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Phase 2a > Cardio > Flashcards

Cardio Flashcards

1
Q

What is atherosclerosis?

A

A combination of fatty deposits in artery wall (athero) and hardening/stiffening of blood vessels (sclerosis)

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2
Q

What are the effects of atherosclerotic plaques?

A

-Stiffening
-Stenosis (narrowing of arteries)
Plaque rupture

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3
Q

What does stenosis cause?

A

Reduced blood flow

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4
Q

What does stiffening of the artery wall do?

A

Causes hypertension + strain on heart as trying to pump against more resistance

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5
Q

What does plaque rupture do?

A

Creates a thrombus that can block distal vessels e.g. acute coronary syndrome where a coronary artery becomes blocked

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6
Q

List 3 non-modifiable risk factors for CVD

A

-Older age
-Family history
-Male

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7
Q

List 8 modifiable risk factors for CVD

A

-Hyperlipidaemia
-Smoking
-Alcohol consumption
-Poor diet
-Lack of exercise
-Obesity
-Poor sleep
-Stress

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8
Q

Name 5 medical comorbidities that increase the risk of CVD

A

-Diabetes
-Hypertension
-Chronic kidney disease
-Inflammatory conditions e.g. rheumatoid arthritis
-Atypical antipsychotic meds

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9
Q

Name 6 conditions atherosclerosis can cause

A

-Angina
-MI
-TIA
-Strokes
-Peripheral arterial disease
-Chronic mesenteric ischaemia

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10
Q

What does an atherosclerotic plaque consist of?

A

-Lipid
-Necrotic core
-Connective tissue
-Fibrous cap

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11
Q

How does high LDL lead to inflammation + atherosclerosis?

A

LDL can pass in + out of arterial wall + in XS accumulates in wall, then undergoes oxidation + glycation-damages endothelial cells

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12
Q

What are chemoattractants?

A

Chemicals that attract leukocytes, they are released from endothelium at the site of injury + produce a concentration gradient

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13
Q

What is the fibrous cap of fibrous plaques made of?

A

-Collagen
-Elastin

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14
Q

What 4 cells are contained within fibrous plaques?

A

-Smooth muscle cells
-Macrophages
-Foam cells
-T lymphocytes

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15
Q

What is a TCFA?

A

Thin capped fibroatheroma (what occurs before plaque rupture when cap thins)

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16
Q

What causes plaque rupture?

A

Increase in inflammatory conditions e.g. more enzyme activity, cap is weakened + ruptures

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17
Q

Name 5 differences between ruptured plaques + eroded plaques

A

-Rup=large lipid core, eroded=small lipid core
-Rup=lots of inflammatory cells
-Eroded=more fibrous tissue
-Eroded=larger lumen
-Ruptured=red thrombus (RBCs + fibrin) vs eroded=white thrombus (platelets + fibrinogen)

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18
Q

What does aspirin do?

A

Irreversibly inhibits platelet cyclo-oxygenase

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19
Q

How do PCSK9 inhibitors help reduce risk of atherosclerosis?

A

They are monoclonal antibodies that inhibit the PCSK9 protein in the liver-improved clearance of cholesterol from blood

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20
Q

What do statins do?

A

Reduce cholesterol synthesis in liver by inhibiting HMG CoA reductase

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21
Q

Name 4 lifestyle changes that reduce the risk of developing atherosclerosis

A

-Stop smoking
-Reduce alcohol consumption
-Improve diet-fat less than 30% of calories, more wholegrains, less sugar, 5 a day fruit, 2 a week fish etc
-Increase exercise

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22
Q

How much exercise does NICE recommend weekly?

A

-150mins+ of moderate intensity exercise or 75mins vigorous activity
-Strength training 2+ days a week

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23
Q

What is a QRISK score?

A

Estimates % risk that a patient will have a stroke/MI in the next 10 years

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24
Q

In relation to the QRISK score, when should patients be offered statins?

A

Results above 10%

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25
Q

What medication (including dose) should patients with a QRISK score >10% be offered?

A

Statin-initially atorvastatin 20mg at night

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26
Q

Patients with which conditions are offered atorvastatin as primary prevention?

A

-Chronic kidney disease
-Type 1 diabetes

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27
Q

What are the 4 A’s of CVD secondary prevention?

A

-Antiplatelet meds e.g. aspiring, clopidogrel
-Atorvastatin
-Atenolol (or other beta-blockers)
-ACE inhibitor (often ramipril)

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28
Q

What is the inheritance pattern for familial hypercholesterolaemia?

A

Autosomal dominant

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29
Q

What are the 3 types of acute coronary syndrome?

A

-Unstable angina
-ST elevation MI (STEMI)
-Non-ST elevation MI (NSTEMI)

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30
Q

What is thrombosis?

A

Blood coagulation inside a vessel

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31
Q

rName the 5 most common causes of aterial thrombosis

A

-Atherosclerosis *
-Inflammatory
-Infective
-Trauma
-Tumour

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32
Q

What are the most common presentation of an arterial thrombosis?

