all Flashcards
(126 cards)
1
Q
What is aortic dissection?
A
A rare but serious cause of chest pain.
2
Q
What is the pathophysiology of aortic dissection?
A
Tear in the tunica intima of the wall of the aorta.
3
Q
What is the most important risk factor for aortic dissection?
A
Hypertension.
4
Q
Name two syndromes associated with aortic dissection.
A
- Marfan’s syndrome
- Ehlers-Danlos syndrome
5
Q
What are some associations with aortic dissection?
A
- Trauma
- Bicuspid aortic valve
- Collagens (Marfan’s syndrome, Ehlers-Danlos syndrome)
- Turner’s syndrome
- Noonan’s syndrome
- Pregnancy
- Syphilis
6
Q
What is the typical nature of pain associated with aortic dissection?
A
Typically severe and ‘sharp’, ‘tearing’ in nature.
7
Q
Where is the pain typically maximal in aortic dissection?
A
At onset.
8
Q
In type A dissection, where is chest pain more common?
A
Chest pain is more common.
9
Q
In type B dissection, where is back pain more common?
A
Upper back pain is more common.
10
Q
What are some common features of aortic dissection?
A
- Pulse deficit
- Weak or absent carotid, brachial, or femoral pulse
- Variation (>20 mmHg) in systolic blood pressure between the arms
- Aortic regurgitation
- Hypertension
11
Q
What can result from the involvement of specific arteries in aortic dissection?
A
- Coronary arteries → angina
- Spinal arteries → paraplegia
- Distal aorta → limb ischaemia
12
Q
What ECG changes are typically seen in patients with aortic dissection?
A
Majority have no or non-specific changes; ST-segment elevation may be seen in a minority.
13
Q
What are the two types in the Stanford classification of aortic dissection?
A
- Type A - ascending aorta, 2/3 of cases
- Type B - descending aorta, distal to left subclavian origin, 1/3 of cases
14
Q
Describe the DeBakey classification type I.
A
Originates in ascending aorta, propagates to at least the aortic arch and possibly beyond it distally.
15
Q
Describe the DeBakey classification type II.
A
Originates in and is confined to the ascending aorta.
16
Q
Describe the DeBakey classification type III.
A
Originates in descending aorta, rarely extends proximally but will extend distally.
17
Q
What is the correct answer for a significant increase in blood pressure after 20 weeks of gestation without proteinuria?
A
gestational hypertension
This condition is diagnosed when there is new-onset hypertension during pregnancy without any proteinuria or features of pre-eclampsia.
18
Q
What blood pressure reading indicates gestational hypertension?
A
≥140/90 mmHg
This threshold is used to diagnose gestational hypertension according to UK guidelines.
19
Q
What is required for a diagnosis of gestational hypertension?
A
new-onset hypertension without proteinuria or features of pre-eclampsia
Gestational hypertension is specifically characterized by the absence of proteinuria.
20
Q
When is gestational hypertension diagnosed during pregnancy?
A
after 20 weeks of gestation
Diagnosis occurs if hypertension develops after this point in pregnancy.
21
Q
What does COPD stand for?
A
Chronic Obstructive Pulmonary Disease
22
Q
Which biomarker can be falsely elevated in patients with COPD?
A
B-type natriuretic peptide (BNP)
23
Q
Where is BNP primarily released from?
A
Ventricular myocytes
24
Q
What triggers BNP release from ventricular myocytes?
A
Increased wall tension and volume overload
25
What complications can develop in COPD patients leading to increased BNP production?
Pulmonary hypertension and right ventricular strain
26
What other factors related to COPD can stimulate BNP release?
Hypoxia and inflammatory state
27
True or False: Elevated BNP levels in COPD patients always indicate heart failure.
False
28
When interpreting BNP results in COPD patients, what should clinicians consider?
Values may be elevated due to the underlying respiratory condition
29
What is the first-line investigation for all patients according to the updated NICE guidelines issued in 2018?
N-terminal pro-B-type natriuretic peptide (NT-proBNP) blood test
## Footnote
This test is now required regardless of previous myocardial infarction history.
