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Phase 2a Concise > CV P2 > Flashcards

CV P2 Flashcards

1
Q

Acute coronary syndrome

A

STEMI, NSTEMI, unstable angina

patho - thrombus

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2
Q

STEMI

A

complete occlusion of major coronary artery, full thickness damage to heart muscle, troponin release

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3
Q

NSTEMI

A

complete occlusion of minor artery or partial occlusion of major artery, partial thickness damage, troponin release

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4
Q

Unstable angina

A

angina of increasing frequency/severity, partial occlusion but no damage to heart, occurs on minimal exertion/at rest, no troponin

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5
Q

ACS RFs

A

ABCDEF

age, BP, cholesterol, diabetes, exercise, fags, fat, family

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6
Q

ACS Px

A

Silent MI - no chest pain - elderly, diabetic

signs
distress, anxiety
pallor
pulse low/high
BP high/low
4th heart sound
signs of HF - raised JVP, 3rd heart sound, basal crepitations
pansystolic murmur maybe
symptoms
central chest pain
N+V, fatigue
sweaty
SOB
palpitations
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7
Q

ACS DDx

A

CV - acute pericarditis, myocarditis, aortic stenosis, aortic dissection, PE, cardiomyopathy

Resp - pneumonia, pneumothorax

GI - oesophageal spasm, GORD, acute gastritis, cholecystitis, acute pancreatitis

MSK - chest pain, broken ribs,

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8
Q

ACS Ix

A

ECG
STEMI - ST elevation, pathological Q waves, tall T waves, new LBBB
NSTEMI - ST depression, T wave inversion, maybe normal ECG
Unstable angina - normal ECG usually

Troponin - I/T - raised in MI

CXR
ECHO
Bloods - FBC, U+E, glucose, lipids,

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9
Q

ACS Mx

A 
MONA
Morphine
Oxygen
Nitrates - GTN spray
Aspirin
\+ P2Y12 inhibitor - clopidogrel, ticagrelor

BBs - atenolol
ACEi - ramipril
Statin - atorvastatin

Thrombolysis if indicated
PCI/CABG if indicated

Modify risk factors - stop smoking, lose weight, healthy diet, control diabetes

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10
Q

AAA

A

aneurysm - permanent dilatation of artery >50% normal

True - dilatation involves all layers of arterial wall

False - pseudoaneurysm, blood leaks through wall but contained by adventitia or perivascular tissue

degradation of elastic lamellae - leukocyte infiltrate - proteolysis and smooth muscle cell loss

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11
Q

AAA RFs

A

atherosclerotic damage, FHx, smoking, male, older, HTN, COPD, trauma, hyperlipidaemia

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12
Q

AAA Px

A

unruptured
asymptomatic
pain in abdo, back, loin, groin
pulsatile abdo swelling

ruptured
abdo pain
more pronounced pulsatile abdo swelling
collapse, shock, hypotension, tachycardia
anaemia, death
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13
Q

AAA DDx

A

GI bleed, ischaemic bowel, MSK pain, perforated GI ulcer, pyelonephritis, appendicitis

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14
Q

AAA Ix

A

Abdo USS

CT/MRI angiography

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15
Q

AAA Mx

A

Monitor small aneurysms
Modify RFs - BP, statins, smoking, diet

Surgery - open/endovascular

Ruptured - ABCDE, surgery, permissive hypotension

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16
Q

AAA Cx

A

tear in posterolateral aneurysm wall - retroperitoneal bleed - blood fills space, seals bleed for a while

Anterior wall bleed - severe, rapid

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17
Q

Thoracic aortic aneurysm

A

in aorta in thorax

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18
Q

TAA patho

A

strong genetic link
connective tissue disorders - Marfan’s, Ehlers-Danlos syndrome
Aortic dissection in some cases

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19
Q

TAA Px

A

asymptomatic

signs
aortic regurgitation
fever if infective cause
collapse, shock, sudden death
cardiac tamponade

symptoms
due to compression of local structures - hoarseness, cough SOB
haemoptysis

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20
Q

TAA Ix

A

CT/MRI
USS
ECHO
Aortography - xray + contrast

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21
Q

TAA Mx

A

Regular monitoring
Modify RFs - BP, cholesterol

Surgery

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22
Q

Aortic dissection

A

disruption of medial layer of wall, results in separation of aortic wall layers, false lumen formation

tear in intimal lining of aorta, blood enters aortic wall, separates intima from adventitia

causes - degenerative, atherosclerotic, inflammatory, trauma

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23
Q

Aortic dissection Px

A

Mimics MI
Distal extension - maybe AKI, acute lower limb ischaemia, visceral ischaemia
Peripheral pulses maybe absent

signs
HTN
maybe radio-radial delay (both radial pulses not in sync)
Shock
aortic regurgitation, coronary ischaemia, cardiac tamponade

symptoms
severe, central chest pain, tearing, may radiate to back, down arms

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24
Q

Aortic dissection Ix

A

CXR - widened mediastinum

CT, ECHO, MRI

ECG

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25
Q

Aortic dissection Mx

A

Control BP - metoprolol (BB), GTN (vasodilator)