A

-MI
-Stroke
-Peripheral vascular disease

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33
Q

Name 4 Tx’s for a cardiac arterial thrombosis

A

-Aspirin/other antiplatelets
-Low molecular weight heparin (LMWH)/Fondaparinux
-Thrombolytic therapy
Reperfusion-catheter directed Tx + stents

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34
Q

Name 4 Tx’s for a cerebral arterial thrombosis

A

-Aspirin
Thrombolysis
-Reperfusion

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35
Q

How would you diagnose a venous thrombosis?

A

-Signs + symptoms
-Blood test e.g. D-dimer
-Imaging

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36
Q

What are the 3 parts of Virchows triad?

A

-Endothelial damage
-Stasis/lack of blood flow
-Blood constituents

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37
Q

How could you treat a venous thrombosis?

A

-Heparin/LMWH
-Warfarin
-DOAC (direct oral anticoagulants)

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38
Q

Name 3 ways you can prevent venous thrombosis

A

-Mechanical/chemical thromboprophylaxis
-Early mobilisation
-Good hydration

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39
Q

Why is LMWH now given more than heparin?

A

Longer half-life, once-daily, less variation in dose + renally excreted

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40
Q

What are the drawbacks with warfarin?

A

-Hard to use
-Individual variation in dose
-Need to monitor

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41
Q

How does aspirin work?

A

Inhibits thromboxane formation + therefore platelet aggregation

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42
Q

What does heparin do?

A

Binds to antithrombin + increases activity

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43
Q

How does warfarin work?

A

-Stops synthesis of factors II, VII, IX + X
-Is a vit K antagonist
-Prolongs prothrombin time

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44
Q

What are NOAC/DOAC used for?

A

Extended thromboprophylasis and treatment of AF and DVT/PE

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45
Q

Name 3 antiplatelets

A

-Clopidogrel
-Aspirin
-Ticagrelor

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46
Q

What are the signs + symptoms for DVT?

A

-Leg pain
-Swelling
-Tenderness
-Warmth
-Discolouration

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47
Q

Name a complication of DVT

A

Phlegmasia (extreme DVT)

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48
Q

What is the most common cause of angina?

A

Ischaemic heart disease

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49
Q

What is angina?

A

Chest pain caused by reduced blood flow to the heart

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50
Q

What are the predisposing factors for IHD?

A

-Age
-Smoking
-FH
-DM
-Hyperlipidemia
-Hypertension
-CKD
-Obesity
-Physical inactivity
-Stress

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51
Q

Name 3 environmental factors for CVD

A

-Cold weather
-Heavy meals
-Emotional stress

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52
Q

When does myocardial ischemia occur?

A

When there is an imbalance between the heart’s O2 demand + supply from an increase in demand/limit in supply

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53
Q

Name 3 ways in which the heart’s O2 supply can be limited

A

-Impairment of blood flow by arterial stenosis
-Increased resistance e.g. ventricular hypertrophy
-Reduced O2 carrying capacity of blood e.g. anaemia

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54
Q

Name 4 types of angina other than stable

A

-Prinzmetal’s angina (coronary spasm)
-Microvascular angina
-Crescendo angina
-Unstable angina

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55
Q

What is the pneumonic for investigating pain?

A

OPQRRRSTT

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56
Q

What does OPQRRRSTT stand for in relation to pain?

A

-Onset
-Position
-Quality (nature/character)
-Relationship (with exertion, posture, meals, breathing etc)
-Radiation
-Relieving/aggregating factors
-Severity
-Timing
-Treatment

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57
Q

Name 6 differential diagnoses for chest pain

A

-MI
-Pericarditis/myocarditis
-PE
-Chest infection
-Aortic dissection
-GORD

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58
Q

What investigations could you do for chest pain?

A

-Bloods
-Lipids
-ECG
-CT coronary angiogram
-Exercise testing
-Stress echo
-Perfusion MRI

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59
Q

Name 4 treatments for angina, prescribed in GP

A

-Aspirin
-GTN
-Beta blocker
-Statin

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60
Q

What effect do beta blockers have on the heart?

A

-Decrease HR, LV contractility, CO + therefore O2 demand

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61
Q

Name 4 side effects of beta blockers

A

-Tiredness
-Bradycardia
-Erectile dysfunction
-Cold hands + feet

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62
Q

What is the main contra-indication for beta blockers?

A

-Severe asthma

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63
Q

What do nitrates do?

A

Venodilation

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64
Q

How does aspirin work?

A

-Cyclo-oxygenase inhibitor
-Decreases prostaglandin synthesis, including thromboxane, decreases platelet aggregation

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65
Q

What is the main side effect of aspirin?

A

Gastric ulceration

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66
Q

Name an ACE inhibitor

A

Ramipril

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67
Q

Name 4 Tx’s for angina prescribed in hospital

A

-ACE inhibitor
-Long acting nitrate
-Calcium channel blocker
-Potassium channel opener

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68
Q

Name 2 surgeries for more serious/uncontrolled angina/CHD

A

-Coronary angioplasty/stenting/PCI
-CABG

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69
Q

What are the pros of PCI?

A

-Less invasive
-Convenient
-Repeatable

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70
Q

What are the pros of CABG?

