Cardiovascular system Flashcards
What is the recommended treatment for a 62 year old man with intermittent claudication, currently taking clopidogrel and simvastatin. He takes regular exercise but is still symptomatic, O/E there is no critical limb ischaemia.
Angioplasty (or stenting/bypass surgery)
What can be the various causes of heart failure? (7)
- Ischaemia
- Valvular insufficiency
- Hypertensive or congenital heart disease
- Cardiomyopathy
- Myocarditis
- Endocarditis
- PE
What can be the precipitating factors for heart failure? (9)
- MI
- Infection
- Arrhythmia
- Anaemia
- Thyrotoxicosis
- Electrolyte disturbance
- PE
- Pregnancy
- Vitamin deficiencies e.g. Beri beri
What are the symptoms of left sided heart failure? (7)
- Dyspnoea
- Orthopnoea
- Paroxysmal nocturnal dyspnoea
- Fatigue
- Lung crepitations
- Pleural effusions
- Cyanosis
What are the symptoms of right sided heart failure? (5)
- Peripheral oedema
- Abdominal distension/ascites
- Tender pulsatile hepatomegaly
- Increased jugular venous pressure
- Hepatojugular reflux
What symptoms indicate severe heart failure? (5)
- Reduced pulse pressure
- Hypotension
- Cool peripheries
- 3rd +/- 4th heart sounds
- Gallop rhythm
What investigations are important to carry out for someone with suspected heart failure? (4)
- Bloods - FBC, U&Es, LFTs, lipid profile, TFTs, glucose, cardiac enzymes
- ECG
- CXR
- Echo with colour doppler
What can be done to treat someone with heart failure? (7)
- Treat any risk factor e.g. cholesterol reduction, glycaemic control, weight loss, smoking cessation
- Remove any precipitant
- Diuretics
- ACE inhibitors
- Beta blockers
- Digoxin
- GTN infusion
What is the commonest cause of ischaemic heart disease?
Atherosclerotic plaques
In addition to athersclerosis, what are the other causes of ischaemia? (4)
Any restriction of coronary blood flow …so:
- Coronary spasm
- Emboli
- Aortic stenosis with left ventricular hypertrophy
- Severe anaemia
What are the risk factors for ischaemic heart disease? (6)
- Obesity
- Smoking
- Insulin resistance/T2DM
- High fat diet
- Hypertension
- High cholesterol
What investigations need to be carried out for someone with suspected acute coronary syndrome? (5)
- Bloods - FBC, U&Es, glucose, lipids, cardiac enzymes
- CXR
- ECG (t wave inversion, st depression)
- Exercise testing
- Stress echo +/- coronary angiography
What treatment is recommended for someone with an acute episode of acute coronary syndrome?
- Oxygen
- GTN spray
- Aspirin/clopidogrel
- Morphine
- LMWH +/- GTN infusion
- Glycoprotein IIb/IIIa inhibitors e.g. tirofiban
What is tirofiban and when is it used?
It is a reversible antagonist of fibrinogen binding to the glycoprotein (GP) IIb/IIIa receptor, the major platelet surface receptor involved in platelet aggregation.
Used in combination with unfractionated heparin, aspirin, and clopidogrel for prevention of early myocardial infarction in patients with unstable angina or non-ST-segment-elevation myocardial infarction (NSTEMI) and with last episode of chest pain within 12 hours (with angiography planned for 4–48 hours after diagnosis)
What is the long-term treatment for acute coronary syndrome? (7)
- Nitrates
- Beta blockers
- Calcium channel blockers
- Aspirin
- Clopidogrel (for up to 1 year following non-ST elevation MI)
- Nicorandil
- Coronary revascularization
What is nicorandil and when is it used?
It is a vasodilatory drug that acts on arterioles and large coronary arteries by activating potassium channels. It works by hyperpolarizing potassium channel membranes and increasing intracellular concentrations of cyclic GMP.
It is often used for patients with angina who remain symptomatic despite optimal treatment with other anti-anginal medications.
What are the causes of secondary hypertension? (5)
- Endocrine disorders e.g. Cushings syndrome, phaeochromocytoma, acromegaly, Conn’s syndrome, thyrotoxicosis
- Renal disease e.g. chronic renal failure, renal artery stenosis
- Acute porphyria
- Coarctation of the aorta
- Iatrogenic e.g. ciclosporin, steroids, contraceptives
If someone presents with central chest pain and aortic regurgitation murmur, with ST elevation in leads II, III and aVF, what are the main differentials? (2)
- Proximal aortic dissection
2. Inferior MI
What is Boerhaave syndrome?
Boerhaave syndrome, is a spontaneous perforation of the esophagus that results from a sudden increase in intraesophageal pressure combined with negative intrathoracic pressure (eg, severe straining or vomiting
What is the common presentation for a patient with Boerhaave syndrome?
Central chest pain and vomiting, with some mild crepitus in the epigastric region. Often they are middle aged men with a background of alcohol abuse.
What is the Mackler triad for Boerhaave syndrome?
- Vomiting
- Thoracic pain
- Subcutaneous emphysema
Why does pulmonary oedema occur?
When fluid leaks from the pulmonary capillary network into the lung interstitium and alveoli. The filtration of fluid exceeds the ability of the lymphatics to clear the fluid.
What are the two main types of pulmonary oedema?
- Cardiogenic (hydrostratic)
2. Non-cardiogenic
What is the cardiogenic cause of pulmonary oedema?
An elevated pulmonary capillary pressure from left-sided heart failure
What are the non-cardiogenic pulmonary oedema causes?
- Volume overload due to oliguric renal failure
- Altered alveolar-capillary membrane permeability - e.g. acute respiratory distress syndrome or lymphatic insufficiency (e.g. following lung transplant or lymphangitic carcinomatosis)
What are the cardiac causes of raised pulmonary capillary pressure? (9)
- Coronary heart disease e.g. MI or ACS
- Mechanical causes of ACS e.g. rupture of interventricular septum, mitral valve chordal rupture)
- Valvular e.g. acute aortic/mitral regurgitation, severe aortic stenosis, endocarditis
- Hypertensive crisis
- Acute pulmonary embolism
- Acute myocarditis
- Cardiac tamponade
- Aortic dissection
- Cardiomyopathy
What are the renal causes of increased pulmonary capillary pressure? (2)
- AKI or CKD
2. Renal artery stenosis
What are the other causes of increased pulmonary capillary pressure?
- Iatrogenic fluid overload
2. High-output heart failure
Instead of increasing pulmonary capillary pressure, what can lead to an increased pulmonary capillary permeability? (6)
- ARDS
- High altitude
- Inhaled/aspirated toxic substances
- Radiation
- Liver failure
- Fat embolism/amniotic fluid embolism
How may a patient present with acute pulmonary oedema? (5)
It can be a very frightening experience, with symptoms of:
- Severe breathlessness
- Sweaty
- Nauseated
- Anxious
- Dry/productive cough (sometimes with pink/frothy sputum)
What are the signs for acute pulmonary oedema? (9)
- Pallor
- Tachypnoeic
- Tachycardic
- Cyanosis
- Raised JVP
- Basal/widespread crackles
- Hypotension (orthopnoea)
- O2 sats <90% on RA
- Gallop rhythm/murmur
What investigations are important to carry out in suspected acute pulmonary oedema? (6)
- Blood tests - U&Es, glucose, cardiac enzymes, LFTs, clotting tests, natriuretic peptide (distinguish between acute PO and other causes of dyspnoea)
- ABG
- ECG
- CXR
- ECHO
- Urinary catheter - accurate measurement of output
What should you look for on an ECG of a patient with acute pulmonary oedema? (3)
- Arrhythmia
- MI
- Left ventricular hypertrophy
What is the management in hospital for patients with acute pulmonary oedema? (6)
- IV loop diuretic
- High-flow oxygen
- Thrombo-embolism prophylaxis
- Opiates e.g. morphine
- Vasodilators
- Inotropic agents NOT recommended unless the patient is hypotensive (systolic <85)
After a patient with pulmonary oedema is stabilised, what are the longer term treatments? (5)
- ACEi
- BBs
- Mineralcorticoid (aldosterone) receptor antagonist e.g. spironolactone
- Digoxin
- Possibly non-invasive ventilation e.g. CPAP
What are the treatments for patients with pulmonary oedema with hypotension, hypoperfusion or shock? (4)
- Electrical cardioversion (if arrhythmia is thought to be cause)
- IV inotrope (dobutamine)
- Short term mechanical circulatory support
- A vasopressor
What are the causes of aortic regurgitation AKA aortic insufficiency and aortic incompetence? (7)
- Bicuspid aortic valve
- Rheumatic fever
- Infective endocarditis
- Collagen vascular disease
- Degenerative aortic valve disease
- Hypertension
- Atherosclerosis
What is the most common cause of AR worldwide?
Rheumatic heart disease (caused by strep A infection e.g. Scarlett fever)
What are the most common causes of AR in developed countries? - and what is the peak age of these presenting?
Congenital and degenerative valve abnormalities.
Peak age - 40-60 years
What are the rheumatological/congenital causes of aortic regurgitation? (7)
- SLE
- Marfan’s syndrome
- Ehlers-Danlos syndrome
- Turner syndrome
- Ankylosing spondylitis/reactive arthritis
- Takaysau’s disease
- Bechet’s disease
What are the most common causes of acute severe aortic regurgitation? (2)
- Infective endocarditis
2. Aortic dissection
What is the murmur associated with aortic regurgitation?
Diastolic murmur with exaggerated arterial pulsations and low diastolic pressure
What happens to the left ventricle with aortic regurg?
Regurg leads to an increase in LV end-diastolic pressure, which leads to LV dilatation and hypertrophy
What are the symptoms of aortic regurg? (5)
- Dyspnoea
- Arrhythmias
- Orthopnoea
- Paroxysmal nocturnal dyspnoea
- Angina
What are the signs associated with aortic regurg?
