List I - Core Conditions Flashcards

Question

Where do the triggers come from in most AF?

Answer 1

* Pulmonary veins

Answer 2

Used to assess a person's stroke risk. Adding together the points allocated to each risk factor gives a total which guides the decision to offer anti-thrombotic treatment * CHF/LVHF with REF or people with recent HF requiring hospital = 1 * HTN (defined as 140/90 on at least 2 occasions) or current anti-hypertension treatment = 1 * Age > or equal to 75 years = 2 * Diabetes mellitus (fasting glucose > 7mmol/L or more or treatment with oral hypoglycaemic drugs and/or insulin = 1 * Stoke/TIA = 2 * Vascular disease (prior MI, peripheral arterial disease or aortic plaque) = 1 * Age 65-74 = 1 * Sex (female) = 1

Answer 3

* Identifies modifiable bleeding risk factors that can help you to advise patients to manage

Answer 4

Identifies people at high risk of bleeding who could benefit from increased vigilance and correction of modifiable risk factors 1 point score for each of the following risk factors: * Hypertension (uncontrolled >160 systolic) * Abnormal liver function * Abnormal renal function * Stroke (previous history, particularly lacunar strokes) * Bleeding (history or predisposition) * Labile INR's <60% of time in therapeutic range * Elderly (aged over 65 years) * Drugs (antiplatelet agents or NSAID's) * Harmful alcohol consumption

Answer 5

* No flying restrictions provided AF is stable and has not recently worsened or become more symptomatic

Answer 6

* Advise the patient it is their responsibility to inform the DVLA of any condition that may affect their ability to drive * Group 1 (cars and motor bikes) - driving must cease if the arrhythmia is likely to cause incapacity, driving may be permitted when the underlying cause has been identified and controlled for at least 4 weeks, DVLA need not be notified unless there are distracting or disabling symptoms * Group 2 ( lorries and buses) - disqualified if the arrhythmia has caused or is likely to cause incapacity, driving may be permitted when the arrhythmia is controlled for at least 3 months, LV fraction is equal to or greater than 0.4 and there is no other disqualifying condition

Answer 7

* At least annually

Answer 8

* Within 1 week of starting the rate control treatment (or any dose alteration), check that the person is tolerating the drug and review the symptoms (palpitations, SOB, fatigue), heart rate and BP * Target resting ventricular rate at 60 to 80 BPM at rest and between 90 and 115 BPM during moderate exercise * Alternative rate control drug if they are not tolerating the current one * If HR and/or BP are not controlled consider one of the following: - Increase dose - Combination treatment (beta blocker, digoxin, diltiazem - seek specialist advice) * If symptoms are not controlled by combination treatment, refer promptly (within 4 weeks) to a cardiologist

Answer 9

* For people taking warfarin - assess INR, daily or alternate days initially until within the therapeutic range (between 2 and 3) on two consecutive occasions, then monitor twice weekly for 1-2 weeks, followed by weekly measurements untilat least two INR measurements are within therapeutic range, then longer intervals e.g. 12 weeks agreed locally * Calculate the time in therapeutic range at each subsequent visit to ensure that the person is maintaining an INR between 2 and 3 over a longer period of time - Calculate the TTR over a maintenance period of at least 6 months - Use a validated method of measurement such as the Rosendaal method for computer based dosing or proportion of tests in range for manual dosing - Exclude measurements taking in the first 6 weeks of treatment

Answer 10

* TTR <65% * Two INR values of 5 or higher or one INR value higher than 8 within the past 6 months * Two INR values <1.5 within the past 6 months

Answer 11

* Correct the factors contributing to poor control if possible: - Impaired cognitive function - Poor adherence to prescribed treatment - Illness - Use of concurrent medications that may interact with warfarin - Diet and alcohol

Answer 12

* Consider switching to a DOAC (apixaban, edoxaban, dabigatran or rivaroxaban) * Good compliance is required for DOAC due to shorter half life * No specific anti-dote to DOAC

Answer 13

* Check for symptoms of AF at rest and during exercise and assess HR * Review the medications - symptom control, compliance and identify and manage any drug interactions * Increase dose/alter medication if symptom control is poor * Review CHA2DS2VASC stroke risk and HASBLED annually (routinely when a person is 65 + or develops DBM, HF, CVD, stroke, TIA or VTE) * Anticoagulate if needed * If already taking anticoagulant manage any modifiable bleeding risks * Assess and manage CVD risk - QRISK2 * Assess and manage complications of AF

Answer 14

* DOAC's | - Apixaban, Rivaoxaban, Dabigadran

Answer 15

* DOAC or warfarin | - Antiplatelets only given if needed in the management of other comorbidities

Answer 16

* 2 weeks after the stroke | - If the imaging shows a very large cerebral infarct, anticoagulation may be delayed

Answer 17

* Beta blockers * Calcium channel blockers * Digoxin (not first line but considered if the patient has coexistent heart failure)

Answer 18

* Amiodarone (if structural heart disease) | * Flecanide (if no structural heart disease)

Answer 19

* Calcium channel blocker - diltiazem

Answer 20

* No treatment required

Answer 21

* Coexistent heart failure * First onset AF * Obvious reversible cause

Answer 22

* Treat the underlying cause if there is one e.g. infection * DC cardioversion when there is life threatening haemodynamic instability caused by new onset AF * Pharmacological cardioversion

Answer 23

* Group of paroxysmal SVT (junctional arrhythmias) with accessory pathways of specialized conducting tissue between atria and ventricles * Episodes are characterised by the sudden onset of a narrow complex tachycardia, typically an atrioventricular nodal re-entry tachycardia (AVNRT) * Atrio-ventricular re-entry tachycardia (AVRT) are extranodal * Wolf-Parkinson-White Syndrome (WPW) - is pre-excitation with accessory pathway (bundle of Kent) conducting atrial depolarisation directly into ventricular myocardium

Answer 24

* 35/100,000/year * M:F = 1:2 (<65yrs) * M:F = 3:1 (>65yrs) * AVNRT:AVRT = 2:1

Answer 25

* Is the rhythm regular or irregular?

