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Year 3 Medicine > CVS > Flashcards

CVS Flashcards

1
Q

define pre-load and after-load

A

pre-load = volume in ventricle at end of diastole

after-load = total peripheral resistance

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2
Q

what is Frank-Starling’s law?

A

more ventricular distension during diastole = greater volume ejected during systoe

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3
Q

How would you calculate the heart rate from an ECG strip?

A

Each strip is 10 seconds long

Count the amount of QRS and then multiply by 6

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4
Q

What lead is normally the most positive? What would be the most positive in LBBB and RBBB respectively?

A

Lead II is normally the most positive

LBBB - Lead aVL

RBBB- Lead III

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5
Q

State the normal parameters for the PR interval, the QRS interval and the QT interval

A

PR - 120-200ms QRS - <120ms QT - 2 large squares

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6
Q

RBBB can be present without heart disease, however name three common causes of LBBB

A
  • Anterior MI
  • Congestive Heart Failure
  • Left Ventricular Hypertrophy
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7
Q

Describe the diagnostic features of a STEMI

A
  • Cardiac Chest Pain
  • ECG changes (persistent ST elevation or new LBBB)
  • Raised Troponin I (greater than 100 nanograms)
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8
Q

What are the parameters for ECG changes in a STEMI?

A

ST elevation in atleast 2 leads

Elevation greater than 1mm in limb leads and 2mm in chest leads

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9
Q

Describe the ECG changes in an NSTEMI

A

may show: ST segment depression T wave inversion Normal

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10
Q

When might an STEMI be mistaken for an NSTEMI?

A

If you have ST segment depression in V1-V4, it may be the reciprocal changes of a posterior STEMI

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11
Q

Describe the pathophysiology of ACS

A
  • Plaque rupture
  • Thrombosis to varying degrees
  • Inflammation
  • Artery occlusion and reduced blood supply to myocardium
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12
Q

What layer of the heart do the coronary arteries lie in?

A

Epicardium

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13
Q

Describe 5 of the classical presentations of ACS

A
  • Central crushing chest pain lasting >20 mins
  • Nausea
  • Sweating
  • Breathlessness
  • Palpitations
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14
Q

Some ACS can be ‘Silent’, what groups of people can this occur in? How would they present?

A
  • Elderly and Diabetics
  • Syncope, Epigastric Pain
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15
Q

What is the S4 heart sound?

A

Blood striking against a non compliant ventricle

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16
Q

What happens to Troponin I in an MI

A

Begin to rise 3-4hrs post MI Remain elevated for up to 2 weeks

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17
Q

what level of hs-TnI is highly likely of myocardial necrosis in men and women?

A

34 in men

16 in women

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18
Q

When should Troponin I be sampled?

A

One sample on admission If onset of the symptoms was less than 3 hours ago, take another sample one hour after the original

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19
Q

Give 4 false positives of Troponin I

A
  • Advanced renal failure
  • Large PE
  • Severe CCF
  • Aortic Dissection
  • sepsis
  • stroke
  • cardiomyopathy
  • malignancy
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20
Q

Give 3 possible features of an MI on a CXR

A
  1. Cardiomegaly
  2. Pulmonary Oedema
  3. Widened Mediastinum
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21
Q

In four steps describe the initial medical management of suspected ACS

A

1) Morphine and Antiemetic (Metacloperamide)
2) Oxygen (Sats>94% or <88% if COPD)
3) Nitrates (GTN Spray)
4) Asparin 300mg Loading Dose

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22
Q

What are the four requirements for Prasugrel in an MI?

A
  1. Undergoing PCI
  2. Less than 75 y/o
  3. Weight >60kg
  4. No prior TIA/Stroke
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23
Q

non-pharmacological management long term post MI (other than the 5 drugs what else can be done?

A
  • Cardiac Rehab
  • Cut out smoking
  • Diet and Alcohol,
  • DVLA advice (able to drive after one week, if a bus/lorry driver can’t for 6 weeks)
  • ?Dyspepsia (provide PPI with Asparin)
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24
Q

what are the 5 drugs patients must have following an MI?

A
    1. Aspirin
    1. ACEi - Ramipril
    1. B-blocker - Bisoprolol
    1. Statin - Atrovostatin
    1. ADP- receptor antagonist - ticagrelor
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25
Q

Describe the management of NSTEMI

A
  • Pain relief
  • Aspirin 300mg
  • LMWH
  • Repeat ECG
  • Risk assessment of patient with elevated hs-Tnl - grace score
    • Ticagrelor if risk >3%
  • Anti-anginals - nitrates
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26
Q

What is the Grace Score?

