CARDIO

Question 1

ATHEROSCEROSIS
Define atherosclerosis

Answer 1

Build up of plaque in the intima of an artery

Question 2

ATHEROSCLEROSIS
What can an atherosclerotic plaque cause?

Answer 2

1. Heart attack
2. Stroke
3. Gangrene

Question 3

ATHEROSCLEROSIS
what are the risk factors for atherosclerosis?

Answer 3

1. Family history
2. Increasing age
3. Smoking
4. High serum cholesterol (LDL)
5. Obesity
6. Diabetes
7. Hypertension

Question 4

ATHEROSCLEROSIS
What are the constituents of an atheromatous plaque?

Answer 4

Lipid core
Necrotic debris
Connective tissue surrounded by foam cells
Fibrous cap
Lymphocytes

Question 5

ATHEROSCLEROSIS
In which arteries would you most likely find an atheromatous plaque?

Answer 5

Peripheral and coronary arteries - circumflex, LAD and RCA
Focal distribution along the length

Question 6

ATHEROSCLEROSIS
What histological layer of the artery may be thinned by an atheromatous plaque?

Answer 6

Media

Question 7

ATHEROSCLEROSIS
What is the precursor for atherosclerosis?

Answer 7

Fatty streaks

Question 8

ATHEROSCLEROSIS
What can cause chemoattractant release?

Answer 8

Endothelial cell injury

Question 9

ATHEROSCLEROSIS
What is the function of chemoattractants?

Answer 9

Signal leukocytes and produce a concentration gradient

Question 10

ATHEROSCLEROSIS
What is the function of leukocytes?

Answer 10

Leukocytes accumulate and migrate into vessel walls and release cytokines leading to inflammation

Question 11

ATHEROSCLEROSIS
What inflammatory cytokines are found in plaques?

Answer 11

IL-1
IL-6
IFN-gamma

Question 12

ATHEROSCLEROSIS
Describe the process of leukocyte recruitment

Answer 12

1. Capture
2. Rolling
3. Slow rolling
4. Adhesion
5. Transmigration

Question 13

ATHEROSCLEROSIS
What types of molecules are present during leukocyte recruitment?

Answer 13

1. Chemoattractants
2. Selectins (1-3)
3. Integrins (3-5)

Question 14

ATHEROSCLEROSIS
Describe the 5 steps of progression of atherosclerosis

Answer 14

1. Fatty streaks
2. Intermediate lesions
3. Fibrous plaque/advanced lesions
4. Plaque rupture
5. Plaque erosion

Question 15

ATHEROSCLEROSIS
At what age do fatty streaks begin to appear?

Answer 15

< 10 years old

Question 16

ATHEROSCLEROSIS
What are the constituents of fatty streaks?

Answer 16

Foam cells and T lymphocytes within the intimal layer of the vessel wall

Question 17

ATHEROSCLEROSIS
What are the constituents of intermediate lesions?

Answer 17

Foam cells
Smooth muscle cells
T lymphocytes
Platelet adhesion and aggregation
Extracellular lipid pools

Question 18

ATHEROSCLEROSIS
What are the constituents of fibrous plaques?

Answer 18

Fibrous cap overlies lipid core and necrotic debris
Smooth muscle cells
Macrophages
Foam cells
T lymphocytes

Question 19

ATHEROSCLEROSIS
What are fibrous plaques able to do?

Answer 19

Impede blood flow and they are prone to rupture

Question 20

ATHEROSCLEROSIS
Why might a plaque rupture?

Answer 20

Fibrous plaques are constantly growing and receding
Fibrous cap has to be resorbed and redeposited in order to be maintained
If balance is shifted in favour of inflammatory condition, the cap becomes weak and the plaque ruptures
Thrombus formation and vessel occlusion

Question 21

ATHEROSCLEROSIS
What the primary treatment for atherosclerosis?

Answer 21

Percutaneous Coronary Intervention (PCI)

Question 22

ATHEROSCLEROSIS
What is the major limitation of PCI?

Answer 22

Restenosis

Question 23

ATHEROSCLEROSIS
How can restenosis be avoided following PCI?

Answer 23

Drug eluting stents –> anti-proliferative and drugs that inhibit healing

Question 24

ATHEROSCLEROSIS
What is the key principle behind pathogenesis of atherosclerosis?

