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Medicine Year 3 > CVS and Cancer > Flashcards

CVS and Cancer Flashcards

1
Q

Abdominal aortic aneurysm

A

Abnormal, persistent, localised dilatation of the aorta (>3 cm across)
RF: Male, over 60, smoking, atherosclerosis, hypertension, genetic

Clinical presentation: majority asymptomatic (detected incidentally), worsening abdominal or back pain, hypotension, and/or expansile abdominal mass, collapse(ruptured)

Tests: USS, abdominal CT/MRI

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2
Q

Aortic dissection

A

Tear in the tunica intima of the aorta forms, and the high-pressured blood flowing through the aorta begins to tunnel between the tunica intima and tunica media creating a false lumen.

Causes: Chronic hypertension, blood vessel coarctation, marfans, ehlers danlos, aneurysm

Symptoms: Sudden tearing chest pain radiating to the beack, limb ischemia and kidney ischemia, cardiac temponande

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3
Q

Aortic regurgitation (insufficiency)

A

Causes:
<50yrs: Post-inflammatory: Rheumatic heart disease, infective endocarditis, syphilis, SLE, ankylosing spondylitis

> 50yrs: Aortic root/ascending aorta dilatation: Systemic hypertension, aortic dissection, Marfans, arthritis,

Signs: wide pulse pressure, collapsing pulse, displaced hyperdynamic apex beat, ,high-pitched early diastolic murmur (heard best in expiration, with patient sitting forward)

Doppler Echocardiography is diagnostic.

ECG (signs of LVH)

Chest xray (cardiomegaly)

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4
Q

Aneurysm

A

An artery with a dilatation >50% of its original diameter

True aneurysm - all layers
False aneurysm - collection of blood in the outer layer only which communicates with the lumen

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5
Q

Bladder Cancer

A

More common in men
Most are TCC
Presentation: Painless haematuria, recurrent UTIs, voiding irritability
Associations: smoking, aromatic amines (rubber industry), chronic cystitis, schistosomiasis (increased risk of SCC), pelvic irradiation

Tests: Cystoscopy with biopsy is diagnostic
Urine: MCS (sterile pyuria)
CT urogram is both diagnostic and provides staging

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6
Q

Breast Cancer

A

Affects 1 in 9 women
RF: FH, age, uninterrupted estrogen exposure (not have given birth, not breast feeding, early menarche, late menopause, HRT), obesity, BRCA gene, past breast cancer

Invasive ductal carcinoma (70%)
Invasive lobular carcinoma (10-15%)

60-70% are estrogen receptor positive (better prognosis)

30% overespress HER2 and are associated with

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7
Q

Aortic Regurgitation Pathophysiology

A

Aortic valve becomes leaky and blood flows back into the left ventricle in diastole.
Diastolic murmur
LV increases in size -> Left ventricular hypertrophy
Syncope

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8
Q

Aortic Regurgitation Symptoms

A

Chronic AR: initially asymptomatic. Later, symptoms of heart failure (exertional dyspnoea, orthopnoea, fatigue, angina)

Severe acute AR: sudden cardiovascular collapse

symptoms related to aetiology

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9
Q

Aortic Regurgitation Signs

A

Collapsing Pulse
Wide pulse pressure
Hyperdynamic displaced apex beat

Early diastolic murmur: lower left sternal edge, better heard with patient sitting forward and with breath held at expiration.

Austin Flint mid-diastolic murmur: Over the apex, from turbulent reflux hitting mitral valve causing a physiological mitral stenosis

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10
Q

Aortic Stenosis

A

Causes:

  1. Stenosis secondary to rheumatic heart disease (commonest worldwide)
  2. Calcification of congenital bicuspid aortic valve
  3. Degeneration/calcification of tricuspid valve due to age
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11
Q

Aortic stenosis epi.