Morphine

Surgery, replace, or insert stent

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26
Q

AF

A

supraventricular tachycardia

chaotic, irregular atrial rhythm

AVN respond intermittently -> irregular ventricular rate

No coordinated mechanical contraction of atria

risk of stroke from thromboembolism

also reduction in CO -> HF

Causes
idiopathic, HTN, HF, cardiac surgery, damage to atria…

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27
Q

AF Px

A

signs
irregularly irregular pulse
1st heard sound variable intensity
LVF signs

symptoms
asymptomatic
chest pain
palpitaitons
SOB, fatigue, syncope, TIA
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28
Q

AF DDx

A

AFl, atrial extrasystoles, SVTs, VT, WPW syndrome

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29
Q

AF Ix

A

ECG
absent P waves, rapid irregular QRS, absence of isoelectric baseline, variable ventricular rate

24hr ambulatory ECG for paroxysmal

Bloods - TFTs, FBC, renal function, electrolytes, LFTS, coag screen, cardiac enzymes

CXR - may show cardiac structural causes, eg mitral disease, HF

ECHO

CT/MRI brain if suggestion of stroke

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30
Q

AF Mx

A

Treat cause if due to precipitating event

Cardioconversion - DC shock, give LMWH (enoxaparin) as risk of thromboembolism with procedure

Anti-arrhythmic drug - amiodarone, flecainide

Verapamil, bisoprolol, digoxin - rhythm control

Anticoagulation - warfarin, aspirin, DOAC

CHA2DS2-VASc score to calculate stroke risk

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31
Q

Afl

A

organised abnormal atrial rhythm

caused by re-entry circuit in RA

Causes
idiopathic, CHD, HTN, HF, COPD, pericarditis, alcohol intoxication, structural abnormalities…

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32
Q

Afl Px

A 
palpitations
SOB
Chest pain
dizziness, syncope
fatigue, HF, rapid pulse
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33
Q

Afl Ix

A

ECG
‘sawtooth’ appearance
narrow complex tachycardia
regular QRS

ECHO

CXR, TFTs, FBC, ESR, renal, LFTs…

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34
Q

Afl Mx

A

Electrical cardioconversion

Catheter ablation - try to block re-entrant wave

Amiodarone, bisoprolol

Anticoagulants

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35
Q

Heart block

A

AV block - block in AVN or bundles of His

Bundle branch block - block in lower conduction system

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36
Q

First-degree AV block

A

PR prolongation >0.22s

every atrial dep followed by conduction to ventricles but with delay

Causes - hypokalaemia, myocarditis, inferior MI, AVN blocking drugs (BBs, CCBs, digoxin)

Asymptomatic, no tx

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37
Q

Second-degree AV block

A

Mobitz T1
progressive lengthening of PR interval, then beat dropped and QRS missing

Causes - AVN blocking drugs, inferior MI

Light-headedness, dizziness, syncope

May need pacing

Mobitz T2
PR interval constant, but occasional atrial dep without ventricular dep (eg 2:1)

Causes - anterior MI, mitral valve surgery, SLE, lyme disease, rheumatic fever

SOB , postural hypotension, chest pain

Pacemaker insertion

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38
Q

Third-degree heart block

A

complete absence of AV conduction, P waves independent to QRS, AV dissociation

Causes - structural, MI, HTN, endocarditis, lyme

Tx depends on cause - pacemaker, atropine

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39
Q

RBBB

A

no dep down right branch, action of RV delayed, as dep has to spread across septum from LV

Causes - PE, IHD, septal defect

Wide physiological splitting of second heart sound

ECG - QRS >120ms, MARROW - first letter M, so lead 1 has complex resembling an M (R wave) and last letter is W, so lead 6 has complex resembling W (slurred S wave)

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40
Q

LBBB

A

Impulse has to spread from RV to LV

Causes - IHD, aortic valve disease

Reverse splitting of second heart sound

ECG - QRS >120ms, WILLIAM - first letter W, so lead 1 has complex resembling W (slurred S wave), 6th letter is M, lead 6 has complex resembling M (R wave)

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41
Q

Sinus tachycardia

A

> 100bpm

originates from SAN - normal P then QRS on ECG

Causes - anaemia, anxiety, exercise, pain, HT, PE

Tx cause, BB if necessary

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42
Q

AV nodal re-entrant tachycardia (AVNRT)

A

Two pathways in AV node - slow/fast - one acts as antegrade limb, the other retrograde

Px - rapid, regular palpitations, abrupt onset, chest pain, SOB
Neck pulsations - jugular venous pulsations due to atrial contractions against closed AV valves
polyuria - release of ANP in response to increased atrial pressures