Answer 26

* Vagal manoeuvres * Adenosine 6 mg rapid IV bolus - No effect give 12mg - No effect give further 12mg * Monitor ECG continuously

Answer 27

* Sinus rhythm achieved? * Yes - Probable re-entry paroxysmal SVT - Record 12 lead ECG in sinus rhythm - If SVT recurs consider anti-arrhythmic prophylaxis * No - Seek expert help - Possible atrial flutter - Control rate e.g. beta blocker

Answer 28

* Probably AF - Control rate with beta-blocker or diltiazem - If in heart failure consider digoxin or amiodarone - Assess thromboembolic risk and consider anticoagulation

Answer 29

* ECG - regular P waves may be visible between QRS, regular narrow QRS tachycardia (c.150-200bpm), compare to previous ECG * Screen for WPW - short PR, delta wave (slurred upstroke of QRS due to myocyte-myocyte transmission as opposed to conduction via specialised conducting tissue * Electrophysiological study - induces a tachycardia to map the site of the re-entrant pathway

Answer 30

* Valsalva maneuver - hold nose, blow out * Cough * Gag * Cold water on face * Carotid sinus massage - one side only - Lateral to thyroid, massage the carotid artery - this triggers baroreceptor reflex and increases vagal tone, affecting SA and AV nodes

Answer 31

* Paroxysmal SVT - often self terminating narrow complex tacycardia's * Recurrence - 80% with 1 month (20% 2 yrs) * Usually self terminating in the young and with no other structural heart disease

Answer 32

* Broad complex tachycardia (<0.12s) originating from a ventricular ectopic focus * Has the potential to precipitate ventricular fibrillation and hence requires urgent treatment

Answer 33

* Monomorphic VT: Most commonly caused by myocardial infarction * Polymorphic VT: Subtype of polymorphic VT is torsades de pointes which is precipitated by prolongation of the QT interval

Answer 34

* Congenital - Jervell-Lange-Nielsen syndrome (includes deafness and is due to abnormal potassium channel) - Romano-Ward syndrome (no deafness) * Drugs - Amiodarone, sotalol, class 1a antiarrhythmic drugs - TCA's, fluoxetine - Chloroquine - Terfenadine - Erythromycin * Others - Hypocalcaemia - Hypokalaemia - Hypomagnesaemia - Acute MI - Myocarditis - Hypothermia - Subarachnoid haemorrhage

Answer 35

* Monomorphic VT: Re-entrant circuits in anatomically abnormal substrate e.g. MI scar tissue * Polymorphic VT: Abnormal activity in ventricular myocardium, often resulting from triggers that increase the QT interval

Answer 36

Symptoms * Palpitations, especially if post MI, collapse, angina (underlying IHD), SOB (underlying heart valve disease/cardiomyopathy) * PMH - recent MI, valvular disease * DH - anti-arrhythmics Signs * Weak pulse (or absent), RJVP (cannon waves), HS1 variable intensity, +/- hypotension

Answer 37

* SVT with aberrant conduction e.g. atrial fibrillation/flutter

Answer 38

* Bloods - U and E's, Mg2+, cardiac markers (if chest pain) * Radiology - transthoracic echocardiogram if suspected HF/heart valve disease * St - ECG and compare with previous to determine QT baseline - Monomorphic VT: regular, 120-190bpm (may be independent electrical activity: dissociated P waves) - Polymorphic VT: less regular, more chaotic, phasic variation in QRS (torsades des pointes: twisting of the points) - Electrophysiological studies if recurrent, symptomatic VT

Answer 39

* If the patient has adverse signs - Systolic BP <90 mmHg - Chest pain - Heart failure - Syncope * Immediate synchronised DC shock is indicated - Conscious patients require sedation or GA for cardioversion

Answer 40

* Broad QRS (>0.12s), regular - Amiodarone 300mg IV over 20 - 60 mins, then 900mg over 24 hrs - Ideally administered through a central line * Alternatives - Lidocaine: use with caution in severe LV impairment - Procainamide * If drug therapy fails - Electrophysiological study - Implantable cardioverter-defibrillator (ICD) - Particularly indicated in patients with significantly impaired LV function

Answer 41

* Risk of syncope * Cardio-genic shock * Cardiac arrest * Sudden cardiac death * Torsades de pointes

Answer 42

* Long term medication (all shown to improve LV function) - Beta blockers - Amiodarone - ACEi - Spironolactone * Revascularisation - For severe CAD (PTCA/CABG) * Implantable cardioverter defibrillator (ICD) - If had cardiac arrest - Spontaneous sustained VT with LV dysfunction - Haemodynamically significant sustained VT resistant to drug therapy

Answer 43

* Compromised mitral valve competence by disease affecting any part of the mitral apparatus (annulus, leaflets, chordae, papillary muscles, LV function)

Answer 44

* Narrowing of mitral valve orifice (treatment required if <2.5cm : normally 4-6cm)

Answer 45

* Primary - Myxomatous degeneration (Ehler's Danlos/Marfan's) - IHD - Endocarditis - Rheumatic fever - Cardiomyopathy - Congenital - Appetite suppressants: fenfluramine * Secondary (functional) - Ventricular dilation due to HF

Answer 46

* Rheumatic fever * Congenital * Mucopolysaccharidoses * Endocardial fibroelastosis * Malignant carcinoid * Prosthetic valve

Answer 47

* F>M * More common in India due to rheumatic fever * Usually presents >40 yrs

Answer 48

* Myxomatous degeneration - Fibroelastic tissue defect (mitral valve prolapse/Barlow's syndrome) - Annular dilatation - Posterior leaflet prolapse - Elongated chordae * IHD - Episodic/reversible MR - Posterior papillary muscle ischaemia +/- papillary muscle infarct (MI) - Rupture - Acute MR - Acute LVF * Acute rheumatic fever - Annular dilatation - Leaflet thickening/calcification * Acute endocarditis - Bacterial destruction - Perforates leaflet - Chordae rupture

Answer 49

* Rheumatic fever * Rheumatic carditis * Leaflet thickening/commissural of chordal fusion * Narrowed orifice

Answer 50

* LV dilatation * Increases end diastolic volume * Increases stroke volume * Leads to irreversible LV dysfunction

Answer 51

* Reduced cardiac output * Severe left atrial enlargement * Pressure on organs (oesophagus, dysphagia/Ortner's syndrome; recurrent laryngeal: hoarse voice)

Answer 52

* Both - Asymptomatic or SOB - Fatigue - Palpitations (AF) - CVA (thrombus) - Haemoptysis (pulmonary HTN) * MS - Chest pain - Pressure symptoms - Hoarseness - Dysphagia - Chest infections

Answer 53

* MR - Displaced thrusting apex - RV heave - Soft S1, loud S2 - Pansystolic murmur (apex in axilla) * MS - Low volume pulse - Malar flush (reduced CO) - Undisplaced tapping apex (palpable S1) - Loud S1 - Opening snap (pliable valve) - Mid diastolic rumbling murmur (apex in L lateral position) - Graham-Steell murmur (systolic murmur of PR due to pulmonary HTN in severe MS) * Causes - IHD, endocarditis * Complications - AF - RHF from pulmonary hypertension (RJVP, loud P2, RV heave, peripheral oedema)

Answer 54

* Left heart murmurs | - MR, MS, AR, AS, flow murmurs (infection), valve replacements

