Cardiovascular - Level 2 Flashcards
1
Q
Description of pathology of stable angina?
A
- Pain (discomfort) arising from the heart due to myocardial ischaemia
- Coronary artery disease – atherosclerotic plaques cause progressive narrowing of the arteries (coronary), decreasing blood supply and thus oxygen/nutrients to myocardium
- Symptoms occur when blood flow does not provide adequate oxygen in times of high demand (exercise)
2
Q
Epidemiology of stable angina?
A
- More than 1.5 million in UK
- CVD accounts for 25% of deaths – CHD 45% of CVD deaths
3
Q
Risk factors of stable angina?
A
- Older age, male gender, ethnicity
- Hyperlipidaemia, hypertension, DM, obesity
- Smoker, FHx, lack of exercise, high fat diet, stress, alcohol
4
Q
Symptoms of stable angina?
A
Central, crushing, retrosternal chest pain
o Comes on exertion, relieved by rest, exacerbated by cold weather, anger and excitement
o Radiates to arms, shoulders, jaw and neck
Provoked by physical exertion, especially after meals, anger and in cold weather
Pain fades within minutes with rest
5
Q
Symptoms of decubitus angina?
A
o Angina lying down, associated with LV dysfunction due to CAD
6
Q
Symptoms of nocturnal angina?
A
o Occurs at night and may wake patient, provoked by vivid dreams
o Usually in critical CAD and may be vasospasm
7
Q
Symptoms of variant (prinzmetal) angina?
A
o Without provocation, usually at rest due to coronary artery spasm
o Often women, ST elevation during pain/spasm
8
Q
Symptoms of unstable angina?
A
o Classed as ACS
o Increasing rapidly in severity, occurs at rest with <1 month onset
9
Q
Who to refer in stable angina?
A
- Refer all people with typical or atypical angina to specialist chest pain clinic
10
Q
Management of stable angina whilst awaiting diagnosis?
A
o Sublingual GTN spray used to relieve symptoms
If they experience chest pain, stop and rest, use GTN as instructed
Take 2nd dose after 5 mins, if pain still present call 999
o Aspirin (75mg) if likely to be stable angina
11
Q
Initial tests in specialist chest pain service of stable angina??
A
Bloods
• FBC (anaemia), TFTs, HbA1c, Lipids
ECG
• May show ST depression, T wave flattening/inversion, pathological Q waves, LBBB
12
Q
Diagnostic imaging in specialist chest pain service of stable angina??
A
1st line - CT coronary angiography
2nd line - Non-invasive functional imaging, offer when CT angiogram has shown CAD of uncertain functional significance or non-diagnostic
• Myocardial perfusion scintigraphy with SPECT
• Stress Echo
• Contrast MRI
3rd line – Invasive coronary angiography, if results inconclusive
13
Q
Investigations if known CAD in stable angina? Criteria for this?
A
o If known CAD (previous MI, revascularisation, previous angiograpy)
Exercise testing ECG – ST depression <6 mins
14
Q
Diagnosis of angina confirmed when?
A
- Significant CAD during invasive or 64-slice CT angiography or,
- Reversible myocardial ischaemia during non-invasive functional imaging
15
Q
General advice given in management of stable angina?
A
o Lose weight, regular exercise, control DM
o Stop smoking, limit alcohol consumption
o Impact of stress on angina
o Take GTN before sex if needed
o Inform DVLA
16
Q
Drug treatments given in stable angina?
A
o Sublingual GTN spray (sublingual tablets) used to relieve symptoms
If they experience chest pain, stop and rest, use GTN as instructed
Take 2nd dose after 5 mins, if pain still present call 999
o Beta-blocker/CCB (N-DHP) (1st line regular)
Use both if symptoms persist (BB & DHP CCB)
Alternatives if cannot tolerate BB/CCB or both CI: Isosorbide mononitrate, nicorandil, ivabradine, ranolazine
o Monitor 2-4 weeks after starting or changing dose
17
Q
Secondary prevention of CVD in stable angina?
A
o Aspirin 75mg OD
o Atorvastatin 80mg OD
o ACEi (if hypertensive/diabetic)
18
Q
Follow up in stable angina?
A
o Review every 6-12 months depending on severity
19
Q
When to refer to cardiologist and for what in stable angina?
A
- Referral to cardiologist for angiography (and possible revascularisation) if:
o Extensive ischaemia on ECG
o On optimal drug treatment given (2 drugs max doses)
20
Q
Definitive management for patient of stable angina - for people adequately controlled on medical therapy?
A
Consider further functional or anatomical testing (if not already available) to assess whether benefit from surgery
Coronary angiogram – if functional testing indicates extensive ischaemia or likely left main stem or proximal three-vessel disease
Coronary Artery Bypass Graft (CABG) if left main stem disease or proximal three-vessel disease
21
Q
Definitive management for patient of stable angina - for people not adequately controlled on medical therapy?
A
Revascularisation (CABG/PCI)
22
Q
Management if remain symptomatic despite reperfusion interventions?
A
o Offer Myocardial perfusion scintigraphy using SPECT
23
Q
Complications of stable angina?
A
- Stroke, MI, Unstable angina
- Sudden Cardiac death
- Reduced QoL and anxiety
24
Q
Prognosis of stable angina?
A
- Indicators of prognosis – extent and severity of CAD, LV function, exercise tolerance and comorbidities
25
Description of AF?
- Atrial activity chaotic and ineffective, rapidly firing cells cause conduction through atria but only proportion activate AV node
- Irregular ventricular RR intervals and often >160bpm – atrial rhythm 300-600bpm
26
Definition of paroxysmal AF?
2 or more episodes >30 seconds but <7days and self-terminating/recur
rent
27
Definition of persistent AF?
o Episodes >7 days
28
Definition of permanent AF?
o AF fails to terminate using cardioversion or > 1 year where cardioversion is not indicated
29
Definition of atrial flutter?
o Abnormal, rapid heart rhythm
| o Macro-reentrant tachycardia
30
Types of atrial flutter?
