.
4. Palpitations.
293
Give 3 side effects of verapamil.
Side effects due to being negatively chronotropic:
1. Bradycardia.
2. AV block.
Side effects due to being negatively inotropic:
1. Worsening of cardiac failure.
294
Give 5 side effects of bendroflumethiazide.
Side effects of diuretics:
1. Hypovolemia.
2. Hypotension.
3. Reduced K, Na, Mg, Ca.
4. Hyperuricaemia -> gout.
5. Erectile dysfunction.
295
Name 4 valvular heart diseases.
1. Aortic stenosis.
2. Mitral regurgitation.
3. Mitral stenosis.
4. Aortic regurgitation.
296
Briefly describe aortic stenosis.
A disease where the aortic orifice is restricted and so the LV can't eject blood properly in systole = pressure overload.
297
Describe the aetiology of aortic stenosis.
1. Congenital bicuspid valve.
| 2. Acquired e.g. age related degenerative calcification and rheumatic heart disease.
298
Describe the pathophysiology of aortic stenosis.
Aortic orifice is restricted e.g. by calcific deposits and so there is a pressure gradient between the LV and the aorta. LV function is initially maintained due to compensatory hypertrophy. Overtime this becomes exhausted = LV failure.
299
Give 3 symptoms of aortic stenosis.
1. Exertional syncope.
2. Angina.
3. Exertional dyspnoea.
Onset of symptoms is associated with poor prognosis.
300
Give 3 signs of aortic stenosis.
1. Slow rising carotid pulse and decreased pulse amplitude.
2. Soft or absent heart sounds.
3. Ejection systolic murmur: <> shape.
301
What investigation might you do in someone who you suspect to have aortic stenosis?
Echocardiography.
302
Describe the management for someone with aortic stenosis.
1. Ensure good dental hygiene.
2. Consider IE prophylaxis.
3. Aortic valve replacement or TAVI.
303
Who should be offered an aortic valve replacement?
1. Symptomatic patients with aortic stenosis.
2. Any patient with decreasing ejection fraction.
3. Any patient undergoing CABG with moderate/severe aortic stenosis.
304
What is mitral regurgitation?
Back flow of blood from the LV to the LA during systole - LV volume overload.
305
Describe the aetiology of mitral regurgitation.
1. Myxomatous degeneration.
2. Ischaemic mitral regurgitation.
3. Rheumatic heart disease.
4. IE.
306
What is the pathophysiology of mitral regurgitation?
LV volume overload! Compensatory mechanisms: LA enlargement and LVH and increased contractility. Progressive LV volume overload -> dilatation and progressive HF.
307
Give 2 symptoms of mitral regurgitation.
1. Dyspnoea on exertion.
| 2. HF.
308
Give 3 signs of mitral regurgitation.
1. Pansystolic murmur (always there).
2. Soft 1st heart sound.
3. 3rd heart sound.
In chronic MR the intensity of the murmur correlates with disease severity.
309
What investigations might you do in someone who you suspect to have mitral regurgitation?
1. ECG.
2. CXR.
3. Echocardiogram: estimates LA/LV size and function.
310
Describe the management of mitral regurgitation.
Rate control for AF e.g. beta blockers. Anticoagulation for AF. Diuretics for fluid overload. IE prophylaxis. If symptomatic = surgery.
311
What is aortic regurgitation?
A regurgitant aortic valve means blood leaks back into the LV during diastole due to ineffective aortic cusps.
312
What is the aetiology of aortic regurgitation?
1. Bicuspid aortic valve.
2. Rheumatic.
3. IE.
313
Describe the pathophysiology of aortic regurgitation.
Pressure and volume overload. Compensatory mechanisms - LV dilatation, LVH. Progressive dilation -> HF.
314
Give 3 symptoms of aortic regurgitation.
1. Dyspnoea on exertion.
2. Orthopnea.
3. Palpitations.
4. Paroxysmal nocturnal dyspnea.
315
Give 3 signs of aortic regurgitation.
1. Wide pulse pressure.
2. Diastolic blowing murmur.
3. Systolic ejection murmur.
316
What investigations might you do in someone who you suspect to have aortic regurgitation?
CXR and echocardiogram.
317
Describe the management for someone with aortic regurgitation.
IE prophylaxis. Vasodilators e.g. ACEi. Regular echo's to monitor progression. Surgery if symptomatic.
318
What is mitral stenosis?