A

Used on ACS patients to estimate their inpatient and 3 year mortality

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27
Q

Describe the complications of an MI

A
  • DARTH VADER
    • Dresler syndrome - pericarditis post MI
    • Arrhythmias
    • Rupture of heart
    • Tamponnade
    • HF
    • Valve complications
    • Aneurysm of ventricle
    • Death
    • Emboli
    • Recurrence
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28
Q

Name four STEMI mimics on ECG

A
  • Early repolarisation in young & fit
  • Pericarditis (saddle shaped)
  • Brugada Syndrome (Sodium Channelopathy)
  • Takotsubo Cardiomyopathy (temporary and brought on by stress - broken heart syndrome)
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29
Q

what is significant about an ECG showing ST depression in leads V1-V4 and what should be done?

A

may be a true STEMI in posterior aspect of heart so should be treated as a STEMI and should have posterior leads done - V7-9 as well as Right ventricular lead

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30
Q

what is ST elevation in RV4 highly sensitive for?

A

right ventricular infarction

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31
Q

What is stable angina?

A

Chest discomfort provoked by effort/emotion and relieved by rest

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32
Q

Describe four potential symptoms of Stable Angina

A
  • Chest Pain
  • Throat tightness
  • Arm Heaviness
  • Exertional Breathlessness
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33
Q

What features would make Angina unlikely?

A

Continuous/Very prolonged pain

Unrelated to activity level

Associated with other symptoms such as dizziness/dysphagia

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34
Q

Describe two methods of functional imaging

A

Stress Echo

Cardiac MRI

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35
Q

Describe pharmacological managements of Stable Angina

A
  • Immediate - GTN spray
  • Prevent symptoms - B-blocker, CCB, nitrates
  • Secondary prevention - AAAA
    • Aspirin, ACEi, Atorvostation, Atenelol (Bblocker)
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36
Q

When would you prescribe Ivabradine?

A

As an alternative to a Beta Blocker, for example if the patient is Hypotensive

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37
Q

When would you prescribe Ranolazine in Stable Angina?

A
  • If intolerant to all the other drugs
  • Commenced by consultants
  • eGFR>30 (reduces sodium and hence calcium - relaxes muscle)
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38
Q

Other than Stable/Unstable, describe two other types of Angina

A
  • Decubitus Angina - precipitated by lying flat
  • Vasospastic Angina - spasm of coronary artery
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39
Q

How would you educate a patient in how to use GTN spray in Stable Angina?

A
  • Repeat dose after 5 minutes if required If still persisting after 5 minutes of the second dose, call an ambulance
  • SE: Headache, Hypotension
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40
Q

Describe the classes of HTN in terms of clinic readings

A
  • Class 1 - 140/90
  • Class 2 - 160/100
  • Severe - 180/110
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41
Q

Describe the classes of HTN in terms of home readings

A
  • Class 1 - 135/85
  • Class 2 - 150/95
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42
Q

what is essential hypertension?

A
  • accounts for 95% of hypertension
  • aka primary hypertension
  • hypertension has developed on its own and does not have a secondary cause
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43
Q

Give 4 broad causes of Secondary HTN

A
  • Renal (Renal Artery Stenosis, PCKD)
  • Pregnancy
  • Drugs (Steroids, COCP, Cocaine)
  • Endocrine (Cushings, Conns)
  • Obesity
  • (ROPED)
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44
Q

what are some complications of hypertension?

A
  • Ischaemic heart disease
  • Cerebrovascular accident (i.e. stroke or haemorrhage)
  • Hypertensive retinopathy
  • Hypertensive nephropathy
  • Heart failure
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45
Q

at what blood pressure should a patient be offered ambulatory monitoring?

A

>140/90

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46
Q

when should treatment be initiated for hypertension?

A

treat stage 1 if <80 and

  • evidence of end organ damage
  • cvd
  • enal impairement
  • DM
  • 10-year risk >20%

treat all stage 2

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47
Q

What is Malignant Hypertension?

A
  • Rapid rise in blood pressure to over 200/130, leading to vascular and organ damage
  • Can causes bilateral retinal haemorrhages, headache, visual disturbances
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48
Q

How does Hypertension present?

A

Generally asymptomatic - may have headache

If sweating/palpitations - Phaeochromocytoma

If muscle tetany/weakness - Hyperaldosteronism

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49
Q

Describe 5 investigations (apart from BP) necessary for HTN

A
  1. Full range of bloods (inc cholesterol)
  2. Urinalysis (A:Cr, Protienuria, Haematuria)
  3. ECG
  4. Fundoscopy
  5. Cardiac Echo
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50
Q

You should aim to reduce blood pressure slowly in Hypertensive patients. What is the BP goal in treated patients?