A

-Prognosis
-Deals with complex disease

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71
Q

What does PCI stand for?

A

Percutaneous coronary intervention

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72
Q

What does CABG stand for?

A

Coronary artery bypass graft

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73
Q

What are the cons of PCI?

A

-Risk stent thrombosis
-Not for complex disease
-Dial antiplatelet therapy

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74
Q

What are the cons of CABG?

A

-Invasive
-Risk of stroke/bleeding
-Can’t do if frail/comorbidities
-Length of stay + recovery

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75
Q

Name 4 psychosocial factors that play a role in onset + management of CHD

A

-Coronary prone behaviour pattern
-Depression + anxiety
-Psychosocial work characteristics
-Social support

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76
Q

What investigations would you do for a DVT?

A

-D-dimer
-US
-CT
-MR venogram

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77
Q

How would you treat a DVT?

A

-LMWH for min 5 days
-Oral warfarin for 3-6mths
-Compression stockings
-Treat any underlying causes

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78
Q

How can you prevent a DVT?

A

-Hydration
-Early mobilisation
-Compression stockings
-Foot pumps
-LWMH

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79
Q

What are the signs + symptoms of a PE?

A

-Breathlessness
-Pleuritic chest pain
-Tachycardia
-Tachypnoea
-Pleural rub

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80
Q

Name 6 differential diagnoses of a PE

A

-MSK pain
-Infection
-Malignancy
-Pneumothorax
-Cardiac causes
-GI causes

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81
Q

Describe the layers of the pericardium

A

-Fibrous parietal layer
-Pericardial cavity
-Visceral single layer stuck to epicardium

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82
Q

What is acute pericaditis?

A

Inflammatory pericardial syndrome with/without effusion

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83
Q

What is pericardial effusion?

A

Build-up of extra fluid in the space around the heart

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84
Q

What are the 4 requirements for diagnosing pericarditis?

A

Need 2/4 of:
-Chest pain
-Friction rub
-ECG changes
-Pericardial effusion

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85
Q

What are the most common causes of pericarditis?

A

-*Viral e.g. enteroviruses
-Bacterial e.g. myobacterium TB
-Autoimmune e.g. Sjorgen syndrome, rheumatoid arthritis
-Neoplastic
-Metabolic e.g. uraemia, myxoedema
-Trauma
-Iatrogenic injury
-Aortic dissection
-Amyloidosis

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86
Q

What are the key presenting symptoms for pericarditis?

A

-Sharp, rapid onset + pleuritic chest pain, it can radiate to arm + is relieved by sitting forward
-Dyspnoea
-Cough
-Hiccups

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87
Q

Name 7 differential diagnoses for pericarditis

A

-MI
-Pneumonia
-PE
-GORD
-Pneumothorax
-Pancreatitis
-Peritonitis

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88
Q

What investigations would you do for suspected pericarditis?

A

-*ECG
-Bloods
-Chest x-ray
-Echocardiogram
-Clinical exam

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89
Q

What would you be looking for in a clinical exam for pericarditis?

A

-Signs of effusion e.g. Kussmauls sign
-Fever
-Sinus tachycardia
-Pericardial rub-crunching snow sound

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90
Q

Name 3 ways in which you might manage pericarditis

A

-Sedentary activity until resolution of symptoms/ECG
-NSAID/aspirin
-Colchicine reduces recurrence

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91
Q

What are the major complications + risks of pericarditis?

A

-Large pericardial effusion
-Cardiac tamponade

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92
Q

What are the minor complications + risks of pericarditis?

A

-Myopericarditis
-Immunosuppression
-Trauma

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93
Q

What causes of pericarditis increase the risk of a constriction developing?

A

-Bacterial causes - particularly with TB + purulent pericarditis

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94
Q

What ECG changes indicate pericarditis?

A

-Diffuse ST elevation
-Concave ST
-No reciprocal ST depression
-Saddle shaped
-PR depression

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95
Q

What is a normal adult heart rate?

A

60-100bpm

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96
Q

Define tachycardia

A

Heart rate >100 bpm

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97
Q

Define bradycardia

A

Heart rate <60bpm

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98
Q

How do you calculate heart rate using a regular rhythm ECG?

A

300/number of large squares between 2 complexes (R-R interval)

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99
Q

How do you calculate heart rate with an ECG when the rhythm is irregular?

A

Count number of complexes per strip, multiply by 6

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100
Q

How long does a small square on ECG represent?

A

0.04s

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101
Q

How long does a large square on ECG represent?

A

0.2s

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102
Q

How long do 5 large squares on ECG represent?

A

1s

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103
Q

What is an ECG lead?

A

Graphical representation of of the heart’s electrical activity

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104
Q

How many physical electrode are attached in a 12-lead ECG?

A

10

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105
Q

How many chest electrodes are there?

A

6

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106
Q

How many limb leads are there + where are they placed?

A

4:
-Ulnar process of right arm
-Ulnar process of left arm
-Malleolus of left leg
-Malleolus of right leg

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107
Q

What view of the heart do the chest leads give?