- Wide pulse pressure
- Large volume collapsing ‘waterhammer’ pulse
- Early diastolic, high-pitched murmur (heard best at lower left sternal edge, patient sat forward)
- Visible carotid pulsations - Corrigan’s sign
- Capillary pulsations in the nail bed - Quincke’s sign
- ‘Pistol shot’ over the femoral arteries - Traube’s sign
- Head nodding in time with the pulse - de Musset’s sign
- Mid-diastolic murmur heard at the apex - Austin Flint murmur
What investigations should be carried out in someone with suspected AR?
- ECG
- ECHO
- CXR
What may be seen on ECG in someone with AR?
- LV hypertrophy
2. Left axis deviation
What is the medical treatment for AR?
- Diuretics
- ACEi
- Vasodilators
What is the surgical management for AR?
Aortic valve replacement
What are the causes of mitral regurgitation? (9)
- Rheumatic heart disease
- Ischaemic heart disease
- Complication of MI
- Hypertrophic cardiomyopathy
- Degenerative calcification
- Infective endocarditis
- Mitral valve prolapse
- LV dilatation
- Connective tissue disorders
What are the symptoms of mitral regurg? (4)
- Dyspnoea
- Fatigue
- Orthopnoea
- Right-sided heart failure
What are the signs associated with mitral regurg? (7)
- Jerky pulse
- Soft 1st heart sound
- Displaced apex beat
- Apical thrill
- 3rd heart sound
- Pansystolic murmur
- Pulmonary oedema
What investigations are carried out for someone with suspected mitral regurg? (4)
- ECG
- CXR (LA may be massively enlarged +/- pulmonary oedema
- ECHO
- Cardiac catheterization
What is the medical treatment for mitral regurg?
Treatment aimed at symptomatic relief - diuretics, ACEi, digoxin
What is the surgical treatment for mitral regurg?
Mitral valve replacement
What are the causes of carotid artery stenosis? (7)
- Carotid atherosclerosis (90%)
- Aneurysms
- Arteritis
- Carotid dissection
- Fibromuscular dysplasia
- Vasospasm
- Coils and kinks
Which area of the carotid is most commonly affected by atherosclerosis?
Bifurcation of the common carotid artery
What are the branches of the external carotid artery?
Superior thyroid artery Ascending pharyngeal artery Lingual artery Facial artery Occipital artery Posterior auricular artery Maxillary artery Superficial temporal artery (Some Anatomists Like Freaking Out Poor Medical Students)
When is carotid endarterectomy strongly recommended?
For severe symptomatic stenosis - people experiencing TIAs or minor strokes
What are the risk factors for carotid artery stenosis?
- Increasing age
- Smoking
- High systolic blood pressure
- Total cholesterol
How may carotid artery stenosis present?
- TIAs or CVEs - contralateral weakness, ipsilateral vision loss, dysphasia, speech apraxia
- Cognitive impairment and decline may be associated with asymptomatic stenosis of the left internal carotid artery
- Asymptomatic patients may be identified with a carotid bruit being heard of examination
How do arterial ulcers appear and what are their characteristics?
They are caused by a reduction in arterial blood flow leading to decreased perfusion of the tissues and subsequent poor healing.
They often form as small deep lesions with well-defined borders and a necrotic base. They most commonly occur distally at sites of trauma and in pressure areas.
What are the risk factors for developing an arterial ulcer? (9)
- Atherosclerosis
- Diabetes
- Smoking
- Hypertension
- Hyperlipidaemia
- Increasing age
- Positive family history
- Obesity
- Physical inactivity
In addition to an arterial ulcer, what other features may be present in someone with peripheral arterial disease? (2)
- Intermittent claudication
2. Critical limb ischaemia (pain at night)
How quickly do arterial ulcers develop?
They develop over a long period of time, with little to no healing (therefore no or little granulation tissue)
Which ulcers are painful and which ones painless between arterial and venous?
Arterial are painful, venous painless
What are the signs of an arterial ulcer? (5)
- Punched out edge
- Sloughy base
- May be very deep
- Poor peripheral pulses
- Pallor/cyanosis
What % of lower limb ulcers are of venous origin?
80%
What causes venous ulcers?
Venous insufficiency AKA venous reflux disease. The pathophysiology is poorly understood, but it is thought valvular incompetence or venous outflow obstruction leads to impaired venous return, with the resultant venous hypertension causing the ‘trapping’ of WBCs in capillaries and the formation of a fibrin cuff around the vessel hindering oxygen transportation into the tissue. The WBC subsequently become activated with the release of inflammatory mediators leading to resultant tissue injury, poor healing, and necrosis.
What are the risk factors for venous ulcers? (5)
- Increasing age
- Pre-existing venous incompetence or history of venous thromboembolism
- Pregnancy
- Obesity or physical inactivity
- Severe leg injury or trauma
Where are venous ulcers commonly found?
In the ‘gaiter’ distribution or region of the legs (often near the medial/lateral malleolus)
What symptoms may present before venous ulceration?
- Aching
- Itching
- Bursting sensation
On examination how may lower limbs appear in someone predisposed to developing venous ulcers?
- Varicose veins
- Ankle/leg oedema
- Features of venous insufficiency - varicose eczema, thrombophlebitis, haemosiderin skin staining
What invesitgations are carried out in suspected venous ulcers?
- Duplex USS
- ABPI
- Swab cultures
In which veins is venous incompetence most common?
Sapheno-femoral or sapheno-popliteal junctions
When is compression therapy not suitable for someone with a venous ulcer?
When infection is suspected or when the ABPI is less than 0.6
What is the conservative management for someone with a venous ulcer?
- Leg elevation
- Increased exercise
- Weight reduction (if necessary)
- Improved nutrition
- Antibiotics if infection
- Multicomponent compression bandaging
What % of venous leg ulcers will heal after six months of compression bandage therapy?
30-75%
What is the conservative and medical management for arterial ulcers?
- Lifestyle changes - smoking cessation, weight loss, increased exercise
- Cardiovascular medication e.g. statin, antiplatelet therapy, optimising blood pressure and glucose levels
What is the surgical management of arterial ulcers?
Angioplasty (with or without stenting) or bypass grafting (any non-healing ulcers despite a good blood supply, may be offered skin reconstruction with grafts)
What is a neuropathic ulcer?
One that occurs as a result of peripheral neuropathy. Due to the nature of peripheral neuropathy, as there is a loss of sensation, unnoticed injuries can occur forming and resulting in painless ulcers on the pressure points of the limb. Concurrent vascular disease will often contribute to their formation and reduce the healing potential.
What are the two most common causes of neuropathic ulcers (and therefore peripheral neuropathy)? (2)
- Diabetes
2. B12 deficiency
What is the common distribution for peripheral neuropathy?
‘Glove and stocking’ distribution
A bicuspid aortic valve is associated with what congenital heart problem?
Coarctation of the aorta
What are the two characteristics seen on ECG of wolf-parkinson-white syndrome?
Delta waves and a short PR interval
What is the first line anti-hypertensive for someone with diabetes (regardless of age) (not regardless of ethnicity)?
ACE inhibitor (or ARB if necessary) (if the patient is of afro-caribbean origin then it would be a CCB
What is the name given to a triad of right bundle branch block, first degree heart block and left axis deviation (or left anterior/posterior hemiblock)?
Trifasicular block
In an episode of severe anaphylaxis, what treatment needs to be given immediately?
- Adrenaline IM
- Hydrocortisone
- Chlorphenamine
What is the mechanism of action of dipyridamole?
Phosphodiesterase inhibitor
What is the difference between unstable angina and a NSTEMI?
Elevated troponins/cardiac enzymes in an NSTEMI
What is AF?
Disorganised atrial activity, resulting in an irregular ventricular response. It arises in the left atrium around the pulmonary veins.
What causes AF? (14)
Cardiac causes: 1. Ischaemic heart disease 2. Valvular heart disease 3. Hypoxia 4. Hypertension 5. Rheumatic heart disease 6. Atrial septal defect 7. Heart failure 8. Cardiomyopathy Others: 9. Thyrotoxicosis 10. Alcohol 11. Sepsis 12. Pneumonia 13. PE 14. Iatrogenic
What are the symptoms of AF? (5)
- Can be asymptomatic
- Fatigue/lethargy
- Dizziness
- Palpitations
- SOB
- Discomfort/pain chest
What are the signs of AF?
Irregularly irregular pulse with or without haemodynamic compromise
What investigations should be carried out with AF?
- Bloods - FBC, U&Es, TFTs
2. ECG
What is the rate-controlling treatment for AF? (3)
- Beta blockers
- Digoxin
- Calcium channel blockers
What is the rhythm controlling treatment for AF? (4)
- Flecainide
- Amiodarone
- Sertalol
- Dronedarone
If a young person presents with new-onset AF within 48 hours of developing it, what can be done?
Cardioversion - don’t need to be started on anticoagulants.
Any time after 48 hours or if they have had AF before, then must be anticoagulated
How can someone with chemically cardioverted?
IV flecainide 150mg over 10 minutes
What score is used and what are the components of it for calculating requirement for anticoagulation with AF?
CHA2DS2-VASC C- coronary heart disease H - hypertension A - age >75 years old (2 points) D - diabetes S - stroke or TIA (2 points)
V - vascular disease (MI etc.)
A - age (65-74)
Sc - sex (male or female) - female = 1
What are the surgical options for management of paroxysmal AF?
Ablation - pulmonary vein isolation
What is the therapeutic range for warfarin?
2-3
What are the risks with not being in the therapeutic range using warfarin i.e. below 2 or above 3?
Below 2 = risk of CVA
Above 3 = risk of bleeding
What are the three main types of AF? (3)
- Paroxysmal (stops within 48 hours)
- Persistent (lasts up to 5 days)
- Permanent (established AF - no longer trying to revert back to sinus rhythm)
What are the three types of medication used in the treatment for AF?
- Anti-arrhythmias
- Rate controls
- Anticoagulants
What is atrial flutter?
Atrial re-entry tachycardia, leading to rapid atrial rate (300 bpm), usually occurs with slower ventricular rate due to 2:1 or 3:1 block in the AVN.
What are the causes of atrial flutter?
Acute cardiac or respiratory problems e.g. pericarditis or pneumonia
What are the symptoms of atrial flutter? (2)
- Palpitations
2. Dizziness
What are the signs of atrial flutter?