A
  • Normal <140/90
  • Diabetic <130/80
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51
Q

non-pharmacological treatments for hypertension

A

wieght reduction

minimise salt intake

minimise alcohol

aerobic exercise

smoking cessation

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52
Q

Describe the four step (up) management of Hypertension

A
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53
Q

Describe the 3 classes of CCBs, an example of each and their actions

A
  • Dihydropyridine - acts on peripheral vasculature (eg Amlodipine, Nifedipine)
  • Phenylalkamine - acts on cardiac vasculature (eg Verapamil)
  • Benzothiazepine - acts on cardiac and peripheral vasculature (eg Diltiazem)
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54
Q

Describe the difference between a Hypertensive Emergency and a Hypertensive Urgency

A

Emergency - High BP with critical illness (AKI,MI, Encephalopathy)

Urgency - High BP without critical illness at the moment, often accompanied by retinal damage

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55
Q

Describe the management of a Hypertensive EMERGENCY

A

Reduce diastolic to 110mmHg in 3-12hrs

Use IV Sodium Nitroprusside/Labetolol/GTN/Esmolol (acts in 30s)

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56
Q

Describe the management of a Hypertensive URGENCY

A
  • Reduce diastolic to 100mmHg in 48-72hrs
  • Usually use Nifedipine AND Amlodipine for 3 days and then continue Amlodipine alone
  • some patients have ACEi and calcium antagonist
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57
Q

how does phaeochromocytoma present? (triad)

A
  • episodic headache
  • sweating
  • tachycardia

(most wont have all 3)

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58
Q

how is a diagnosis of phaeochromocytoma made?

A
  • measuments of urinary and plasma fractionated metanephrines and catecholamines
  • 24 hour urine collection
  • CT or MRI scan of abdomen and pelvis to detect adrenal tumours
  • MIBG scan can detect tumours not detected by CT or MRI
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59
Q

how is a phaeochromocytoma managed?

A
  • all patients should undergo resection
  • hyptension control in meantime is combined alpha and beta adrenergic blockade
  • phenoxybenzamine most commonly used
  • BETA NEVER INITIATED BEFORE ALPHA
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60
Q
A
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61
Q

Heart Failure is when cardiac output fails to meet the body’s requirements. Using the mnemonic HEART MAy DIE, give some causes.

A
  • Hypertension
  • Embolism
  • Anaemia
  • Rheumatic fever
  • Thyrotoxicosis
  • MI
  • Arrhythmia
  • Diet
  • Infection
  • Endocarditis
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62
Q

what are the 2 categories of heart failure?

A

diastolic = (filling) ventricular volume/capacity for blood is reduced, too stiff or ventricular walls thick (HRpEF)

systolic - (contractility) cant pump with enough force, walls thin/fibrosed, chamber enlarged, abnormal or uncoordinated myocardial contraction (HFrEF)

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63
Q

Describe the features of SYSTOLIC Heart Failure

A

Inability of the heart to contract, EF<40% Caused by IHD/MI/Cardiomyopathies

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64
Q

Describe the features of DIASTOLIC Heart Failure

A
  • Inability of the heart to relax, EF>50% (HFpEF)
  • Caused by Ventricular Hypertrophy/Tamponade
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65
Q

Right Ventricular Failure is caused by LVF or Chronic Lung Disease, give 3 features

A
  1. Peripheral Oedema
  2. Ascites
  3. Facial Engorgement
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66
Q

State 3 causes of ACUTE Heart Failure

A
  1. Infections
  2. Anaphylaxis
  3. PE
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67
Q

Heart Failure can be Low Output or High Output, give some causes of High Output and what is it?

A
  • IE High but not high enough Pregnancy, Hyperthyroidism, Anaemia
  • heart has enlarged and becomes fragile
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68
Q

Describe the use of BNP

A
  • BNP can be used to rule out Heart Failure if it is less than 100ng/l
  • Not diagnostic as BNP can be raised by anything that causes chamber stress (AF etc)
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69
Q

Using the A-E mnemonic describe the 5 features of a CXR of Heart Failure

A
  • A - Alveolar Oedema (Bat Wings)
  • B - Kerley B Lines (Interstitial Oedema)
  • C - Cardiomegaly
  • D - Dilated Veins
  • E - Effusions
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70
Q

Other than bloods and CXR, what is the gold standard for testing cardiac function?