A

Prevalence in >75yrs

if congenital bicuspid instead of tri may present earlier

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12
Q

Aortic Stenosis symptoms

A

Angina (Increased oxygen demand of hypertrophied ventricles)
Syncope or dizziness on exercise
Symptoms of heart failure

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13
Q

Aortic Stenosis exam

A

narrow pulse pressure
slow rising pulse
Harsh ejection systolic murmur at aortic area, radiating to the carotids and apex
Second heart sound may be softer or absent
Ejection click: bicuspid

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14
Q

Aortic Stenosis Investigation

A

ECG (LVH)
CXR (calcification of valve)
Echocardiogram ( visualises stenosis)

Cardiac angiography (check for CAD)

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15
Q

Arterial Ulcers

A

Caused by insufficient arterial blood supply to the lower limb, either in the major arteries or in the small distal capillaries leading to ischaemia or necrosis.

Reduced arterial flow starves the tissue of oxygen and nutrients, making them vulnerable to trauma and breakdown.

Diabetes, RA, vasculitis, peripheral vascular disease, IHD, cerebrovascular event (stroke and TIA) can lead to vascular insufficiency.

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16
Q

Arterial Ulcers

A

Usually foot, toes, ankle and back of the calf

rapid progression -> especially if infection is present

Minimal oedema

Foot pulses may be diminished or absent. Doppler USS or duplex scan necessary. Monophasic

Skin: Pale, shiny, cold to touch. Skin may be dark pink when hung down and white on elevation. Nails rough and hair loss due to lack of oxygenation to the hair follicles.

Low exudate levels.

Deep punched out ulcer. Presence of sloughy, necrotic tissue. Underlying bone, tendon or muscle may be present.

Contributing factors: smoking, hyperlipidaemia

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17
Q

Atrial fibrillation

A

Characterised by rapid, chaotic, and ineffective atrial electrical conduction.

  1. No cause
  2. Secondary causes lead to abnormal atrial electrical pathways that result in AF

Systemic causes: Thyrotoxicosis, hypertension, pneumonia, alcohol

Heart: Mitral valve disease, IHD, rheumatic heart disease, cardiomyopathy, pericarditis, sick sinus syndrome, atrial myxoedema

Lungs: Pulmonary embolus, bronchial carcinoma

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18
Q

Atrial Flutter

A

Characterised by atrial rate of 300 bpm and ventricular rate of 150 bpm

Sawtoothed appearance on ECG

Reversed with vagal manoeuvres, IV adenosine, or chemical cardioversion.

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19
Q

A FIB

A

Very common in the elderly

Symptoms: often asymptomatic. Some patients experience palpitations or syncope. Symptoms of the cause of A fib.

Exam: Irregularly irregular pulse. Difference in apical beat and radial beat.

Investigation:
ECG: uneven baseline (fibrillations) with absent p waves. Irregular QRS.
Blood: Cardiac enzymes
ECHO: Valvular disease

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20
Q

Management of AFIB

A

Treat any reversible cause (pneumonia, thyrotoxicosis)

  1. Rhythm control
    - If <48 hours cardioversion (IV Flecainide or DC cardioversion)
    - If >48hrs anticoagulate for a few weeks before attempting cardioversion
  2. Rate control (aim-90)
    - Digoxin, Beta-blocker, CCB (verapamil)
  3. Stroke risk
    Calculate risk using CHADS2 and CHADS2VASc
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21
Q

AFIb complications and prognosis

A

Thromboembolism
Worsens heart failure

Chronic AF in diseased heart does not usually return to sinus rhythm.