ECG dx - sometimes BBB seen, P waves not seen or are immediately before/after QRS due to simultaneous atrial and ventricular activation

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43
Q

AV re-entrant tachycardia (AVRT)

A

accessory pathway connecting atria and ventricles, impulses can travel down/up this pathway

WPW
accessory pathway - bundle of Kent, no slowing of conduction between atria and ventricles (as AVN does) -> pre-excitation
ECG - short PR, wide QRS, begins with delta wave

Tachyarrhythmia only with premature beat from SAN, then signal travels as normal, then up accessory pathway - re-entry circuit -> tachyarrhythmia

Px - palpitations, dizziness, SOB, syncope

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44
Q

AVRT and AVNRT Tx

A

Emergency cardioconversion if haemodynamically unstable

Stable - breath holding, carotid massage, valsalva

IV adenosine

Surgery - catheter ablation of accessory pathway

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45
Q

Ventricular tachycardias

A

VF - very funny

VT - very tidy

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46
Q

Ventricular ectopic

A

premature ventricular contraction

patient complains of extra beats, missed beats, heavy beats, may feel uncomfortable, faint/dizzy, pulse irregular

ECG - QRS widened

Reassure, BB if symptomatic

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47
Q

Prolonged QT syndrome

A

QT prolonged

Causes - congenital, hypokalaemia, hypocalcaemia, drugs (amiodarone, TCAs), bradycardia, acute MI, diabetes

Px - syncope, palpitations

ECG

Tx cause, if acquired - IV isoprenaline

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48
Q

Cardiomyopathy

A

disease of the myocardium, affects mechanical/electrical function of heart, all carry arrhythmic risk

generally inherited genetic conditions, some acquired types

RFs - FHx, HTN, obesity, diabetes, previous MI

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49
Q

Hypertrophic cardiomyopathy

A

ventricular hypertrophy - thickening of muscle

non-compliant ventricles impair diastolic filling - reduced SV and CO

thick, powerful heart -> disarray of cardiac myocytes - conduction affected

Px
signs
- cardiac arrhythmia
- ejection systolic murmur
- jerky carotid pulse
symptoms
- chest pain/angina
- SOB
- dizziness, palpitation, syncope

DDx
other causes of LVH - obesity, athletic training, amyloidosis

Ix
ECG - LVH with progressive T wave inversion, deep Q waves
ECHO
CXR
Genetic analysis

Mx
Amiodarone - anti-arrhythmic
CCB - verapamil
BB - atenolol

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50
Q

Dilated cardiomyopathy

A

dilated LV which contracts poorly

Caused by - ischaemia, alcohol, thyroid disorder, genetic, cytoskeletal gene mutations

Px
signs
- arrhythmias
- increased JVP
- HF signs - since heart can't contract
symptoms
- SOB, fatigue

Ix
CXR
ECG - tachycardia, arrhythmia, non-specific T wave changes
ECHO - dilated ventricles

Mx
Tx HF and AF
Diuretics, ACEi, digoxin, BBs, nitrates

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51
Q

Restrictive cardiomyopathy

A

increased myocardial stiffness - ventricle incompliant - impaired filling/dilatation - is restrictive

Causes - amyloidosis, idiopathic, sarcoidosis, endomyocardial fibrosis

Px
similar to constrictive pericarditis
signs
- elevated JVP
- hepatic enlargement, ascites, oedema
- S3, S4
symptoms
- SOB, fatigue
- embolic symptoms

Ix
CXR, ECHO, ECG
Cardiac catheterisation to diagnose

Mx
Poor prognosis
Cardiac transplantation
HF - diuretics, ACEi
BBs, CCBs for arrhythmias
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52
Q

Arrhythmogenic right ventricular cardiomyopathy

A

progressive fatty and fibrous replacement of ventricular myocardium

cause unknown, is genetic

Px
arrhythmia, RHF, syncope

Ix
ECG - maybe normal, T wave inversion
ECHO
Genetic testing

Mx
BBs - atenolol
Amiodarone for symptomatic arrhythmias
Cardiac transplant

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53
Q

Heart failure

A

CO is inadequate for body requirements

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54
Q

Cor pulmonale

A

abnormal enlargement of right heart from disease of lungs/pulmonary blood vessels - eg COPD

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55
Q

HF patho

A

Systolic
inability of ventricle to contract normally, reduced CO (EF <40%) - IHD, MI, cardiomyopathy

Diastolic
inability of ventricle to relax and fill normally, SV decreased - hypertrophy, constrictive pericarditis, tamponade, restrictive cardiomyopathy, obesity, aortic stenosis (causes LVH)

Left / right sided / CCF

Low-output cardiac failure
CO reduced and failure to increase with exertion - excessive preload (fluid overload, mitral regurgitation), pump failure, excessive afterload (HTN, aortic stenosis)

High-output
CO normal but fails to rise to meet demands - anaemia, pregnancy, hyperthyroidism, Paget’s