Answer 55

* Chest x-ray (both) - LA enlargement (double R heart shadow) - Calcified mitral annulus in rheumatic heart disease - Features of CCF * MR - Cardiomegaly * MS - Splaying of carina - Tenting of L heart border * Transthoracic echocardiogram (TTE) / Transoesophageal echocardiogram (TOE) - Quantify extent of LV function (ejection fraction) - Measure LV dimensions (end diastolic and end diastolic diameter) * MR - Doppler to assess size/site of regurgitant jet * MS - Measure size of mitral orifice

Answer 56

* Both - ECG - AF, P-mitrale if sinus rhythm (LA enlargement) - MR - Previous MI, LVH (S wave in V1 and R wave in V5/6 >35mm) - MS - RVH from chronic pulmonary HTN - R wave taller than S wave in V1 and RAD * Left heart catheterisation/LV angiography - Replaced by TTE (but used with coronary angiography before valve surgery in selected patients, previous valvotomy, other valve disease, angina, calcified mitral valve, pulmonary HTN

Answer 57

* Both - Antibiotic prophylaxis before dental treatment - MR - stable in most cases of mild MR, only selected patients require surgery - Surveillance - yearly clinical and TTE assessment if MR (mild/moderate without LV dysfunction/pulmonary HTN) or MS (asymptomatic mild: orifice >1.5cm without evidence of pulmonary HTN)

Answer 58

* Warfarin - if AF (plus rate control) | * Loop diuretic - if pulmonary oedema

Answer 59

* Indications * MR - NYHA 2-4 SOB, TTE evidence of LV dysfunction/ejection fraction <60%, LV end diastolic diameter >50mm * MS - Treat with moderate to severe <1.5cm or mild-moderate with increased pulmonary artery pressure >60mmHg or PCWP >25mmHg, transmitral gradient pressure >15mmHg * Benefits - Prolonged survival by improved LV function (repair/replacement), avoidance of long term warfarin in patients with sinus rhythm (repair/replacement)

Answer 60

1) Percutaneous balloon mitral commissurotomy * Indications - MS only if favourable anatomy (pliable, non-calcified valve, minimal chordae fusion * Procedure - Balloon tipped catheter via femoral artery into mitral valve, inflate balloon to widen orifice * Problems - severe MR 10%, embolism, MI, mortality 2% 2) Mitral valve repair * Indications - Procedure of choice for both MR/MS * Procedure - Median sternotomy, cardiopulmonary bypass, heart stopped with cardioplegia solution, access via LA - Repair - MR: resection/patch repair/chordae shortening/annuloplasty ring, MS: Commissurotomy * Problems - 5% risk conversion to valve replacement 3) Mitral valve replacement * Indications - If repair impossible (multiple extensive lesions, severe calcification)/failed * Types - Mechanical (young: durable, need warfarin), tissue (old: shorter lifespan, no anticoagulation) * Problems - Disruption by sutures (3rd degree heart block, MI, ischaemia) * Post op - on ICU, warfarin for 6 weeks (or life if mechanical valve)

Answer 61

* Both - AF, emboli (CVA), pulmonary HTN - MS - bronchial/oesophageal obstruction, infective endocarditis

Answer 62

* MR - poor if pulmonary HTN, surgery (5-10 yr survival rates for repair vs replacement: 83%-68% vs 69%-52%) * MS - 60% 10 yr survival - reduced to 15% with functionality limiting symptoms, post surgery 5-10 yrs survival is 75%-56%

Answer 63

* Antibiotic prophylaxis | - Before dental treatment (and oral penicillin against recurrent rheumatic fever if that is the cause)

Answer 64

* Narrowing of the aortic valve orifice * Severe <1cm * Moderate 1-1.5cm * Mild 1.5-3cm * Normal 3-4cm * Better measurement is aortic valve orifice area index - Orifice area/body surface area - normal 2.2, severe <0.6

Answer 65

* Incompetence due to any disease affecting the aortic valve or aortic root

Answer 66

* AS - Calcific degeneration - Senile - Congenital - bicuspid valve leads to fibrosis/calcification, William's syndrome - Rheumatic fever * AR - Aortic valve disease - calcific degeneration, infective endocarditis, rheumatic fever, congenital bicuspid valve - Aortic root disease - dilatation (idiopathic including age related?Marfan's, aortic dissection, Takayasu's arteritis - Rare - Trauma, RA, SLE, AS, Reiter's syndrome, psoriatic arthropathy, IBD

Answer 67

* AS - increases with age, 3% 75-86 yrs | * AR - mild is common, M:F = 1:1.5

Answer 68

* Chronic (compensated) - AS progressing at 0.12cm/yr - LV compensates with concentric hypertrophy - Increased force of contraction to increase pressures - Reduced LV compliance - LV unable to relax/refill properly - Diastollic dysfunction - Eventually hypertrophy cannot match progression - Systolic HF - Angina (unable to meet O2 demand of hypertrophied muscle * Subaortic stenosis - Congenital membrane * Supra-valvular aortic stenosis - Williams syndrome - HCM (narrow LV outflow tract from gross septal hypertrophy (not true AS))

Answer 69

* Severe acute (endocarditis, ascending aortic dissection, chest trauma) - Limited capacity of LV to adapt to sudden volume overload - Pulmonary oedema * Chronic (compensated) - LV dilatation (compliance) - Increased SV and CO, often normal ejection fraction and LV dysfunction usually reversible in early stages

Answer 70

* Symptoms - Asymptomatic or angina - Exertional syncope - SOB (also dizzy faints) * Signs - Low volume slow rising pulse - Narrow pulse pressure - Palpable thrill over A area - Undisplaced heaving apex (palpable S2) - Quiet A2 (with progression S2 may reverse) - Ejection systolic murmur (A area - carotids, length correlates with severity not intensity) - Ejection click (if pliable valve)

Answer 71

* Symptoms - Asymptomatic (many years) - SOB on exertion - Orthopnoea - Fatigue - Palpitations - Angina - Syncope - CCF * Signs - Quincke's sign (capillary pulsations of nail bed) - Large volume collapsing pulse - Wide pulse pressure - Corrigan's/De Musset's signs (head bobbing) - Displaced thrusting apex - Early diastolic blowing murmur at LSE with bell sitting forward (may also hear ejection systolic flow murmur at A area from increased flow) - Duroziez's sign (occlude temporal artery with 2cm prox. to stethoscope gives systolic murmur/2cm distal give diastolic murmur) - Traube's sign - pistol shot sound over femoral arteries - Austin-Flint murmur - flutter of anterior mitral valve cusp from regurgitant stream: severe AR * Complications - CCF, RJVP (later as RHF develops) * Causes of AR - Endocarditis, Marfan's (aortic dissection/dilation, mitral valve prolapse, lens dislocation, flat cornea, increased axial length, tall stature, pectus carinatum/excavatum, arm span-height ratio >1.05, scoliosis, joint hypermobility, Steinberg's sign, high arched palate, elongated asymmetrical face