Answer 24

It is an inflammatory process

Question 25

ATHEROSCLEROSIS Define atherogenesis

Answer 25

The development of an atherosclerotic plaque

Question 26

ANGINA Define angina

Answer 26

Type of ischaemic heart disease It is a symptom of O2 supply/demand mismatch to the heart

Question 27

ANGINA What is the most common cause of angina?

Answer 27

Narrowing of the coronary arteries due to atherosclerosis

Question 28

ANGINA Give 5 possible causes of angina

Answer 28

- atheroma/stenosis of coronary arteries - valvular disease - aortic stenosis - arrhythmia - anaemia

Question 29

ANGINA How reduced does the diameter of an artery need to be before symptoms occur?

Answer 29

Diameter has to fall below 70%

Question 30

ANGINA Name 3 types of angina

Answer 30

- Stable angina - Unstable angina - Prinzmetal's angina

Question 31

ANGINA Name 3 non-modifiable risk factors for angina

Answer 31

1. Increasing age 2. Family history 3. Gender - Male 4. ethnicity - south Asian

Question 32

ANGINA Give 5 modifiable risk factors for angina

Answer 32

1. Smoking 2. Diabetes 3. Hypertension 4. Hypercholesterolaemia 5. Sedentary lifestyle/obesity 6. Stress 7. alcohol

Question 33

ANGINA Name 3 exacerbating factors for angina that effect the supply of O2

Answer 33

1. Anaemia 2. Hypoxaemia 3. Polycythaemia 4. Hypothermia 5. Hyper/hypovolaemia

Question 34

ANGINA Name 3 exacerbating factors for angina that effect the demand of O2

Answer 34

1. Hypertension 2. Tachyarrhythmia 3. Valvular heart disease 4. Hyperthyroidism 5. Cold weather 6. Heavy meals 7. Emotional stress

Question 35

ANGINA Briefly describe the pathophysiology of angina that results from atherosclerosis

Answer 35

On exertion there is increase O2 demand Coronary blood flow is obstructed by an atherosclerotic plaque --> myocardial ischaemia --> angina

Question 36

ANGINA Briefly describe the pathophysiology of angina the results from anaemia

Answer 36

On exertion there is increased O2 demand In someone with anaemia there is reduced O2 transport --> myocardial ischaemia --> angina

Question 37

ANGINA Briefly describe the pathophysiology of Prinzmetal's angina

Answer 37

Occurs due to coronary artery spasm

Question 38

ANGINA Name 3 differential diagnoses for angina

Answer 38

1. Pericarditis/myocarditis 2. PE 3. Chest infection 4. Dissection of aorta 5. GORD

Question 39

ANGINA How would you describe the chest pain in angina?

Answer 39

Crushing central chest pain that is heavy and tight - angina pectoris

Question 40

ANGINA What 3 things are used to assess whether it is typical angina, atypical pain or non-anginal pain?

Answer 40

1. Have central, tight, radiation to arms, jaw and neck 2. Precipitated by exertion 3. Relieved by rest or GTN spray 3/3 = Typical angina 2/3 = Atypical pain 1/3 = Non-anginal pain

Question 41

ANGINA Give the clinical presentation of angina

Answer 41

1. Crushing central chest pain 2. Pain is relieved with rest or GTM spray 3. Pain is provoked by physical exertion 4. Pain may radiate to arms, neck or jaw 5. Dyspnoea 6. Nausea

Question 42

ANGINA What investigations might you do in someone you suspect to have angina?

Answer 42

1. ECG - usually normal, sometimes ST depression, flat or inverted T waves 2. Echocardiography 3. CT angiography - high NPV and good at excluding disease (gold standard) 4. Exercise tolerance test - induces ischaemia 5. Invasive angiogram - tells you FFR (pressure gradient across stenosis) 6. SPECT - radio labelled tracer taken up by metabolising tissues

Question 43

ANGINA How can angina be reversed?

Answer 43

Resting - reducing myocardial demand

Question 44

ANGINA Describe the primary prevention for angina

Answer 44

1. Modify risk factors 2. Treat underlying causes 3. Low dose aspirin

Question 45

ANGINA Describe the secondary prevention of angina

Answer 45

1. Modify risk facotrs 2. Pharmacological therapies for symptom relief and to reduce the risk of CV events 3. Interventional therapies (e.g. PCI)

Question 46

ANGINA what is the management?