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22
Q

Cardiac Arrest

A

Acute cessation of cardiac function

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23
Q

Causes of cardiac arrest
4 Hs
4Ts

A

Hypoxia
hypothermia
hypovolaemia
Hypo- or hyperkalaemia

Tamponade
Tension pneumothorax
Thromboembolism
Toxins and metabolic diorders

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24
Q

Patient unconscious not breathing absent carotid pulse

A

cardiac arrest

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25
Cardiac arrest investigations
Cardiac monitor: Classification of rhythm directs management Bloods: ABG, U&E, FBC, cross-match, toxicology screen
26
Management cardiac arrest
BLS ALS Treatment of reversible causes Complications: irreversible hypoxic brain damage
27
Cardiac failure
Inability of cardiac output to meet the bodies demand despite normal venous pressures 10% of >65
28
Cardiac Failure cause
Low output (decreased cardiac output) left heart failure: IHD, hypertension right heart disease: secondary to left heart failure, infarction, pulmonary hypertension/ embolus/ valve disease, chronic lung disease Biventricular failure: cardimyopathy, arrhytmias ``` High output ( increased demand) anaemia, beriberi, pregnancy, pagets disease, hyperthyroidism ```
29
Left Heart failure
``` Tachycardia displaced apex beat bilateral basal crackles (fluid overload) third heart sound gallop rhythm pan-systolic murmur ``` orthopnea, PND, fatigue, wheeze, pink frothy sputum, fatigue, decreased perfusion of body
30
Right heart failure
Increased JVP hepatomegaly ascites ankle/sacral oedema swollen ankles, fatigue, anorexia nausea, increased weight due to oedema, decreased exercise tolerance
31
Heart failure invest
Bloods CXR: cardiomegaly, pleural effusion, kerley b lines, perihilar shadowing, fluid in the fissures ECHO
32
Management acute HF
``` ACUTE LVF: cardiogenic shock (dopamine) sit up patient 60-100 % oxygen consider CPAP diamorphine GTN infusion IV furosemide ```
33
Management chronic HF
``` treat the cause Ace inhibitors Beta blockers Furosemide ARB Aldosterone antagonist Hydralazine and nitrate digoxin Cardiac resynchronisation therapy ```
34
HF
Respiratory failure cariogenic shock death 50 % of patients with severe hf die in 2 years
35
Cardiomyopathy
Primary disease of the myocardium (heart muscle) May be dilated -muscle walls stretched and thin (post-viral, alcohol, drugs, thyrotoxicosis), restrictive - stiff and and rigid (amyloidosis, sarcoidosis, haemachromatosis), or hyperpertrophic- muscle enlarged and walls of heart chamber have thickened (genetic) Dilated symptoms: HF symptoms, arrhythmia, embolism, FH sudden death Hypertrophic: Usually none. same as above
36
Pericarditis
Inflammation of the pericardium idiopathic, infective, connective tissue disease (SLE, sarcoid), Post MI, dresslers syndrome uncommon Sharp central chest pain, which may radiate to the neck and shoulder. Made worse by coughing, deep inspiration, and lying flat relieved by leaning forward Dyspnoea and nausea ``` Exam: fever, pericardial friction rub - heard best left sternal lower border leaning forward , heart sounds may be faint due to effusion Cardiac tamponade (becks triad) Constrictive pericarditis ``` ECG - saddle shaped st segment
37
Coronary angiography
Xray imaging to see heart blood vessels angiogram can proceed into angioplasty ( open up clogged arteries) Indications: coronary artery disease, angina, aortic stenosis, heart failure Complications: radiation, heart attack, stroke, injury to artery and bleeding, infection
38
Coronary artery bipass graft
Treat coronary artery disease Healthy blood vessels from elsewhere in the body are used to bipass the blocked or narrowed arteries Risk of stroke heart attack, bleeding, infection
39
DC cardioversion