A

V1-septal
V2-septal
V3-anterior
V4-anterior
V5-lateral
V6-lateral

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108
Q

What are the three main types of cardiomyopathy?

A

-Hypertrophic
-Dilated
-Arrhythmogenic

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109
Q

What causes hypertrophic cardiac myopathy (HCM)?

A

Sarcomeric protein gene mutations

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110
Q

What can HCM cause?

A

-Angina,
-Dyspnoea
-Palpitations
-Syncope
-Left ventricular outflow obstruction

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111
Q

How does dilated cardiomyopathy (DCM) present?

A

Heart failure symptoms

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112
Q

What is the main presenting feature of arrhythmogenic cardiomyopathy (ACM)?

A

Arrhythmia

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113
Q

What are cardiac channelopathies?

A

Defect in microscopic channels in the walls of heart cells through which electrolytes e.g. Na, K, Ca pass.

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114
Q

What do cardiac channelopathies cause?

A

Heart rhythm disturbances

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115
Q

Name 4 cardiac channelopathies

A

-Long QT
-Short QT
-Brugada
-CPVT

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116
Q

What causes arrhythmic CD?

A

Desmosome gene mutations

117
Q

What is the main target for blood pressure control?

A

Peripheral resistance - interplay between RAAS + sympathetic nervous system

118
Q

What do ACE inhibitors do?

A

Stop/reduce conversion angiotensin I -> angiotensin II, therefore decreasing blood pressure

119
Q

Name 3 main conditions that ACE inhibitors are used for

A

-Hypertension
-Heart failure
-Diabetic nephropathy

120
Q

Name a key ACE inhibitor

A

Ramipril (ACE inhibitors = ‘il’s)

121
Q

What are the main adverse effects of ACE inhibitors?

A

-Hypotension
-Acute renal failure
-Hyperkalaemia
-Foetal abnormalities
-Cough
-Rash
-Anaphylactoid reaction

122
Q

Why can ACE inhibitors cause rashes, cough, anaphylactoid reactions?

A

ACE also helps break down bradykinins, if it is inhibited, kinins build up

123
Q

What are the most common uses of angiotensin II receptor blockers (ARB)?

A

-Hypertension
-Diabetic nephropathy
-Heart failure (when ACE-I contraindicated)

124
Q

Name 3 angiotensin II receptor blockers

A

-Candesartan
-Valsartan
-Losartan
(ARB’s = ‘sartan’s)

125
Q

What are the main adverse effects of ARBs?

A

-Hypotension
-Hyperkalaemia
-Renal dysfunction
-Rash
-Angio-oedema
-Foetal abnormalities

126
Q

What are the main conditions that calcium channel blockers are used in?

A

-Hypertension
-Ischaemic heart disease-angina
-Arrhythmia

127
Q

Name 4 calcium channel blockers

A

-Amlodipine
-Nifedipine
-Verapamil
-Diltiazem
CCB’s often end in ‘dipine’

128
Q

What are the main differences between amlodipine, verapamil + diltiazem?

A

-All calcium channel blockers BUT
-Amlodipine targets peripheral vessels
-Verapamil targets heart
-Diltiazem targets both

129
Q

What are the main adverse effects of CCBs?

A

Due to peripheral vasodilation:
-Flushing
-Headache
-Oedema
-Palpitations
Others:
-Verapamil: Bradycardia. AV block, constipation
-Diltiazem: Bradycardia + AV block

130
Q

What are the main uses of beta-adrenoceptor blockers?

A

-Ischaemic heart disease
-Heart failure
-Arrhythmia
-Hypertension

131
Q

Name 3 beta-adrenoceptor blockers (BB)

A

-Bisoprolol
-Atenolol
-Propranolol
BB = ‘olol’

132
Q

What are the main adverse effects of BB?

A

-Fatigue
-Headache
-Sleep disturbance
-Bradycardia
-Hypotension
-Cold peripheries
-Erectile dysfunction
-Worsening of: asthma, COPD, PVD, heart failure

133
Q

What are the main uses of diuretics?

A

Hypertension
-Heart failure

134
Q

What are the 4 classes of diuretics?

A

-Thiazides
-Loop diuretics
-Potassium-sparing diuretics
-Aldosterone antagonists

135
Q

Give an example of a thiazide

A

Bendroflumethiazide

136
Q

Give an example of a loop diuretic

A

Furosemide

137
Q

Give an example of a potassium-sparing diuretic

A

Spironolactone

138
Q

What are the main adverse effects of diuretics?

A

-Hypovolaemia
-Hypotension
-Low electrolytes e.g. hypokalaemia
-Raised uric acid (gout)
-Impaired glucose tolerance
-Erectile dysfunction (thiazides)

139
Q

Name a drug that can be used for hypertension in pregnancy

A

Methyldopa

140
Q

What medication would you prescribe for hypertension for a diabetic/under 55yrs?

A

ACE inhibitor OR angiotensin II receptor blocker

141
Q

What medication would you prescribe for hypertension for over 55yrs/Afro-Caribbeans

A

Calcium channel blocker

142
Q

Name the angiotensin II blocker + neprilysin inhibitor used in conjunction in heart failure

A

Valsartan (AIIB)
Sacubitril (NI)

143
Q

What do neprilysin inhibitors do?