Tachycardia with or without haemodynamic compromise
What is Wolff-Parkinson-White syndrome?
Atrial re-entry tachycardia with an accessory excitatory pathway linking the atrium to the ventricle (bundle of Kent)
What are the symptoms of WPW syndrome? (3)
- Palpitations
- Dizziness
- Syncope
What is seen on an ECG of someone with WFW syndrome? (2)
- Short PR interval
2. Delta wave (slurred upstroke to QRS), wide QRS
What are the treatments for WFW syndrome? (4)
- DC cardioversion
- B-blockers
- CCBs
- Catheter ablation
What is the complication which can occur with WFW syndrome?
Can progress to ventricular fibrillation (VF)
What is malignant hypertension?
Fibrinoid necrosis of small arterioles/arteries, and dilatation of cerebral arteries
What are the symptoms associated with malignant hypertension? (5)
- Headache
- Vomiting
- Visual disturbance
- Convulsions
- Papilloedema
What is the treatment for malignant hypertension? (2)
- IV labetalol/GTN
2. Bring blood pressure down slowly
What are the complications with malignant hypertension? (5)
- Microangiopathic haemolytic anaemia
- Renal failure
- Cerebral haemorrhage
- Coma
- Death
When is VT classed as sustained VT?
When it lasts longer than 30 seconds or causes haemodynamic compromise
What are the causes of VT? (6)
- Ischaemic heart disease
- MI
- Cardiomyopathy
- Metabolic abnormalities
- Drug toxicity
- Long QT syndrome
What are the symptoms of VT? (3)
- Palpitations
- Chest pain
- Syncope
What are the signs of VT? (3)
- Tachycardia with hypotension
- Varying 1st heart sound
- Occasional cannon waves (giant ‘a’ waves in JVP)
What is the treatment for VT? (3)
- Anti-arrhythmias (amiodarone, lidocaine)
- DC cardioverson
- Implantable cardiac defibrillator to treat recurrent
What is the complication that can occur with VT?
VF
What are the classic symptoms of ACS? (4)
- Chest pain radiating to arms, back and/or jaw > 15 minutes
- Acute dyspnoea
- Nausea, vomiting and sweaty
- Haemodynamically unstable
What is the immediate management for a SUSPECTED ACS? (6)
- Morphine
- Oxygen (if required)
- GTN
- Aspirin 300mg PO
- ECG
- Blood markers - trop T+I and CK
What is the immediate management for a confirmed STEMI or NSTEMI? (9)
…for it to be confirmed you will have ECG and cardiac enzymes back…
- Secure IV access
- Oxygen if sats <94% (risk of reperfusion injury)
- Morphine 2.5-10mg IV PRN
- Metoclopramide 10mg IV or haloperidol
- GTN (unless hypotensive) and BB
- Aspirin 300mg PO and clopidogrel 300mg (or ticagrelor 180mg loading dose)
- Fondaparinux
- FBC, U&Es, glucose, lipid profile (LDL, HDL, triglycerides)
- CXR
What is the long-term medications for someone post NSTEMI or STEMI?
ABCs
A - ACE i - indefinite
B - beta blockers (or CCBs) for 12 months
C - anti-Coagulants - DAPT for 12 months
S - statin
+ GTN / nitrates as they are essential to manage symptoms
What is a less typical presentation of an MI?
- Epigastric pain
- Back pain
- ‘Silent’ infarct
- Syncope
- Confusion
Who is more likely to experience a silent MI? (4)
- Elderly
- Diabetic
- Hypertensive patient
- Female
What is the first sign on an ECG of an MI?
Peaked T wave
Why is there a high risk of heart block if it is an inferior MI?
Because an inferior MI corresponds to the right coronary artery, and this vessel supplies the SAN, so if it is occluded/damaged then it is more likely for heart block to occur
Which artery corresponds to the anterior/septal aspect of the heart?
LAD - leads V1 - V4
Which artery corresponds to the lateral aspect of the heart? and which leads is this seen in?
The circumflex artery - AVL, V5-6, I
What other change on an ECG can signify an MI?
Left bundle branch block
If there is ST depression in leads V1-V4 (anteriori leads) what type of MI does this indicate?
A posterior STEMI
What are the two types of troponin blood tests useful to measure in suspected ACS?
TnT and TnI - peak at 12 hours
When does CK peak for MI?
12 hours
When should coronary angiogram and primary PCI be performed from presentation of MI/onset of symptoms?
Within 12 hours of symptoms onset
What medication treatment is given in the management of NSTEMI which isn’t given with a STEMI?
Glycoprotein iib/iia (Tirofiban)
What can be used to stratify risk for thrombolysing patients with MI?
TIMI - thrombolysis in MI and GRACE - global registry of acute coronary events
In addition to the post-MI medications all patients receive, what else is given if the patient has heart failure and left ventricle systolic dysfunction?
Aldosterone antagonists e.g. eplerenone
What lifestyle advice is given to someone post-MI? (5)
- Exercise 20-30 minutes per day until slightly breathless
- May resume sex 4 weeks post MI
- Can use Sildenafil 6 months post MI but never if already prescribed nitrates or nicorandil
- Switch to mediterranean diet
- Avoid oily fish and omega 3 supplements
What are the complications of an MI? (11)
- Cardiac arrest
- Cardiogenic shock
- Chronic heart failure
- Tachyarrhythmias
- Bradyarrhythmias
- Pericarditis
- Dressler’s syndrome
- Left ventricular aneurysm
- Left ventricular free wall rupture
- Ventricular septal defect
- Acute mitral regurgitation
In what type of MI is acute mitral regurgitation more often seen?
Infero-posterior infarction due to ischaemia or rupture of the papillary muscle.
What is heart failure?
Pump failure of the left, right or both sides of the heart resulting in characteristic symptoms dependent upon which side if affected
What happens in the heart in systolic heart failure?
The ventricles are enlarged and become unable to contract fully –> so cardiac output and ejection fraction is <40%
What are the causes of systolic heart failure? (3)
- IHD
- MI
- Cardiomyopathy
What is diastolic heart failure?
Stiff ventricles cannot relax fully, and ejection fraction >50%
What are the causes of diastolic heart failure? (3)
- Constrictive pericarditis
- Cardiomyopathy
- Hypertension
What are the symptoms associated with left ventricular failure? (7)
- Dyspnoea
- Orthopnoea
- Nocturnal cough - pink frothy sputum
- Weight loss
- Cachexia
- Fatigue
- Lethargy
What are the signs on examination of someone with left sided heart failure? (5)
- Cyanosis
- Basal fine crepitations
- Displaced apex beat
- Third heart sound
- Pulsus alternans
What are the signs/symptoms of right sided heart failure? (7)
- Ascites
- Fatigue
- Enlarged liver and spleen
- Weight gain
- Peripheral oedema
- Anorexia and complaints if GI distress
- Raised JVP
A young patient presents with palpitations - an ECG shows a shortened PR interval and wide QRS complex with a slurred upstroke in lead II. Considering the likely diagnosis, what is the definitive management of this condition?
Accessory pathway ablation
A 52 year old patient presents with tearing central chest pain, and he has an aortic regurgitation murmur. An ECG shows ST elevation in leads I, III and aVF. What is the likely diagnosis/cause?
Proximal aortic dissection
What is aortic dissection?
A tear in the tunica intima of the wall of the aortic
What is aortic dissection associated with? (6)
- Hypertension
- Bicuspid aortic valve
- Marfan’s syndrome/Ehlers-Danlos syndrome
- Turner’s/Noonan’s syndrome
- Pregnancy
- Syphilis
What are the features of aortic dissection? (4)
- Chest pain - typically severe, radiates through to the back and ‘tearing’ in nature
- Aortic regurgitation
- Hypertension
- The majority of patients have no ECG changes but in a minority there may be ST elevation in inferior leads
Which classification systems are used for aortic dissection?
Stanford classification
DeBakey classification
Which blood tests need to be performed before starting someone on amiodarone?
- TFTs
- LFTs
- U&Es
- CXR
What is amiodarone?
Amiodarone is a class III anti-arrhythmic agent used in the treatment of atrial, nodal and ventricular tachycardias. The main mechanism of action is by blocking potassium channels which inhibits repolarisation and hence prolongs the action potential. It also has other actions such as blocking sodium channels (a class I effect)
What adverse effects can amiodarone cause? (9)
- Thyroid dysfunction
- Corneal deposits
- Pulmonary fibrosis/pneumonitis
- Liver fibrosis
- Peripheral neuropathy, myopathy
- Photosensitivity
- Thrombophlebitis and injection site reactions
- Bradycardia
In hypothermia, why are platelets and WBCs low on bloods?
Due to splenic sequestration
What would an ECG show for a patient with hypothermia?
J waves -also known as an Osborn wave
What adverse effect can loop diuretics cause?
Ototoxicity - bilateral tinnitus and hearing loss
What are the 8 reversible causes of cardiac arrest? (4 H’s and 4 T’s)
- Hypothermia
- Hypoxia
- Hypovolaemia
- Hypokalaemia
- Tension pneumothorax
- Toxins
- Tamponade
- Thrombosis
When should patients with unstable angina or NSTEMI be given intravenous glycoprotein IIb/IIIa receptor antagonists?
According to NICE 2013 guidelines, they should be given to patients with an intermediate or high risk of adverse cardiovascular events and who are scheduled to undergo angiography within 96 hours of hospital admission.
Name 3 glycoprotein IIb/IIIa receptor antagonists?
- Abciximab
- Eptifibatide
- Tirofiban
When should anti-thrombin treatment be offered to patients with unstable angina/NSTEMI?
Fondaparinux should be offered to patients who are not at a high risk of bleeding and who are not having angiography within the next 24 hours. If angiography is likely within 24 hours or a patients creatinine is >265 umol/l unfractionated heparin should be given.
Why is a combination of a beta blocker and non-dihydropyridine CCB contraindicated?
Due to a risk of bradycardia
What is atrial myxoma?
Atrial myxoma is a benign tumour most commonly occurring in the left atrium.
What is atrial myxoma a triad of?
A triad of:
- Mitral valve obstruction
- Systemic embolisation
- Constitutional symptoms
What are the constitutional symptoms associated with atrial myxoma? (3)
- Breathlessness
- Weight loss
- Fever
What would show on an ECHO in someone with atrial myxoma?