Convert abnormal heart rhythm to normal one using electrical shock Most common arrhythmias: AF Risk of blood clots Complications: irritation around pad area, doesn't work need pacemaker or ICD
40
2 coronary artery revascularisation techniques
PCI | and coronary artery bipass grafting
41
Implanted cardiac defibrillator
Monitors heart rhythm. If it senses dangerous rhythms, it delivers a shock. Defibrillation. Small device placed in your chest or abdomen if you have an irregular heartbeat or are at risk for sudden cardiac arrest. Needed in life threatening abnormal heart rhythm ICD continually monitors heart rhythm and can send low-or high-energy electrical pulses to correct an abnormal heart rhythm. Will initially send low and then high energy electrical pulses when low ineffective. Pacemakers only give low energy impulses to restore heart rhythm. ICD more effective in patients with high risk for sudden cardiac arrest.
42
PCI vs. CABG
PCI less invasive and shorter time to recover. CABG if multiple arteries are involved or structure of blood vessel near your heart is abnormal.
43
DVT
Formation of a thrombus within the deep veins (calf or thigh) ``` Causes: Virchows triad (Venous stasis, vessel wall injury, hypercoagulability) ``` RF: OCP, surgery, prolonged immobility, obesity, pregnancy, dehydration, smoking, active malignancy Common Usually asymptomatic (may have swelling or tenderness) or presents with pulmonary embolus Investigate: Doppler USS (veins) Bloods: d-dimer (negative predictor in low risk patients) ECG, CXR, ABG if there is suggestion there might be PE Management: Anticoagulation: Heparin and warfarin If high risk embolism or anticoagulation contraindicated -> fit an IVC filter Prevention: Compression socks. Movement. Prophylactic heparin for high risk patients (for example hospitalized patients that are immobile) Complications: PE Heparin can induce bleeding and low platelet count The higher up the DVT the more likely it is to embolise
44
Gangrene
Necrosis of body tissue due to a lack of blood flow or bacterial infection. Affects extremities commonly (fingers, toes) RF: diabetes, smoking, obesity, immunosuppression, atherosclerosis (dry gangrene), Bacterial infection (wet gangrene), peripheral artery disease, Raynaud's phenomenon Symptoms: Skin discoloration, clear line between healthy and damaged tissue, severe pain or numbness, foul-smelling, swelling, sores and blisters in the affected area Investigations: Basic obs, bloods (CRP, ESR)
45
Heart Block
Impairment of the AV node impulse conduction Cause: IHD, infection (rheumatic fever, infective endocarditis), drugs (digoxin), metabolic (hyperkalaemia), infiltration of the conduction system (sarcoidosis, amyloidosis) majority of pacemakers implanted are due to heart block Investigate: ECG for 24 hours Check for other differentials Management Chronic block: Permanent pacemaker in 2 and 3) Acute block: Secondary to anterior MI -> Clinical deterioration -> IV atropine and temporary pacemaker
46
Heart Block 1
Asymptomatic PROLONGED pr INTERVAL (>0.2s)
47
Heart Block 2 type I Wenchebach Mobitz
Progressive lengthening of the PR interval One non-conducted P wave Next conducted p wave has a shorter pr interval Asymptomatic
48
Heart Block 3
``` Strokes Adams (syncope due to lack of blood supply to the brain) Dizziness, palpitations, chest pain, and heart failure ``` No relationship[ between P waves and QRS Abnormally shaped QRS complex
49
Heart Block 2 Type II | Mobitz
PR interval constant One p wave not followed by QRS complex May have pattern to it 2:1 ``` Strokes Adams (syncope due to lack of blood supply to the brain) Dizziness, palpitations, chest pain, and heart failure ```
50
Infective endocarditis
Infection of the endocardial structures of the heart (usually valves) Most common organisms to colonize the endocardium: 1. Streptococci (40%) 2. Staphylococci (35%) 3. Enterococci (20%) 4. OTHERS: HACEK (haemophilius, actiinobacillus, cardiobacterium, eikenelaa, kingella), Coxiella burnetii, histoplasma