Causes
IHD, HTN, MI, alcohol excess, cardiomyopathy, valvular

Mechanisms of HF
increased preload
increased afterload
salt and water retention
myocardial remodelling
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56
Q

HF Px

A

SOB, fatigue, ankle swelling

signs
tachycardia
displaced apex beat (LV dilatation)
RV heave (pul HTN)
added heart sounds - gallop (S3), murmurs, raised JVP
hepatomegaly
ascites
peripheral oedema
PO
cyanosis
pleural effusions
symptoms
SOB, fatigue
cold peripheries
PND - paroxysmal nocturnal dyspnoea
nocturnal cough (maybe pink frothy sputum)
orthopnoea (SOB when lying down)
wheeze
light-headed/syncope

NYHA classification for severity I-IV

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57
Q

HF Ix

A

Bloods - brain natriuretic peptide - secreted in ventricles in response to increased myocardial wall stress - if normal, HF unlikely, and other blood tests

ECG - underlying causes - ischaemia, LVH, arrhythmia

ECHO

CXR - ABCDE
Alveolar oedema (bat's wing shadowing)
Kerley B lines - septal lines
Cardiomegaly - cardiothoracic ratio >50%
Dilated prominent upper lobe veins (upper lobe diversion)
Pleural Effusions
58
Q

HF Mx

A

lose weight, exercise, stop smoking

Diuretics - furosemide, thiazide, spironolactone

ACEi - ramipril, enalapril (S/E cough, hypotension, hyperkalaemia, renal dysfunction)

ARB

BB - bisoprolol

Surgery to repair cause, heart transplant

59
Q

HF Cx

A

renal dysfunction
rhythm disturbances
DVT, PE…

60
Q

HTN

A

High BP

Stage 1 - 140/90
Stage 2 - 160/100
Stage 3 - 180/110

61
Q

HTN patho

A

Primary - unknown cause, 95% of cases

Secondary - inc renal disease, endocrine causes, aorta coarctation, drugs

62
Q

HTN Px

A

Asym

Retinal haemorrhage, papilloedema, headaches - malignant htn

63
Q

HTN Ix

A

24hr ABPM

Urinalysis, bloods, fundoscopy, ECG, echo

64
Q

HTN Mx

A

Lifestyle

ACEi (under 55yo)/CCB (55+, afro-caribbean)
Then the other one
Then thiazide
Then another diuretic (spironolactone), alpha/beta blockers

65
Q

IE

A

infection of endocardium

fever + new murmur = IE until proven otherwise

66
Q

IE patho

A

Valves most commonly affected - mitral most commonly affected, tricuspid in IVDU

Valves do not have direct blood supply

Causes
S.aureus, S.viridans, candida…

RFs
valvular heart disease, valve replacement, congenital heart disease, IVDU, skin breaches

67
Q

IE Px

A

Fever, rigors, night sweats, malaise, wt loss, anaemia, splenomegaly, clubbing, myalgia, anorexia

New murmur or change to murmur

Aortic root abscess - long PR, maybe complete AV block

Immune complex deposition
vasculitis
microscopic haematuria
glomerulonephritis/AKI
splinter haemorrhages
Osler's nodes, Janeway lesions, Roth spots

Abscesses in organs from emboli

68
Q

IE Ix

A

Modified Dukes Criteria to dx

Blood cultures - 3 sets, different times, different sites

Bloods - anaemia, neutrophilia, ESR/CRP raised

Urinalysis - for microscopic haematuria

CXR
ECG
ECHO
CT - look for emboli

69
Q

IE Mx

A

ABs

Surgery if HF, valvular obstruction…

70
Q

IE Cx

A

MI, pericarditis, arrhythmias, heart valve insufficiency, CCF, stroke sydromes

71
Q

MI

A

necrosis of myocardial tissue due to ischaemia

NSTEMI/STEMI

from thrombus/atherosclerosis

72
Q

MI Px

A

silent MI - elderly, diabetics

signs
pale, clammy, sweaty
distress, anxiety
BP high/low
4th HS
Signs of HF - raised JVP, 3rd HS, basal crepitations
pansystolic murmur
pericardial rub/PO
symptoms
central chest main, crushing
radiation to jaw, neck, left arm
N+V
SOB
palpitations
73
Q

MI Ix

A

ECG
STEMI - ST elevation, tall T waves, LBBB, later T wave inversion and pathological Q waves
NSTEMI - ST depression, T wave inversion, maybe no change

Cardiac enzymes - troponin, myocardial muscle creatine kinase (CK-MB)