30
What should be arranged if NT-proBNP levels are 'high'?
Specialist assessment (including transthoracic echocardiography) within 2 weeks
## Footnote
High levels are defined as > 2000 pg/ml.
31
What should be arranged if NT-proBNP levels are 'raised'?
Specialist assessment (including transthoracic echocardiography) within 6 weeks
## Footnote
Raised levels are defined as 400-2000 pg/ml.
32
What hormone is produced mainly by the left ventricular myocardium in response to strain?
B-type natriuretic peptide (BNP)
## Footnote
Very high levels of BNP are associated with a poor prognosis.
33
What are the high level thresholds for BNP and NT-proBNP?
* BNP: > 400 pg/ml (116 pmol/litre)
* NT-proBNP: > 2000 pg/ml (236 pmol/litre)
## Footnote
These thresholds indicate high levels of the respective peptides.
34
What are the raised level thresholds for BNP and NT-proBNP?
* BNP: 100-400 pg/ml (29-116 pmol/litre)
* NT-proBNP: 400-2000 pg/ml (47-236 pmol/litre)
## Footnote
These thresholds indicate raised levels of the respective peptides.
35
What are the normal level thresholds for BNP and NT-proBNP?
* BNP: < 100 pg/ml (29 pmol/litre)
* NT-proBNP: < 400 pg/ml (47 pmol/litre)
## Footnote
These thresholds indicate normal levels of the respective peptides.
36
List factors that can increase BNP levels.
* Left ventricular hypertrophy
* Ischaemia
* Tachycardia
* Right ventricular overload
* Hypoxaemia (including pulmonary embolism)
* GFR < 60 ml/min
* Sepsis
* COPD
* Diabetes
* Age > 70
* Liver cirrhosis
## Footnote
These factors can cause elevated BNP levels.
37
List factors that can decrease BNP levels.
* Obesity
* Diuretics
* ACE inhibitors
* Beta-blockers
* Angiotensin 2 receptor blockers
* Aldosterone antagonists
## Footnote
These factors can cause reduced BNP levels.
38
What are the two classes of drugs used in diabetic nephropathy?
Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs)
## Footnote
Examples include ramipril for ACE inhibitors and candesartan for ARBs.
39
What is the primary purpose of using ACE inhibitors and ARBs in diabetic nephropathy?
To reduce proteinuria and its progression
## Footnote
These drug classes have been shown to slow the progression of diabetic nephropathy.
40
What effect do ACE inhibitors and ARBs have on the afferent and efferent arterioles?
They dilate both afferent and efferent arterioles, but have a greater dilatory effect on efferent arterioles
## Footnote
This reduces intraglomerular pressure.
41
Why do ACE inhibitors and ARBs reduce intraglomerular pressure?
Angiotensin II normally has a stronger vasoconstrictive effect on the efferent arteriole
## Footnote
By dilating the efferent arteriole, these drugs decrease mechanical stress on the glomeruli.
42
What is the consequence of reduced intraglomerular pressure?
Decreased mechanical stress on the glomeruli and reduced protein leakage into the urine
## Footnote
This helps in preventing further glomerular damage.
43
Who should be offered an ACE inhibitor or ARB in the context of diabetic nephropathy?
All diabetic patients with hypertension and diabetic nephropathy and an ACR of 3 mg/mmol or more
## Footnote
ACR stands for albumin-to-creatinine ratio.
44
Fill in the blank: ACE inhibitors like _______ are used to treat diabetic nephropathy.
ramipril
45
Fill in the blank: ARBs like _______ are commonly prescribed for diabetic nephropathy.
candesartan
46
True or False: ACE inhibitors and ARBs can prevent further glomerular damage in diabetic nephropathy.
True
47
What are the two scenarios where cardioversion may be used in atrial fibrillation?
1. Electrical cardioversion as an emergency for haemodynamically unstable patients
2. Electrical or pharmacological cardioversion as an elective procedure for rhythm control
48
What is the purpose of synchronizing electrical cardioversion to the R wave?