Obstruction to LV inflow that prevents proper filling during diastole.
319
Give 3 causes of mitral stenosis.
1. Rheumatic heart disease.
2. IE.
3. Calcification.
320
Describe the pathophysiology of mitral stenosis.
1. LA dilation -> pulmonary congestion.
2. Increased trans-mitral pressures -> LA enlargement and AF.
3. Pulmonary venous hypertension causes RHF symptoms.
321
Give 3 symptoms of mitral stenosis.
1. Dyspnea.
2. Haemoptysis.
3. RHF symptoms.
322
Give 3 signs of mitral stenosis.
1. 'a' wave in jugular venous pulsations.
2. Signs of RHF.
3. Pink patches on cheeks due to vasoconstriction.
4. Low pitched diastolic murmur.
5. Loud opening 1st heart sound snap.
323
What investigations might you do in someone who you suspect to have mitral stenosis?
1. ECG.
2. CXR.
3. Echocardiogram - gold standard.
324
Describe the management for mitral stenosis.
If in AF rate control e.g. beta blockers/CCB. Anticoagulation if AF. Balloon valvuloplasty or valve replacement. IE prophylaxis.
325
Why does medication not work for mitral and aortic stenosis?
The problem is mechanical and so medical therapy does not prevent progression.
326
What is infective endocarditis?
Infection of the heart valves or other endocardial lined structure within the heart.
327
Name 4 types of IE.
1. Left sided native IE.
2. Left sided prosthetic IE.
3. Right sided IE (rarely prosthetic).
4. Device related IE e.g. pacemakers, defibrillators.
328
Which type of IE is more likely to spread systemically?
Left sided IE - these are more likely to cause thrombo-emboli.
(Right side IE could spread to the lungs).
329
Give 2 risk factors for IE.
1. Having a regurgitant or prosthetic valve.
| 2. If infectious material is introduced into the blood stream or during surgery.
330
What bacteria are most likely to cause IE?
1. Staph aureus.
2. Staph epidermidis (coagulase negative staph).
3. Strep viridans (alpha haemolytic).
331
Give 3 groups of people who are at risk of IE.
1. Elderly.
2. IVDU.
3. Those with prosthetic valves.
4. Those with rheumatic fever.
332
Describe the pathogenesis of IE.
Microbial adherence (infection) -> vegetation on valve -> cardiac valve distortion -> cardiac failure and septic problems.
333
What is the hallmark of IE?
Vegetation - lumps of fibrin hanging off the heart valves.
334
IE: Name 2 sites where vegetation is likely?
1. Atrial surface of AV valves.
| 2. Ventricular surface of SL valves.
335
Give 3 symptoms of IE.
1. Signs of systemic infection e.g. fever, sweats.
2. Embolisation e.g. stroke, PE, MI.
3. Valve dysfunction e.g. HF, arrhythmia.
336
Give 5 signs of IE.
1. Splinter haemorrhages.
2. Osler's nodes.
3. Janeway lesions.
4. Roth spots.
5. Heart murmurs.
337
What investigations might you do in someone who you suspect to have IE?
1. Blood cultures are essential for diagnosis.
2. Echocardiogram shows endocardial involvement e.g. TTE or TOE.
3. Bloods - raised ESR/CRP.
4. ECG.
338
Give 2 advantages and 1 disadvantage of a trans-thoracic echo (TTE).
1. Safe.
2. Non-invasive, no discomfort.
3. Poor images.
339
Give 1 advantage and 2 disadvantages of a trans-thoracic echo (TTE).
1. Excellent images.
2. Discomfort.
3. Small risk of perforation or aspiration.
340
Describe the treatment for IE.
1. Antibiotics based on cultures.
2. Treat any complications.
3. Surgery.
341
Give 4 indications for surgery in IE.
1. Antibiotics not working.
2. Complications.
3. To remove infected devices.
4. To replace the valve.
5. to remove large vegetations before they embolise.
342
Why is it important to remove large vegetations?
To prevent them embolising and causing a stroke, MI etc.
343
Why might blood cultures be negative in a person with IE?
They may have previously received antibiotics.
344
What is giant cell arteritis?
A common type of vasculitis: localised, chronic and granulomatous inflammation of temporal arteries.
345
What are the signs of giant cell arteritis?
1. Thickened often palpable blood vessels.
| 2. Evidence of granulomatous inflammation.
346
Give a possible consequence of giant cell arteritis.