Pedunculated hetergeneous mass
In someone with newly diagnosed AF, what is the most appropriate drug to control heart rate? (if there are no contraindications)
Beta blockers - bisoprolol
- beta blockers are preferable to digoxin
What are the features of symptomatic aortic stenosis? (3)
- Chest pain
- Dyspnoea
- Syncope
What are the causes of aortic stenosis? (4)
- Degenerative calcification
- Bicuspid aortic valve
- William’s syndrome (supravalvular aortic stenosis)
- Post-rheumatic disease
When is aortic stenosis managed surgically? (2)
- If the patient is symptomatic
2. If they are asymptomatic but the valvular gradient is >40mmHg
When is balloon valvuloplasy performed instead of valve replacement in someone with aortic stenosis?
If the patient has critical aortic stenosis and is not fit for valve replacement
What is hypertrophic obstructive cardiomyopathy?
HOCM is an autosomal dominant disorder of muscle tissue caused by defects in the genes encoding contractile proteins. It is important as it is the most common cause of sudden cardiac death in young people.
The most common defects involve a mutation in the gene encoding beta-myosin heavy chain protein or myosin-binding protein C, which results in predominantly diastolic dysfunction.
What is the diastolic dysfunction caused by hypertrophic obstructive cardiomyopathy?
Left ventricle hypertrophy –> decreased compliance —> decreased cardiac output
What are the clinical features of HOCM? (7)
- Often asymptomatic
- Exertional dyspnoea
- Angina
- Syncope
- Sudden death
- Jerky pulse
- Ejection systolic murmur
What are the causes of sudden death in someone with HOCM?
Most commonly due to ventricular arrhythmias or heart failure
The mnemonic MR SAM ASH is used to remember what is seen on ECHO in someone with HOCM, what does it refer to?
Mitral regurgitation
Systolic anterior motion of the anterior mitral valve leaflet
Asymmetric hypertrophy
What is seen on an ECG of someone with HOCM? (4)
- Left ventricular hypertrophy
- Non-specific ST segment and T-wave abnormalities, progressive T wave inversion
- Deep Q waves
- Atrial fibrillation
What will an ABG of someone with a PE most commonly show?
Respiratory alkalosis - due to hyperventilation
What is atrial flutter a form of?
Supraventricular tachycardia - characterised by a succession of rapid atrial depolarisation waves
What is Wellen’s syndrome?
This refers to a specific ECG anormality in the precordial T wave segment, which are associated with critical stenosis of the LAD. Wellen’s is AKA LAD coronary T-wave syndrome.
When listening for murmurs, what is the useful mnemonic to remember which side will be loudest on inspiration and which will be loudest on expiration?
RILE
Right sided - loudest on - inspiration
Left sided - loudest on - expiration
What medication can be used to treat orthostatic hypotension?
Fludrocortisone or midodrine are pharmacological options. Fludrocortisone increases renal sodium reabsorption and increases the plasma volume.
In a young woman with low potassium and hypertension, what is the likely cause?
Primary hyperaldosteronism (e.g. Conn’s syndrome)
Although the normal target INR for a patient on warfarin is 2-3, what is the target for someone who experiences recurrent PEs?
3.5
If an ECG shows tall R waves in leads V1-2, what can indicate?
Posterior MI
How do you differentiate between an anterior MI and acute pericarditis on an ECG, as they will both show ST elevation?
In acute pericarditis there is PR depression
What are the features of pericarditis?
- Chest pain - may be pleuritic, it is often relieved by sitting forwards
- Non-productive cough
- Dyspnoea
- Flu-like symptoms
- Pericardial rub
- Tachypnoea
- Tachycardia
What are the causes of pericarditis? (8)
- Viral infections e.g. coxsackie
- TB
- Uraemia
- Trauma
- Post-MI infarction, Dressler’s syndrome
- Connective tissue disease
- Hypothyroidism
- Malignancy
What are the classic features of percarditis on an ECG? (3)
- The changes are often global/widespread, as opposed to the territories’ seen in ischaemic events
- Saddle-shaped ST elevation
- PR depression
What other investigation should all patients with suspected acute pericarditis receive?
Transthoracic echo
What is the first line medication used for the treatment of idiopathic or viral pericarditis? (2)
- NSAIDs
2. Colchicine
A young patient presents with acute onset palpitations with BP 124/84, and HR 150bpm. An ECG shows narrow complex tachycardia. IV access is gained and 6mg of adenosine is given with no effect. What is the next step in the management?
12mg IV adenosine
Where is the site of action of furosemide?
Furosemide inhibits the Na-K-Cl co-transporter in the ascending loop of Henle
Head bobbing AKA De Musset’s sign, is associated with which heart murmur?
Aortic regurgitation
What pathologies are associated with systolic murmurs?
Aortic stenosis (ejection systolic) Mitral regurgitation (pan systolic) Aortic sclerosis
Which pathologies are associated with diastolic murmurs?
Aortic regurgitation (early diastolic murmur) Mitral stenosis (mid-diastolic rumbling murmur)
What is chronic pericarditis?
A long-lasting, gradual inflammation of the pericardium, causing accumulation of fluid in the pericardial space or thickening of the pericardium.
What are the two types of chronic pericarditis?
- Chronic effusive
2. Chronic constrictive
What are the layers of the pericardium?
Outer fibrous and inner serous
Approximately how much fluid is normally in the intrapericardial space/cavity?
50ml
Why is the pericardium useful normally? (3)
- Helps cardiac efficiency by limiting dilatation, aids atrial filling
- Protects the heart by reducing external friction and providing a barrier to extension of infection and malignancy
- Fixes the heart anatomically through ligamentous connections
What are the different groups of causes of pericarditis? (7)
- Idiopathic
- Infective
- Inflammation
- Metabolic
- CV disease
- Neoplastic
- Misc.
What are the infective causes of pericarditis? (2)
- TB - main cause of constrictive pericarditis in developing nations but is less common in developed countries
- Others - viral, bacterial, fungal or parasitic
11% - 50% of patients with which inflammatory condition will have pericarditis on autopsy?
Rheumatoid arthritis
In addition to rheumatoid arthritis, what are the other causes of chronic pericarditis? (4)
- SLE
- Scleroderma
- Sarcoidosis
- Granulomatosis with polyangiitis (Wegener’s granulomatosis)
What are the metabolic causes of chronic pericarditis? (3)
- Renal failure - 35-50% of patients with uraemia, pre-dialysis have pericarditis
- Hypothyroidism
- Cholesterol pericarditis (gold paint pericarditis)
What are the cardiovascular diseases that can cause pericarditis? (3)
- MI - causes acute pericarditis (transmural infarcts, persistent ST elevation)
- Dressler’s syndrome (2-3 weeks after MI)
- Aortic dissection
Which drugs can cause pericarditis? (7)
- Doxorubicin
- Cyclophosphamide
- Drug-induced SLE
- Methysergide - smallpox vaccination
- Dantrolene
- Phenytoin
- Minoxidil
What are the symptoms of chronic effusive pericarditis? (9)
- Dyspnoea on exertion
- CV symptoms - e.g. chest pain, pressure or discomfort, syncope, light-headedness and palpitations
- Asymptomatic
- Respiratory symptoms e.g. cough, hoarseness
- Fatigue
- Hiccups
- Anxiety
- Confusion
What is Beck’s triad? (3)
They are the three medical signs associated with cardiac tamponade
- Hypotension
- Raised JVP
- Diminished heart sounds
In a patient with Down syndrome who is found to have a ventral septal defect, what is the classic murmur that may be heard on auscultation?
Pansystolic murmur
What are the causes of mitral stenosis? (4)
- Rheumatic heart disease
- Congenital valve abnormality
- Endocarditis
- SLE
What is the pathology behind mitral stenosis?
When the mitral valve orifice is <2cm, the left atrium requires abnormally high pressures to propel blood into the LV and maintain cardiac output; this leads to a high AV pressure gradient backward transmission of the high LA pressure leads to pulmonary hypertension
What are the symptoms of mitral stenosis? (5)
- Dyspnoea
- Orthopnoea
- Paroxysmal nocturnal dyspnoea
- Palpitations
- Right-sided heart failure
What are the signs of mitral stenosis? (6)
- Malar flush
- Atrial fibrillation
- Pulmonary oedema
- Increased JVP with prominent waves
- Loud 1st heart sound
- Mid-diastolic murmur
What is the treatment for mitral stenosis?
Medical - aimed at symptom relief - diuretics, beta blockers, digoxin) and warfarin if AF/systemic emboli
Surgical - mitral valvotomy or mitral valve replacement
What are the three types of atrial septal defect - and which do the majority of cases account for?
- Ostium primum - septal defect lies adjacent to AV valve
- Ostium secundum - mid-septum, 70% of cases
- Sinus venous - high in septum, near superior vena cava
What are the causes of atrial septal defects?
- Congenital
2. Down syndrome (associated with ostium primum)
What are the symptoms associated with atrial septal defects? (4)
- Usually asymptomatic until adulthood
- Palpitations (arrhythmias)
- Dyspnoea
- Cyanosis
What are the signs of atrial septal defects? (6)
- Left parasternal heave
- Wide fixed splitting of 2nd heart sound
- Mid-systolic murmur at left sternal edge (due to increased flow across the pulmonary valve)
- Cyanosis
- Clubbing
- Mid-diastolic murmur
What would an ECG of ostium secundum ASD show? (2)
- Right axis deviation
2. Right bundle branch block
How can symptoms associated with pericarditis be relieved?
By sitting forward (worse when lying flat and on inspiration)
What can an ECG show of someone with pericarditis?
Widespread ST elevation, concave in shape, followed by T-wave inversion
What are the causes of myocarditis?
- Infection
- Drugs
- Radiation
What is the commonest cause of myocarditis?
Viruses - coxsackie
What are the symptoms of myocarditis?
- Asymptomatic
- Chest pain
- Palpitations
- Heart failure
- Death
What are the signs, if any, of myocarditis?
Often normal, occasionally 3rd heart sound, pansystolic murmur
What is the difference between systolic and diastolic heart failure?