A

Echocardiography

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71
Q

What is Cardiac MRI used for in the context of Heart Failure?

A
  • Better at imaging the RV
  • Good at assessing scar tissue
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72
Q

Give 5 features of Heart Failure

A
  • Cyanosis
  • Low BP
  • Narrow Pulse Pressure
  • Apex Displacement
  • RV Heave
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73
Q

Describe the New York Classification of Heart Failure

A
  • I - Heart Disease present but no limitations
  • II - Comfortable at rest but dyspnoea in normal activities
  • III - Less than ordinary activity causes dyspnoea
  • IV - Dyspnoea at rest
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74
Q

There are many medications that can be given for Heart Failure, but what device could patients have fitted?

A

Cardiac Resynchronisation Therapy Adds pacing to septal and lateral walls will reduce QRS width Considered if signs of LBBB Can combine with Defib device

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75
Q

describe NICE management of HF

A
  • Furosemide
  • ACEi
  • ARB
  • Bblockers
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76
Q

physiological effects of betablockers in heart failure

A
  1. reduce HR
  2. reduce BP
  3. 1+2= reduced myocaridal oxygen demand
  4. reduce mobilisation of glycogen
  5. negate unwanted effects of catecholamines
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77
Q

whan is ivabradine used in heart failure?

A
  • when pt cannot tolerate B blockers
  • resting hr higher than 75 despite B blockers
  • has no impact on blood pressure
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78
Q

when are vasodilators hydralazine and isosorbide mononitrate used in heart failure?

A
  • in combination shown to be beneficial
  • african or carribean patients
  • if pt cannot take ARB or ACEi
  • add to ACEi or ARB in resistant CCF
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79
Q

what is the benefit of using nitrates in HF

A

reduce preload, reduce pulmonary oedema, reduce ventricular size

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80
Q

when are nitrates used in heart failure?

A
  • IV used in acute HF if underlying ischaemia, hypertension or regurgitant aortic and mitral valve disease
  • chronic - relief of orthopnoea and exertional dyspnoea
81
Q

State four causes of Aortic STENOSIS

A
  1. Senile Calcification
  2. Congenital (Bicuspid Valves)
  3. CKD
  4. Rheumatic Fever
82
Q

Describe the triad of Aortic STENOSIS

A
  1. Angina
  2. Heart Failure (dyspnoea)
  3. Syncope
83
Q

Give four features of the murmur heard in Aortic STENOSIS

A
  • Ejection Systolic
  • Aortic Area
  • Radiates to carotids
  • Crescendo Decrescendo
84
Q

non surgical management of aortic stenosis

A
  • antihypertensives
  • treat HF symptoms as with HF
  • anti arrythmic drugs as indicated
85
Q

What instances would you consider a valve replacement in Aortic Stenosis

A

Symptomatic Asymptomatic with abnormal LV function, abnormal exercise test, other cardiac surgeries

86
Q

what procedure would you do for aortic stenosis if they werent fit for surgery?

A

TAVI - Transcatheter Aortic Valve Insertion - through femoral artery

87
Q

Give two acute and two chronic causes of Aortic REGURGITATION

A

Acute - Chest Trauma, Infective Endocarditis

Chronic - Congenital, Rheumatic Fever

88
Q

Describe three features of Aortic REGURGITATION

A
  • Exertional Dyspnoea (decreased exercise tolerance) 1st symptom
  • Orthopnea
  • PND
89
Q

Other than the murmur, describe 3 signs of Aortic REGURGITATION

A
  • Corrigan’s Pulse - Collapsing pulse
  • De Musset’s Sign - Head bobbing with heartbeat
  • Quinkes - systolic pulsation on light pressure of the nail bed
90
Q

Describe three features of the murmur of Aortic REGURGITATION

A

Early Diastolic

Left Sternal Edge Best heard sat forward in expiration

91
Q

Describe two managements of Aortic REGURGITATION

A
  • Afterload reduction (ACEI/ARB)
  • Valve replacement
92
Q

State three causes of Mitral STENOSIS

A
  • Rheumatic Fever
  • Congenital
  • Infective Endocarditis
93
Q

Describe two ways in which Mitral STENOSIS can present

A
  • Pulmonary Hypertension (Dyspnoea, Haemoptysis, Malar Flush)
  • LA Compression (Hoarseness, Dysphagia)
94
Q