Typical – origin in right atrium at level of tricuspid valve
Atypical – Origin elsewhere in right or left atrium
31
How common is AF?
- Most common sustained arrhythmia – 10% of patients >65 years
32
Causes of AF?
- IHD
- Hypertension
- Valvular heart disease
- Hyperthyroidism
- Rheumatic heart disease
- Sick sinus syndrome
- Heart failure
- Cardiomyopathy
- Thyroxine, bronchodilators
- Acute infection
- PE
33
Risk Factors for AF?
- Caffeine
- Alcohol intake
- Obesity
34
Symptoms of AF?
```
o Asymptomatic
o Chest pain
o Palpitations
o SOB
o Syncope
o Reduced exercise tolerance
```
35
Signs of AF?
o Irregularly irregular pulse
o Tachycardia
o 1st HS variable intensity
o Signs of reduced LVF
36
Investigations to perform if suspected AF?
- Pulse – irregularly irregular
- ECG
o No P waves, chaotic baseline, irregularly irregular rate
o Tachycardia
o Atrial flutter- sawtooth baseline prominent in AVF, II, III and V1
- Bloods
o FBC, Ca, Mg, glucose, TFTs, U&Es, Cardiac enzymes
37
Investigations to perform if paroxysmal AF suspected?
o 24-hour ambulatory ECG monitor/7-day Holter monitor
38
Management of acute AF (<48 hours) - investigations?
Investigations
o Bloods – FBC, VBG, TFT, LFT, U&E
o CXR
Are there signs of haemodynamic instability?
o BP<100
o Tachycardia
o LoC or dizziness
39
Management of acute AF (<48 hours) - if no life-threatening signs of haemodynamic instability?
Offer rate or rhythm control if <48 hours
BB or CCB – target HR<110bpm
Consider cardioversion
Electrical DC cardioversion
Pharmacological
• IV amiodarone (preferred in structural heart disease) or IV flecainide
Offer rate control if >48 hours
40
Management of acute AF (<48 hours) - if haemodynamically unstable?
```
o O2
o Emergency electrical DC cardioversion
o Treat cause
o Verapamil/Bisoprolol
o LMWH
```
41
Management of chronic AF - rate control?
Monotherapy Beta-blocker/CCB (bisoprolol/diltiazem)
Add on other drug if not controlled with monotherapy
Digoxin if needed/sedentary
42
Management of chronic AF - rhythm control?
o Refer to cardiologist for consideration of rhythm-control
o Rhythm Control (if symptoms continue after HR control or not successful)
DC cardioversion
• DC if <48 hours
• If >48 hours, need 3 weeks anticoagulation and 4 weeks after
• Amiodarone for >4 weeks before and 12 months after
Pharmacological cardioversion
• Flecainide
• Amiodarone (if structural heart disease)
43
Management of chronic AF - rhythm control if drug measures fail?
* Catheter ablation of left atrium or AV node or pulmonary veins
* Pacing?
44
Management of chronic AF - paroxysmal specifically?
PRN flecainide – Pill in the pocket
| • If no LVHF, valvular disease, IHD, have BP >100 and HR >70
45
Management of chronic AF - anticoagulation?
o Use CHA2DS2-VASc stroke-risk score and HASBLED major-bleed score to assess risk – IN NON-VALVULAR DISEASE (valvular disease ALWAYS ANTICOAGULATE – mitral regurgitation or prosthetic valve)
o Offer anticoagulation when CHADVASc score of 2 or above/1 or above in men
DOACs (Apixaban/dabigatran) or warfarin (if DOACs not tolerated)
Calculate TTR at each visit (Rosendaal method)
Review annually
46
When to review anticoagulation in AF?
o Review at aged 65 if not taking anticoagulant or when they develop diabetes, HF, PAD, CHD, CVA
47
Management of chronic AF - general advice?
o Harmful alcohol consumption
o Inform DVLA
o Flying OK
48
Management of chronic AF - Follow up?
o 1 week of starting rate-control treatment
o After starting anticoagulation treatment
Warfarin
• Calculate time in therapeutic range (TTR) and INR
• Poor control need correction of compliance, medications, lifestyle factors such as diet and alcohol
Dabigatran/Apixaban
• Calculate time in therapeutic range (TTR)
• At least annually
49
Complications of AF?
- Stroke and thromboembolism
- Heart Failure
- Tachycardia-induced cardiomyopathy
- Reduced QoL
50
Prognosis of AF?
- 2x more likely to die prematurely
- Associated with CVD
- 5x more likely for stroke
51
Description of SVT?
- Supraventricular tachycardia is narrow complex tachycardia
| - Rate>100bpm, QRS<120ms
52
Pathology of SVT?
o Reentry circuit forming next to, or within, the AV node
| o The circuit most often involves two tiny pathways one faster than the other
53
Types of narrow complex tachycardias?
```
o Sinus tachycardia
o SVT
o AF
o Atrial flutter
o Atrial tachycardia
o Junctional tachycardia
o WPW
```
54
Symptoms and signs of SVT?
- Palpitations
- Chest pain
- Presyncope/Syncope
- Hypotension or pulmonary oedema
- SOB
55
ECG findings in SVT?
o Regular rhythm
o High HR
o P waves absent or inverted after QRS (merged in T wave)
o Normal QRS
56
Initial management of tachyarrhythmias?
o Monitor O2, give oxygen if hypoxic
o Monitor ECG and BP and record 12-lead ECG
o Obtain IV Access
o Identify and treat any electrolyte abnormalities (K, Mg, Ca)
Bloods – U&Es, cardiac enzymes, Ca, Mg, K
VBG
ABG (if pulmonary oedema, sepsis)
57
Management of tachyarrhythmias - assessing for adverse features? What are they? Management of yes or no?