CXR, ECHO, cardiac catheterisation and angiography

74
Q

MI Mx

A 
Pre-hospital
Aspirin 300mg
GTN
Morphine, O2
Thrombolytic drugs if indicated - reteplase/tenecteplase
Hospital
Morphine, O2
PCI - balloon angioplasty, stent
CABG
Thrombolytic drugs - streptokinase, alteplase, if indicated

secondary prevention
statins
aspirin
BBs, ACEi, clopidogrel

Stop smoking, lose weight, exercise, healthy diet

75
Q

Acute pericarditis

A

inflammation of the pericardium

76
Q

Acute pericarditis causes

A

Viral
Bacterial
Autoimmune
Neoplastic - secondary metastatic tumours - lung, breast, lymphoma
Trauma, iatrogenic
Others - amyloidosis, aortic dissection, pulmonary arterial HTN

77
Q

Acute pericarditis Px

A

signs
pericardial friction rub (crunching snow)
tachycardia
tachypnoea
fever
lymphocytosis
signs of effusion - pulsus paradoxus, Kussmaul’s sign

symptoms
chest pain - sharp, pleuritic, radiates to arm, worse on inspiration or lying flat
SOB
Cough, non-productive
Hiccups - phrenic involvement
viral symptoms
78
Q

Acute pericarditis Ix

A

ECG
diffuse ST elevation (all leads)
Saddle-shaped ST elevation
PR depression

Bloods - FBC, ECR, CRP, troponin

CXR

79
Q

Acute pericarditis Mx

A

Tx cause

NSAIDs - ibuprofen, also aspirin

Colchicine for 3 months

Maybe prednisolone

Pericardiectomy

80
Q

Pericarditis Cx

A

Pericardial effusion, tamponade, constrictive pericarditis, chronic pericardial effusion (slow fluid accumulation, rarely causes tamponade)

81
Q

Constrictive pericarditis

A

rigid pericardium

82
Q

Con. pericarditis patho

A

Causes - idiopathic, viral, TB, mediastinal irritation, post-surgical

restricts ventricular filling

83
Q

Con pericarditis Px

A 
signs
Kussmaul's sign - rise in JVP, increased neck vein distension during inspiration
pulsus paradoxus - systolic BP drops >10mmHg during inspiration
diffuse heart sounds, eg apex beat
HSM
ascites
oedema
RHF signs
atrial dilatation
symptoms
fatigue
hiccups
anxiety/confusion
hoarseness/cough
84
Q

Con pericarditis DDx

A

Restrictive cardiomyopathy, dilated cardiomyopathy, pericardial effusion

85
Q

Con pericarditis Ix

A 
CXR
ECG - low voltage QRS
ECHO
CT/MRI - to distinguish from restrictive cardiomyopathy
Cardiac catheterisation
86
Q

Con pericarditis Mx

A

Resection of pericardium

87
Q

Pericardial effusion

A

accumulation of fluid in the pericardial sac (there is normally 50ml)

88
Q

Cardiac tamponade

A

pericardial effusion raises intrapericardial pressure, reducing ventricular filling, dropping CO

89
Q

Pericardial effusion causes

A 
idiopathic
acute pericarditis
malignancy
TB
myocardial rupture
aortic dissection (great vessels in pericardium)
90
Q

Pericardial effusion Px

A 
signs
soft, distant heart sounds
apex beat obscured
raised JVP
bronchial breathing at left base

symptoms
SOB
chest pain
nausea

91
Q

Tamponade Px

A 
high pulse, low BP
high JVP
Kussmaul's sign
Pulsus paradoxus
reduced CO
92
Q

Pericardial effusion Ix

A

CXR - large globular heart
ECG - low voltage QRS, sinus tachycardia
ECHO

93
Q

Tamponade Dx

A

CXR - large globular heart
Beck’s triad - falling BP, rising JVP, muffled heart sounds
ECG - low voltage QRS
ECHO

94
Q

Pericardial effusion Mx

A

most resolve spontaneously

treat cause

pericardial fenestration - create window to allow slow fluid release

95
Q

tamponade Mx

A

pericardiocentesis - drain fluid, risk of cardiac arrest

96
Q

Peripheral arterial disease

A

narrowing of artery, from atherosclerosis/thrombus, leads to insufficient perfusion of limb and lower limb ischaemia

97
Q

PAD patho

A 
3 main patterns of Px:
intermittent claudication
cramping/burning/aching pain in calf, thigh, buttock after walking certain distance, relieved by rest
pain in calf - femoral disease
pain in buttock - iliac disease

critical limb ischaemia
rest pain, typically nocturnal

acute limb-threatening ischaemia
sudden decrease in arterial perfusion, limb threatened

RFs
smoking, diabetes, high cholesterol, HTN, physical inactivity, obesity

98
Q

PAD Px

A 
signs
absent pulses
cold, white legs
atrophic skin
punched out ulcers
Buerger's angle (angle that leg goes pale when raised off couch) <20 degrees
CRT >15s

symptoms
claudication
ischaemic rest pain - relieved by hanging foot out of bed

99
Q

PAD DDx

A

Lower limb pain - sciatica, spinal stenosis, DVT, entrapment syndromes, muscle/tendon injury