Describe two features of the murmur of Mitral STENOSIS

A

Mid Diastolic murmur Best heard on expiration with patient on left

95
Q

Describe four possible managements of Mitral STENOSIS

A
  • AF - Rate control and anticoagulate
  • Diuretics
  • Balloon Valvuloplasty
  • Valve Replacement
96
Q

Describe four causes of Mitral REGURGITATION

A
  • Rheumatic Fever
  • Mitral Valve Prolapse (APCKD, Marfans)
  • IHD
  • Infective Endocarditis
97
Q

Give 5 features of Mitral REGURGITATION

A
  • Dyspnoea
  • Fatigue
  • Palpitations
  • Displaced Apex
  • AF
98
Q

State 3 features of the Mitral REGURGITATION murmur

A
  1. Pan Systolic Murmur
  2. Heard in Mitral Area
  3. Radiates to Axilla
99
Q

What two features indicate Infective Endocarditis unless proven otherwise

A
  • Fever
  • New Murmur
100
Q

Give 4 risk factors of Infective Endocarditis

A
  1. Mitral Valve Prolapse
  2. Prosthetic Material (not stent)
  3. Rheumatic Heart Disease
  4. Poor Dental Hygiene + Procedure
101
Q

Signs and Symptoms of infective endocarditis

A
  • F fever
  • R roth spots
  • O osler nodes
  • M murmur
  • J janeway lesions
  • A anaemia
  • N nail bed haemorrhages
  • E emboli
102
Q

State the two most effective diagnostic methods for Infective Endocarditis

A

Blood Cultures - Atleast 3 from different sites over a few hours TOE

103
Q

Describe the criteria of MAJOR Infective Endcarditis

A
  1. Positive Blood Cultures
  2. Endocardial Involvement
  3. Positive Echo (vegetation, abscess)
  4. new valvular Regurgitation
104
Q

Describe the criteria of MINOR Infective Endcarditis

A
  1. Predisposing valvular or cariac abnormalities
  2. IV drug abuser
  3. Pyrexia >38
  4. Embolic or vasculitic phenomenon
  5. Blood cultures suggestive (organism growth but not meeting major criteria)
  6. Suggestive ECHO findings (not meeting major criteria)
105
Q

what criteria have to be met to make a diagnosis of IE?

A

2 MAJOR

1 MAJOR & 3 MONOR

5 MINOR

106
Q

Antibiotics are given via a central line in Infective Endocarditis. Give the Empirical, Strep, Enterococci and Staph management

A
  • Empirical - Amoxicillin and Gentamicin
  • Strep - Benzylpenicillin and Gentamicin
  • Enterococci - Amoxicillin and Gentamicin
  • Staph - Flucloxacillin and Gentamicin
107
Q

How would you monitor Infective Endocarditis? and why?

A

Echo Weekly (assess vegetation and look for complications)

ECG Twice Weekly (may indicate aortic root abscess in aortic valve infection)

Bloods Twice Weekly

108
Q

what are some indications for surgery in infective endocarditis?

A
  • moderate to severe cardiac failure
  • valve dehiscence
  • uncontrolled infection despite appropriate antimicrobial therapy
  • relapse after optimal medical therapy
109
Q

Bradycardia can be caused by SA or AV node dysfunction. Give 4 causes of SA node dysfunction

A

Hypothyroidism Hypothermia Rheumatic Fever Haemachromatosis

110
Q

What is Sick Sinus?

A

Sinus Node Fibrosis Presents as Tachy Brady

111
Q

What is 1st Degree HB? How would you manage?

A

PR Interval >0.2 seconds (5 large squares) No specific treatment, just monitor

112
Q

What is 2:1 HB? How would you manage?

A

AKA Wenkebach Progressive lengthening of PR followed by drop of QRS Can occur in young fit patients OR after MI No specific treatment, just monitor

113
Q

What is 2:2 HB? How would you manage?

A

Constant PR interval then QRS suddenly dropped Pacing required as can progress to complete HB

114
Q

Complete HB occurs when there is no relationship between P and QRS. How does the ECG change depending on where the block is?

A

Occurring at Bundle of His - Narrow Escape Complex Occurring below Bundle of His - Broad Escape Complex

115
Q

Give 3 causes of Complete HB

A

Digoxin toxicity Inferior STEMI Severe Hyperkalaemia

116
Q

Complete HB requires urgent pacing. What medical management can you give?

A

Atropine - Muscarinic Antagonist Isoprenaline - Beta Agonist

117
Q

What is a Junctional Rhythm

A

Abnormal rhythm arising from AV node

118
Q

Give 4 causes of AF

A

Heart Failure Hypertension PE Hypokalaemia

119
Q

What investigations would you do for AF?