Systolic = ventricles enlarged, become unable to contract fully, so cardiac output + ejection fraction <40%
Diastolic = stiff ventricles cannot relax fully, leading to an increase in filling pressures, ejection fraction >50%
- both usually co-exist
What are the typical causes of systolic heart failure? (3)
- Ischaemic heart disease
- MI
- Cardiomyopathy
What are the typical causes of diastolic heart failure? (3)
- Constrictive pericarditis
- Cardiomyopathy
- Hypertension
In the NYHA classification of heart failure, what do scores 1-4 refer to?
1 = no limitation - normal activity 2 = slight limitation of physical activity - comfortable at rest 3 = marked limitation of physical activity - comfortable at rest, less than ordinary activity 4 = unable to carry out any physical activity without discomfort - symptoms of HF present at rest
What is superficial thrombophlebitis?
Superficial vein becomes inflamed and forms a clot within
Which vein does superficial thrombophlebitis typically affect?
Long saphenous of leg
What are the risk factors for superficial thrombophlebitis? (8)
- Virchow’s triad - damage to vessel, stasis of blood flow, hypercoagulability
- Amiodarone
- Obesity
- Smoking
- COCP
- Pregnancy
- IVDU
- thrombophilia
What is the typical clinical presentation for someone with superficial thrombophlebitis?
- Erythema
- Swelling
- Tenderness
What is the red flag/complication that can occur with thrombophlebitis?
Suppurative thrombophlebitis - pus in vein and sepsis develops
What is the management for superficial thrombophlebitis?
- Elastic support
- Exercise
- Analgesia - TOP naproxen
- LMWH - tinzaparin or dalteparin for >1 month
- Surgery - if recurs
What is the differential for superficial thrombophlebitis?(2)
- Cellulitis
2. DVT
What are the acute, chronic and transient causes of peripheral arterial/vascular disease?
Acute = embolus Chronic = atherosclerosis Functional = vasospasm
What are the symptoms/signs of upper limb peripheral arterial disease? (5)
- Pulse deficit
- Arm pain
- Pallor
- Paraesthesia
- Cold
What is Leriche’s syndrome?
A claudication pain in the buttocks/thighs with absent femoral pulses and male impotence - due to saddle aorto-iliac obstruction
When do calculating the ABPI for peripheral vascular examination, what score indicates calcified/stiff arteries and what is normal score?
>1.2 = calcified stiff arteries 1-1.2 = normal
What ABPI score would indicate an urgent referral is required for peripheral arterial disease?
<0.5
What is the management for acute limb ischaemia using the Rutherford classification?
- Dusky leg = viable = arteriography
- White leg, paralysis = threatened = surgery
- Fixed skin staining/mottling, tense muscle = irreversible = amputation
What is reperfusion injury?
- This can cause more damage than the initial ischaemia - neutrophils migrate to reperfused tissue and inflammation occurs.
- Limb oedema due to capillary membrane permeability can lead to compartment syndrome
- Leakage from damaged cells leads to acidosis, increasing potassium leading to arrhythmias and AKI
If someone has chronic limb peripheral arterial disease, what can be done to help/manage/treat? (6)
- Exercise programme
- Smoking cessation
- Analgesia for pain - paracetamol
- Treat co-morbidities e.g. hypertension, diabetes, obesity, cholesterol
- Clopidogrel if symptomatic
- Angioplasty and stenting
What is the difference on ECG between SVT and VT?
The QRS complex - in SVT it is narrow, and in VT it is broad
What is SVT?
A narrow complex tachyarrhythmia characterised by abnormally fast heart rate, arising from within the atrium. The main types or causes are AF, paroxysmal SVT, atrial flutter, and WPW syndrome.
What are the risk factors for SVT? (4)
- Previous SVT
- Structural abnormality
- Alcohol
- Caffeine
What are the acute causes of aortic regurgitation? (3)
- Infective endocarditis
- Aortic dissection
- Chest trauma
What are the chronic causes of aortic regurgitation? (4)
- Marfan’s
- Ehlers danlos
- Rheumatic fever
- SLE, rheumatoid arthritis
What is the most common valvular disease?
Aortic stenosis
What are the causes of aortic stenosis?
- Degenerative lipid deposition (calcification)
- Congenital bicuspid valve - high risk of calcification
- Post-inflammatory
- Rheumatic fever
What is the classic triad for aortic stenosis? - related to symptoms?
- SOB - heart failure
- Chest pain - angina
- Syncope
Which murmur is associated with malar flush?
Mitral stenosis
Which murmur is associated with AF?
Mitral regurgitation
What is an aneurysm?
Artery with a progressive, permanent dilatation >50% of its original diameter, which includes all layers of the material wall
What are the two types of aneurysm?
- Fusiform - e.g. AAA
2. Sac like - e.g. Berry (SAH)
Where are the common sites of aneurysms to occur?
Aorta, iliac, femoral, popliteal
What are the risk factors for an AAA? (6)
- Male (ratio 3:1)
- Previous heart disease (atherosclerosis)
- Hypertension
- Age >50
- Smoking
- Hyperlipidaemia
What size would an AAA on USS have to be to warrant elective surgery?
> 5.5cm
On a CXR, what is the ‘water bottle’ sign indicative of?
Pericardial effusion - pericarditis
What is seen on an ECG for someone with pericarditis?
Saddle ST elevation - widespread
What are the causes of large pericardial effusions? (4)
- Malignancy
- TB
- Uraemic pericarditis
- Myxoedema
What are the causes of SVC obstruction?
- Malignancy (>90% of cases) - lung, mediastinal lymphoma, thymoma
- Goitre
- Infection
- Idiopathic
What is the management for SVCO? (2)
- Dexamethasone - 16mg + PPI
- Balloon venoplasty + SVC stent
- treat underlying cause e.g. tumour biopsy and excision
What is a red flag/complication of pericardial effusion?
Cardiac tamponade
What is Becks triad of cardiac tamponade? (3)
- Raised JVP
- Muffled heart sounds
- Hypotension
What are the risk factors for acute mesenteric ischaemia? (6)
- Increasing age
- AF
- Emboli risk factors e.g. endocarditis, malignancy
- Smoking
- Hypertension
- Cocaine
What two symptoms/signs should always made you think mesenteric ischaemia?
AF + abdominal pain
How does mesenteric ischaemia present?
Acutely with AF and tender painful abdomen (soft) with lactic acidosis, hypovolaemia and history of coronary vascular disease
What is seen on an ABG of someone with mesenteric ischaemia?
Persistent metabolic lactic acidosis
What investigation is diagnostic for mesenteric ishcaemia?
- Mesenteric angiography or CT/MRI
What is the complication with mesenteric ischaemia?
Septic peritonitis - would find rebound tenderness and guarding
What is chronic mesenteric ischaemia also known as?
Intestinal angina
What is the first line drug for Raynaud’s?
Nifedipine 5-20mg TDS
Which drug combination can be used to treat severe attacks or digital gangrene caused by Raynaud’s?
Sildenafil and prostacyclin
What are the three classifications of cardiomyopathy? (3)
- Dilated
- Hypertrophic
- Restrictive
When calibrating an ECG, what is the standard paper speed that should be set?
25mm/sec
What does 1 small square on an ECG equate to in time?
0.04 seconds
What does 1 large square on an ECG equate to in time?
0.2 seconds
What does 2 large squares equate to in terms of cm?
1cm = 1mV
How do you calculate rate accurately from an ECG?
Count the number of large squares between first and second R waves and divide by 300.
e.g. 7.5 large squares / 300 = 40bpm rate
How do you assess rhythm on an ECG?
Use a prolonged rhythm strip - lead II gives a good view of the P wave.
If the P wave is visible - sinus rhythm is present.
Does a QRS follow each P wave?
Is the PR interval normal and constant?
What is the rhyme used to remember cardiac axis and left and right axis deviation?
Reaching = right Leaving = left
What is a normal PR interval in terms or seconds and small squares?
0.12 - 0.2 seconds
AKA
3-5 small squares
What are the causes/risk factors for heart failure?
- Obesity
- Smoking
- Hypertension
If infective endocarditis is caused by a dental procedure/poor oral health, what is the most common bacterial cause?
Strep. viridans
Which bacterial commonly causes infective endocarditis in IVDU?
Staph aureus either MSSA or MRSA
Which bacteria commonly causes infective endocarditis in people with prosthetic heart valve replacements?
Staph epidermitis
What type of organism is known to cause infective endocarditis in immunocompromised/elderly/colon cancer?
S.bovis and Gallolyticus
What is overall the most common cause of infective endocarditis?
Strep viridans
What is the type of endocarditis that people with SLE can get?
Libman-Sacks endocarditis - it is non-bacterial and is one of the most common heart-related manifestations of lupus.
Libman-Sacks endocarditis is one manifestation of lupus, what is the more common heart-related manifestation?
Pericarditis
Of the following, which is the biggest risk factor for infective endocarditis?
- Mitral valve prolapse with regurgitation
- Rheumatic fever without valvular defects
- Presence of a prosthetic heart valve
- IVDU
- Presence of a prosthetic heart valve
What are the septic signs of infective endocarditis? (8)
- Fever
- Rigors
- Night sweats
- Malaise
- Weight loss
- Anaemia
- Splenomegaly
- Clubbing
What can be found on examination to indicate infective endocarditis? (4)
- Vasculitis in any vessel
- Roth spots (boat shaped retinal haemorrhage with pale centre)
- Oslers node - painful pulp infarcts in fingers/toes
- Janeway lesions (painless palmar/plantar macules)
What might be present on cardiac examination for infective endocarditis? (not the peripheral stigmata) (2)
- New murmur
2. Change in pre-existing murmur
What investigations need to be performed in suspected infective endocarditis? (6)
- Blood cultures - 3x peripheral from different sites 6 hours apart
- Blood tests - normocytic normochromic anaemia, neutrophilia, high CRP/ESR
- RF +ve immunological phenomena - Urinalysis - microscopic haematuria
- ECGs - looking for heart block - AV node is near aortic root, often have abscess and endocarditis here
- Echo - TTE, TOE
- CT - ?emboli - spleen, brain, joints
What is the name of the criteria used in infective endocarditis?