OA, neuropathy

100
Q

PAD Ix

A

Buerger’s angle <20 degrees, CRT >15s

ESR/CRP - exclude arteritis

FBC - exclude anaemia/polycythaemia

ECG - look for cardiac ischaemia

ABPI - the smaller the ratio of BP in ankle/arm, more severe

USS, MRI/CT angiography

101
Q

PAD Mx

A

Quit smoking, exercise, healthy diet

Tx HTN, statins, clopidogrel, vasoactive drugs (naftidrofuryl oxalate)

Percutaneous transmural angioplasty, surgical reconstruction, amputation

102
Q

PAD Cx

A

Qol reduced, infection, poor tissue healing, ulceration, gangrene, amputation

103
Q

Acute limb ischaemia

A

sudden decrease in arterial perfusion - thrombotic/embolic causes

104
Q

Acute limb ischaemia Px

A 
pale
pulseless
pain
paralysed
paraesthesia
perishingly cold
105
Q

Acute limb ischaemia Mx

A

Surgery/angioplasty

Heparin post-op

106
Q

Shock

A

circulatory failure leads to inadequate organ perfusion

can result from inadequate CO, loss of SVR, or both

107
Q

Shock patho

A

Hypovolaemic - haemorrhagic, burns, DKA, D+V

Cardiogenic - heart not pumping properly - MI, heart block, secondary causes of pump failure (PE, tension pneumothorax, tamponade)

Distributive - septic shock, anaphylactic, neurogenic (spinal cord transection, interrupts ANS, decreases SNS/increases PNS, decreased PVR)

Anaemic shock and cytotoxic shock also

Can classify haemorrhagic shock I-IV

108
Q

Shock Px

A 
reduced GCS, agitation, confusion
pale skin, cold, sweaty, vasoconstricted
cool peripheries - cyanosis
tachycardia
tachypnoea
oliguria
CRT increased
weak rapid pulse
pulse pressure reduced (MAP may be maintained)

Neurogenic
instant hypotension, warm flushed skin, priapism, bradycardia

109
Q

Shock Ix

A 
ABCDE
General review of signs of shock
Tachycardic and hypotensive
If JVP raised, cardiogenic shock likely
look for trauma
110
Q

Shock Mx

A

Haemorrhagic
Stop bleed
Permissive hypotension
Blood, FFP, crystalloid/fluid boluses

Neurogenic
Fluids
peripheral vasoconstrictors to return tone to normal

111
Q

Cardiogenic shock

A

inadequate tissue perfusion due to cardiac dysfunction

112
Q

Cardiogenic shock Px

A

Signs of heart failure - raised JVP, gallop rhythm, basal crackles, PO

Signs of shock

Symptoms of condition, eg MI

113
Q

Cardiogenic shock Ix

A

ECG changes
ECHO
MI troponin levels
basically look for cause

114
Q

Cardiogenic shock Mx

A

ABCDE
Supportive
Tx cause
Surgery, eg if trauma is cause

115
Q

Sepsis

A

infection and systemic inflammatory response (cytokine release) - dysregulated host response to infection

endothelial cell damage, vasodilation, increased capillary permeability, organ failure

septic shock - sepsis with lactate >2mmol/L or need vasopressors to maintain MAP >65

116
Q

Sepsis RFs

A 
age - old/very young
instrumentation/surgery
indwelling line, catheter
alcohol abuse
DM
breach of skin
immunocompromised
high dose steroids, chemo
IVDU
pregnancy
117
Q

Sepsis Px

A

earlier presentation of infection, rapid deterioration
pyrexia, rigors, vasodilation, warm peripheries, bounding pulse, N+V

Sepsis screening
systolic BP<90
HR >130
sats <91%
RR >25
reduced GCS
Lactate >2mmol/L
118
Q

Sepsis Ix

A

Assess risk - high/moderate-to-high/low

H+E

ABG for lactate, observations - HR, BP, RR, sats, temp, ECG, urine dip, urine output

Blood cultures, micro samples of sputum/urine, swab wounds

CXR/CT/MRI of suspected source

119
Q

Sepsis Mx

A 
Sepsis six resus bundle
High flow O2
take blood cultures, consider infective source
IV ABs
IV fluid
check Hb, serial lactates
hourly urine output measurement

surgical involvement, eg wound debridement

Manage acute Cx - shock, AKI, DIC, ARDS, arrhythmias

120
Q

Anaphylactic shock

A

acute life-threatening T1 IgE-mediated hypersensitivity reaction

rapid histamine release from mast cells, basophils - cap leakage, mucosal oedema, shock, asphyxia

Causes
drugs, latex, food, venom

121
Q

Anaphylactic shock Px

A

Itching, sweating, D+V, erythema (red skin), urticaria (hives), oedema (larynx, tongue, lips)