Answer 72

* Best heard on expiration | - AS, AR, MS, MR, flow murmurs (infection), valve replacements, HCM

Answer 73

* Chest x-ray (both) * AS - post stenotic aortic dilatation, calcified aortic arch, cardiomegaly (late) * AR - dilatation of ascending aorta, cardiomegaly * TTE - to confirm grade/severity

Answer 74

* ECG (both) - LVH and LV strain (poor R wave progression from V1-V6) AS - P-mitrale, LAD (L anterior hemi block), LBBB, 3rd degree heart block (calcified ring) * Left heart catheterisation - Before cardiac surgery to assess coronary arteries if IHD suspected or when non-invasive assessment of AS inconclusive (can make direct measurements of aortic ventricular gradient)

Answer 75

* Patient education - Both need antibiotic before dental treatment - AS moderate/severe should avoid competitive sports * Surveillance (clinical and TTE assessment) - AS 5 yearly (asymptomatic/mild), 2 yearly (moderate), yearly (severe) - AR - Yearly (asymptomatic with normal ejection fraction >50%)

Answer 76

* Severe AS - Diuretics, digoxin, cautious ACEi use (relieve pulmonary oedema) * Severe AR - Vasodilators to reduce SBP (nifedipine, ACEi)

Answer 77

* AS - severe with symptoms * AR - NYHA 3-4, SOB or CCS 2-4 angina, LV impairment (ejection fraction <49% or LV end diastolic diameter >55cm, or NYHA 2 SOB with progressive LV dilation/declining ejection fraction

Answer 78

* Percutaneous valvuloplasty - AS - not fit for surgery * Aortic valve replacement - Tissue valve (better for >65yrs, women of child bearing age, contact sports) - Mechanical valve (anticoagulation needed, lasts longer) * Procedure - Median sternotomy - Cardiopulmonary bypass - Heart stopped with cardioplegia solution - Native valve excised (excess Ca2+ removed) - New valve sutured into place * Problems - CVA - Permanent pacemaker required if injury to conduction system - Mortality 2%

Answer 79

* AS - CVA (embolisation of calcific debris), sudden death (ventricular arrhythmias) * AR - LV dysfunction, CCF (worse outcome if CCF >12 months)

Answer 80

* AS - Life expectancy reduced by 5 yrs (with angina), 3 yrs (with syncope), 2 yrs (with SOB) - After surgery 5-10 yrs survival 78-55% * AR - 10% following symptom onset

Answer 81

* Antibiotic prophylaxis before dental treatment | * Avoid competitive sports if moderate to severe AS

Answer 82

* Microbial infection of the endothelial lining of the heart (heart valve infection is most common clinical manifestation)

Answer 83

* Strongest RF is previous episode of endocarditis * Following types of patients are affected: - Previously normal valves (50%, typically acute presentation) - Mitral valve is most commonly affected - Rheumatic valve disease (30%) - Prosthetic valves - Congenital heart defects - IVDU - typically causing a tricuspid lesion - Others - recent piercings

Answer 84

* Staphylococcus aureus (most common in developed countries and particularly common in acute and IVDU presentations) * Coagulase negative staphylococci such as staphylococcus epidermis commonly colonize indwelling lines and are most cause of endocarditis in patients following prosthetic valve surgery, usually the result of perioperative contamination (After 2 months the spectrum of endocarditis causing organisms returns to normal i.e. staph aureus most common * Streptococcus viridans (most common in developing countries) and accounts for around 20% of cases - Two most notable viridans streptococci are: - Streptococcus mitis - Streptococcus sanguinis - Both commonly found in the mouth in dental plaque so endocarditis caused by these are due to poor dental hygiene or following a dental procedure * Streptococcus bovis is linked to colorectal cancer - Subtype streptococcus gallolyticus is most linked with colorectal cancer * Non-infective: SLE (Libman-Sacks), malignancy: marantic endocarditis * Culture negative causes - Prior antibiotic therapy - Coxiella burnetii - Bartonella - Brucella - HACEK: Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella

Answer 85

* 4/100000/year (up to 15/100,000 >50yrs * M:F = 1:1 * 50% occur on normal valves, 10% cultures are negative

Answer 86

Symptoms * Non specific flu like symptoms (septic signs) - Fever, night sweats, rigors, malaise, weight loss, anaemia * Acute heart failure, embolic effects - Neurological deficits (CVA), abdominal pain (splenic infarcts), lung (if R sided) * Immune complex mediated - Haematuria (glomerulonephritis), arthralgia * Heart block (aortic root abscess) - Syncope, dizzy, palpitations Signs * Clubbing * Splinter haemorrhages (>5) * Osler's nodes * Janeway lesions * Skin petechiae * Pale conjunctivae (anaemia) * Roth spots (boat shaped retinal haemorrhages with pale centres) * New/changing murmur (AR/MR) * Signs of LVF (rare) * Abdominal distention (splenomegaly) * Signs of renal failure

Answer 87

Modified Dukes Criteria * Diagnosis of infective endocarditis can be made if: - Pathological criteria positive, or - 2 major criteria, or - 1 major and 3 minor criteria, or - 5 minor criteria

Answer 88

* Positive histology or microbiology of pathological material obtained at autopsy or cardiac surgery (valve tissue, vegetations, embolic fragments or intracardiac abscess content)

Answer 89

* Positive blood cultures - Two positive blood cultures showing typical organisms consistent with infective endocarditis, such as Streptococcus viridans and the HACEK group, or - Persistent bacteraemia from two blood cultures taken >12 hours apart or 3 or more positive blood cultures where the pathogen is less specific such as Staph aureus and Staph epidermidis, or - Positive serology for Coxiella burnetii, Bartonella species or Chlamydia psittaci, or - Positive molecular assays for specific gene targets * Evidence of endocardial involvement - Positive echocardiogram (oscillating structures, abscess formation, new valvular regurgitation or dehiscence of prosthetic valves), or - New valvular regurgitation

Answer 90

* Predisposing heart conditions or IVDU * Microbiological evidence does not meet major criteria * Fever >38c * Vascular phenomena: major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions, petechiae or purpura * Immunological phenomena: glomerulonephritis, Osler's nodes, Roth spots

Answer 91

* FBC (low Hb, normal MCV, raised WCC) * U and E (cause or aminoglycosides use) * LFT * CRP raised/ESR * Mg2+ * Blood cultures (liase with micro) x3 from different sites (6hrs apart) at peak fever (over 24h, or 12h if severely ill) * If severe sepsis or septic shock, take 2 sets of blood cultures at different times in the first hour before starting empirical therapy ``` Paired serology (if culture -ve) - Detect Abs - Coxiella burnetti, Chlamydia psittaci, Mycoplasma, Bartonella, Candida ```