```
o Shock (sBP<90, pallor, sweating, cold, clammy, confusion)
o Syncope (transient LoC)
o Myocardial ischaemia (typical chest pain and/or MI on ECG)
o Heart failure (pulmonary oedema and/or raised JVP)
```
If yes, Synchronised DC cardioversion – up to 3 attempts
• Then Amiodarone 300mg IV over 10-20 mins and repeat shock then 900mg over 24 hours
• Correct K and Mg
• Further cardioversion if needed
• Consider flecainide, lidocaine
If no, move down
• Correct K and Mg
58
Management of tachyarrhythmias - assessing QRS complexes?
o If >0.12s – broad complex tachycardia treatment
| o If <0.12s – narrow complex tachycardia – move below
59
Management of tachyarrhythmias - assessing rhythm - if irregular narrow complex?
o Irregular – Treat as AF
Rate control with B-Blockers or digoxin
If <48h – cardioversion with either amiodarone 300mg IVI over 20-60 mins then 900mg over 24h or DC shock
Anticoagulation
60
Management of tachyarrhythmias - assessing rhythm - if regular narrow complex tachycardia?
o Regular Narrow complex tachycardia
Vagal manoeuvres (carotid sinus massage, Valsalva manoeuvre)
Adenosine 6mg IV bolus
• 2nd 12 mg and then 3rd 12mg if needed
• CI in 2o and 3o heart block, WPW and asthmatics
Continuous ECG trace
If adenosine fails, Verapamil 5mg IV over 2-3 mins (not if on BB)
• 2nd 5mg if <60
61
What happens if management of regular narrow complex tachycardia does not resolve with initial management?
If resolves, probable re-entrant paroxysmal SVT
| If still not resolved – expert help
62
Description of VT?
```
- Broad complex tachycardias
o ECG shows rate >100bpm with QRS >120ms
- Ventricular tachycardia defined as >3 ventricular complexes at rate of >100
- If >30s – sustained
- Can be monomorphic or polymorphic
```
63
Pathology of VT?
o The electrical signals causing this rapid beating originate in the ventricles
o May lead to life threatening conditions such as ventricular fibrillation, asystole and sudden death
64
Predisposing condition to VT?
```
o Brugada syndrome
o WPW
o Prolonged QT (Macrolides, metoclopramide, TCA, haloperidol, methadone)
o Abnormal K, low Mg, low Ca
o Structural heart disease
```
65
Symptoms and signs of VT?
- Palpitations
- Chest pain
- Presyncope/Syncope
- Hypotension or pulmonary oedema
- SOB
66
What is Torsades de pointes?
o Polymorphic VT associated with low Mg, K, long QT)
o QRS undulate in amplitude and may degenerate VF
o Rx with magnesium sulphate
67
ECG findings in VT?
o Regular, tachycardia
o Broad QRS, often bizarre
o Positive QRS concordance in chest leads
o Marked left axis deviation
o AV dissociation or AV block
o Fusion beats (normal beat fuses with VT complex)
o Capture beats (normal QRS between abnormal beats
68
Initial management of tachyarrhythmias?
o ABCDE Approach
o Monitor O2, give oxygen if hypoxic
o Monitor ECG and BP and record 12-lead ECG
o Obtain IV Access
o Identify and treat any electrolyte abnormalities (K, Mg, Ca)
Bloods – U&Es, cardiac enzymes, Ca, Mg, K
VBG
ABG (if pulmonary oedema, sepsis)
69
Management of tachyarrhythmias - adverse features?
```
o Shock (sBP<90, pallor, sweating, cold, clammy, confusion)
o Syncope (transient LoC)
o Myocardial ischaemia (typical chest pain and/or MI on ECG)
o Heart failure (pulmonary oedema and/or raised JVP)
```
If yes, Synchronised DC cardioversion – up to 3 attempts
• Then Amiodarone 300mg IV over 10-20 mins and repeat shock then 900mg over 24 hours
• Correct K and Mg
• Further cardioversion if needed
• Consider flecainide, lidocaine
If no, move down
• Correct K and Mg
70
Management of tachyarrhythmias - assessing QRS complex and assessing rhythm?
- Assess QRS complex
o If >0.12s – broad complex tachycardia – see below
- Assess rhythm
o Irregular – Seek expert help
Possible AF with BBB, pre-excited AF or polymorphic VT
o Regular – move on
71
Management of regular broad complex tachycardias?
o Amiodarone 300mg IV over 20-60 mins via central line
o Then Amiodarone 900mg over 24 hours
o May need cardioversion
72
Description of mitral stenosis?
- Fusion, thickening and immobility of valves leaflets reduces orifice area and leads to obstruction from LA to LV
- Atrial pressure elevates and leads to pulmonary hypertension and RVF
- Normal mitral valve orifice area is 4-6cm2 but severe stenosis is <1cm2
73
Epidemiology of mitral stenosis?
- 50% had rheumatic fever and 90% had rheumatic heart disease
- Women > Men
- Usually in 4th and 5th decades
74
Causes of mitral stenosis?
```
o Rheumatic heart disease following rheumatic fever
Group A beta-haemolytic streptococci
RF: overcrowding, poor hygiene
Symptoms: sore throat (3 weeks prior), arthritis, carditis, chorea, subcutaneous nodules, fever, ESR/CRP raised
Ix: antibody titres, throat swab, ECG
Rx: Penicillin, aspirin
o Congenital
o Carcinoid tumours
```
75
Symptoms of mitral stenosis?
```
o Exertional dyspnoea (worsening)
o Orthopnoea
o Productive blood-tinged cough
o Palpitations (AF)
o Chest pain
o Fatigue
```
76
Signs of mitral stenosis?