To prevent delivery of a shock during the vulnerable period of cardiac repolarisation when ventricular fibrillation can be induced
49
According to the 2014 NICE guidelines, what should be offered if the onset of atrial fibrillation is less than 48 hours?
Rate or rhythm control
50
What should be started if atrial fibrillation onset is more than 48 hours or is uncertain?
Rate control
51
What anticoagulation treatment should be given if atrial fibrillation onset is less than 48 hours?
Patients should be heparinised and those with stroke risk factors should be put on lifelong oral anticoagulation
52
What are the options for cardioversion if atrial fibrillation is confirmed to be less than 48 hours?
1. Electrical - 'DC cardioversion'
2. Pharmacological - amiodarone if structural heart disease, flecainide or amiodarone if no structural heart disease
53
Is further anticoagulation necessary after electrical cardioversion if AF is confirmed as less than 48 hours duration?
No, further anticoagulation is unnecessary
54
What should be done if the patient has been in atrial fibrillation for more than 48 hours?
Anticoagulation should be given for at least 3 weeks prior to cardioversion
55
What alternative strategy can be performed to exclude a left atrial appendage thrombus before cardioversion?
Transoesophageal echo (TOE)
56
What does NICE recommend for cardioversion in patients with AF for more than 48 hours?
Electrical cardioversion rather than pharmacological
57
What should be done if there is a high risk of cardioversion failure?
At least 4 weeks of amiodarone or sotalol prior to electrical cardioversion
58
For how long should patients be anticoagulated following electrical cardioversion?
At least 4 weeks
59
What should be considered after 4 weeks of anticoagulation following electrical cardioversion?
Decisions about anticoagulation should be taken on an individual basis depending on the risk of recurrence
60
What type of medication is Warfarin?
Oral anticoagulant
## Footnote
Used for managing venous thromboembolism and reducing stroke risk in patients with atrial fibrillation.
61
What has largely superseded Warfarin in treatment?
Direct oral anticoagulants (DOACs)
## Footnote
DOACs do not require the same level of monitoring as Warfarin.
62
What is the mechanism of action of Warfarin?
Inhibits epoxide reductase preventing the reduction of vitamin K
## Footnote
This vitamin K is essential for the carboxylation of clotting factors II, VII, IX, and X.
63
Which clotting factors are affected by Warfarin?
* Factor II
* Factor VII
* Factor IX
* Factor X
## Footnote
Mnemonic for remembering these factors is 1972.
64
What are the indications for Warfarin use?
* Mechanical heart valves
* Venous thromboembolism
* Atrial fibrillation
## Footnote
Target INR varies based on condition and valve type.
65
What is the target INR for venous thromboembolism when using Warfarin?
2.5, if recurrent 3.5
## Footnote
INR stands for International Normalised Ratio.
66
What is the target INR for atrial fibrillation when using Warfarin?
2.5
## Footnote
A consistent INR is crucial for effective treatment.
67
How are patients monitored while on Warfarin?
Using the INR (international normalised ratio)
## Footnote
This ratio compares the patient's prothrombin time to the normal prothrombin time.
68
What is a characteristic of Warfarin's half-life?
Long half-life
## Footnote
Achieving a stable INR may take several days.
69
What factors may potentiate the effects of Warfarin?
* Liver disease
* P450 enzyme inhibitors (e.g., amiodarone, ciprofloxacin)
* Cranberry juice
* NSAIDs (displace warfarin from plasma albumin and inhibit platelet function)
## Footnote
These factors can increase the risk of bleeding.
70
What are some common side effects of Warfarin?
* Haemorrhage
* Teratogenic effects
* Skin necrosis
* Purple toes
## Footnote
Skin necrosis can occur due to a temporary procoagulant state after starting Warfarin.
71
What happens to protein C biosynthesis when starting Warfarin?
Reduced
## Footnote
This can lead to a temporary procoagulant state, normally managed with concurrent heparin administration.
72
True or False: Warfarin can be used in breastfeeding mothers.
True
## Footnote
Warfarin is teratogenic but can be administered during breastfeeding.
73
What is pulsus paradoxus?
Greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration, leading to faint or absent pulse in inspiration.