A

Increase levels of natriuretic peptides

144
Q

What are the main uses of nitrates?

A

Ischaemic heart disease
-Heart failure

145
Q

What cardiac effects do nitrates have?

A

-Lower bp
-Arterial + venous dilators
-Reduction of preload + afterload

146
Q

Give 3 examples of nitrates

A

-GTN spray
-GTN infusion
-Isosorbide mononitrate

147
Q

How are antiarrhythmic drugs classified?

A

Vaughan Wiliams classification:
I-Na channel blockers
II-beta blockers
III-action potential prolongers
IV-Ca channel blockers

148
Q

How does Digoxin work?

A

Inhibits Na/K pump-causes Ca lvls to rise

149
Q

What effects does Digoxin have?

A

-Bradycardia
-Slowing of AV conduction
-Increased force of contraction

150
Q

What is Digoxin used for?

A

-AF to reduce ventricular rate response
-Severe heart failure

151
Q

What does it mean that Digoxin has a narrow therapeutic range?

A

Small differences in dose can lead to serious therapeutic failures/ adverse drug reactions

152
Q

What does amiodarone do?

A

Prolongs QT interval

153
Q

What are the adverse effects of amiodarone?

A

-Interstitial pneumonia
-Abnormal liver function
-Hyper/hypothyroidism
-Optic neuropathy
-Sun sensitivity

154
Q

What is aortic stenosis?

A

Narrowing of the aortic valve

155
Q

What are the 3 types of aortic stenosis?

A

-Valvular-most common
-Supravalvular
-Suvalvular

156
Q

When do symptoms of aortic stenosis start?

A

When valve area has narrowed to 1/4 of normal area

157
Q

What are the most common causes of aortic stenosis?

A

-Congenital
-Degenerative calcification-onset in 70s/80s
-Rheumatic heart disease-adhesions + fusion of comissures

158
Q

What is another congenital cause of aortic stenosis (BAD)?

A

Bicuspid aortic stenosis-born with bicuspid rather than tricuspid valve

159
Q

What effect does A. stenosis have on the left ventricle?

A

-Pressure gradient develops between l ventricle + aorta
-L ventricle compensates with hypertrophy
-But compensatory mechanisms become exhausted +l ventricle function declines

160
Q

How does a. stenosis present?

A

-Exertional syncope
-Angina
-Dyspnoea (laboured breathing)
-Sudden death <2%

161
Q

What are the signs of a. stenosis?

A

-Slow rising carotid pulse
-Soft/absent 2nd heart sound
-Ejection systolic murmur

162
Q

What investigations would you perform for a. stenosis?

A

-Echocardiogram

163
Q

Name some general management points for a. stenosis

A

-Fastidious dental hygiene + care
-Consider IE prophylaxis in dental procedures

164
Q

What medications are contraindicated with severe a. stenosis?

A

Vasodilators

165
Q

How can a. stenosis be surgically treated?

A

-Aortic valve replacement - TAVI

166
Q

What is a TAVI?

A

Transcatheter aortic valve implantation

167
Q

When would a patient be considered for an aortic valve replacement?

A

-Symptomatic with severe AS
-Patient with decreasing ejection fraction
-CABG patients with moderate/severe AS

168
Q

What is mitral regurgitation?

A

Backflow of blood from left ventricle to left atrium during systole

169
Q

What are the 2 types of mitral regurgitation?

A

Primary-disease of leaflets
Secondary-disease of ring/architecture around leaflets

170
Q

What are the causes of primary mitral regurgitation?

A

-MVP
-Rheumatic heart disease
-Infective endocarditis

171
Q

What is the main cause of secondary mitral regurgitation?

A

Dilated cardiomyopathy

172
Q

What causes mitral regurgitation?

A

Volume overload

173
Q

How does mitral regurgitation present?

A

-Pansystolic murmur at apex
-Exertion dyspnoea
-SOB
-Heart failure

174
Q

What investigations would you order for mitral regurgitation?

A

*Echocardiogram
-ECG
-Chest x-ray

175
Q

How is mitral regurgitation managed?

A

-Beta-blockers for a-fib
-Anticoagulants for a-fib + flutter
-Nitrates/diuretics in acute
-Serial echocardiography + monitoring

176
Q

What are the indications for surgery in mitral regurgitation?

A

Symptoms at rest/exercise OR
asymptomatic but ejection fraction <60%

177
Q

What are the surgical treatments for mitral regurgitation?

A

-TEER-transcatheter edge to edge repair
-Mechanical/tissue mitral valve replacement

178
Q

What is aortic regurgitation?

A

Leakage of blood into LV during diastole due to ineffective coaptation of the aortic cusps

179
Q

What are the causes of chronic a. regurgitation?

A

-Bicuspid aortic valve
-Rheumatic
-Infective endocarditis

180
Q

What causes aortic regurgitation?

A

Pressure + volume overload

181
Q

What are the compensatory mechanisms for aortic regurgitation?