A

ECG - May wish to use home monitor if intermittent Echo - to look for any underlying structural abnormalities/prepare for cardioversion

120
Q

How would you manage ACUTE AF (<48hrs ago)? What do you need to consider?

A

Give Heparin and aim to DC cardiovert Generally cardiovert young patients due to stroke risk (always listen for carotid bruits first)

121
Q

What anticoagulation would you give in Chronic AF? State the two scoring systems used.

A

DOACs - Rivaroxiban, Apixiban, Dabigatran Warfarin CHADS VASc and HAS BLED

122
Q

Describe the rate control of AF

A

1 - Beta Blockers 2 - CCB 3 - Amioderone

123
Q

Describe the rhythm control of AF

A

Flecainide or Amioderone If cardioverting will require atleast 3 weeks of anticoagulation and an echo prior

124
Q

AVRTs are Narrow Complex Tachycardias, describe their pathway

A

Impulse starts in AV node, travels to ventricles and then back up into atria via accessory pathway (ORTHODROMIC)

125
Q

AVNRTs are Narrow Complex Tachycardias, describe their pathway

A

Re-entrant loops form within the AV node itself

126
Q

What is diagnostic on an ECG about AVRT/AVNRTs?

A

No P Waves

127
Q

Describe the managements of AVRT/AVNRT

A

Aim to transiently block the AVN (also helps differentiate it from AF) 1 - Vagal Manouvres 2 - IV Adenosine (6mg, then 12g, then 12mg with long flush)

128
Q

Describe 3 side effects of Adenosine

A

Chest Discomfort Transient Hypotension Flushing

129
Q

Describe the 2 types of VT

A

Monomorphic - Appearance of all beats match eachother, common post MI scarring Polymorphic - Beat to beat variation, includes Torsades de Pointes

130
Q

What is Torsades de Pointes? Give two causes.

A

A type of long QT syndrome Amioderone, Hypokalaemia

131
Q

Ventricular Tachycardia can be managed medically (lidocaine), but when would you cardiovert?

A

If haemodynamically compromised

132
Q

What are fusion beats?

A

Sinus and ventricular beats fuse

133
Q

What are capture beats?

A

Normal conduction of SVT beats Appears normal

134
Q

What is SVT with Aberrancy?

A

Aberrancy is a functional BBB with increased HR Won’t be able to tell the different between SVT with BBB until back in sinus rhythm

135
Q

What is Antidromic WPW?

A

AVRT that conducts the opposite way Conducts down through accessory pathway and up through AV node Delta waves form as the impulse passes through accessory pathway Treated the same as NCT

136
Q

What is a Cardiac Tamponade?

A

Accumulation of blood/fluid/pus/clots/gas resulting in reduced ventricular filling an haemodynamic compromise

137
Q

Give 5 causes of Cardiac Tamponade

A

Malignancy Trauma Aortic DIssection Infective Drugs (Hydralazine, Isoniazid)

138
Q

Give 5 presentations of Cardiac Tamponade

A

Dyspnoea Tachycardia Tachypnoea Distended jugular vein Pericardial Friction Rub

139
Q

What is Pulsus Parodoxus?

A

Exaggeration of a normal decrease in systolic in inspiration in Cardiac Tamponade Helps differentiate between that and Pericardial Effusion

140
Q

Name two investigations you would do for Cardiac Tamponade. What would they show?

A

Bloods - CK, Troponin, Us and Es CXR - Water Bottle shaped heart

141
Q

Describe three managements of Cardiac Tamponade

A

Pericardiocentesis Oxygen Leg Elevation - promotes venous return

142
Q

How would an Ostium Secondum ASD present?

A

Usually asymptomatic until left to right shunt develops Shunt becomes more exaggerated as you age due to decreased LV compliance Onset of Dysponea/HF aged 40-60

143
Q

How would an Ostium Primum ASD present? What are it’s associations?

A

Usually presents in childhood May be asymptomatic or may be fatigued, dyspnoea Associated with Downs Syndrome and AV Valve abnormalities

144
Q

How would ASD present on an ECG and a CXR?

A

RBBB with LAD (primum) or RAD (secondum) CXR - Atrial Enlargement, Small aortic knuckle

145
Q

Give two complications of ASD

A

Eisenmenger Syndrome (Reversal of shunt an subsequent cyanosis) Paradoxical Emboli

146
Q

Describe some possible presentations of VSD

A

May present with Heart Failure in infancy, or may remain asymptomatic until later life Signs of Pulmonary Hypertension Murmur (Harsh pansystolic at left sternal edge with left parasternal heave)

147
Q

VSD present normally on an ECG, how would they present on a CXR?