Blindness if the occular artery is affected.
347
What is the name of the criteria used to diagnose IE?
The duke criteria.
348
Name a disease might cause flattening of the P wave.
1. Hyperkalaemia.
| 2. Obesity.
349
Name a disease that might cause tall P waves.
1. Right atrial enlargement.
350
Name a disease that might cause broad notched P waves.
Left atrial enlargement.
351
What aspect of the heart is represented by leads 2, 3 and aVF?
The inferior aspect.
352
What might ST elevation in leads 2, 3 and aVF suggest?
RCA blockage.
These leads show the activity of the inferior aspect of the heart and the RCA supplies the inferior aspect of the heart with blood.
353
Give 3 effects of hyperkalaemia on an ECG.
1. Tall 'tented' T waves.
2. Flat P waves.
3. Broad QRS.
354
Give 2 effects of hypokalaemia on an ECG.
1. Flat T waves.
2. QT prolongation.
3. ST depression.
4. Prominent U waves.
355
Give an effect of hypocalcaemia on an ECG.
1. QT prolongation.
2. T wave flattening.
3. Narrowed QRS.
4. Prominent U waves.
356
Give an effect of hypercalcaemia on an ECG.
1. QT shortening.
2. Tall T waves.
3. No P waves.
357
What is the main pacemaker in the heart?
The sinus node.
358
What controls the sinus node discharge rate?
The autonomic nervous system.
359
Define sinus rhythm.
Sinus rhythm - a P wave precedes each QRS complex.
360
Give 3 potential consequences of arrhythmia.
1. Sudden death.
2. Syncope.
3. Dizziness.
4. Palpitations.
5. Can also be asymptomatic.
361
Define bradycardia.
< 60 bpm.
362
Define tachycardia.
> 100 bpm.
363
Give the two broad categories of tachycardia.
1. Supra-ventricular tachycardia's.
| 2. Ventricular tachycardia's.
364
Where do supra-ventricular tachycardia's arise from?
They arise from the atria or atrio-ventricular junction.
365
Do supra-ventricular tachycardia's have narrow or broad QRS complexes?
Supraventricular tachycardias are often associated with narrow complexes.
366
Where do ventricular tachycardia's arise from?
The ventricles.
367
Do ventricular tachycardia's have narrow or broad QRS complexes?
Ventricular tachycardias are often associated with broad complexes.
368
Name 5 supra-ventricular tachycardia's.
1. Atrial fibrillation.
2. Atrial flutter.
3. AV node re-entry tachycardia (AVNRT).
4. Accessory pathway.
5. Focal atrial tachycardia.
369
Give 4 causes of sinus tachycardia.
1. Physiological response to exercise.
2. Fever,
3. Anaemia.
4. Heart failure.
5. Hypovolemia.
370
Describe 2 characteristics of an ECG taken from someone with atrial fibrillation.
1. Absent P waves.
| 2. Fine oscillation of the baseline.
371
The ECG taken from someone with atrial fibrillation shows a fine oscillation of the baseline and absent P waves. Why?
The atria fire a lot, it is chaotic. The AV node and ventricles can't keep up -> irregularly irregular pulse.
372
Give 4 symptoms of atrial fibrillation.
1. Palpitations.
2. Shortness of breath.
3. Fatigue.
4. Chest pain.
5. Increased risk of thromboembolism and therefore stroke.
373
What score can be used to calculate the risk of stroke in someone with atrial fibrillation?
CHADS2 VASc.
374
What does the CHADS2 VASc score take into account?
The CHADS2 VASc score is used to calculate the risk of stroke in patients with atrial fibrillation. It considers:
1. Age.
2. Hypertension.
3. Previous stroke/TIA.
4. Diabetes.
5. Female.
A score >2 indicates the need for anticoagulation.
375
Describe the treatment for atrial fibrillation.
1. Rate control - beta blockers, CCB and digoxin.
2. Rhythm control - electrical cardioversion or pharmacological cardioversion using flecainide.
3. Flecainide can be taken on a PRN basis in people with infrequent symptomatic paroxysms of AF.
4. Long term - catheter ablation and a pacemaker.
376
Atrial fibrillation treatment: what might you give someone to help with rate control?
Beta blockers, CCB and digoxin.
377
Atrial fibrillation treatment: what might you give someone to help restore sinus rhythm (rhythm control)?
Electrical cardioversion or pharmacological cardioversion using flecainide.