51
Ischemic heart disease
Decreased blood supply to the heart muscle resulting in chest pain. Stable angina or Acute Coronary Syndrome (unstable angina, NSTEMI, STEMI) RF: male, diabetes, FH, hypertension,hyperlipideamia, smoking, previous history common ``` Investigations: Bloods (CK-MB and troponin, sensitive maker for cardiac injury after 12 hours increased) ECG CXR: heart failure? Exercise ECG testing radinuclide myocardial perfusion imaging ECHO Pharmacological stress testing Angiography Coronary calcium scoring ```
52
Angina pectoris
Myocardial oxygen demand exceeds oxygen supply. Cause: Atherosclerosis, spasm (cocaine), arteritis, emboli Stable: Chest pain bought on by exertion and relieved with rest
53
Acute coronary syndrome
Chest pain or discomfort of acute onset central, heavy, tight, gripping pain that radiates to arms (usually left), neck, jaw, or epigastrium. Occurring at rest. Increase in severity and frequency from stable angina May be silent (old, diabetic) or associated with SOB, sweating, nausea, vomiting
54
Myocardial infarction
Cardiac muscle necrosis due to ischemia Sudden occlusion of a coronary artery due to rupture of an atheromatous plaque and thrombus formation.
55
Aortic coarctaition
Radio-femoral (radio) delay
56
keith- wagner classification
Retinopathy (1) Silver wiring (2) above and arteriovenous nipping (3) above and flame hemorrhage and cotton wool spots (4) above and papilloedema
57
Papilloedema
Increased intracranial pressure causing optic disc swelling
58
Management of Hypertension <55
<55yrs Step 1: ACE Inhibitor ( ARB if intolerant to ACE) Step 2: A+C (CCB) or A+D (thiazide diuretic) Step 3: A+C+D Step 4: add further diuretic therapy, alpha-blocker, or beta blocker
59
Constrictive Pericarditis
chronic inflammation of the pericardium Increased JVP with inspiration (kussmaul sign) pulsus paradoxus (BP reduced by greater than 10mmHg on inspiration) hepatomegaly ascites oedema pericardial knock AF
60
Thrill
Palpable murmur | ringing phone or fly trapped in hand
61
Management of Hypertension >55 or Afro-Caribbean
Step 1: C or D (thiazide type diuretic) Step2: A+C or A+D Step 3: A+C+D Step 4: Add further diuretic, or alpha blocker, or beta blocker
62
Complication of hypertension
``` Heart failure IHD Retinopathy peripheral arterial disease renal failure Stroke ```
63
Severe hypertension >140mmHg diastolic
atenolol or nifedipine
64
management of hypertension:
Assessment and modification of CVS risk factors Conservative: stop smoking, reduce weight, reduce alcohol, reduce dietary sodium If BP higher then 160/100 treatment or if evidence of organ damage or any other cardiac problems
65
Atherosclerosis
1. Endothelial injury 2. Migration of monocytes into subendothelium and differentiation into macrophages 3. Macrophages accumulate LDL lipids and become foam cells. 3. Foam cells release GFs which stimulate smooth muscle proliferation, production of collagen and proteoglycans. Leads to formation of atheromatous plaque.
66
STEMI
ST elevation on ECG: complete occlusion of coronary artery, most urgent to treat STEMI equivalents: New onset LBBB Posterior MI (Changes in V1-V3: ST depression, tall R waves, tall T waves)
67
STEMI Inferior wall
Changes in leads II, III, aVF
68
STEMI anterior wall
Changes in leads V1 and V2 (septum) V3-4 (apex) V5-6
69
STEMI lateral wall
changes in leads | I, aVL
70
NSTEMI
no st elevation permanent myocardial damage Elevation of troponin and creatine kinase
71
Unstable angina
ischaemia at rest but no significant permanent damage: negative troponin at 12 hours
72
NSTEMI vs. Unstable angina
NSTEMI and unstable may both show no abnormal ECG or st depression. Diefferentiate between them using troponin.
73