A

LV dilation-progresses + leads to heart failure

182
Q

What pulse changes + murmurs would occur with aortic regurgitation?

A

-Wide pulse pressure
-Diastolic blowing murmur
-Austin flint murmur
-Systolic ejection murmur

183
Q

How would you investigate aortic regurgitation?

A

-Chest x-ray
-Echocardiogram

184
Q

How is aortic regurgitation managed?

A

-IE prophylaxis
-Vasodilators
-Serial echocardiograms
-SAVR surgery (TAVI much rarer)

185
Q

What is mitral stenosis?

A

Obstruction of LV inflow that prevents proper filling during diastole

186
Q

What is the main cause of mitral stenosis?

A

Rheumatic carditis-becoming rarer as incidences of rheumatic heart disease decrease

187
Q

What does mitral stenosis cause?

A

-Progressive dyspnoea
-Increased transmitral pressure
-Right heart failure
-Hemoptysis

188
Q

What are the signs of mitral stenosis?

A

-Prominent ‘a’ wave in jugular venous pulsations
-Signs of r heart failure
-Mitral facies-pink/purple patches on cheeks when mitral stenosis is severe

189
Q

How would you investigate mitral stenosis?

A

*Echocardiogram-gold standard diagnostic
-ECG
-Chest x-ray

190
Q

How is mitral stenosis managed?

A

-Serial echocardiography
-Beta-blockers, calcium channel blockers, digoxin for symptoms
-Surgery-percutaneous mitral balloon valvotomy

191
Q

What blood pressure readings count as hypertensive?

A

Above 140/90 in clinical setting
Above 135/85 with home readings

192
Q

What are the four types of hypertension?

A

-Primary-develops on its own
-Secondary-underlying causes
-Accelerated/malignant
-White-coat
-Masked-readings higher at home than clinic

193
Q

What is the mnemonic for secondary causes of hypertension?

A

ROPED

194
Q

Using the mnemonic ROPED, what are the secondary causes of hypertension?

A

Renal disease
Obesity
Pregnancy
Endocrine
Drugs-alcohol, steroids, NSAIDs, oestrogen, liquorice, anti-anxiety drugs, anti-TNF’s

195
Q

What is the most common cause of secondary hypertension?

A

Renal disease

196
Q

Name 2 endocrine causes of hypertension

A

-Conn’s syndrome
-Pheochromocytoma

197
Q

What complications are associated with hypertension?

A

-Ischaemic heart disease
-Cerebrovascular accident
-Vascular disease
-Hypertensive retinopathy + nephropathy
-Vascular dementia
-Heart failure
-Left ventricular hypertrophy

198
Q

With one antihypertensive, how much would you expect bp to drop by?

A

-Systolic vol 8-10mmHg
-Diastolic 4-6mmHg

199
Q

What is the white coat effect on bp?

A

Effect of bp being taken by doctor/nurse - more than 20/10mmHg difference in bp in clinic vs home readings

200
Q

What should you do with patients with a clinic bp between 140/90 and 180/120 to diagnose hypertension?

A

24hr ambulatory blood pressure

201
Q

What are the 3 stages of hypertension?

A

Stage 1-above 140/90
Stage 2-above 160/100
Stage 3-above 180/120

202
Q

What risk assessment should also be performed on those with hypertension?

A

QRISK score

203
Q

What should happen if a QRISK score is >10%?

A

Offered statin-atorvastatin 20mg at night

204
Q

What are the symptoms of hypertension?

A

Very few symptoms-only symptomatic relief with Tx is reduction in headaches

205
Q

What is the bp target for routine + older patients?

A

Routine-140/90
Older-150/90

206
Q

What groups have a lower target bp? (130/80)

A

-CKD + diabetes
-Previous stroke

207
Q

What medications are used in the management of hypertension?

A

-ACE inhibitors
-Beta blockers
-Calcium channel blockers
-Thiazide-like diuretic
-Angiotensin II receptor blocker - ARBs used instead of ACE inhibitors, not together

208
Q

What is accelerated/malignant hypertension?

A

Extremely high bp - >180/120, with retinol haemorrhages or papilloedema

209
Q

What should you do with a patient with accelerated hypertension?

A

-Same-day referral
-Fundoscopy (eye) exam

210
Q

What drugs can you give in a hypertensive emergency?

A

-Sodium nitroprusside
-Labetalol
-Glyceryl trinitrate
-Nicardipine

211
Q

What lifestyle modifications would you advise for a hypertensive patient?

A

-Increase exercise
-Reduce dietary salt
-Reduce caffeine
-Stop smoking
-Reduce alcohol

212
Q

What is Tetralogy of Fallot?

A

Most common cyanotic congenital heart disease aka ‘blue baby syndrome’
-4 defects

213
Q

What are the 4 defects on Tetralogy of Fallot?

A

-Ventricular septal defect
-Pulmonary stenosis
-Overriding aorta
-Right ventricular hypertrophy

214
Q

What are some of the causes of Tetralogy of Fallot?

A

Genetic-Down’s, DiGeorge, CHARGE, VACTERL

215
Q

What happens at birth in babies with TofF?