Answer 92

* MSU - Dipstick (haematuria, proteinuria, glomerulonephritis/renal infarct)

Answer 93

* Chest x-ray - cardiomegaly * TTE - oscillating masses on valve/supporting structures (if >2mm), regurgitation jets, intracardiac fistulae, abscesses (TOE better for aortic root abscess/mitral lesions), mycotic aneurysms of aortic root * TOE - if TTE inadequate from poor images/-ve despite strong clinical suspicion (use if suspect prosthetic valve IE)

Answer 94

* ECG (liase early with cardiology) | - Prolonged PR, 3rd degree AV block (aortic root abscess)

Answer 95

* Patient education | - Maintain good oral health, risks of invasive procedures (piercings, tattooing, IVDU)

Answer 96

* Empirical treatment (Leeds Pathways) * Ideally blood cultures first * Native valve - Vancomycin IV and Ciprofloxacin IV * Prosthetic valve - Vancomycin IV, Gentamicin and Rifampicin

Answer 97

* Severe valvular incompetence * Aortic abscess (often indicated by a lengthening PR interval) * Infections resistant to antibiotics/fungal infections * Cardiac failure refractory to standard medical treatment * Recurrent emboli after antibiotic therapy * Haemodynamic instability (emergency: acute HF from free MR, AR)

Answer 98

* 1/3 patients require surgery for IE, risks of the surgery are similar to normal valve replacement but increase with severity of infection

Answer 99

* Cardiac - perforated valve leaflets, papillary muscle rupture, AR/MR (acute LVF/cardiogenic shock), fistulae (from infection extension), abscess (if involves fibrous skeleton of heart, usually aortic root - heart block may result), mycotic aortic aneurysm * Embolism (sterile/septic emboli from valve vegetations) - CVA, cerebral abscess, skin/mucous membranes (petechiae), eye (retinal haemorrhages), lung (septic emboli from R sided endocarditis), spleen (splenic infarcts), kidneys (renal infarcts), coronary arteries (MI: rare) * Immunological - Glomerulonephritis, arthralgia, arthritis, (RhF may be falsley +ve)

Answer 100

* 5-50% overall * 30% staphylococci * 14% enterococci * 6% streptococci

Answer 101

* NICE recommend the following do not require prophylaxis: - Dental procedures - Upper and lower GI tract procedures - GU tract including urological, gynaecological and obstetric procedures and childbirth - Upper and lower respiratory tract, includes ENT and bronchoscopy procedures * Guidelines do however suggest: - Any episodes of infection in people at risk of infective endocarditis should be investigated and treated promptly to reduce the risk of endocarditis developing - If a person at risk of developing endocarditis is receiving antimicrobial therapy due to a procedure at a site where there is suspected infection they should be given an antibiotic that covers organisms that cause infective endocarditis

Answer 102

* Blockage of the main lung artery or one of its branches * Usually embolism has travelled from elsewhere to reach the lung * Common source is DVT - 15% of DVT's migrate to form PE's * Two are often combined in the term venous thromboembolism (VTE) * Other causes include air, fat, talc and amniotic fluid

Answer 103

Signs: * Tachycardia * Hypotension (massive PE) * Raised JVP * Pleural rub (rare) * May have no signs

Answer 104

* Classically the chest will be clear * SOB * Chest pain (usually pleuritic) * Cough * Haemoptysis (<5%) * Associated leg swelling * Collapse

Answer 105

* Current DVT * Immobility * Major surgery * Long bone fracture * Active malignancy * Oral contraceptive pill * Pregnancy

Answer 106

* Pulmonary Embolism Severity Index | - Predicts 30-day mortality of patients with pulmonary embolism using 11 clinical criteria

Answer 107

* Pneumonia * LRTI * ACS * Pleurisy * MSK chest pain * Upper GI symptoms

Answer 108

[Plain film x-ray is necessary before both] * * CT pulmonary angiogram * V/Q scanning (women age 40 and younger and pregnant women)

Answer 109

* Saddle embolus seen | * Danger is a piece could break off

Answer 110

30 mortality after a PE * I 0-1.6% * II 1.7-3.5% * III 3.2-7.1% * IV 4.0-11.4% * V 10-25%

Answer 111

* Wells score

Answer 112

* Score 4 or greater = high chance of PE diagnosis | * Score <4 = low chance of PE diagnosis

Answer 113

* DOAC's are first line treatment for most people with VTE e.g. Apixaban, Rivaroxaban

Answer 114

* NICE support the use of a validated risk stratification tool e.g. PESI score * Key requirements for outpatient management would clearly be haemodynamic stability, lack of comorbidities and support at home

Answer 115

* Thrombolysis - Now recommended as the first line treatment for massive PE where there is circulatory failure e.g. hypotension - Other invasive approaches should be considered where appropriate facilities exist

Answer 116

* Consideration for an IVC filter * Work by stopping clots formed in the deep veins of the leg from moving to the pulmonary arteries * IVC filter use is currently supported by NICE guidelines, other studies suggest weak evidence base

Answer 117

* Text book triad is pleuritic chest pain, dyspnoea and haemoptysis * PIOPED study 2007 looked at frequency of different symptoms and signs in patients with PE and reported the following: - Tachypnea (respiratory rate >20/min) - 96% - Crackles - 58% - Tachycardia (heart rate >100/min) - 44% - Fever (temperature >37.8c - 43%

Answer 118

* PERC rule * Low probability is defined as <15% although it is clearly difficult to quantify such judgements * If suspicion of PE is greater than this then patients should be assessed using the 2 step Wells score

Answer 119

* Only use in patients with a useful result - Not after surgery - Not in pregnancy - Not after trauma - Not in sepsis * Use a risk score (Wells) to identify patients level of risk

Answer 120

1) PE possible 2) Stratify risk 4+high or <4 low using Wells score 3) High=CTPA, Low=D-Dimer 4) Positive D-Dimer= CTPA, Negative D-Dimer= PE excluded

Answer 121

* SI, QIII, TIII | * Sinus tachycardia most common ECG finding

Answer 122

* Enters the abdomen at T12 via the aortic hiatus, bifurcates L4 (umbilicus)

Answer 123

* Tunica intima (endothelial cells) * Elastin * Tunica media (smooth muscle) * Tunica adventitia (loose fibrous connective tissue) * Serosa (epithelial cells)

Answer 124

* Permanent localized dilatation >50% original diameter * True aneurysm - all 3 layers of wall involved * False aneurysm - only part of wall (blood collects outside vessel wall post trauma and communicates with vessel lumen)

Answer 125

* Abdominal aorta - Infra-renal between renals and iliacs - most common, juxtarenal, suprarenal * Thoracic aorta - Ascending arch/descending (most common thoracic type) * Others - Iliac, femoral, popliteal Morphology * Fusiform, saccule e.g. Berry, expansile, dissecting