Wheeze, laryngeal obstruction, cyanosis

Tachycardia, hypotension

122
Q

Anaphylactic shock Ix

A

straight to Mx if suspected

Serum mast-cell tryptase to confirm - shows mast cell degranulation

123
Q

Anaphylactic shock Mx

A

ABCDE
high flow O2
IM adrenaline - acts on beta receptors to dilate bronchi (0.5mg)
IV fluid
Chlorphenamine - H1 antihistamine
Hydrocortisone - suppresses prostaglandin and leukotriene mediators

Continuing resp deterioration - bronchodilator - salbutamol/ipratropium

124
Q

Stable angina

A

chest pain from reversible myocardial ischaemia

125
Q

Angina patho

A

Stable - induced by effort, relieved by rest, 3 features:

  1. constricting/heavy discomfort to chest, jaw, neck, shoulders, arms
  2. symptoms brought on by exertion
  3. symptoms relieved in 5 mins by rest or GTN

3 features = typical angina, 2 = atypical, 1 = non-anginal chest pain

Unstable angina
crescendo angina, angina of increasing frequency or severity, occurs on minimal exertion/rest

Both cases - mismatch between blood supply and metabolic demand

Causes - atherosclerosis, valvular disease, aortic stenosis, arrhythmias, anaemia

126
Q

Angina RFs

A

FHx, smoking, diabetes, metabolic syndrome, HTN, obesity, lack of exercise, cardiac abnormalities

127
Q

Stable angina Px

A

Provoked by exertion - after meal, cold, windy, exercise, angry/excited

signs
sweaty
distressed

symptoms
central chest tightness or heaviness
pain may radiate
SOB
nausea, feeling faint
128
Q

Stable angina Ix

A 
ECG - may be normal, ST depression, flat/inverted T waves
Treadmill test/exercise ECG
Bloods - FBC to exclude anaemia
ECHO
CXR
Coronary angiography
129
Q

Stable angina Mx

A

Modify RFs - stop smoking, exercise, lose weight, atorvastatin

Aspirin

GTN - dilates systemic veins, reducing venous return to heart, reduces preload, also dilates coronary arteries

BBs - atenolol, bisoprolol
CCB - verapamil
Long acting nitrates
Ivabradine - HCN channel blocker, reduces HR

Maybe surgery - PCI, CABG

130
Q

Structural heart defects

A

1% of all live births have some form of cardiac defect

Causes of congenital heart disease
maternal prenatal rubella infection
maternal alcohol misuse
single genes - trisomy 21
drugs - thalidomide, amphetamines, lithium
diabetes of mother
genetic abnormalities
131
Q

Atrial septal defect

A

abnormal connection between atria, often first dx in adulthood

Patho
LAp > RAp
shunt left-to-right, thus NOT blue, acyanotic
increased flow into right heart and lungs
RV compliant, easily dilates, but can result in:
- RVH
- Pulmonary HTN
- Eisenmenger’s - high pressure pulmonary flow, damages pulmonary vasculature, resistance to blood flow through lungs increases, RV pressure increases, shunt direction reverses, patient becomes blue, clubbing

Large defect
significant flow through right heart - dilatation, SOBOE, increased chest infections

Small
small increase in flow through right side, no dilatation, no symptoms

Px
atrial arrhythmias from RA dilatation, pulmonary flow murmur, fixed split second heart sound (delayed closure of pulmonary valve - more blood has to get out)
SOBOE

Ix
CXR
ECG
ECHO

Mx
Surgical closure

132
Q

Bicuspid aortic valve

A

2 cusps instead of 3

commonly causes aortic stenosis, degenerates, becomes regurgitant

133
Q

Ventricular septal defects

A

abnormal connection between two ventricles

Patho
LVp > RVp
L-R shunt, NOT blue, acyanotic, increased flow through lung

Large defects
large volumes of blood through heart vessels, pulmonary HTN, Eisenmenger’s, then R-L shunt, cyanotic

Small defects
asymptomatic, IE risk, no intervention needed

Px
LARGE defects
small breathless skinny baby
increased RR
tachycardia
cyanosis
murmurs
SMALL defects
loud systolic murmur
thrill (buzzing sensation)
well grown, normal HR, normal heart size

Ix
CXR

Mx
surgical closure

134
Q

Atrio-ventricular septal defects

A

hole in centre of heart

Instead of two separate AV valves, just one big malformed one, associated with Down’s

Px
COMPLETE defect
breathless neonate
poor weight gain, feeding
torrential pulmonary flow, can result in Eisenmenger, cyanosis
PARTIAL defect
can present in late adulthood
SOB, tachycardia, exercise intolerance

Mx
Surgical repair

135
Q

Patent ductus arteriosus

A

persistent communication between proximal left pulmonary artery and descending aorta

foetal life - pulmonary vascular resistance high (bronchioles filled with fluid), vessels constricted (lack of O2), right heart pressure exceeds left, flow from RA to LA through foramen ovale, also from pulmonary artery to aorta through ductus arteriosus

abnormal L-R shunt (aorta to pulmonary artery), lung circulation overloaded, Eisenmenger’s, right sided cardiac failure (RVH in response to increased afterload)