```
o Malar flush
o Low volume pulse
o AF
o Tapping apex beat
o Loud S1
o Rumbling mid-diastolic murmur (worse on expiration, left side)
```
77
Investigations of mitral stenosis?
- ECG
o Progressive RAD, AF, LA hypertrophy (bifid P wave), RVH
- CXR
o Left atrial enlargement, pulmonary oedema, calcifications
- Transthoracic Echo
o Diagnostic – hockey stick-shaped mitral deformity
o Used to measure mitral orifice area and assess pulmonary artery pressure
- Cardiac Catheterisation
o If surgical correction planned, severe
78
Management of mitral stenosis - if asymptomatic?
o No treatment
79
Management of mitral stenosis - if symptomatic?
o Diuretics (furosemide 40mg)
o Surgery
Percutaneous balloon valvotomy
Mitral valve repair/replacement
- Follow Up
o Annual
80
Complications of mitral stenosis?
```
o AF
o Pulmonary hypertension
o Emboli
o Hoarseness
o Dysphagia
o Infective endocarditis (rare)
```
81
Description of mitral regurgitation?
- Mitral valve consists of anterior and posterior leaflets, chordae tendineae, anterolateral and posteromedial papillary muscles and mitral annulus
- Mitral valve regurgitation may result from defects in any part of valve
82
Pathology of mitral regurgitation?
o Longstanding regurgitation produces increase in atrial pressure and dilatation
o Increase can cause pulmonary hypertension and oedema – LV dilatation
83
How common is mitral regurgitation?
- 2nd most prevalent valve disease after aortic stenosis
84
Aetiology of mitral regurgitation?
```
o Functional (LV dilatation)
o Annular calcification
o Rheumatic heart disease
o Mitral valve prolapse
o Infective Endocarditis
o Ruptured chordae tendineae
o Papillary muscle rupture
o Hypertrophic Cardiomyopathy
o Ehlers Danlos Syndrome
```
85
Symptoms of mitral regurgitation?
```
o SOB (exertional)
o Fatigue
o Lethargy
o Palpitations
o Oedema
```
86
Signs of mitral regurgitation?
```
o Heart failure
o Apex beat laterally displaced
o RV heave
o Soft S1
o S3 in early diastole
o Pansysytolic murmur
Loudest at apex, radiates axilla
```
87
Investigations of mitral regurgitation?
- ECG
o AF, P-mitrale, LVH
- CXR
o Dilated LA/LV, calcification, pulmonary oedema
- Transthoracic or oesophageal Echo
o Assess severity and function
- Doppler
o Assess severity of regurgitation, LV dimensions and size and function of RV
- Catheterisation
o Exclude other valve disease, assess CAD
88
Management of severe, acute mitral regurgitation?
```
o Annuloplasty or mechanical valve
o Diuretics (furosemide)
```
89
Management of chronic mitral regurgitation - asymptomatic?
If LVEF >60%
• ACE inhibitors (captopril/enalapril/lisinopril)
• Beta-blockers (metaprolol/atenolol)
If LVEF <60%
• Valvuloplasty/annuloplasty/mechanical/prosthetic valve replacement
90
Management of chronic mitral regurgitation - symptomatic?
LVEF >30%
• Valvuloplasty/ annuloplasty/ mechanical/ prosthetic valve replacement
• ACE inhibitor (captopril/enalapril/lisinopril)
• Beta-blocker (metaprolol/atenolol)
• Diuretic (furosemide)
LVEF <30%
• ACE inhibitor (captopril/enalapril/lisinopril)
• Beta-blocker (metaprolol/atenolol)
• Diuretic (furosemide)
• Intra-aortic balloon counterpulsation (reduces afterload)
91
Follow up of chronic mitral regurgitation?
o Regular follow up and echocardiogram
92
Complications of chronic mitral regurgitation?
```
o Prosthesis stenosis
o AF
o Pulmonary Hypertension
o Post-operative stroke
o Heart Failure
```
93
Prognosis of chronic mitral regurgitation?
o Progression variable
| o May remain asymptomatic for many years
94
Description of aortic stenosis?
- Degeneration and calcification of aortic valve
o Endocardium of valve damaged and inflamed, leading to deposition of calcium on valve – limits aortic leaflet mobility and stenosis
o Occurs slowly and pressure overload leads to LVH (increased afterload)
o Increased myocardial oxygen demand, relative ischaemia
95
Epidemiology of aortic stenosis?
- Most common valvular disease
- 2nd most common cause for cardiac surgery
- Incidence highest in over 70s
- Bicuspid valve and William’s syndrome present earlier
96
Risk factors of aortic stenosis?
o Advanced age
o Congenital bicuspid valve
o Rheumatic fever
o CKD
97
Aetiology of aortic stenosis?
o Senile degeneration
o Congenital (bicuspid valve, Turner’s syndrome, William’s syndrome)
o Rheumatic heart disease
98
Symptoms of aortic stenosis?
- Usually asymptomatic until <1/3 normal size
```
- Symptoms
o Exertional SOB
o Angina
o Exertional syncope
o Dizziness
```
99
Signs of aortic stenosis?
```
o Congestive heart failure
o Slow rising pulse
o Narrow pulse pressure
o Heaving, non-displaced apex
o LV heave, aortic thrill
o Ejection systolic murmur
Heard best at right sternal edge, radiates to carotid
o Ejection click (or S4)
```
100
Investigations and their findings in aortic stenosis?