variant (prinzmetal) angina
coronary artery vasospasm
74
Investigations into ACS
Gold standard: coronary angiography
75
Chest pain management
ECG -> Toponin +ve: angiography -ve: ETT
76
Stable angina management
Minimize cardiac risk factors: control BP, lipids, and diabetes Lifestyle change all patients should receive 75mg aspirin unless contraindicated Immediate symptom relief: GTN Long-term treatment: B blocker (atenolo), CCb (verapamil), nitrates PCI: localized area of stenosis not controlled despite on medication CABG (more severe cases than PCI, usually more than 3 vessels affected)
77
Contraindication for giving beta blockers
``` acute heart failure cardiogenic shock bradycardia heart block asthma ```
78
Management of ACS
MONOBASH Immediate and assess for coronary re-perfusion therapy Morphine (analgesia) and anti-emetic (metoclopromide)
79
Management of ACS
MONABASH Immediate and assess for coronary re-perfusion therapy Morphine (analgesia) and anti-emetic (metoclopromide) Oxygen Nitrates (vasodilatation) Aspirin (300mg loading dose and copidogrel300-600mg) Beta-blockers (reduce myocardial oxygen demand) ACE-inhibitors Statins Heparin
80
Management of Acute STEMI
12-lead ECG IV access (bloods) Brief assessment ( RF and history of IHD, Examination, check if PCI contraindicated) Aspirin Morphine +anti-emetic STEMI on ECG and PCI available within 120 min YES -> Primary PCI NO-> Fibrinolysis -> transfer to monitoring
81
Post-MI complications
DARTH VADER ``` Death Arrhythmia (AF, Heart block, VT) Rupture (papillary muscle- causes acute mitral regurgitation) Tamponade Heart Failure Valve Disease Aneurysm Dressler's Syndrome/Simple pericarditis Embolism Re-infarction ```
82
Infetive endocarditis aetiology
Vegetation form as a result of organisms lodging on the heart valves during periods of bacteriaemia. Poorly penetrated by immune system. Vegetation destroys valve leaflets. Activation of immune system -> immune complexes-> vasculitis, glomerulonephritis, arthritis
83
RF for Infective endocarditis
Abnormal valve (congenital, post-rheumatic fever, calcification) Prosthetic valve Turbulent flow (patent ductus arteriosus or ventricular septal defect) bacteraemia and recent dental work
84
Infective endocarditis
Fever, malaise, pain in muscle and joints Clubbing, new regurgitant murmur (mitral most likely) or muffled heart sound Roth's spots (petechiae on retina) janeway lesions and oslers nodes splinter hemorrhage
85
Infective endocarditis
Blood: Rheumatoid factor positive, signs of infection Blood cultures Tran thoracic echo DUkes classifictaion for diagnosis of infective endocarditis Magement: antibiotics for 4-6 weeks Clinical suspicion: benzylpenicillin and gentamicin and after dependent on which organism was present Surgery valve replacement if bad Fatal if not treated Even if treated 15-30 % mortality Complications: valve incompetence, abscess, heart failure, renal failure
86
Mitral regurgitation
Retrograde flow of blood from LV to LA during systole Mitral valve damage or dysfunction: 1) rheumatic heart disease 2) Infective endocarditis 3) Mitral valve prolapse 4) Papillary muscle rupture or dysfunction (secondary to IHD or cardiomyopathy) 5) Connective tissue diseases (Ehlers danllos, marfans) May be secondary to left ventricular dilation Acute MR: symptoms of left sided ventricular failure Chronic: asympy., or palpitations, fatigue EXAM: apex beat displaced and thrusting Pan-systolic murmur, loudest at apex, radiating to axilla, (palpable as a thrill) S1 soft and S3 may be heard Mitral valve prolapse: Mid-systolic click and late systolic murmur. Click moves towards first heart sound on standing and away from first heart sound on lying down. Investigate: ECG (normal) CXR: acute mitral regurgitation may show signs of left ventricular failure Chronic mitral regurgitation shows signs of left atrial enlargement, cardiomegaly, or mitral valve calcification ECHO to monitor