Modified Duke’s Diagnostic criteria
What is in the major criteria for infective endocarditis? (2)
- Positive blood cultures
2. Evidence of endocardial involvement by ECHO
What is the medical management for infective endocarditis?
4-6 weeks of IV high dose antibiotics
- native valve = vancomycin + ciprofloxacin
- prosthetic valve = vancomycin + gentamicin + PO rifampicin
What are the complications of infective endocarditis? (6)
- MI
- Pericarditis
- Cardiac arrhythmias
- Heart valve insufficiency
- Congestive heart failure
- Aortic root/myocardial abscesses
What type of murmur is heard with aortic stenosis?
Ejection systolic
What type of murmur is heard with pulmonary regurgitation?
Diastolic
What type of murmur is heard with aortic regurgitation?
Diastolic
What type of murmur is heard with mitral regurgitation?
Systolic
What type of murmur is heard with tricuspid stenosis?
Diastolic
What type of murmur is heard with tricuspid regurgitation?
Diastolic
What type of murmur is heard with pulmonary stenosis?
Systolic
What are the causes of aortic stenosis? (5)
- Calcification (most common cause in older patients >65 years old)
- Bicuspid aortic valve (congenital - most common cause in younger patients)
- Post-rheumatic fever/disease
- William’s syndrome (supravalvular aortic stenosis)
- Subvalvular HOCM
How can aortic stenosis present? (4)
SAD
- Syncope (particularly on exertion)
- Angina
- Dyspnoea
also. . - Heart failure
What are the clinical signs of aortic stenosis? (5)
- Slow rising pulse
- Narrow pulse pressure
- JVP is normal!
- Thrill
- Forceful apex (not displaced)
What is the sound of the murmur with aortic stenosis?
Ejection systolic murmur which radiates to the carotids, loudest in the left sternal edge
(LUB WHOOSH DUB)
What investigations are carried out for someone with aortic stenosis? (4)
- ECG - LVH, LBBB, AV block, notched P waves
- CXR - left ventricular hypertrophy
- ECHO - diagnostic - (P gradient >50 - severe, valv area <0.5cm2 - bad)
- Cardiac catheter - assess LV function and coronary disease
What are the risks with aortic stenosis and what is the treatment? (3)
Risk of sudden death
- If asymptomatic then just monitor
- Valve replacement
- Balloon valvuloplasty (BAV) limited to patients with critical aortic stenosis who are not fit for valve replacement
What type of murmur/sound is heard for aortic regurgitation?
Early diastolic murmur
What are the causes of aortic regurgitation due to valve disease? (5)
- Rheumatic disease/fever
- Infective endocarditis
- Connective tissue diseases e.g. Marfan’s syndrome
- RA + SLE
- Biscuspid aortic valve
What are the clinical signs of aortic regurgitation?
- Collapsing pulse (Corrigan’s pulse)
- Wide pulse pressure
- Quinke’s sign (nailbed pulsation)
- De Musset’s sign (head bobbing)
- Mid-diastolic Austin-Flint murmur in severe AR
What are the causes of aortic regurgitation due to aortic root disease? (5)
- Aortic dissection
- Spondylarthropathies e.g ankylosing spondylitis
- Hypertension
- Syphilis
- Marfan’s, Ehlers-Danlos syndrome
What is the management for aortic regurgitation? (2)
- Replace valve if severe
2. Treat LVF with ACEi, diuretics
What are the presenting complaints of aortic regurgitation? (3)
- SOB
- Heart failure
- Angina
What are the causes of mitral stenosis?
- Rheumatic fever
2. Congenital
What are the presenting features of mitral stenosis? (5)
- SOB
- Cough +/- blood
- Palpitations (AF)
- Angina
- Heart failure
What are the signs of mitral stenosis? (2)
- Malar flush
2. Tapping apex (not displaced)
What type of murmur is heard in mitral stenosis?
Mid diastolic murmur
What is the management for mitral stenosis? (5)
- AF rate control
- Anticoagulation
- Diuretic (to reduce preload)
- Balloon valvuloplasty
- Valve replacement
What type of murmur is heard in mitral regurgitation?
Pan systolic murmur - radiates to the axilla, loudest if roll on side and doing valsalva
What are the causes of mitral regurgitation? (3)
- Rheumatic fever (70%)
- Endocarditis
- LV dilatation or MI causing valve prolapse
How can mitral regurgitation present? (5)
- Palpitations (AF)
- Increased dyspnoea
- Fatigue
- Infective endocarditis (fever, weight loss, clubbing)
- Heart failure (orthopnoea, ankle swelling)
What is the diagnostic investigation for mitral regurgitation?
ECHO - regurg jet measured
What is the management for mitral regurgitation? (4)
- AF treatment e.g. BB or CCB or digoxin
- Anticoagulate
- If infective endocarditis - IV ABX
- Valve repair/replacement
What are the risk factors for mitral regurgitation? (7)
- Female sex
- Lower BMI
- Age
- Renal dysfunction
- Prior MI
- Prior mitral stenosis/valve prolapse
- Collagen disorders e.g. Marfan’s syndrome
A 75 year old man presents with difficulty breathing at night, occasional palpitations and tight chest pain. O/E he has a collapsing pulse and a laterally shifted apex beat. You also notice his head bobs in time with his pulse. What murmur would you expect to hear and what are the names of the two signs elicited? (3)
1. An early diastolic murmur Signs: 2. De Mussets (head bobbing) 3. Corrigan's pulse (collapsing pulse) - aortic regurgitation
What are the types of cardiomyopathy? (5)
- Ischaemic
- Dilated
- Hypertensive
- Hypertrophic
- Restrictive/infiltrative
What are the causes of dilated cardiomyopathy? (5)
- Idiopathic
- Alcohol
- Drug toxicity
- Viral (HIV)
- Muscular dystrophies
What are the three most common causes of cardiomyopathy?
- Coronary heart disease
- Hypertensive heart disease
- Degenerative valvular disease
What are the less common causes of cardiomyopathy?
- Congenital heart disease
- Myocardial disease
- Rheumatic heart disease
What are the causes of low output heart failure? (low output meaning cardiac output is low but the demand for blood flow is normal, yet the heart is unable to meet demand) (5)
- Ischaemic heart disease
- Hypertension
- Dilated cardiomyopathy
- Valvular heart disease
- Pericardial disease
What is high output heart failure?
Cardiac output is normal or a bit higher, but demand for blood flow is abnormally high, and thus the heart is unable to deliver the increased amount of blood flow
What are the causes of high output heart failure? (5)
- Hyperthyroidism
- Anaemia
- Pregnancy
- AV fistulas
- Paget’s disease
What is the pathophysiology behind systolic heart failure?
There is impaired myocardial contractility leading to a dilated, baggy, heart – meaning the ventricles are enlarged and fill with plenty of blood but don’t have a forceful contraction to expel it
What is the pathophysiology behind diastolic heart failure?
There is impaired relaxation and filling of the heart leading to hypertrophied heart - meaning the ventricles are stiff and fill with less blood than normal
What happens to the ejection fraction in systolic and diastolic heart failure?
Systolic = reduced Diastolic = normal
What is the single biggest factor that leads towards systolic heart failure?
Prior myocardial infarction
What are the patient characteristics for diastolic heart failure? (5)
- Older
- Women
- Obesity
- Hypertensive
- Atrial fibrillation
How can heart failure be classified? (5)
According to:
- Compensation e.g. compensated/decompensated
- Side involved - left/right/bilateral
- Cardiac output - low/high
- Duration - acute/chronic
- Type of function affected - systolic/diastolic
In a cardiac history for heart failure, what questions are important to ask? (8)
- Symptom onset
- Symptom duration
- Exacerbating/relieving factors
- Exercise relation
- Worse at night
- Frequent hospital admissions?
- Associated features: chest pain, sweating, fever, syncope
- Change in medications: NSAID use, withdrawal of diuretics, CCB
What are the risk factors for heart failure? (7)
- Ischaemic heart disease
- Hypertension
- Alcohol
- New onset AF
- Poorly controlled arrhythmia
- Previous cancer treatment - chemo
- Chronic lung disease/recurrent PE/pulmonary hypertension
What are the symptoms/signs of left sided heart failure?
- Breathlessness / dyspnoea
- Orthopnoea
- Paroxysmal nocturnal dyspnoea
What happens in left ventricular failure? (5)
- Decreased cardiac output
- Reduction in renal perfusion
- Activation of renin-angiotensin-aldosterone system
- Retention of salt and water with consequent expansion of interstitial fluid and blood volumes
- Pulmonary oedema
What are the causes of right sided heart failure? (5)
- Usually a consequence of left sided heart failure
- Cor pulmonale
- Pulmonary emboli (multiple)
- Valvular heart disease
- Congenital heart disease
On CXR, what can be seen in heart failure? (A - E)
A - alveolar oedema
B - B lines Kerley - interstitial oedema
C - cardiomegaly
D - dilated prominent upper lobe vessels
E - effusion (pleural)
What pressures are generally in the left atrium for pulmonary oedema to occur?
> 25mmHg
What type of fluid is in the lungs in heart failure - transudate or exudate?
Transudate - protein poor fluid
What are the causes of pulmonary oedema? (8)
Left sided disease: 1. Dilated cardiomyopathy 2. Acute ischaemia 3. Arrhythmia 4. Diastolic HF 5. Valve disease Other causes: 6. Sepsis 7. High output failure e.g. thyrotoxicosis 8. Injudicious IV fluids
When using brain natriuretic peptides - what level indicate a low probability of HF?
<100pg/ml
if NT-proBNP <300
What BNP level indicates an intermediate probability of HF?
100-400pg/ml
NT-proBNP 300-1800
What BNP level indicates high probability of HF?
> 500pg/ml
NT-proBNP >1800pg/ml
What this acutely cause a rise in NT-proBNP? (5)
- ACS
- PE
- AKI
- Pulmonary artery hypertension
- Sepsis
What are the causes of chronic dyspnoea which can give a rise in NT-proBNP? (5)
- Age >75 years
- AF
- Renal dysfunction
- LVH
- Severe COPD
Heart failure with reduced ejection fraction is associated with which type of heart failure (systolic or diastolic) and vice versa for preserved ejection fraction?