378
What is the long term treatment of atrial fibrillation?
Catheter ablation - it targets the triggers of AF.
379
Describe the ECG pattern taken from someone with atrial flutter.
1. Narrow QRS.
| 2. 'sawtooth' flutter waves.
380
The ECG shows a continuous undulating pattern and sawtooth flutter waves. What arrhythmia is this describing?
Atrial flutter.
381
What pathophysiological mechanism can cause atrial flutter?
The re-entry mechanism - there is blockage of the normal circuit. Another pathway forms, takes a different course and re-enters the circuit -> tachycardia.
382
What is the commonest supra-ventricular tachycardia?
AV node re-entry tachycardia (AVNRT).
383
Do you see P waves in AVNRT?
No - the P waves are within the QRS complex.
384
Give 4 symptoms of AVNRT.
1. Sudden onset/offset palpitations.
2. Neck pulsation.
3. Chest pain.
4. Shortness of breath.
385
Describe the acute treatment of AVNRT.
Acute treatment: vagal manoeuvre and adenosine.
386
What drugs might you give to someone to suppress future episodes of AVNRT?
Beta blockers, CCB, flecainide.
387
Describe the pathophysiology of accessory pathway arrhythmias.
Congenital muscle strands connect the atria and ventricles - accessory pathway. This can result in pre-excitation of ventricles.
388
Describe 3 characteristics of an ECG taken from someone with accessory pathway arrhythmia.
1. Delta wave.
2. Short PR interval.
3. Slurred QRS complex.
389
Give an example of an accessory pathway arrhythmia.
Wolff-Parkinson-White syndrome.
390
Describe the pathophysiology of focal atrial tachycardia.
Another area of the atrium becomes more autonomic than the sinus node and so sinus node function is taken over -> focal atrial tachycardia.
391
What might you see on an ECG taken from someone with focal atrial tachycardia.
Abnormal P waves appear before a normal QRS.
392
What is the treatment for ventricular tachycardia in an urgent situation?
DC cardioversion.
393
What is the long term treatment for ventricular tachycardia in high risk patients?
Implantable defibrillator.
394
What are ectopic beats?
Very common, generally benign arrhythmias caused by premature discharge. The patient may complain of symptoms of 'skipped beats'.
395
Give 3 causes of long QT syndrome.
1. Congenital.
2. Electrolyte disturbances e.g. hypokalaemia and hypocalcaemia.
3. A variety of drugs.
396
Give 2 signs of long QT syndrome.
1. Palpitations.
| 2. Syncope.
397
Give 4 causes of sinus bradycardia.
1. Ischaemia.
2. Fibrosis of the atrium.
3. Inflammation.
4. Drugs.
398
Give 3 causes of heart block.
1. CAD.
2. Cardiomyopathy.
3. Fibrosis.
399
What kind of heart block is associated with wide QRS complexes with an abnormal pattern?
RBBB or LBBB.
400
Describe first degree AV block.
Fixed prolongation of the PR interval due to delayed conduction to the ventricles.
401
Describe second degree AV block.
There are more P waves to QRS complexes because some atrial impulses fail to reach the ventricles and so you don't get a QRS complex.
402
Types of second degree AV block: describe Mobitz type 1.
PR interval gradually increases until AV node fails and no QRS is seen.
403
Types of second degree AV block: describe Mobitz type 2.
There is a sudden unpredictable loss of AV conduction and so loss of QRS. PR interval is constant but every nth QRS complex is missing.
404
Describe third degree AV block.
Atrial activity fails to conduct to the ventricles. P waves and QRS complexes therefore occur independently.
405
LBBB: what would you see in lead V1 and V6?
A 'W' shape would be seen in the QRS complex of lead V1 and a 'M' shape in V6.
WiLLiaM.
406
RBBB: what would you see in lead V1 and V6?
A 'M' shape would be seen in the QRS complex of lead V1 and a 'W' shape in V6.
MaRRoW.
407
Cardiac arrhythmias: what is the treatment of choice in a patient who is hemodynamically unstable due to the underlying rhythm?
DC cardioversion.
408
What is a consequence of peripheral arterial occlusion?
Gangrene.
409
Give 2 diseases that result from stress indicued ischaemia.
1. Exercise induced angina.
| 2. Intermittent claudication.
410
Give 2 diseases that result from ischaemia due to structural/functional breakdown.
1. Critical limb ischaemia.
| 2. Vascular dementia.