- ECG
o P-mitrale
o LVH with strain pattern (T-wave inversion, ST depression)
o LBBB or complete block
- Transthoracic Echo & doppler
o Diagnostic – elevated aortic pressure gradient, measures valve area and LVEF
- CXR
o LVH, calcified aortic valve, post-stenotic dilatation of ascending aorta
- Cardiac Catheterisation
o Used if echo inconclusive
o Assess function and CAD but risks emboli
101
Management of aortic stenosis - asymptomatic?
follow up and echo
102
Management of aortic stenosis - symptomatic?
o Surgery
Aortic valve replacement
TAVI
o Anticoagulation
Vitamin K antagonist (warfarin)
• If prosthetic mechanical valve
103
Management of aortic stenosis - general management?
o Good oral hygiene
104
Complications of aortic stenosis?
o Congestive heart failure
o Infective endocarditis
o Systemic emboli
105
Definition of aortic regurgitation?
- Diastolic leakage of blood from aorta into left ventricle
- Due to inadequate coaptation of valve leaflets
- Leads to LV hypertrophy and dilatation
- Stroke volume increases and pulse pressure rises
106
Acute risk factors of aortic regurgitation?
Infective Endocarditis
Ascending aortic dissection
Chest trauma
107
Chronic risk factors of aortic regurgitation?
```
Congenital – bicuspid aortic valve
Connective tissue disorders (Marfans, Ehlers-Danlos)
Rheumatic fever
Takayasu arteritis
RA
SLE
Hypertension
Syphilis
```
108
Symptoms of aortic regurgitation?
```
o Exertional SOB, orthopnoea, PND
o Palpitations (pounding)
o Angina
o Syncope
o Congestive heart failure
```
109
Signs of aortic regurgitation?
o Collapsing (Waterhammer pulse)
o Wide pulse pressure
o Displaced laterally-thrusting apex beat
o High-pitched early diastolic murmur
Heard best in aortic area on expiration, with patient sitting forwards
110
Investigations of aortic regurgitation?
```
Investigations - ECG
o LVH (strain pattern - T-wave inversion, ST depression)
```
- Echocardiogram & Doppler
o Diagnostic
- CXR
o Cardiomegaly, dilatation of ascending aorta, pulmonary oedema
- Cardiac Catheterisation
111
Management of aortic regurgitation - asymptomatic?
Asymptomatic patients (LVEF>50%):
o Regular 6-12 month follow up and echo
o ACE inhibitors – if hypertensive
112
Management of aortic regurgitation - symptomatic?
- Symptomatic patients, enlarging heart, ECG changes, LVEF <50%:
o Aortic valve replacement
o TAVI
113
Management of acute, severe aortic regurgitation?
o Inotropes and vasopressors
| o Urgent aortic valve replacement
114
Definition of infective endocarditis?
- Infection of endocardium of heart valve
- Mass of fibrin, platelets and infectious organisms form vegetations along edges of valves
- Virulent organisms destroy valve and produce regurgitation
115
Risk factors of infective endocarditis?
```
Cardiac disease
Valvular heart disease (stenosis or regurgitation)
Hypertrophic cardiomyopathy
Previous IE
Structural congenital heart disease
Valve replacement
Dermatitis
IVDU
Renal failure
Organ transplant
DM
```
116
Organisms of infective endocarditis?
o Staph Aureus (indwelling catheters, IVDU, DM, cellulitis)
o Streptococcal viridans (oral disease/procedures)
o Enterococci (GU disease, hospitalisation)
o Streptococcal bovis (bowel malignancy)
o HACEK organisms
Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella corrodens, Kingella kingae
o Culture negative (prior Abx, Coxiella, chlamydia, legionella)
o SLE
o Malignancy
117
Most common valves of infective endocarditis?
o Mitral valve
o Aortic valve
o Combined aortic and mitral
o Tricuspid valve
118
Symptoms of infective endocarditis?
o Fever + new murmur (endocarditis until proven otherwise)
| o Fatigue, flu-like illness, arthralgia, weight loss
119
Signs of infective endocarditis - systemic?
Fever, Rigors, night sweats, malaise, weight loss, anaemia, splenomegaly, clubbing
120
Signs of infective endocarditis - cardiac?
New murmur
Regurgitation
Aortic root vegetation may prolong PR interval – heart block
121
Signs of infective endocarditis - immune complex?
Vasculitis
Microscopic haematuria
Acute glomerulonephritis
122
Signs of infective endocarditis - FROMJASE?
Fever
Roth spots (boat-shaped retinal haemorrhage with pale centre)
Oslers nodes (painful pulp infarcts in fingers and toes)
Murmur
Janeway Lesions (painless, red haemorrhagic spots on palms/soles)
Anaemia
Splinter Haemorrhages
Emboli
123
Investigations performed in infective endocarditis?
Blood Cultures
o Before antibiotics, 3 sets over 24 hours from different peripheral sites
```
Bloods
o FBC (normochromic normocytic anaemia, neutrophilia), CRP (raised), ESR (raised), LFT, U&Es
```
Urinalysis
o Microscopic haematuria
CXR
ECG
Echocardiogram <24 hours (TTE then TOE)
Cardiac CT scan can be used
124
Diagnostic criteria of infective endocarditis?
o Duke Criteria for IE
125
What are major diagnostic criteria in infective endocarditis?
* Positive blood culture (typical organism in 2 separate cultures or persistently positive in 3)
* Endocardium involved (positive echo or new valvular regurgitation)
126
What are minor diagnostic criteria in infective endocarditis?
* Predisposition (heart problems, IVDU)
* Fever >38
* Vascular signs (arterial emboli, septic pulmonary infarcts, infectious aneurysms, intracranial haemorrhage, conjunctival haemorrhage, Janeway lesions)
* Immunological phenomenon (glomerulonephritis, Oslers nodes, Roths spots, RF)
* Positive blood culture or positive echo that does not meet criteria
127
Criteria for diagnosis of infective endocarditis?
2 major or 1 major and 3 minor or all 5 minor
128
Management of infective endocarditis - empirical?
o 4-6-week IV course of antibiotics
Native – Amoxicillin +/- gentamicin
• Pen allergic: use vancomycin +/- gentamicin
Prosthetic – Vancomycin + Gentamicin + Rifampicin
129
Specific management of infective endocarditis - staphylococcus? Native and prosthetic?