Preserved ejection fraction = diastolic heart failure
Reduced ejection fraction = systolic heart failure
For an ejection fraction to be classed as reduced, what % must it be reduced by?
<40%
What is the management for acute heart failure? (10)
- Sit patient up and give 02
- Gain IV access
- Opiates: morphine/diamorphine
- Vasodilators e.g. buccal nitrates or IV nitrate
- Loop diuretics furosemide IV 20-40mg
- Identify the cause…
- Cardiac monitor
- Urinary catheter
- Hypotensive/shocked - ionotropes (consultant/registrar only)
- Respiratory failure - CPAP
When should you not give nitrates to someone with acute HF or MI?
If they are shocked (hypotension) or have severe aortic stenosis
If a 75 year old patient presents with SOB at rest, retrosternal chest pain and palpitations, is pale and clammy, previous extensive cardiac history, BP 80/50mmHg, HR 188bpm, and RR35, what is the management?
- ECG
- Portable CXR
- IV access + routine bloods
- ABG
- Temperature
- History and examination
For the shocked patient with SOBAT and haemodynamically unstable, the ECG shows irregular tachycardia and CXR show pulmonary oedema, what is the management?
Need to work out if symptoms have occurred within 48 hours or not.
- rhythm control or rate control
- offload fluid
- restore perfusion
- pain relief
If the patient who is SOBAT and acute unwell with AF and pulmonary oedema, presents within 48 hours, what is the management?
- Oxygen
- Anaesthetic support or midazolam sedation
- Heparin 5000units IV bolus
- Synchronized DC cardioversion (150-200 J biphasic)
Instead of DC cardioversion, what chemical cardioversion can be done for someone in AF presenting within 48 hours?
- IV amiodarone 300mg over 30-60 minutes
- IV flecainide 2mg/kg over 30 minutes (max 150mg)
ONLY IF
- no IHD
- no valvular heart disease
- normal ECHO
What are the drug treatments for heart failure? (6)
- ACEi/ARBs
- BBs (bisoprolol/metoprolol/cavedilol)
- Mineralcorticoid receptor antagonists
- Angiotensin receptor neprilysin inhibitor
- Diuretics
- Digoxin
What are the treatment guidelines/goals for heart failure with preserved ejection fraction?
- Control hypertension
- Slow ventricular rate in atrial fibrillation
- Treat congestion/oedema
- Treat/prevent ischaemia
- Restore/maintain sinus rhythm
Which new drug is indicated for chronic heart failure - NYHA stage II - IV, in combination with standard therapy including BB or if a BB is not tolerated/contraindicated?
Ivabradine
What is the mnemonic and management for acute left ventricular failure AKA acute pulmonary oedema?
iPOD MAN OR OMFG
I - IV access P - position upright O - oxygen D - diuretics (furosemide 40mg) M - morphine A - antiemetic - metoclop 10mg N - nitrates (10-200mcgs/min)
OR
O - oxygen
M - morphine/metoclop
F - furosemide
G - GTN spray
When is a heart rate classed as tachy/brady-cardia?
Tachycardia = <60 Bradycardia = >100
What are the most common tachyarrhythmias? (4)
- AF
- Atrial flutter
- Supraventricular tachycardia
- VT
What are the common bradycardia’s? (2)
- Sick sinus syndrome
2. AV conduction block
What are the cardiac causes of arrhythmias? (8)
- Congenital abnormal conduction pathways e.g. Wolf-Parkinson white syndrome
- Cardiomyopathy
- Ischaemia
- Post MI
- Pericarditis
- Myocarditis
- Atheroma
- Structural pathology e.g. mitral stenosis
What are the non-cardiac causes of arrhythmias? (3)
- Metabolic disturbances e.g. K+, Ca2+, Mg2+, hypoxia/hypercapnia, acidosis
- Thyroid disease
- Pneumonia
What are the drugs that can cause arrhythmias? (5)
- Inhalers (B2-A)
- Digoxin
- L-Dopa
- Tricyclics
- Caffeine/smoking/alcohol
What are the clinical features of arrhythmias? (6)
- Palpitations
- Chest pain
- Syncope ‘funny turn’
- Angina attacks
- Hypotension
- Pulmonary oedema
(though often they are asymptomatic and found incidentally)
What investigations are required if someone is found to have an arrhythmia? (4)
- Bloods: FBC (anaemia), U&Es (electrolytes - spesh potassium), glucose, TFTs
- ABG: hypoxia/hypercapnia acidosis
- ECG (often 24 hour)
- ECHO - looking for evidence of structural disease
What is the Vaughan-Williams classification? (classes I - IV)
It is how anti-arrhythmia drugs are classified according to their effect on cardiac conduction cycles.
Class I = fast sodium channel inhibitors
Class II = beta blockers
Class III = amiodarone
Class IV = calcium channel blockers
What are the phases of cardiac conduction? (4 phases)
Phase 0 = action potential - Sodium enters cardiac cells through fast channels
Phase I = early/1st depolarisation - Na+ channels close and K+ channels open, K+ leaves cells)
Phase 2 = Plateau - only in cardiac muscles, balance between calcium inflow and potassium outflow, to allow heart time to carry out its function
Phase 3 = late/2nd depolarisation - closure of calcium channels. Potassium continues to exit cells to cause more repolarisation.
Phase 4 = slow depolarisation - all ion concentrations are restored. Sodium enters through slow channels to create next conduction cycle
What do class I anti-arrhythmias do?
They are fast Na+ channel inhibitors - so they slow phase 0 (action potential) of the conduction cycle. Cardiac conduction is prolonged and the heart rate is decreased. Can be further divided into three sub-groups.
What are the three sub-groups of the fast sodium channel inhibitors?
1a - disopyramide (inhibits fast sodium channels and prolongs the action potential)
1b - lidocaine (inhibits fast sodium channels but shortens action potential)
1c - flecanide (inhibits sodium channels but has no effect on action potential BUT prolongs QRS complex)
Which of the fast sodium channel inhibitor anti-arrhythmias can be used to treat both atrial and ventricular arrhythmias?
1a and 1c (disopyramide and flecanide)
Where in the heart dose lidocaine work?
The purkinje fibres (particularly slows down conduction here) - hence why it only treats ventricular arrhythmias and not atrial
When should flecanide not be given to patients to treat arrhythmias? (3)
If they have pre-existing…
- Heart failure
- Past MI
- Chronic/untreated AF
How do beta-blockers work - what effect on the conduction cycle do they have?
They have very little affect on the actual conduction cycle - they work by slowing conduction through the AV node, prolonging stage 4 and lengthening time before the next action potential is generated
What is the risk with beta blockers?
They can slow down the heart rate too much and cause bradycardia, heart failure and hypotension
How do class III anti-arrhythmias work? (amiodarone)
Prolongs action potential and inhibit repolarisation, by affecting potassium channels and also prolongs refractory period between conduction cycles. Can be used in ALL tachyarrhythmias.
What are the side effects of amiodarone?
- N&V
- Lung fibrosis
- Hyper/hypo-thyroidism
- Hepatitis
- Decreased HR/BP
What tests to be done to monitor the side effects of amiodarone? (3)
- LFTs
- TFTs
- CXR
Name a class IV anti-arrhythmia drug?
Verapamil - only CCB used in arrhythmia, as it primarily affects the heart and not peripheries. (It is a non-dihydropyridine group)
Why should beta blockers and calcium channel blockers not be given together?
They can cause a severely decreased HR
How is atropine different to the other anti-arrhythmias and how does it work?
It treats bradycardia’s rather than tachy - it is an anti-cholinergic so blocks vagal tone therefore encouraging sinus node to act ‘automatically’. It speeds AV node conduction to increase the heart rate.
What side effects can adenosine cause and the patient should be warned about when it is being given? (3)
- SOB
- Chest pain
- Flushing
When does adenosine work? (clue in its name)
Acts on adenosine receptors in the sinoatrial node to slow conduction through AV node, therefore causing bradycardia.
Which condition is digoxin used in and how does it work?
AF - slows conduction through AV node by blocking sodium/potassium exchange and increases vagal tone to decrease heart rate
Why is it important to monitor U&Es and digoxin plasma levels closely when someone is taking digoxin?
As there is a very narrow therapeutic index and adverse effects can occur if dosing is wrong e.g. visual disturbance, headaches, arrhythmias, potassium level imbalance.
What is the management for someone who presents with arrhythmias of unknown cause/origin?
- Assess pulse (if absent - CPR)
- High flow O2
- Monitor vital signs
- Look for adverse signs of heart failure/haemodynamic instability
- If no signs - give amiodarone 150mg IV
- If signs of heart failure/instaiblity - ALS shock protocol, correct any potassium imbalance and call for expert help.
What is the management for someone presents with palpitations whose ECG is normal and patient appears asymptomatic?
Reassurance - no drug required
What are the 4 H’s and 4 T’s describing the reversible causes of cardiac arrest?
Hypoxia Hypothermia Hypovolaemia Hypo/hyperkalaemia Tamponade cardiac Tension pneumothorax Toxicity Thromboembolism
Which drugs should always be available to give during a cardiac arrest? (6)
1. Adrenaline 2 Atropine (symptomatic bradycardia) 3. Amiodarone 4. Magnesium 5. Thrombolytic drugs e.g. alteplase 6. Sodium bicarbonate
When is defibrillation indicated?
VF and pulseless VT
What are the three types of cardiomyopathy?
- Dilated (commonest)
- Obstructive
- Restrictive (rarest)
How can you best hear a diastolic murmur - mitral stenosis?
Lying the patient on their left hand side and listening with the cell in the apex for a low-pitched sound
How can you best hear an aortic regurgitation murmur - diastolic?
Sit the patient forward and listen at the end of expiration with the diaphragm applied to the left sternal edge for the high pitched early diastolic murmur
What is the lub-dub sound of the heart caused by?
The first sound is caused by closure of the mitral and tricuspid valves and the second sound by the closure of the aortic and pulmonary.
What are all the signs of endocarditis?