A

Small VSD - Normal Large VSD - Cardiomegaly, Large pulmonary arteries

148
Q

What is Coarctation of the Aorta? Name two associations

A

Congenital narrowing of descening aorta usually distal to left subclavian Associated with Bicuspid Valve and Turner’s Syndrome

149
Q

Name 5 presentations of Coarctation of the Aorta

A

Radioradial delay Weak femoral pulse Hypertension Systolic murmur over left scapula Cold feet

150
Q

Name two investigations for Coarctation of the Aorta

A

CT/MRI Aortogram CXR - Rib notching (blood diverts down intercostal arteries to supply lower body, causing these vessels to dilate and erode ribs)

151
Q

Tetralogy of Fallot is the most common cyanotic heart defect, what is the embryological cause?

A

Abnormal separation of Truncus Arteriosus into Aorta and Pulmonary Artery

152
Q

What are the four abnormalities in Tetralogy of Fallot

A

VSD Pulmonary Stenosis RV Hypertrophy Overriding Aorta

153
Q

How might Tetralogy of Fallot present?

A

May be asymptomatic at birth but gets more cyanotic as PA closes May squat (increases vascular resistance to decrease the degree of shunting) Repaired adult - exertional dyspnoea, palpitations

154
Q

What 3 investigations could you do for suspected Tetralogy of Fallot

A

ECG - RV hypertrophy with RBBB CXR - classical boot shaped heart Echo

155
Q

What is Dressler’s Syndrome?

A

Late onset Pericarditis post MI Usually 1-6 weeks after initial MI (may be immune mediated)

156
Q

How might Dressler’s Syndrome present?

A

Pain - left shoulder, pleuritic, worse when lying down Malaise Dyspnoea Fever

157
Q

Describe 3 Investigations of Dressler’s Syndrome

A

FBC - Leucocytosis Heart Autoantibodies ECG - ST Elevation

158
Q

Describe the management of Dressler’s Syndrome

A

Asparin - 750-1000mg tds for 2 weeks before tapering Colchicine - Improves response to NSAIDs

159
Q

State two congenital causes of Long QT syndrome

A

Jervell and Lange Nielson Syndrome - sensorineural deafness Romano Ward

160
Q

Describe the pathophysiology of Rheumatic Fever

A

Peak incidence between 5-15 y Triggered 2-4wks after Strep Pyogenes infecton

161
Q

Why does Rheumatic Fever cause valvular manifestations?

A

Antibody to carbohydrate wall of Streptococcus cross reacts with valve tissue (antigenic mimicry)

162
Q

What is the Jones Criteria for Rheumatic Fever?

A

Requires evidence of Strep Infection (titre, throat culture) +2 major symptoms OR 1 major and 2 minor

163
Q

How do you manage Rheumatic Fever?

A

Bed rest until CRP has been normal for 2 weeks (this may take up to 3 months) IV Benzylpenicillin Penicillin V Asparin

164
Q

Describe three features of Salicyclate Toxicity

A

Tinnitus, Hyperventilation, Metabolic Acidosis

165
Q

State three associations of Dilated Cardiomyopathy

A

Alcohol Hypertension Haemochromatosis

166
Q

How does Dilated Cardiomyopathy present?

A

Same symptoms as Heart Failure

167
Q

Define Cardiomyopathy

A

Myocardial disorder where the heart muscle is structurally or functionally abnormal without Coronary Artery Disease, Hypertension, Valvular, or Congenital Heart Defects

168
Q

What is Hypertrophic Cardiomyopathy?

A

Autosomal Dominant genetic disorder characterised by LV Hypertrophy, impaired diastolic filling, and abnormalities of mitral valve Most common cause of sudden cardiac death in young adults and athletes

169
Q

How does Hypertrophic Cardiomyopathy present?

A

Varies between asymptomatic to profound exercise limitations, arrhythmias and sudden death Symptoms of mitral regurg

170
Q

What is the most common arrhtyhmia seen in Hypertrophic Cardiomyopathy?

A

Atrial Fibrillation

171
Q

Describe three possible managements for Hypertrophic Cardiomyopathy

A

Rhythm Control (Anti Arrhythmics, Catheter Ablation) Anticoagulation (AF risk) ICD (Implantable Cardioverter Defibrillator)

172
Q

What is Restrictive Cardiomyopathy?