Native – Flucloxacillin (4 weeks, at least 6 weeks if secondary lung abscess or osteomyelitis)
• If pen allergic or MRSA – vancomycin + rifampicin
Prosthetic – Flucloxacillin + rifampicin + gentamicin (6 weeks, review need for gentamicin at 2 weeks)
• If pen allergic – vancomycin + rifampicin + gentamicin
130
Specific management of infective endocarditis - streptococcus?
Benzylpenicillin +/- gentamicin (4-6 weeks, 6 weeks prosthetic valve)
• If pen allergic – vancomycin + gentamicin
131
Specific management of infective endocarditis - enterococci?
Amoxicillin + gentamicin (4-6 weeks, 6 weeks for prosthetic valve, after 2 weeks review need for gentamicin)
• If pen allergic – vancomycin + gentamicin
• If gentamicin resistant – Amoxicillin + streptomycin
132
Specific management of infective endocarditis - HACEK microorganisms?
Amoxicillin + gentamicin (4 weeks, 6 weeks for prosthetic valve, stop gentamicin after 2 weeks)
• If amoxicillin resistant – ceftriaxone + gentamicin
133
Surgical management of infective endocarditis? When is it indicated?
o Total removal of infected tissues and reconstruction of cardiac morphology or valve replacement
Indications:
o severe valvular incompetence
o aortic abscess (often indicated by a lengthening PR interval)
o infections resistant to antibiotics/fungal infections
o cardiac failure refractory to standard medical treatment
o recurrent emboli after antibiotic therapy
134
Complications of infective endocarditis?
```
o MI, pericarditis, arrhythmias
o CHF
o Valvular insufficiency
o Aortic root or myocardial abscesses
o Emboli
o Glomerulonephritis
```
135
Prognosis of infective endocarditis?
o 1-year mortality at 30%
136
Definition of PE?
- DVT embolised into pulmonary circulation
137
Pathology of PE?
o Embolism obstructs outflow tract and causes acute right sided failure
o Lung tissue ventilated but not perfused so no gas exchange
138
Risk factors of PE?
```
o Surgery (pelvic/abdominal)
o Thrombophilia
o Leg fracture
o Bed rest/Reduced mobility
o Malignancy
o Pregnancy
o OCP/HRT
```
139
Causes of PE?
```
o Embolism of DVT
o RV thrombosis (post-MI)
o Right endocarditis
o Fat, air or amniotic fluid
o Neoplastic cells
```
140
Symptoms of PE?
```
o Acute dyspnoea
o Pleuritic chest pain
o Cough and Haemoptysis
o Syncope
o Symptoms of DVT
```
141
Signs of PE?
```
o Tachycardia
o Tachypnoea
o Hypotension
o Pyrexia with lung infarction
o Pleural rub
o Cyanosis
o Gallop rhythm
o Increased JVP
o RV heave
```
142
Assessment of patient with suspected PE? What is PE rule out criteria?
```
o ECG
o CXR
o Pulmonary Embolism Rule-Out Criteria
Rule out PE if none of 8 criteria are present with low Wells Score (<2)
• age < 50 years
• pulse < 100 beats min
• SaO2 ≥ 95%
• No haemoptysis
• No oestrogen use
• No surgery/trauma requiring hospitalization within 4 weeks
• No prior VTE
• No unilateral leg swelling
```
143
Initial management of PE?
o Full history and examination of respiratory and CV systems
o Examine legs for signs of DVT
o CXR
Often normal – wedge shaped area of infarction, decreased vascular markings, small pleural effusion
Excludes pneumonia and pneumothorax
o PE Wells Score
144
What is the PE Well's score?
Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) 3
An alternative diagnosis is less likely than PE
3
Heart rate > 100 beats per minute 1.5
Immobilisation for more than 3 days or surgery in the previous 4 weeks 1.5
Previous DVT/PE 1.5
Haemoptysis 1
Malignancy (on treatment, treated in the last 6 months, or palliative) 1
145
Interpretation of PE Well's Score?
Score of more than 4 – PE likely
| Score of 4 or less – PE unlikely
146
Management of PE Well's score more than 4? When is PE diagnosed?
• Immediate CTPA
o If CTPA cannot be carried out immediately – interim LMWH anticoagulation and hospital admission
o IF CTPA negative and DVT suspected – proximal leg US
o V/Q Scan
If allergy to contrast or renal impairment (eGFR<30) or pregnant or woman <40
* Diagnosed PE with positive CTPA or V/Q scan
* Consider alternative diagnosis if negative CTPA and no suspected DVT
147
Management of PE Well's score 4 or less? When is PE excluded?
• D-Dimer
o If positive, then CTPA
If CTPA cannot be carried out immediately – interim LMWH anticoagulation and hospital admission
V/Q Scan
• If allergy to contrast or renal impairment (eGFR<30) or pregnant or woman <40
o If negative D-dimer or positive D-dimer and negative CTPA, then excluded
148
What other tests are performed upon initial assessment of someone suspected of PE?
Bloods
• FBC, U&Es, baseline clotting, D-Dimer (if Wells of <4 to exclude PE)
ABG (if hypoxic, SOB)
• Low PaO2, Low PaCO2, pH often raised
ECG (if tachycardic or chest pain)
• Commonly normal – can have sinus tachycardia, RBBB, RV strain pattern (S1Q3T3), RAD, AF
• S1Q3T3 – in up to 50% (sign of Cor Pumonale)
149
when to perform diagnostic imaging in PE?