Px
continuous 'machinery' murmurs
bounding pulse
Eisenmenger's, clubbed cyanosis, blue toes, but pink and not clubbed fingers
SOB

Ix
CXR
ECG - LA abnormality, LVH
ECHO

Mx
Indometacin (prostaglandin inhibitor) - stimulate duct closure
Surgical closure

136
Q

Coarctation of the aorta

A

narrowing of aorta just distal to insertion of ductus arteriosus (distal to origin of left subclavian artery)

Patho
narrowing just after arch
excessive blood flow through carotid and subclavian vessels into systemic vascular shunts to supply rest of body
stronger perfusion to upper body rather than lower
decreased renal perfusion -> systemic HTN even after surgical correction
body grows collateral vessels around narrowing

Px
Right arm HTN
Bruits over scapulae and back from collateral vessels
murmur
HTN in upper limbs
Radial pulse before femoral pulse - discrepant BP
headaches and nose bleeds from HTN

Ix
CXR
ECG - LVH
CT

Mx
Balloon dilatation and stenting

137
Q

Tetralogy of fallot

A

most common form of cyanotic congenital heart disease, consists of:

  • VSD
  • pulmonary stenosis
  • RVH
  • overriding aorta

patho
stenosis of RV outflow leads to RVp>LVp
blue blood passes from R-L, patients are BLUE, cyanotic

Px
central cyanosis
low birth weight and growth
delayed puberty
systolic ejection murmur
SOBOE

Ix
CXR - boot-shaped heart

Mx
Surgery

138
Q

Pulmonary stenosis

A

narrowing of outflow of RV
can be valvar, subvalvar, supravalvar

Px
RV failure as neonate
collapse
poor pulmonary blood flow
RVH
tricuspid regurgitation
mild - well tolerated for years

Mx
Surgery - balloon valvuloplasty - inflates balloon to crush stenosis
shunt to bypass blockage

139
Q

Aortic stenosis

A

narrowing of aortic valve

Patho
Causes - calcification, bicuspid aortic valve calcified, rheumatic heart disease

narrowing obstructs LV emptying, increases afterload, LVH, then relative ischaemia of LV (hypertrophy = higher blood demand) -> angina, arrhythmias, failure

increased IE risk

Px
Classic triad - angina, syncope, heart failure
EJECTION SYSTOLIC CRESCENDO-DECRESCENDO MURMUR
Prominent S4 from LVH
soft/absent S2
slow rising carotid pulse (pulsus tardus), decreased pulse amplitude (pulsus parvus)

Ix
ECHO
ECG - LVH,
CXR

Mx
Surgical aortic valve replacement - TAVI (transcutaneous aortic valve implantation)

140
Q

Mitral regurgitation

A

Backflow of blood from LV to LA during systole

Patho
Abnormalities of valve leaflets, chordae tendineae (mitral valve prolapse), papillary muscles

Compensatory mechanisms - LA enlargement, LVH (LV puts in same effort to pump less blood, so needs to pump harder to maintain CO), then progressive HF

Px
PANSYSTOLIC MURMUR
soft S1, left-sided murmur so heard loudest on inspiration
prominent S3 in congestive HF
SOBOE, fatigue, lethargy, palpitations, symptoms of RHF

Ix
ECG - LA enlargement (broad P wave), maybe AF, LVH
CXR
ECHO

Mx
ACEi - act as vasodilator - SM relaxer
HR control - BBs, CCB
Diuretics for fluid overload
Mitral valve replacement
141
Q

Aortic regurgitation

A

Leakage of blood into LV during diastole

Causes - rheumatic fever, bicuspid aortic valve, IE

LV dilatation, LVH to compensate

Px
EARLY DIASTOLIC MURMUR
apex beat displaced laterally
SOBOE, palpitations, angina, syncope

Ix
CXR
ECHO
ECG - LVH signs

Mx
Vasodilator - ACEi
Valve replacement

142
Q

Mitral stenosis

A

obstruction of LV inflow from LA - prevents proper filling during diastole

Patho
LA dilatation - pulmonary congestion, AF, RHF symptoms from pulmonary venous HTN, haemoptysis from rupture of bronchial vessels from elevated pulmonary pressure

Causes - rheumatic fever, IE, calcification

Px
MID-DIASTOLIC MURMUR
loud S1, opening snap
malar flush on cheeks - due to low CO
low pulse volume
peripheral oedema
ruddy complexion - mitral facies
SOB
fatigue, palpitations, chest pain, haemoptysis

Ix
CXR
ECG
ECHO

Mx
BBs, CCBx, diuretics
Percutaneous mitral balloon valvotomy
mitral valve replacement

Phase 2a Concise (9 decks)

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