Answer 126

* Stanford Classification - Type A - Involves ascending aorta - Type B - Does not involve ascending aorta

Answer 127

* Atherosclerosis (abdominal, thoracic descending arch) * Connective tissue disorder (thoracic asccending/dissection) - Marfan's, Ehler's Danlos * Hypertension (thoracic ascending) * Infection (mycotic aneurysm) - Infective endocarditis - Tertiary syphilis - Brucellosis - Salmonellosis - TB * Others - Inflammatory (Behcet's/Takayasu: smooth muslce reduced) - Congenital - Traumatic

Answer 128

* IHD * Smoking * FH (12x increase) * HTN * Hyperlipidaemia * Male * Increasing age Rupture * Smoking * Female * Low FEV1

Answer 129

* Abdominal (AAA) - Increases with age, M:F = 5:1 - 5% male >65 yrs - Unruptured 3% >50 yrs - Sites 95% infrarenal, 5% suprarenal, 30% involve iliacs * Ruptured AAA - 13th commonest cause of death world wide

Answer 130

* Artheromatous degeneration - Main contributor to true aneurysms (associated with periadventitial inflammation/fibrotic response) * Cystic medial necrosis (thoracic ascending): - Mucosal degeneration (from immune response, wall stress, proteolytic degradation of connective tissue - Increased matrix metalloprotease activity/inflammation - Degrades extracellular matrix protein of medial collagen/elastic tissue +/- cystic changes - Leads to increased lymphocyte/macrophage infiltration

Answer 131

* Initimal tear * Blood enters diseased media/cleaves it from intima * Dissection of variable length with true and false lumens (if no tear found, may be due to haemorrhage in media)

Answer 132

* T = PR | * Tension in arterial wall = pressure x radius of arterial conduit

Answer 133

* Asymptomatic - 75% abdominal (expansile O/E, calcification on x-ray) - 40% thoracic * AAA - Expanding - epigastric/back pain, blue toes (atheroembolism) - Rupture - intermittent/continuous severe epigastric pain (back, iliac fossa, groins), collapse, shock, visual disturbance, embolisation (shedding of thrombus), others (pressure symptoms, fistulation) - Thoracic (if large) - chest pain, SVC, oesophageal pressure - Dissection - severe, sudden, tearing central chest pain (back/arms/neck)

Answer 134

* AAA - Expanding - expansile/pulsatile mass (>3cm) - Rupture - Tachycardia, hypotension, flank/scrotal bruising - Dissection (sequential branch occlusion due to unfolding) - hemiplegia (carotid artery), unequal arm pulses/BP, acute limb ischaemia, paraplegia (anterior spinal artery), anuria (renal arteries), absent peripheral pulses

Answer 135

* MI * Renal colic * Acute abdomen

Answer 136

* CRP * Cardiac markers (dissection) * FBC (low Hb), clotting screen, cross match 10U packed red cells, 2U platelets and FFP * U and E's, LFT's, amylase

Answer 137

* CT/USS - Size, aortic wall thickness +/- rupture * Thoracic - TOE accurate in diagnosis * Dissection - MRI gold standard * CT and TOE - diagnostic * Chest x-ray - may show widened mediastinum (rare) * Rupture - chest x-ray +/- abdominal x-ray - Calcified aneurysm

Answer 138

* Call for vascular surgeon/anaesthetist/theatre * A - Maintain * B - (SpO2, RR) 15L NRBM * C - (pulse, HR, BP, JVP, ECG, UO - catheter) * IV access x2 bloods) * Treat shock with O negative blood (keep SBP <100mmHg as increased risk of leak if BP too high * Morphine 10mg IV and cyclizine 50mg IV * Straight to theatre - Prophylactic cefuroxime 1.5g and metronidazole 500mg IV - Insert arterial line * Open surgical repair - Clamp aorta above leak - Insert Dacron graft (tube graft if aortic/trouser graft if iliac involved, durable for 20-30 yrs) * Monitor on ICU

Answer 139

* Examination * USS/CT monitoring for size - 3.5-4cm yearly - 4-5cm 6 monthly - >5.5cm offer surgery * Lifestyle - Stop smoking - Low fat intake - Regular exercise * Cardio-pulmonary testing for suitability for surgery * Driving - Group 1 notify DVLA if >6cm (license subject to annual review) - Disqualified if >6.5cm - Can drive after successful treatment - Group 2 disqualified after >5.5cm - Can drive post successful treatment and with evidence of fitness

Answer 140

* Optimise risk factors - BP/DM - Statins (if >4) - Aspirin * Steroids - Relieve symptoms of periadventitial inflammation

Answer 141

* Large asymptomatic * >5.5cm or <5.5cm and saccular, consider fusiform * Rapidly expanding (>1cm/year) * Symptomatic * Ruptured/leaking * Active atheroembolism * Female <5.5cm

Answer 142

* Open surgery | * EVAR

Answer 143

* Revascularisation * Indications - young, fit, as long term durability required * Benefits - Gold standard (>50yr proven results) - Complete repair - <0.5% failure rate - 1 post operative scan then no more follow up * Procedure - Midline abdominal incision - Clamp aorta above leak - Aneurysm resected - Insert Dacron graft (tube graft if aortic, trouser if iliac) * Problems * During - GA needed - Aortic clamping - Long procedure * After - Haemorrhage - Infection - VTE - Distal rash - Ischaemia of leg/colon/mesentery/spine: paraparesis - False aneurysm/rupture - Aorto-enteric fistula - Anastomotic aneurysm - MI - ARF - Multi-organ failure - DIC - ARDS - Pneumonia - CVA - DVT/PE - Long ICU stay (10d) - 6wks - 4 months to recover - 5-8% mortality - 5% if elective, 10-20% severe morbidity

Answer 144

* Raised creatinine * Heart failure * ECG evidence of ischaemia * FEV1 * Increasing age * Female gender

Answer 145

* Endovascular aneurysmal repair/stenting * Indications - Unfit for open major surgery * Contraindications - If <1.5cm below renal arteries (stent has no support) - Iliaces <8mm diameter (stent cannot be passed) - Conical aneurysmal neck * Benefits (vs open) - Less invasive/no clamping - Shorter stay (2 days on normal ward, 2-4 wks for full recovery) - Less morbidity/mortality - Fewer transfusions (less blood loss) - Can be done under LA or regional (maybe GA) - Takes pressure off aneurysm which can thrombose in time

Answer 146

* Insert stent via femoral artery * Problems during - Distal embolism * After - Stent graft migration - Femoral false aneurysm - Endo-leak I at proximal or distal attachment II sac filling via branch vessel - most common 80% III from defect in graft fabric between joints in endograft IV generally porous graft - Not everyone suitable - Lifelong monitoring required (USS/CT contrast) - ARF if blocks renal arteries (and CT contrast scans needed for follow up) - High cost - May not be durable in long term (may still need open)