2 in the hands (clubbing and splinters)
1 in the heart (changing murmurs)
2 in the abdomen (splenomegaly, microscopic haematuria)
+ rarities… Osler’s nodes, Janeway lesions and Roth spots
Which type of murmur is pansystolic in nature?
Mitral regurgitation
Why is mitral regurgitation common?
As it occurs after an MI, and MI’s are very common
What are the causes of aortic regurgitation?
- Rheumatic heart disease
- Endocarditis
- Connective tissue disease e.g. Marfan’s
What type of murmur is heard in aortic stenosis?
Ejection systolic murmur
What are the complications of an MI (sudden death on PREAD street)?
P - pump failure R - rupture of papillary muscle or septum E - embolism A - aneurysm and arrhythmias D - Dressler's syndrome
In the treatment for an MI, when is the use of GTN spray contraindicated?
If the person has aortic stenosis
On examination, how might someone with acute LVF appear? (5)
- Acutely unwell - pale and grey
- Cold clammy peripheries/cyanosis
- Frothy blood stained sputum
- Orthopnoeic using accessory muscles
- May have wheeze
What are the ECG changes in hyperkalaemia? (4)
- Low flat P waves (absent P waves)
- Broad QRS
- Tall tented T waves
- Slurring into the ST segment
Summarise the cardiovascular examination…
General inspection - ?anaemia, ?cyanosis ?breathless
Hands - endocarditis signs - ?clubbing ?splinter haemorrhages
Pulse - check both radial pulses, collapsing, rate, rhythm, character, volume (beware AV fistula for dialysis)
BP
JVP (if not seen - could do hepato-jugular reflex)
Praecordium:
Inspect: ?midline scar, ?intercostal scar
Palpate: aortic and pulmonary areas, left sternal edge and apex
Auscultation: neck, mitral area turned onto left, left sternal edge sitting forward, all other areas
Extras: look for ankle/sacral oedema and auscultate lung bases
What are the indications for a permanent pacemaker? (4)
- Sino-atrial disease e.g. sick sinus syndrome
- AV nodal disease - 2nd degree or 3rd degree heart block
- AF with a slow ventricular rate
- Cardiac resynchronisation therapy for heart failure
What are the complications of pacemaker insertion?
- Pulse generator - haematoma, infection, skin erosion, device failure
- Venous access - pneumothorax, air embolus
- Leads - lead displacement/fracture, venous thrombosis, endocarditis, cardiac perforation
Why can’t you interpret the ST segment in a patient with a pacemaker and chest pain?
Because the pacing activities the right ventricles first, causing a LBBB appearance on ECG
In a patient with complete heart block, how can you tell the pacemaker is working? (2)
- Check the pulse - a regular pulse over 60 suggests a paced rhythm
- Check the ECG - note the pacing spikes, each of which should be followed by a QRS complex
What are the two main types of pacemaker?
Single chamber and Dual chamber
What does a dual chamber pacemaker do?
Senses and paces both right atrium and right ventricle - used most often
What are the indications for an implantable cardiac defibrillator? (ICD) (3)
- Survivor of cardiac arrest due to VT or VF
- Episodes of VT or VF causing syncope
- Familial cardiac condition with high risk of sudden death (e.g. hypertrophic cardiomyopathy)
What is cardiac resynchronisation therapy?
Biventricular pacing with three leads - right atrial sensing + pacing in both left ventricle and right ventricle.
Where is the lead placed in CRT to access the left ventricle?
The LV is accessed via a lead in the coronary sinus (an opening just above the tricuspid valve)
When is cardiac resynchronisation therapy indicated?
Offered to patients with significant heart failure and LV ejection fraction <35% AND where medical treatment alone is insufficient AND who have delayed LV contraction (long QRS)
As there is an increased risk of sudden death in patients with significant heart failure and reduced LV ejection fraction - what is often combined with the CRT?
A defibrillator - so it is a CRT-D
What advice is given to patients who have a pacemaker fitted?
- Avoid lifting your head above shoulder height for the first 6 weeks (as this could dislodge the leads)
- Avoid heavy lifting long-term
- Inform DVLA and insurers
- Keep the generator 6 inches away from microwaves/phones and 2 feet away from induction hobs
- No MRI scans
- Give BHF leaflet
What is the management in terms of drugs for someone with peripheral arterial disease who has a raised cholesterol?
Antiplatelet therapy e.g. clopidogrel and a statin e.g. atorvastatin
What is cervical rib?
Compression of the thoracic outlet by the fibrous band of the rib can result in both neurological and circulatory compromise. When manual tasks are performed in which the hand works overhead, the signs and symptoms will be maximal and this is the basis of Adsons test.
What is the first line imaging investigations for suspected peripheral arterial disease?
Duplex ultrasound
2nd line is MRA magnetic resonance angiography
What signs on examination are typical of venous insufficiency in the legs? (3)
- Haemosiderin - brown pigmentation
- Lipodermatosclerosis - champagne bottle legs (calves significantly wider at the knee than the ankle)
- Eczema
How does acute limb ischaemic present?
The 6 P's: Pale Pulseless Pain Paralysis Paraesthesia Perishingly cold
What is the management for acute limb ischaemia?
Surgical intervention
How does NICE define critical limb ischaemia?
Pain at rest for greater than 2 weeks, often at night, not helped by analgesia
How can you tell the difference between critical and acute limb ischaemia?
Acute limb ischaemia is the 6 P’s whereas the critical limb ischaemia is > 2 weeks of pain at rest not helped by analgesia
Which condition can cause a raised ABPI score - as a result of calcification?
Type 2 diabetes
Which vessel is most likely affected if a patient has claudication pain affecting their buttocks not calves?
Iliac stenosis
Which drug is the first line choice for patients with peripheral arterial disease?
Clopidogrel 75mg
What is the management for peripheral arterial disease? (6)
- Stop smoking
- Treat comborbidities e.g. hypertension, diabetes, obesity
- Exercise training
- Atorvastatin 80mg
- Clopidogrel 75mg
- If severe - angioplasty/stenting/bypass surgery
What is the top differential until proven otherwise for a fever and new murmur?
Infective endocarditis
What is the Duke criteria for infective endocarditis?
Major criteria: - positive blood culture - endocardium involved (positive ECHO) Minor criteria: - predisposition (e.g. IVDU) - fever >38 - vascular/immunological signs - positive blood culture - positive ECHO
Diagnosis is based on 2 major or 1 major and 3 minor. or all 5 minor.
What is important to remember about blood cultures and infective endocarditis?
Three sets of blood cultures must be performed, 12 hours apart.
What is acute myocarditis?
Inflammation of the myocardium
What are the causes of myocarditis? (6)
- Idiopathic (50%)
- Viral (flu, hepatitis, mumps, Coxsackie, polio, HIV)
- Bacterial (TB, meningococcus, mycoplasma)
- Protozoa (Chagas)
- Drugs (cyclophosphamide, herceptin, penicillin, chloramphenicol, sulphonamides, methyldopa, phenytoin, carbamazepine)
- Vasculitis
What are the signs and symptoms of acute myocarditis? (7)
- Fatigue
- Dyspnoea
- Chest pain
- Fever
- Palpitations
- Tachycardia
- S4 gallop
What may be seen on an ECG for acute myocarditis?
May see ST elevation or depression, T wave inversion, arrhythmias
What is the treatment for acute myocarditis?
Treat the underlying cause - patients may recover or get intractable heart failure
What is dilated cardiomyopathy and what causes it? (7)
A dilated, flabby heart, of unknown cause, though does have associations with:
- Alcohol
- Hypertension
- Haemochromatosis
- Viral infection
- Autoimmune
- Peri- or post- partum thyrotoxicosis
- Congenital X-linked
How does dilated cardiomyopathy present?
- Fatigue
- Dyspnoea
- Pulmonary oedema
- Right ventricular failure
- Emboli
- AF
- VT
What are the signs of dilated cardiomyopathy? (10)
- Tachycardia
- Hypotension
- Raised JVP
- S3 gallop
- Mitral or tricuspid regurgitation
- Pleural effusion
- Oedema
- Jaundice
- Hepatomegaly
- Ascites
Which blood test will be positive in dilated cardiomyopathy?
Plasma BNP
Which electrolyte imbalance corresponds with a poor prognosis in dilated cardiomyopathy?
Hyponatraemia
What may be seen on CXR for someone with dilated cardiomyopathy? (2)
- Cardiomegaly
2. Pulmonary oedema
What is the treatment for dilated cardiomyopathy? (7)
- Diuretics
- Digoxin
- ACEi
- Anticoagulation
- Bi-ventricular pacing
- ICDs
- Cardiac transplantation
What is hypertrophic cardiomyopathy?
It is left ventricular outflow tract (LVOT) obstruction from asymmetric sepal hypertrophy. It is the leading cause of sudden cardiac death in the young.
What type of inheritance pattern is HOCM?
Autosomal dominant inheritance - but 50% are sporadic
70% of people with HOCM have mutations in genes coding for what? (3)
- Beta-myosin
- Alpha-tropomyosin
- Troponin T
What are the presenting features of HOCM? (5)
Often sudden death is the first manifestation, however other features include:
- Angina
- Dyspnoea
- Palpitation
- Syncope
- Congestive cardiac failure
What will be seen on ECHO for HOCM?
Asymmetrical septal hypertrophy
What are the causes of restrictive cardiomyopathy?
- Idiopathic
- Amyloidosis
- Haemochromatosis
- Sarcoidosis
- Scleroderma
- Loffler’s eosinophilic endocarditis
- Endomyocardial fibrosis
Restrictive cardiomyopathy presents similarly to which other cardiac condition?
Constrictive pericarditis
What is Takotsubo cardiomyopathy?
It is AKA broken-heart or stress induced cardiomyopathy. It is condition which affects the heart muscle, giving the left ventricle a distinctive shape (causes the heart to balloon). It is thought to be brought on by extreme stressful events, and affects how the heart works. It is usually a temporary condition, and once treated most people recover within a few weeks.
What shape does the left ventricle appear as in Takotsubo cardiomyopathy?
Japanese Octopus trap
How can Takotsubo present?
- Chest pain - sudden and intense
- SOB
- Arrhythmia