## Footnote
Associated with severe asthma and cardiac tamponade.
74
What condition is characterized by a slow-rising or plateau pulse?
Aortic stenosis.
## Footnote
This pulse pattern indicates a gradual rise and fall in arterial pressure.
75
What is a collapsing pulse associated with?
Aortic regurgitation, patent ductus arteriosus, hyperkinetic states (anemia, thyrotoxicosis, fever, exercise/pregnancy).
## Footnote
A collapsing pulse indicates a rapid rise and fall in arterial pressure.
76
What does pulsus alternans indicate?
Regular alternation of the force of the arterial pulse.
## Footnote
Commonly associated with severe left ventricular failure.
77
What is a bisferiens pulse?
'Double pulse' - two systolic peaks.
## Footnote
Seen in mixed aortic valve disease.
78
What is a 'jerky' pulse indicative of?
Hypertrophic obstructive cardiomyopathy (HOCM).
## Footnote
HOCM may occasionally be associated with a bisferiens pulse.
79
What does a normal apex beat indicate in aortic stenosis?
It indicates that the apex beat is not normally displaced.
80
What does displacement of the apex beat in aortic stenosis suggest?
It suggests left ventricular dilatation and hence severe disease.
81
What is Syndrome X?
A condition characterized by angina-like chest pain on exertion, ST depression on exercise stress test, but normal coronary arteries on angiography.
82
What are the features of Syndrome X?
* Angina-like chest pain on exertion
* ST depression on exercise stress test
* Normal coronary arteries on angiography
83
What management options are available for Syndrome X?
Nitrates may be beneficial.
84
True or False: Syndrome X is associated with abnormal coronary arteries.
False
85
Fill in the blank: Syndrome X features _______ on exercise stress test.
ST depression
86
What are the clinical features of symptomatic aortic stenosis?
* chest pain
* dyspnoea
* syncope / presyncope (e.g. exertional dizziness)
* murmur
* ejection systolic murmur (ESM) radiating to the carotids
* decreased following the Valsalva manoeuvre
## Footnote
The ejection systolic murmur is a key diagnostic feature of aortic stenosis, with its characteristic radiation and changes during maneuvers.
87
What are the features of severe aortic stenosis?
* narrow pulse pressure
* slow rising pulse
* delayed ESM
* soft/absent S2
* S4
* thrill
* duration of murmur
* left ventricular hypertrophy or failure
## Footnote
These features indicate the severity of aortic stenosis and help in clinical assessment.
88
What is the most common cause of aortic stenosis in older patients?
degenerative calcification
## Footnote
This is typically seen in patients over 65 years of age.
89
What is the most common cause of aortic stenosis in younger patients?
bicuspid aortic valve
## Footnote
This condition is prevalent in patients under 65 years.
90
Name a genetic syndrome associated with supravalvular aortic stenosis.
William's syndrome
## Footnote
This syndrome is a rare cause of aortic stenosis related to genetic factors.
91
What management approach is typically taken for asymptomatic aortic stenosis?
observe the patient
## Footnote
Observation is the general rule unless other clinical indicators suggest intervention.
92
What is the management for symptomatic aortic stenosis?
valve replacement
## Footnote
Symptomatic patients typically require surgical intervention to replace the affected valve.
93
When should surgery be considered for asymptomatic patients with aortic stenosis?
if valvular gradient > 40 mmHg and features like left ventricular systolic dysfunction
## Footnote
These criteria indicate a higher risk of adverse outcomes, warranting surgical intervention.
94
What are the options for aortic valve replacement (AVR)?
* surgical AVR
* transcatheter AVR (TAVR)
* balloon valvuloplasty
## Footnote
Each option is chosen based on the patient's age, operative risk, and specific clinical circumstances.
95
What is the treatment of choice for young, low/medium operative risk patients with aortic stenosis?
surgical AVR
## Footnote
This approach is preferred due to lower risks and better outcomes in suitable candidates.
96
What is transcatheter AVR (TAVR) used for?
patients with high operative risk
## Footnote
TAVR is a less invasive option for patients who may not tolerate traditional surgery well.