Answer 147

* Thoracic - Open surgery if large 6-7cm - Smaller if Marfan's Dissection - Conservative - acute type B (treat hypertension as occurs in 50%), control pain - Surgery - acute type B A to E management - get urgent cardiothoracic help - Cross match 10U - Surgery - Take to ICU - Antihypertensives - keep SBP 100-110 using IV labetalol or esmolol

Answer 148

* Rupture - 1%/yr if <5.5cm vs 25%/yr if >6cm - Thrombosis - Embolism - Pressure on other organs/structures - Aortic valve incompetence - Inferior MI (if dissection moves proximally) - Fistula between SVC/bowel

Answer 149

* CVA (carotid artery) * Exanguination (rupture) * MI (coronary artery) * Tamponade (rupture into pericardium) * AR (stretched aortic valve)

Answer 150

* Renal failure (renal artery) * Gut ischaemia (celiac/mesenteric) * Lower limb ischaemia (iliac arteries)

Answer 151

* Thoracic - 5 yr survival 70-80% * AAA - elective surgery 5%, open surgery 5-8% (10-20% severe morbidity) * Ruptured AAA - 90-95% if untreated (only 33% reach hospital, 80% of which reach theatre, 50% of which survive) 40-50% if treated * Dissection - Emergency surgery <25%

Answer 152

* AAA screening programme * Consists of a single abdominal USS for males aged 65 years * Outcome of screening is as follows: - <3cm - normal, no further action - 3-4.4cm - small aneurysm - re-scan every 12 months - 4.5-5.4cm - medium aneurysm - re-scan every 3 months - >=5.5cm - large aneurysm - refer within 2 weeks to vascular surgery for probable intervention - Only found 1/1000 patients screened

Answer 153

* Low risk rupture - Asymptomatic, aortic diameter <5.5cm i.e. small and medium - Abdominal surveillance as per indicated according to size - Optimise CV risk factors (e.g. stop smoking) * High risk rupture - Symptomatic, aortic diameter >=5.5cm or rapidly enlarging (>1cm/year) - Refer within 2 weeks to vascular surgery for probable intervention - Treat with EVAR or open repair

Answer 154

* Stanford classification - Type A - ascending aorta, 2/3 of cases - Type B - descending aorta, distal to left subclavian origin, 1/3 of cases * DeBakey classification - Type I - originates in ascending aorta, propagates to at least the aortic arch and possibly beyond it distally - Type II - originates in and is confined to the ascending aorta - Type III - originates in descending aorta, rarely extends proximally but will extend distally

Answer 155

* Type A - Surgical management, but BP controlled to a target systolic of 100-120mmHg whilst waiting intervention * Type B - Conservative management - Bed rest - Reduce BP IV labetalol to prevent progression

Answer 156

* Complications of a backward tear - Aortic incompetence/regurgitation - MI: inferior pattern often seen due to right coronary involvement * Complications of forward tear - Unequal arm pulses and BP - Stroke - Renal failure

Answer 157

* Hypertension - most important * Trauma * Bicuspid aortic valve * Collagens: Marfan's syndrome, Ehler's-Danlos syndrome * Turner's and Noonan's syndrome * Pregnancy * Syphillis

Answer 158

* Chest pain: typically severe, radiates through to the back and tearing in nature * Aortic regurgitation * Hypertension * Other features - Coronary arteries - angina - Spinal arteries - paraplegia - Distal aorta - limb ischaemia * Majority of patients have no or non-specific ECG changes * Minority of patients, ST segment elevation may be seen in the inferior leads

Answer 159

* Long saphenous vein | * Short saphenous vein

Answer 160

* Originates at the 1st digit where the dorsal vein merges with the dorsal venous arch of the foot * Passes anterior to the medial malleolus and runs up the medial side of the leg * At the knee it runs over the posterior border of the medial epicondyle of the femur bone * Then passes laterally to lie on the anterior surface of the thigh before entering an opening in the fascia lata called the saphenous opening * It joins with the femoral vein in the region of the femoral triangle at the sapheno-femoral junction in the saphenous ring (SFJ) Tributaries * Medial marginal * Superficial epigastric * Superficial iliac circumflex * Superficial external pudendal veins

Answer 161

* Originates at the 5th digit where the dorsal vein merges with the dorsal venous arch of the foot which attaches to the great saphenous vein * Passes around the lateral aspect of the foot (inferior and posterior to the lateral malleolus) and runs along the posterior aspect of the leg (with the sural nerve) * Passes between the heads of the gastrocnemius muscle, and drains into the popliteal vein (SPJ), approximately at or above the level of the knee joint

Answer 162

* Venous return - calves, venomotor tone, cardiac output * Perforating veins - blood carried from superficial to deep veins via deep fascia * Valves - prevent blood going from deep to superficial

Answer 163

* Long saccular dilations of superficial veins (often tortuous) * Classifications - Trunk varicosities - Reticular varicosities - Telangiectasia (thread veins)

Answer 164

* Primary - Idiopathic 95% - inherent vein wall weakness - Congenital valve absence (rare) * Secondary - Venous obstruction 5% - DVT, fetus, ovarian/pelvic tumour - Valve destruction - DVT - AV malformation - increased pressure - Constipation - Overactive muscle pumps

Answer 165

* Increasing age * Female * COCP * Prolonged standing * Obesity * FH * Pregnancy

Answer 166

* F>M (31% vs 17% 35-70yrs) * Increase with age * More common in developed countries

Answer 167

* Vein wall weakness * Dilatation * Separation of valve cusps * Incompetence * Increased hydrostatic pressure (gravitational) vs hydrodynamic (muscle pump) forces * Venous reflux * Venous HTN * Dilatation of superficial veins/venous pooling

Answer 168

* Aymptomatic * Pain * Cramps * Tingling * Heaviness * Restless legs * Itching especially male PMH * Previous varicose vein surgery * DVT * Thrombophlebitis

Answer 169

Inspection * Varicosities (distribution) * Oedema * Thin skin * Venous eczema (red/flakey/itchy) * Ulcers (gaiter's area above medial malleolus) * Brown staining (haemosiderin) * Oedema * Haemorrhage * Phlebitis * Atrophie blanche (white scarring of healed ulcer) * Lipodermatosclerosis (purple plaques from SC fibrous caused by chronic inflammation/fat necrosis) Palpation * Course of vein for tenderness (phlebitis) or hardness (thrombosis) * Pulses - if ulcer, exclude arterial disease Cough impulse * SFJ/SPJ for incompetence Percussion * Tap VV distally - palpate transmitted impulse at SFJ (normally interrupted by competent valves) Auscultation * Over VV for bruits (AV malformation)