A

Oxygenated + deoxygenated blood mix-meaning deox blood is sent to body-causes cyanosis

216
Q

What is VSD + its symptoms?

A

Ventricular septal defect - abnormal connection between ventricles
-High pressure LV, low pressure RV
-High pulmonary blood flow
-Breathless, poor feeding, FTT (failure to thrive)

217
Q

What is Eisenmengers syndrome?

A

-Result of defects, when blood flow between heart + lungs is irregular
-High pressure pulmonary blood flow
-Damage to pulmonary vessels
-RV pressure increases, shunt direction reverses + patient becomes blue

218
Q

What is ASD?

A

Atrial septal defect-common, often present in adulthood

219
Q

What does ASD cause?

A

-Higher LA pressure than RA
-Shunt l->r so not blue
-Increased flow to right heart + lungs

220
Q

What are the clinical signs of ASD?

A

-Pulmonary flow murmur
-Fixed split second heart sound
-Big pulmonary arteries + heart on chest x-ray

221
Q

What parts of the heart do AVSDs (atrio-ventricular septal defects) affect?

A

Failure to form centre of heart - involves ventricular septum, atrial septum, mitral + tricuspid valves

222
Q

What condition is associated with AVSD?

A

Down’s syndrome

223
Q

What is PDA?

A

Patent ductus arteriosus-often treated surgically, even if small as risk of endocarditis

224
Q

Name 4 hole congenital defects

A

-PDA
-ASD
-VSD
-AVSD

225
Q

Name 3 narrowing congenital defects

A

-Coarctation of aorta
-Bicuspid aortic valve
-Pulmonary stenosis

226
Q

What is coarctation of the aorta?

A

Narrowing of aorta at site of insertion of ductus arteriosus

227
Q

What are the signs of coarc of aorta?

A

-Right arm hypertension
-Bruits (buzzes) over scapulae
-Murmur

228
Q

How are congenital cardiac defects detected?

A

Foetal echocardiogram
Newborn baby checks

229
Q

What is a ‘tet’ spell in an unrepaired TofF?

A

Sudden episode of profound cyanosis + hypoxia-can be fatal

230
Q

What procedure is performed on patients with univentricular hearts?

A

Fontan procedure

231
Q

What is infective endocarditis (IE)?

A

Infection of heart valves/endocardial lined structures within the heart e.g. septal defects, pacemaker leads etc

232
Q

What effect does infective endocarditis have?

A

Sends infectious material around bloodstream + can damage heart valves-lead to heart failure

233
Q

How is infective endocarditis treated?

A

-Antibiotics/antimicrobials
-Cardiac surgery to remove infectious material/repair damage
-Tx of other complications

234
Q

What are the types of IE?

A

-Left-sided
-Right-sided
-Native
-Prosthetic (early or late)
-Device related
-will be combinations of these e.g. left sided early prosthetic

235
Q

What are the risk factors for IE + who is most at risk?

A

-Abnormal valve
-Infectious material introduced into blood
-Previous IE
-Age
-Young IV drug users
-Young with congenital heart disease
-Anyone with prosthetic heart valves

236
Q

What is the most common sign of IE?

A

Fever

237
Q

What is the clinical presentation of IE?

A

-Signs of infection-fever, sweating etc
-Embolisation-stroke, PE, bone infection, kidney dysfunction, MI
-Valve dysfunction-heart failure, arrhythmia

238
Q

What is the criteria for diagnosing IE?

A

Modified Dukes Criteria

239
Q

What are the major Dukes criteria for IE?

A

-Pathogen grown from blood cultures
-Evidence of endocarditis on echo/new valve leak

240
Q

What are the minor criteria for iE?

A

-Predisposing factors
-Fever
-Vascular issues
-Immune issues
-Ambiguous blood cultures

241
Q

What investigations would you order for suspected IE?

A

-Echocardiogram-transthoracic echo preferred, transoesophageal much more uncomfortable but better image
-Blood cultures
-CRP

242
Q

Name 5 peripheral signs of IE

A

-Petechiae
-Splinter haemorrhages
-Osler’s nodes
-Janeway lesions
-Roth spots

243
Q

When would you operate with IE?

A

-Infection not cured with antibiotics-recurrence/CRP doesn’t fall
-Complications
-To remove infected devices
-To replace valve after infection cured
-To remove large vegetations before they embolise

244
Q

What is IE prophylaxis?

A

Preventative antibiotics for high risk patients with dental procedures

245
Q

What conditions cause left axis deviation?

A

-L ant fascicular block
-L bundle branch block
-L ventricular hypertrophy

246
Q

What conditions cause right axis deviation?

A

*R heart hypertrophy/strain
-L posterior fascicular block

247
Q

What degree of deviation suggests left axis deviation?

A

QRS complex between -30 to -90

248
Q

What degree of deviation suggests right axis deviation?

A

QRS axis between 90 to 180

249
Q

Where should the normal cardiac axis lie?

A

-30 to -90

250
Q

With a normal ECG, which leads should be positive?

A

I, II, II (II = most positive/biggest peak)

251
Q

With a healthy ECG, which lead would be most negative?