CTPA
First-line
When Wells >4 or, elevated D-Dimer
V/Q Scanning
Used in pregnancy or young people (women<40)
Usually need CTPA afterwards to confirm
150
Management of PE - initial management?
o If hypoxic – 15L/min Oxygen
o Analgesia (Morphine) + Antiemetic – if in pain or very distressed
o If massive PE/haemodynamically unstable (BP <90mmHg, hypoxic, tachycardia, tachypnoea):
Urgent ICU help
Rapid colloid infusion
If BP still <90mmHg – consider dobutamine then IV noradrenaline infusion
Alteplase 100mg over 2 hour or 0.6mg/kg over 15 mins
151
Management of PE - pharmacological interventions?
LMWH (175U/kg Tinzaparin SC/24h) as soon as possible for at least 5 days or until INR >2 for at least 24 hours, whichever is longer
• For severe renal impairment (eGFR <30) – Unfractionated heparin (UFH)
• If PE and haemodynamically unstable – offer UFH and thrombolytic therapy
Warfarin offered within 24 hours of diagnosis and continue for 3 months with unprovoked PE
• Alternatives: NOACs (Apixaban, dabigatran, rivaroxaban)
If cannot have anticoagulation therapy:
• Temporary inferior vena cava filter
If recurrent DVT:
• Inferior vena cava filter after alternatives (raise INR 3-4, switching to LMWH)
152
Follow up advice for diagnosed PE?
Follow-up appointment to anticoagulation services and medical outpatient
Advise to return immediately if become breathless or chest pain
153
Management of PE - thrombolytic therapy?
* Consider systemic thrombolytic therapy for patient with haemodynamic instability
* Alteplase 100mg over 2 hour or 0.6mg/kg over 15 mins
154
Investigations to perform following management of patient with PE? When to perform thrombophilia testing?
Cancer investigations for unprovoked DVT:
• Examination
• CXR
• Bloods (FBC, serum Ca, LFTs)
• Urinalysis
• Consider abdomino-pelvic CT scan if >40 with 1st unprovoked DVT
Thrombophilia testing
• Antiphospholipid antibodies in patients with unprovoked DVT if it is planned to stop anticoagulation therapy
• Hereditary thrombophilia testing – unprovoked DVT with 1st degree relative with DVT/PE if planned to stop anticoagulation
155
Definition of varicose veins?
- Dilated, tortuous, superficial veins
| - Most commonly found in legs, visible and palpable
156
Causes of varicose veins?
o Indication of superficial lower extremity venous insufficiency
Incompetent valves in vein lead to reflux of blood and increased pressure in vein distally
Weakness or degeneration of vein wall may contribute
o Unknown, congenital
157
Risk factors of varicose veins?
```
o Increasing age
o FHx of varicose veins
o Females
o Pregnancy
o Obesity
o Prolonged standing/sitting
o Hx of DVT
```
158
Symptoms of varicose veins?
o Dilated veins on leg
o Pain, itching, swelling
Especially after prolonged standing
o Restless legs and leg cramps
159
Signs of varicose veins?
o Irregular bulges consistent with varicose veins
o Telangiectasias
o Skin changes – hyperpigmented, venous eczema, lipodermatosclerosis
o Ulcers or thrombophlebitis
160
Examination of varicose veins?
o Inspect patient standing
o Feel for cough impulse at saphenofemoral junction
o Trendelenberg test – assess SFJ incompetence – patient lying down, elevate leg and empty vein by massaging distal to proximal – occlude superficial veins using tourniquet – patient stands
If veins do not re-fill – incompetent valve above this level
If veins re-fill – incompetent valve lower down
Test then above knee, below knee
161
Management of varicose veins - bleeding varicose veins?
o First aid and admit to vascular service
162
Management of varicose veins - non-bleeding varicose veins - general advice?
```
Reassure complications uncommon
Lose weight
Light-to-moderate physical activity
Avoid standing for too long
Elevate legs where possible
```
163
Management of varicose veins - non-bleeding varicose veins - when to refer to vascular surgeons?
Symptomatic varicose veins
Skin changes (pigmentation or eczema)
Superficial vein thrombosis (hard painful veins)
Leg ulcer – active or healed
164
Management of varicose veins - non-bleeding varicose veins - secondary care investigations?
• Duplex US
165
Management of varicose veins - non-bleeding varicose veins - secondary care treatment?
* Endothermal ablation – seal affected veins
* US-guided Foam Sclerotherapy – injection of irritant foam, inflammation closes vein
* Surgery – Ligation and stripping of affected vein
166
Management of varicose veins - non-bleeding varicose veins - primary care treatment?
Compression stockings following Doppler
• If compression stockings considered:
o Doppler to assess ABPI to exclude arterial insufficiency
<0.5 – severe PAD and stocking contraindicated
0.8-0.5 – avoid stockings – refer
0.8-1.3 – safe to wear
>1.3 – refer as incompressible arteries
167
Management of varicose veins - non-bleeding varicose veins - safety net?
Seek medical advice if hard and painful, skin changes, venous ulcer, bleeding
168
Complications of varicose veins?
```
o Bleeding (after trauma)
o Thrombophlebitis (hard, painful veins)
o DVT
o Skin changes (pigmentation caused by hemosiderin, venous eczema, lipodermatosclerosis)
o Skin Ulceration
o Decreased QoL
```
169
Definition of peripheral artery disease?
- Peripheral artery disease describes narrowing or occlusion of peripheral arteries, affecting blood supply to lower limbs
- Chronic limb ischaemia can present as:
o Intermittent claudication (most common)
o Critical limb ischaemia/Rest Pain
170
Causes of peripheral artery disease?
o Atherosclerosis
o Vasculitis
o Embolism
o Buerger’s disease
171
Risk factors of peripheral artery disease?