411
Give a sign of infarction.
Gangrene.
412
What is intermittent claudication?
A symptom describing muscle pain that is caused by moderate ischaemia. Intermittent claudication occurs when exercising (stress induced) and is relieved with rest.
413
What can intermittent claudication lead on to if left untreated?
Critical ischaemia.
414
Intermittent claudication: is O2 supply normal or low at rest and when you begin exercise?
Normal. Intermittent claudication is stress induced so at rest and when you begin exercise O2 supply is able to meet demand.
415
Intermittent claudication: is O2 supply normal or low when you do moderate/hard exercise?
Low. O2 supply is unable to meet demand -> anaerobic respiration -> lactic acid.
416
Intermittent claudication: is O2 supply normal or low after a short rest?
Low. It takes longer to recover as you're getting rid of the lactic acid. After a long rest however it is normal.
417
Give a symptom of intermittent claudication.
Muscle cramps.
418
What is critical ischaemia?
Blood supply is barely adequate for life. There is no reserve for an increase in demand. Very severe, cells are dying.
O2 supply is ALWAYS low, even at rest!
419
Give 4 signs of critical ischaemia.
1. Rest pain.
2. Classically nocturnal.
3. Ulceration.
4. Gangrene.
420
What can cause acute ischaemia?
Embolism/thrombosis.
421
Give 6 symptoms of acute ischaemia.
1. Pain.
2. Pale.
3. Paralysis.
4. Paraesthesia.
5. Perishing cold.
6. Pulseless.
422
Give 2 examples of acute ischaemia.
1. Stroke.
| 2. MI.
423
Give 5 risk factors for peripheral vascular disease.
1. Hypertension.
2. Hyperlipidaemia.
3. Diabetes.
4. Smoking.
5. Obesity.
424
Give 4 treatments for peripheral vascular disease.
1. Risk factor modification.
2. Vein bypass for critical leg ischaemia.
3. Balloon angioplasty.
4. Stenting of occlusion.
5. Amuptation.
425
Describe 4 steps in the initial management of a STEMI.
1. ABCDE.
2. Morphine.
3. Oxygen (if hypoxic).
4. Nitrates.
5. Aspirin.
426
PCI is the treatment of choice for a STEMI. What might you do instead if you were unable to do PCI?
Thrombolysis using streptokinase.
427
Name a drug that can be used for thrombolysis in the treatment of a STEMI.
Streptokinase.
428
In what type of valvular heart disease would you hear a mid-diastolic murmur and a 1st heart sound snap?
Mitral stenosis.
429
In what type of valvular heart disease would you hear a pan-systolic murmur?
Mitral regurgitation.
430
In what type of valvular heart disease would you hear a ejection systolic murmur?
Aortic stenosis.
431
In what type of valvular heart disease would you see a wide pulse pressure and hear an early diastolic blowing murmur and systolic ejection murmur?
Aortic regurgitation.
432
Name the criteria that is used in the diagnosis of infective endocarditis.
Duke's criteria.
433
Give 2 major points in the Duke's criteria that if present can confirm a diagnosis of IE.
1. Positive blood culture with typical IE microorganism.
| 2. Positive echo showing endocardial involvement.
434
What organism can cause rheumatic fever?
Group A strep e.g. s.pyogenes.
435
A lady presents with a tearing pain and is found to have hypertension. A CT scan is done and a 'tennis ball sign' is observed. What is the likely pathology behind the patient's pain?
Aortic dissection!
436
What type of drug is digoxin?
Digoxin is a cardiac glycoside.
437
What is a typical lesion of atherosclerosis?
Fatty streaks.
438
Write an equation for mAP.
mAP = DP + 1/3 PP.
439
What is the cause of reactive hyperaemia?
When blood flow increases following occlusion to arterial flow.
440
Give the equation for BP.
BP = CO x TPR.
441
Give the equation for stroke volume.
SV = EDV - ESV.
442
Give the equation for cardiac output.
CO = SV x HR.
443
Name the classification system for peripheral vascular disease (PVD).
Fontaine classification.
444
Why does mitral stenosis cause AF?
There is increased LA pressure. This stretches the myocytes in the atria and irritates pacemaker cells -> AF.
445
Why does mitral stenosis lead to a raised JVP?
Pulmonary congestion -> pulmonary hypertension causes a raised JVP.
446
Why might someone with mitral stenosis be breathless? Use Sterling's law in your explanation.