Answer 170

Assess for SFJ competence * Patient supine * Raise leg to empty vein * 2 fingers on SFJ (5cm inferior and medial to femoral pulse) * Stand (keep fingers in place) If incompetent SFJ * VV do not refill until fingers removed If competent SFJ * VV refill lower down before fingers removed

Answer 171

* CEAP classification (for treatment/progression assessment) * Clinical findings - No disease - Telangiectasia - VV - Oedema - Skin changes - Ulcers (active/healing) * Etiology - Congenital, 1st, 2nd * Anatomy - Superficial - Deep - Perforating * Pathology - Reflux - Obstruction - Both

Answer 172

* Saphena varix (dilated GSV where it meets femoral vein: blue tinge)

Answer 173

* Hand held Doppler USS (identify flow in incompetent valves) - Probe applied to SFJ/SPJ - Squeeze calf or tap VV with fingers - Flow >0.5-1s indicates significant reflux * Duplex Doppler USS - Assess real time blood flow - Measure lumen diameter, compressibility, flow direction, velocity * Colour Doppler USS - If recurs - Skin changes - History of DVT/thrombophlebitis * Photoplethysmography - If suspect deep and superficial venous reflux - Measures venous filling time/efficiency of calf pump

Answer 174

* Patient education - Exercise (ankle flexion) - Elevation (15-30 mins above level of the heart) - Avoid prolonged standing - Compression stockings (grades I-IV) - Lose weight - Regular walks (calf muscle aids venous return) * Referral (vascular surgeon) - If bleeding, pain, ulceration, superficial thrombophlebitis, severe impact on QOL

Answer 175

* Treat any underlying cause if known * Injection scleropathy - Indications - below knee varicosities, no gross SFJ incompetence (not for perforator sites) - Procedure - ethanolamine (sclerosant) injected at multiple sites (intravascular granulation tissue causes fibrosis/obliterates the lumen) - Vein compressed for 1-2 wks (avoids thrombosis) - Problems - skin staining, risk of ulcers/DVT * Laser coagulation therapy - Indications - small, isolated varicosities, venous flaring, telangiectasia - Contraindications - coloured skin

Answer 176

* Types - Depend on anatomy/surgical preference - High tie strip and/or avulsions - Ligate 5 tributaries of GSV, avulse the vein distal to proximal at various points - Trendelenberg procedure - saphenofemoral ligation - Pre-procedure - venous mapping, mark varicosities on either side with indelible ink - Post-procedure - bandage legs tightly, elevate for 24 hrs - Encourage regular walking (3 miles per day - many short walks)

Answer 177

* Bleeding, ulceration, superficial thrombophlebitis * Complications of high venous BP - Brown pigmentation (haemosiderin) - Lipodermatosclerosis - Oedema - Eczema Others - DVT if proximally spreading phlebitis of long saphenous vein

Answer 178

* Lifestyle measures * Regular exercise * Elevation of legs

Answer 179

* Gradual onset of ischaemia in limbs > 2 weeks * Claudication * Critical chronic limb ischaemia - > 2 weeks recurrent rest pain needing regular analgesia - Non-healing ulcer/gangrene of foot with ankle SBP <50mmHg or toe SBP <30mmHg

Answer 180

* Atherosclerosis * Rare - fibromuscular dysplasia, vasculitis (thromboangitis obliterans/Beurger's: young heavy smokers) * Anaemia - trigger

Answer 181

* 10% >65 yrs increases with age * Initially M>F, but M:F = 1:1 by 80 yrs * 1/3 patients are DBM

Answer 182

* Subcritical stenosis * Critical stenosis * Occlusion * Ischaemia * Necrosis * Ulceration * Gangrene (dry or wet if superadded infection) * Septicaemia

Answer 183

* Intermittent claudication * Rest pain * Ulceration * Gangrene PMH * DM * MI * Angina * CVA/TIA * HTN * High cholesterol SH * Smoking * Alcohol * Diet

Answer 184

Signs * Prolonged CRT * Calves - Pain - Pallor - Pulseless - Perishingly cold - Atrophic skin - Ulcers (pain, punched out) * Buerger's test - Reactive hyperaemia (postural/dependent colour change

Answer 185

* Fontaine classification - I asymptomatic (but ABPI <1.0) - IIa mild claudication (walk >200m) - IIb moderate-severe claudication (walk >200m) - III rest pain - IV (critical ischaemia) - ulceration/gangrene

Answer 186

* Leg pain - MSK - OA/RA * Neurological - Sciatica - Radiculopathy - Neurogenic/spinal claudication - Cauda equina stenosis - Nerve entrapment

Answer 187

* FBC (low Hb, raised WCC) * Clotting screen * Group and save if angiography planned * U and E's - raised creatinine in reno-vascular disease * Lipids - risk factor * Glucose - DBM * ESR/CRP - arteritis * Syphilis serology if suspected

Answer 188

* Colour duplex USS - For localised disease to determine if the lesion is suitable for angioplasty * Contrast angiography (DSA, MRI/CT) - Pre-procedure - stop metformin on morning of procedure to avoid lactic acidosis (combined stress on kidneys of metformin and contrast) - Procedure - access site/extent of stenoses and quality of distal vessels - Post-procedure - resume metformin when renal function ok

Answer 189

* ABPI - Claudicaton 0.6-0.9 - Rest pain 0.5-0.6 - Critical ischaemia <0.5 - Impending gangrene <0.3 (if >1.0 but claudication suspected, repeat ABPI after treadmill test) - False -ve (calcified incompressible vessels in DM/CRF/severe atherosclerosis) - ECG - cardiac ischaemia (risk factor)

Answer 190

* Patient education - Exercise (supervised: 1/3 improve, 1/3 stay same, 1/3 deteriorate) - Modify risk factors - stop smoking, treat DBM/HTN, avoid beta blockers

Answer 191

* Statin - treat to target cholesterol <4-5, LDL <2-2.5) | * Aspirin 75mg/24 h po (clopidogrel if sensitive)

Answer 192

* Percutaneous transluminal angioplasty - For short stenoses, big arteries e.g. iliacs - Balloon via femoral artery in narrow segment - Stent maintains patency * Bypass graft +/- endarterectomy - For extensive atheromatous disease but good run off - Aspirin post procedure helps maintain patency in prosthetic grafts * Sympathectomy - To relieve rest pain if revascularisation is impossible * Amputation - To relieve intractable pain, prevent death from sepsis - Level must be high enough to allow healing of stump - Above knee heals better, worse rehab - Below knee heals worse, better rehab - Gabapentin for post operative phantom limb pain - may be more effective if started before surgery

Answer 193

* Worse 5 survival for above knee vs below knee amputation (22.5% vs 37.8%)

Answer 194

* Conservative - Patient education - exercise and risk factor modification * Medical - Statins and aspirin