87
Mitral Stenosis
Mitral valve narrowing causing obstruction to blood flow from the left atrium to the ventricle Causes: Rheumatic fever (90%), other causes: Congenital mitral stenosis, SLE, rheumatoid arthritis History: Fatigue, SOB, PND< orthopnea, palpitations (AF) may have haemoptysis (rare) ``` Exam: cyanosis, Pulse quiet or AF Apex beat undisplaced and tapping Loud first heart sound with opening snap Mid diastolic murmur Pulmonary oedema ``` Investigate: CXR: left atrial enlargement, pulmonary congestion, mitral valve calcified Transesophageal echo
88
Myocarditis
Acute inflammation of the myocardium ``` Aetiology: idiopathic: common infection: viruses (cocksackie b virus) non-infection: systemic disorders (SLE, sarcoidosis) drugs chemo agents other cocaine abuse ``` Cocksackie b virus common cause in euroope and america Chagas common cause in south america Prodromal flu like illness SOB sharp chest pain (if in association with pericarditis)
89
Necrotising fasciitis
Life-threatening subcutaneous soft tissue infection can start from relatively minor injury but can rapidly get worse Symptoms develop quickly over hours or days early: flu like symptoms, scratch , intense out of proportion pain with it late: swelling and redness in area, dark bloches on skin that turn into fluid-filled blisters Can cause symptoms of dizziness weakness confusion may be polymicrobial or due to a single organism (streptococcus pyogenes (group A strep)) Suspect in any individual with soft-tissue infection accompanied by pain over infected area. Signs and symptoms of systemic toxicity such as fever or hypothermia. Signs that raise suspicion of necrotising fasciitis: hypotension, raised creatinine, elevated CK, elevated CRP, elevated WBC with marked left shift (more immature cells), low serum bicarbonate
90
Peripheral vascular disease
Range of arterial syndromes caused by atherosclerotic obstruction of lower extremity arteries RF: smoking, diabetes, high lipids, history of CAD, stroke Most are asymptomatic Most often caused by atherosclerosis (may also be aortic coarctation, dissection, arterial embolism) Diminished pulses, Thigh or buttock pain whilst walking Acute limb ischemia: pain, parlysis, paraesthesia (pins and needles), pulselessness, cold, and pallor can get erectile dysfunction, pain worse in one leg than the other, gangrene ulcers Ankle brachial index: <0.9 duplex ultrasound
91
Permanent Pacing
Effective treatments for a variety of bradyarrhytmias. Provide electrical stimuli to cause cardiac contraction during periods when intrinsic cardiac electrical activity is inappropriately slow or absent Indications: Persisting symptomatic bradycardia, complete AV block, Mobitz type 2, sick sinus syndrome Complications: infection, bleeding, Pacmaker mediated tachycardia
92
Pulmonary hypertension
Consistently increased pulmonary arterial pressure (>20mmHg) under resting conditions Cause Primary: Idiopathic Secondary: Left sided heart failure (mitral valve disease, left ventricular failure, left atrial thrombosis) Chronic lung disease (COPD), recurrent pulmonary emboli, increased pulmonary blood flow (Atrial-septal defect, ventricular septal defect, patent ducturs arteriosus), connective tissue disease (SLE), drugs (amiodarone) History: Dyspnoa on exertion, chest pain, syncope, tiredness. symptoms of underlying cause (chronic cough) Increased JVP, Left parasternal hieve (right V hypertrophy) graham steel murmur Loud pulmonary component of S2 Investigation: CXR cardiomegaly (right ventricular enlargement, right ventricular dilatation), prominent main pulmonary arteries ECHO: right ventricualr hypertrophy visualise Lung function test: chronic lung disease Lung function test VQ scan: pulmonary embolism?
93
Supra-ventricular tachycardia