97
In what situation is balloon valvuloplasty used in adults?
limited to patients with critical aortic stenosis who are not fit for valve replacement
## Footnote
This procedure is less common and typically reserved for high-risk individuals.
98
What is a common characteristic of the ejection systolic murmur (ESM) in aortic stenosis?
classically radiates to the carotids
## Footnote
This radiation is a significant clinical finding during auscultation.
99
What changes occur to the ejection systolic murmur during the Valsalva manoeuvre?
decreased
## Footnote
The Valsalva manoeuvre affects the hemodynamics, altering the sound of the murmur.
100
What is multifocal atrial tachycardia (MAT)?
An irregular cardiac rhythm caused by at least three different sites in the atria, demonstrated by morphologically distinctive P waves.
101
In which patient population is MAT more common?
Elderly patients with chronic lung disease, such as COPD.
102
What is a key management step for MAT?
Correction of hypoxia and electrolyte disturbances.
103
What type of medication is often used first-line for MAT?
Rate-limiting calcium channel blockers.
104
True or False: Cardioversion is useful in the management of MAT.
False.
105
Fill in the blank: _______ and digoxin are not useful in the management of MAT.
Cardioversion.
106
What is aortic regurgitation (AR)?
The leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole.
107
What are the two main causes of aortic regurgitation?
1. Disease of the aortic valve
2. Distortion or dilation of the aortic root and ascending aorta.
108
What is the most common cause of aortic regurgitation in the developing world?
Rheumatic fever.
109
Name two causes of aortic regurgitation due to valve disease.
* Calcific valve disease
* Bicuspid aortic valve.
110
List three connective tissue diseases that can cause aortic regurgitation.
* Rheumatoid arthritis
* Systemic lupus erythematosus (SLE)
* Marfan's syndrome.
111
What are two causes of aortic regurgitation due to aortic root disease?
* Hypertension
* Aortic dissection.
112
What type of murmur is associated with aortic regurgitation?
Early diastolic murmur.
113
How is the intensity of the murmur in aortic regurgitation affected?
It is increased by the handgrip manoeuvre.
114
What is Quincke's sign?
Nailbed pulsation associated with aortic regurgitation.
115
What does De Musset's sign indicate?
Head bobbing associated with aortic regurgitation.
116
What is the mid-diastolic murmur in severe aortic regurgitation called?
Austin-Flint murmur.
117
What diagnostic tool is used to investigate suspected aortic regurgitation?
Echocardiography.
118
What is one medical management strategy for aortic regurgitation?
Management of any associated heart failure.
119
When is surgery indicated for aortic regurgitation?
In symptomatic patients with severe AR or asymptomatic patients with severe AR who have LV systolic dysfunction.
120
What type of inhibitor is Apixaban?
Direct and highly selective factor Xa inhibitor
## Footnote
Apixaban is used as an anticoagulant to prevent blood clots.
121
What are the properties of Dipyridamole?
Antiplatelet and vasodilating properties
## Footnote
It inhibits the uptake of adenosine and may inhibit the breakdown of cyclic guanosine monophosphate.
122
How does Aspirin affect platelet aggregation?
Causes irreversible inhibition of COX-1 and COX-2 enzymes, blocking thromboxane A2 formation
## Footnote
This reduction in thromboxane A2 decreases platelet aggregation.
123
What receptors does Ticagrelor block?
P2Y12-receptors
## Footnote
These receptors are important for the activation of platelets.
124
What type of drug is Clopidogrel?
Prodrug
## Footnote
Its metabolite inhibits the binding of ADP to its platelet P2Y12 receptor.
125
What is the mechanism of action of Clopidogrel?
Inhibits binding of ADP to platelet P2Y12 receptor
## Footnote
This prevents ADP from activating the glycoprotein GPIIb/IIIa complex, inhibiting platelet aggregation.
126
Fill in the blank: Dipyridamole is thought to inhibit the uptake of _______ into blood and vascular cells.
adenosine
## Footnote
Adenosine is a potent inhibitor of platelet activation and aggregation.