A

aVR

252
Q

Which patients might have a smaller QRS complex?

A

-Obese
-Have pericardial effusion
-Have infiltrative cardiac disease

253
Q

Name 3 causes of prolonged QT intervals

A

-Congenital causes
-Drugs
-Electrolyte disturbances

254
Q

What does right axis deviation do to leads I, II, III?

A

III=most +ve
I= -ve

255
Q

What does left axis deviation do to leads I, II, III?

A

I=most +ve
II + III= -ve

256
Q

What are the types of AV block?

A

-1st degree
-2nd degree type 1
-2nd degree type 2-more serious
-3rd degree (complete)-more serious

257
Q

Describe 1st degree AV block

A

Consistent prolongation of PR interval >0.2s
No dropped QRS complexes

258
Q

Describe 2nd degree AV block type 1

A

Progressive PR interval prolongation
Some dropped QRS complexes

259
Q

Describe 2nd degree AV block type 2

A

Consistent PR interval duration
Intermittent dropped QRS complexes

260
Q

Describe 3nd degree AV block

A

No communication between atria + ventricles
P waves + QRS complexes functioning independently

261
Q

What are the causes of 3rd degree AV heart block?

A

-Congenital HD
-IHD
-Iatrogenic
-Drugs
-Infection
-Thyroid dysfunction

262
Q

What are the causes of 2nd degree type 2 AV heart block?

A

-MI
-Cardiac surgery
-Autoimmune
-Drugs
-Hyperkalaemia

263
Q

How can you quickly recognise l + right BBB?

A

WiLLiam (l) MaRRoW (r)
Shape of ECG in leads V1 + V6

264
Q

What causes RBBB?

A

-Physiological
-Damage to r bundle branch e.g.
COPD, PE, congenital HD, IHD

265
Q

What causes LBBB?

A

Conduction system degeneration
-IHD
-Cardiomyopathy
-Valvular HD

266
Q

What causes T wave flattening + ST depression?

A

Ischaemia + infarction

267
Q

Describe an ECG for a patient with hyperkalaemia

A

-Tall T waves
-Flat P waves
-Broad QRS

268
Q

Describe an ECG for a patient with hypokalaemia

A

-Flat T wave
-QT prolongation

269
Q

Describe an ECG for a patient with hypercalcaemia

A

-QT shortening

270
Q

Describe an ECG for a patient with hypocalcaemia

A

-QT prolongation

271
Q

What is AF?

A

Cardiac arrhythmia characterised by disorganised electrical activity within the atria resulting in ineffective atrial contraction and irregular ventricular contraction

272
Q

What are the 3 types of AF?

A

-Paroxysmal
-Persistent
-Permanent

273
Q

What are the main causes of AF?

A

-Hypertension
-Obesity
-Alcohol
-Heart failure
-Structural pathology
-Acute infection
-Electrolyte imbalance
-PE
-DM

274
Q

Describe the symptoms of AF

A

-Breathlessness
-Palpitations
-Chest discomfort
-Light-headedness
-Syncope

275
Q

What investigations would you perform for suspected AF?

A

-Basic obs
-ECG-12 lead + ambulatory
-Echocardiogram
-Chest x-ray
-FBC
-U + E
-LFT
-TFT
-CRP
-Clotting screen

276
Q

What are the ECG diagnostic requirements for AF?

A

-12 lead ECG of >30s showing no repeating P waves +
-Irregular RR intervals

277
Q

What are the 3 principles of AF managament?

A

-Rate control
-Restore sinus rhythm
-Maintain sinus rhythm

278
Q

What meds are used in the management of AF?

A

-Rate control: BB, CCB, Digoxin
-Restore sinus rhythm: Electrical/pharmacological cardioversion
-Maintain sinus rhythm: Flecainide, Dronedarone, Sotalol

279
Q

What scoring system is used to asses stroke risk?

A

CHA2DS2-VASc Risk

280
Q

What should happen if a CHADS-VASC score is >1

A

Prescribe anticoagulation with warfarin/DOAC

281
Q

What are the categories in the CHA2DS2-VASc score?

A

Congestive HF
Hypertension
Age 75+ (2)
Diabetes mellitus
Stroke previously/TIA/Thromboembolism (2)
Vascular disease
Age 65-74
Sex category (female)

282
Q

What is heart failure?

A

Inability of the heart to deliver blood + O2 to match the requirements of tissues, despite normal/increased cardiac filling

283
Q

What are the causes of heart failure?

A

-IHD
-Hypertension
-Alcohol XS
-Cardiomyopathy
-Valvular disease

284
Q

What are the symptoms of heart failure?

A

-Breathlessness
-Tiredness
-Cold peripheries
-Leg swelling
-Increased weight

285
Q

What are the signs of HF?

A

-Tachycardia
-Displaced apex beat
-Added sounds/murmurs
-Hepatomegaly
-Ascites
-Peripheral/sacral oedema

286
Q

What are the 2 main types of heart failure?

A

Acute + chronic

287
Q
A
288
Q
A

Phase 2a (8 decks)

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