A

Normal left ventricular cavity size and systolic function, but with increased myocardial stiffness Usually idiopathic or caused by increased deposition (eg Fabry’s Disease)

173
Q

How would you manage Restricitve Cardiomyopathy?

A

Children - Transplant Adults - Heart Failure Management

174
Q

Acute Pericarditis can be primary (idopathic) or secondary. Name four secondary causes.

A

Infective Autoimmune Drugs (Procainamide, Hydralazine, Isoniazid) Metabolic (Uraemia, Hypothyroidism)

175
Q

Describe the presentation of Acute Pericarditis

A

Chest pain WORSE on inspiration/lying flat, IMPROVED by sitting forward May hear pericardial rub

176
Q

What would the ECG of Acute Pericarditis?

A

Saddle shaped ST elevation

177
Q

How would you manage Pericarditis?

A

NSAIDs/Asparin with PPIs for 1-2wks Colcihicine for 3 months for prevention If non resolving/autoimmune - steroids

178
Q

Apart from dyspnoea/chest pain in Pericardial Effusion, give three other signs/symptoms

A

Hiccoughs (compression of phrenic nerve) Nausea (compression of diaphragm) Bronchial Breathing at left lung base (Ewarts Sign)

179
Q

What is Constrictive Pericarditis?

A

Heart is encased in rigid pericardium, normally idiopathic or following TB/Pericarditis

180
Q

How would Constrictive Pericarditis present?

A

Right heart failure with raised JVP Kussmaul’s Sign (JVP rising paradoxically with Inspiration)

181
Q

What would you see on XRAY of Constrictive Pericarditis?

A

Small heart Pericardial Calcification

182
Q

Using LMNOP mnemonic, how would you manage Acute Heart Failure?

A

Loop Diuretics Morphine Nitrates Oxygen Position

183
Q

Name a cause of Right Axis Deviation

A

Pulmonary Embolism

184
Q

Give two points about preparing a patient for an ECG

A
  • The skin must be clean and dry (any recent use of moisturiser will require alcohol wipe) - If excessively hairy and unable to get a good connection (eg by parting the hairs) then the chest must be shaved
185
Q

State the five steps to describing an ECG

A

1) Rhythm (Regular/Irregular) 2) Conduction Intervals (eg prolonged PR) 3) Cardiac Axis (any deviation) 4) QRS Description 5) ST segment description

186
Q

Which Mobitz type is also called Wenkebach ?

A

Type 1

187
Q

Describe the septations of the Left Bundle Branch

A

Divided into anterior and posterior fascicle Anterior fascicle is normally the blocked one

188
Q

How would blockage of the left anterior fascicle present on ECG?

A

LBBB and Left Axis Deviation

189
Q

How would blockage of the Left Posterior Fascicle present on an ECG?

A

Right Axis Deviation

190
Q

What is Bifascicular block and how would it present on an ECG?

A

When there is both RBBB and Left Anterior Fascicle blockage Shows as RBBB and Left Axis Deviation

191
Q

What is Trifascicular Block?

A

Blockage of both the anterior and posterior left fascicles, and the right bundle branch AKA complete HB

192
Q

Name three places that a supraventricular rhythm can originate

A

SA node AV node Atrial Muscle

193
Q

How would ventricular pacing appear on an ECG?

A

A pacing spike prior to each QRS complex

194
Q

How would dual chamber pacing appear on an ECG?

A

A pacing spike before each P wave and each QRS complex

195
Q

Once a STEMI is confirmed, describe the management options if a PCI centre is quickly accessible.

A

If the onset of the STEMI was within 12 hours, and a PCI is available within 2 hours. Give loading dose of Prasugrel (60mg) or Clopidogrel (600mg) AND UFH. PCI

196
Q

Once a STEMI is confirmed, describe the management options if a PCI centre is NOT quickly accessible.

A

Thrombolyse with Alteplase Clopidogrel AND UFH PCI when possible

197
Q

what is the most common sign of phaeochromocytoma?

A

sustained or paroxysmal hypertension

198
Q

when would cushings syndrome be suspected

A
  • typical pysical appearannce
  • hyperglycaemia
  • 24 hour urine cortisol excretion will be elevated
  • low does dexamethasone suppression test
199
Q

when is primary aldosterone suspected

A
  • low serum potassium and high/normal sodium (potassium is normal in up to 50%)
  • consider in pt with hypokalaemia, resistant hypertension, family history of premature hypertension
  • aldosterone:renin ratio measured in the morning
    • plasma renin activity is low or undetectable in pt with primary aldosterone

Year 3 Medicine (15 decks)

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