```
o Smoking
o DM
o Age
o Hypertension
o Hypercholesterolaemia
o Atherosclerosis elsewhere (coronary, carotid)
```
172
When to suspect peripheral artery disease?
o Progressive cramping pain in calf, thigh or buttock on walking which is relieved by rest
o Non-healing wounds
173
What is the Fontaine Classification of peripheral artery disease?
o Asymptomatic
ABPI <0.9
```
o Intermittent Claudication
Felt in calfs, thighs, buttocks
Tightness/cramping pain developing after certain distance
Worse on uphill
Pain disappears when resting
```
```
o Ischaemic Rest Pain
Woken up by pain
Occurs due to gravitational effect lost when lying flat
Relief by swinging legs over bed
Dependent oedema
```
o Ulceration/Gangrene
174
Signs of peripheral artery disease?
```
o Absent pulses
o Cold, hairless, dry, white legs
o Atrophic skin
o Punched out ulcers (painful)
o CRT prolonged
o Buerger’s angle <20o
```
175
Assessment of peripheral artery disease?
o Examine ulcers, temperatures, skin changes, pulses, CRT
o ABPI
<0.9 means peripheral artery disease
<0.5 critical limb ischaemia
>1.2 means vessels not compressible – calcifications - DM likely
176
Management of intermittent claudication - primary care?
Smoking cessation
Diet and weight modification
Clopidogrel 75mg OD (aspirin 75mg OD if clopidogrel CI or not tolerated)
Supervised exercise programme – 3 months twice a week
Refer for vascular surgery
If not for surgery – Praxaline (naftidrofuryl oxalate)
177
Management of intermittent claudication - secondary care?
Supervised exercise programme – 3 months, 2hours, twice a week
Duplex US if revascularisation considered
• +/- contrast-enhanced MR angiography
Angioplasty and stenting
Bypass Surgery and grafts
178
Management of critical limb ischaemia - primary care?
Refer to vascular MDT
PRN paracetamol + weak/strong opioids (+/- antiemetic)
• Refer to pain management services if pain not controlled and revascularisation inappropriate
Manage cardiovascular risk
• Smoking cessation
• Diet and weight modification
• Clopidogrel 75mg OD (aspirin 75mg OD if clopidogrel CI or not tolerated)
179
Management of critical limb ischaemia - secondary care?
Duplex US if revascularisation considered
• +/- contrast-enhanced MR angiography (CT if CI)
Angioplasty and stenting
Bypass Surgery and grafts
Amputation if ALL options have been considered by MDT
180
Prognosis of peripheral artery disease?
o Amputation required in 1-2% of intermittent claudication patients
o Critical limb ischaemia risk of amputation and premature death
o 3x more likely to die from CVD
181
Complications of peripheral artery disease?
o Impaired QoL
o Ulceration and gangrene
o Amputation
o CVD, CVA
182
Definition of AAA?
- Artery with dilatation >50% of its original diameter
o True aneurysms – abnormal dilatations that involve all layers of arterial walls
o False aneurysm – Collection of blood in outer layer only (adventitia)
- May be fusiform (most AAA) or sac-like (Berry aneurysms)
183
Definition of unruptured AAA?
- Unruptured AAA definition >3cm
o 3% of those >50 years
o Males 3:1 Females
o Majority infrarenal
184
Definition of ruptured AAA?
o Majority found infrarenal and haemorrhage into retroperitoneum
o Mortality 41% and untreated 100%
185
Risk factors of AAA?
```
o Hypertension
o Smoker
o Male
o Increasing age
o COPD
o Hyperlipidaemia
o Family history
```
186
Causes of AAA?
o Degeneration of elastic lamellae and smooth muscle loss
187
Symptoms and signs of unruptured AAA?
- Unruptured often have no symptoms – incidental finding
o Pulsatile mass in abdomen
o May have pain in back, abdomen or groin
- Unruptured Signs
o Expansile abdominal mass
o Abdominal bruit
188
Symptoms and signs of ruptured AAA?
```
- Ruptured Symptoms
o Classical central abdominal and lower back pain in patient with known aneurysm
o Sudden onset and severe pain
o PEA cardiac arrest
o Sudden painless collapse
```
```
- Ruptured Signs
o Pale, sweating, tachycardia, hypotensive
o Mottled skin of lower body
o Tender pulsatile abdominal mass
o Pulses in femoral region may be absent
```
189
Investigations in AAA?
- Low clinical suspicion
- USS
- CT Scan
o Used if evaluated for surgery
190
Screening in AAA?
o All men aged 65 years screened USS of abdomen
191
When to refer unruptured AAA to vascular surgeons?
AAA 5.5cm or larger to vascular surgeon within 2 weeks
| AAA 3-5.4cm to vascular surgeon within 12 weeks
192
General management of unruptured AAA?
Stop smoking service
| Treat hypertension
193
Surveillance of unruptured AAA?
Asymptomatic AAA
• Every 3 months if AAA 4.5-5.4cm
• Every 2 years if AAA 3.0-4.4cm
194
Surgical management of unruptured AAA - when and what?
When?
• Aneurysms >5.5cm, larger than 4cm and expanding at >1cm/year or symptomatic
What?
• Open Repair
• Stenting (EVAR)
195
Management of ruptured AAA?
o Get vascular surgeon and anaesthetist, warn theatre
o High flow Oxygen
o 2 large bore cannulas, Bloods (FBC, LFTs, U&Es, amylase, glucose, coagulation screen, Crossmatching (Emergency – 10U Red cells, 8U platelets, 8U FFP)
o IV morphine & 50mg Cyclizine
o IV Fluids (aim BP >90mmHg but <100mmHg due to risk of rupture)
o Portable USS, CXR, Urinary catheter and radial artery line, ECG
o Prophylactic Abx – Cefuroxime + Metronidazole IV
o Vascular surgeon - Aortic cross clamping
Endovascular repair or open surgery
196
Prognosis of AAA?
- No more than 1 in 3 patients with ruptured AAA will reach hospital alive and 20% of those who do, fail to reach theatre