Tachycardia arising above the bundle of his re-entrant circuit 1> AVRT (wolf parkinson white syndrome - bundle of kent) 2> AVNRT (re-entrant circuit around av node) ECG signs when in tachycardia: No p wave. but regular. narrow complex tachycardia ``` ECG signs when in sinus rhythm: short pr interval AVRT ONLY (delta wave) ```
94
Tricuspid regurgitation
Backflow of blood from the right ventricle to the right atrium during systole. Conegenital: Ebstein anomaly Functional: valve prolapse Rheumatic heart disease Infective endocarditis Fatigue, SOB, palpitations, headaches Exam: Increased JVP, parasternal heave, pansystolic murmur heard best at lower left sternal edge, louder on inspiration Right sided cardiomegaly
95
Varicose veins
Subcutaneous permanently dilated veins (3mm or more diameter) when measured in a standing position causative only: Previous DVT and genetics venous valve dysfunction RF: age, FH, female, increasinf number of births, DVT Dilated tortuous veins, leg cramps and fatigue, haemosiderin deposition, restless leg, corona phlebectatica Duplex ultrasound graduated compression stockings -> phlebectomy or sclerotherapy -> ablative procedures
96
vasovagal syncope
see Neural syncope Occurs in response to stimuli, e.g. emotion/pain/fear/prolonged standing
97
Venous ulcers
Due to sustained venous hypertension, which results from chronic venous insufficiency. Valves incompetent. Results in skin and subcutaneous hypoxia, then a minor trauma leads to ulcer. RF: Varicose veins, DVT, chronic venous insufficiency, obesity, leg fracture More common than arterial ulceration. women more prone. Features: Gaiter area (particularly around malleoli) Oedema (worse towards end of day) haemosiderin deposition (brown pigmentation of skin) Lipodermatoscleosis (skin hardening, red, painful, inverted bottle appearance) Atrophie blanche (white area) Usually warm skin and foot pulses present Ulcer, oval, flat, no raised edges, Management: Ulcer cleaned and dressed + compression therapy + pentoxifylline ( aids ulcer healing)+treat pain, infection, oedema, eczema) Surgical debridement if medical treatment not effective
98
Systolic murmurs
Aortic stenosis Pulmonary stenosis Mitral Regurgitation Tricuspid Regurgitation
99
Diastolic murmurs
Mitral stenosis Tricuspid stenosis Aortic regurgitation Pulmonary regurgitation
100
Graham steel murmur
Associated with pulmonary regurgitation. High pitched early diastolic murmur Heard best at the left sternal edge at full inspiration.
101
Austin Flint
Aortic Incompetence ( aortic regurgitation) Murmur is due to turbulent blood flow hitting the anterior leaflets of the mitral valve Mid- diastolic murmur Heard best at apex
102
Syncope definition
1. Loss of consciousness 2. Transient 3. Global cerebral hypo-perfusion
103
Syncope classification
1. Neural 2. Postural 3. Structural (Life-threatening) 4. Arrhythmic (Life-threatening) SNAP
104
Neural Syncope
Inappropriate autonomic reflex in response to a trigger. 1. Vasovagal syncope - common - young people - after emotional response, such as fear, anxiety, disgust, or prolonged standing 2. Situational syncope - occurs consistently after a specific trigger ( cough, micturition) 3. Carotid sinus hypersensitivity - occurs after mechanical manipulation of the carotid sinus (e. g. looking over shoulder) Essential points in neural history: - Precipitant/trigger: If situational, ask if trigger consistently causes syncope - Warning symptoms: classic pre-syncopal symptoms of nausea, sweating, feeling faint - Position: standing in vasovagal Investigation: Lying and standing BP Tilt table testing Carotid sinus massage -difficult
105
Neural syncope differentials
``` Vasovagal situatonal syncope seizures TIA/Stroke Carotid sinus hypersensitivity ```

Medicine Year 3 (13 decks)

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