Mitral stenosis means ventricles don't fill completely -> reduced EDV -> reduced SV -> reduced CO and so breathlessness.
447
Give 2 ECG signs of PE.
1. Sinus tachycardia.
| 2. Atrial fibrillation.
448
Name 2 diseases that are due to moderate ischaemia.
1. Angina.
| 2. Intermittent claudication.
449
Name a disease that is due to severe ischaemia.
Critical limb ischaemia.
450
Give 2 signs of RHF.
1. Raised JVP.
| 2. Ascites.
451
Describe the NYHA classification for heart failure.
1. Class 1: heart disease is present but there is no limitation.
2. Class 2: comfortable at rest but slight limitation on activity - mild HF.
3. Class 3: marked limitation - moderate HF.
4. Class 4: SOB at rest, all activity causes discomfort (moderate HF).
452
Give 4 signs you might see on a CXR taken from someone with heart failure.
1. Pleural effusion.
2. Dilated pulmonary arteries.
3. Kerley B lines.
4. Bat's wings.
5. Cardiomegaly.
453
What coronary event might Dressler's syndrome develop after?
Can develop 2-10 weeks after an MI.
454
What is Dressler's syndrome?
Myocardial injury stimulates formation of autoantibodies against the heart. Cardiac tamponade may occur. Dressler's is a secondary form of pericarditis.
455
Give 3 symptoms of Dressler's syndrome.
1. Fever.
2. Chest pain.
3. Pericardial rub.
Occurs 2-10 week after MI.
456
Describe the treatment for an MI.
1. MONA.
2. PCI or streptokinase.
3. Aspirin and clopidogrel.
4. LMWH.
5. Anti-anginals e.g. beta blockers, CCB, nitrates.
6. Preventing a secondary CV event: ACEi, aspirin, statins, RF modification.
457
How does LMWH work?
It activates anti-thrombin, which then inhibits thrombin and factor 10a.
458
Define ischaemia.
Reversible tissue damage as a result of impaired vascular perfusion depriving tissues of nutrients and oxygen.
459
Define infarction.
Irreversible tissue death due to ischaemia.
460
Why might someone with HF feel tired?
Due to reduced CO.
461
Why might someone with HF feel breathless when lying down?
Due to pulmonary oedema.
462
Why might someone with HF have tachycardia?
Due to activation of the sympathetic system.
463
Why might someone with HF have peripheral oedema?
1. Decreased venous pressure.
| 2. RAAS activation -> sodium and H2O retention.
464
Give 3 clinical features of shock.
1. Low blood pressure.
2. Rapid pulse.
3. Low urine output.
4. Pallor.
5. Sweating.
465
Give 5 signs of anaphylactic shock.
1. Breathlessness.
2. Wheeze.
3. Rash.
4. Swollen lips/tongue.
5. Low BP.
6. Chest tightness.
466
Why might someone with anaphylactic shock have a low BP?
1. Vasodilation.
| 2. Increased vascular permeability.
467
State two common allergens responsible for causing anaphylactic shock.
1. Seafood.
2. Nuts.
3. Grains.
468
Role of LDL in atherosclerosis
It can pass in and out of the arterial walls in excess. Within the wall it undergoes oxidation and glycation
469
Main differences between plaque rupture and plaque erosion
- rupture has a large lipid core while erosion has a small one
- ruptures have a red thrombus and erosions have a white thrombus
- Red thrombus = rbcs and fibrin, white thrombus platelets and fibrinogen
470
What is a Q-wave MI
An MI where new Q-waves develop on the ECG
471
Symptoms of myocardial infarction
Cardiac chest pain that:
- Is unremitting
- usually severe but may be mild or absent
- occurs at rest
- associated with sweating, breathlessness, nausea and/or vomiting
- one third occur in bed at night
472
High troponin indicates …
Cardiac muscle injury
- troponin T and I are highly sensitive indicators of cardiac muscle injury
473
What is crescendo angina
Angina pain that has been steadily getting worse over prior weeks and months, due to coronary heart disease
Serious and requires hospitalisation
474
What is Prinzmetal’s angina
Coronary spasm that narrows the coronary arteries ➡️ symptoms of angina
RARE
475
What is micro vascular angina
- The micro vessels are at fault , meaning they can’t relax to reduce the resistance and increase blood flow ➡️ angina
- The main coronary arteries apparently normal
- mostly affects females
- Cause unknown