Answer 46

SYMPTOM RELIEF - GTN spray (if pain persists after 5 mins repeat dose, if pain remains after anther 5 mins call ambulance) ANTIANGINAL MEDICATION - 1st line = beta blocker or CCB - 2nd line = combination of BB + CCB (nifedipine) - long acting nitrate e.g. ivabradine

Question 47

ANGINA Name 2 complications of angina

Answer 47

1. Acute coronary syndromes 2. Congestive cardiac failure 3. Conduction disease 4. Arrhythmia

Question 48

PHARMACOLOGY Describe the action of beta blockers

Answer 48

Beta 1 specific Antagonise sympathetic activation and so are negatively chronotropic and inotropic Myocardial work is reduced and so is myocardial demand = symptom relief

Question 49

PHARMACOLOGY Give 3 side effects of beta blockers

Answer 49

1. Bradycardia 2. Tiredness 3. Erectile dysfunction 4. Cold peripheries 5. nightmares

Question 50

PHARMACOLOGY When might beta blockers be contraindicated?

Answer 50

DO NOT GIVE in asthma, heart failure/heart block, hypotension and bradyarrhythmia

Question 51

PHARMACOLOGY Describe the action of nitrates

Answer 51

Venodilators Reduce venous return --> reduced preload --> reduced myocardial work and myocardial demand

Question 52

PHARMACOLOGY Describe the action of Calcium channel blockers

Answer 52

Arterodilators Reduce BP --> Reduce afterload --> reduced myocardial demand

Question 53

PHARMACOLOGY What drugs that might be use in someone with angina or in someone at risk of angina to improve prognosis?

Answer 53

1. Aspirin 2. Clopidogrel - antiplatelet 3. Atovostatin - Statin 4. ACEi - ramipril

Question 54

PHARMACOLOGY How does aspirin work?

Answer 54

Antiplatelet Irreversibly inhibits COX --> reduced thromboxane 2 synthesis --> platelet aggregation reduced

Question 55

PHARMACOLOGY What is a caution when prescribing aspirin?

Answer 55

Gastric ulceration

Question 56

PHARMACOLOGY How does clopidogrel work?

Answer 56

Antiplatelet P2Y12 inhibitor --> prevents platelet activation

Question 57

PHARMACOLOGY What are statins used for?

Answer 57

To reduce the amount of LDL in the blood

Question 58

PHARMACOLOGY What is the function of P2Y12?

Answer 58

It amplifies platelet activation

Question 59

PHARMACOLOGY Give 2 potential side effect of P2Y12 inhibitors

Answer 59

1. Bleeding 2. Rash 3. GI disturbances - ulceration

Question 60

REVASCULARISATION What is revascularisation?

Answer 60

Used to restore coronary artery and increase blood flow

Question 61

REVASCULARISATION Name 2 types of revascularisation

Answer 61

1. Percutaneous coronary intervention (PCI) 2. Coronary artery bypass graft (CABG)

Question 62

REVASCULARISATION Give the pros and cons of PCI

Answer 62

ADVANTAGES 1. Less invasive 2. Convenient and acceptable 3. short recovery and repeatable DISADVANTAGES 1. High risk of restenosis 2. not good for complex disease 3. risk of stent thrombosis

Question 63

REVASCULARISATION what are the pros and cons of CABG?

Answer 63

ADVANTAGES 1. Good prognosis after surgery 2. deals with complex disease DISADVANTAGES 1. Very invasive 2. Long recovery time 3. risk of stroke or bleeding

Question 64

ACS What are acute coronary syndromes?

Answer 64

Encompasses a spectrum of acute cardiac conditions from unstable angina, NSTEMI and STEMI

Question 65

ACS What is the common cause of ACS?

Answer 65

Rupture of an atherosclerotic plaque and subsequent arterial thrombosis

Question 66

ACS What are uncommon causes of ACS?

Answer 66

1. Coronary vasospasm 2. Drug abuse 3. Coronary artery dissection 4. Thoracic aortic dissection

Question 67

ACS Briefly describe the pathophysiology of ACS

Answer 67

- Rupture/erosion of fibrous cap on plaque leading to platelet aggregation and thrombus formation - In unstable angina the plaque has a necrotic centre and ulcerated cap and the thrombus results in partial occlusion - In MI the plaque has a necrotic centre and the thrombus results in total occlusion

Question 68

ACS Describe type 1 MI

Answer 68

Spontaneous MI with ischaemia due to a primary coronary event e.g. plaque erosion/rupture, fissuring or dissection

Question 69

ACS Describe type 2 MI

Answer 69

MI secondary to ischaemia due to increased O2 demand or decreased supply such as in coronary spasm, coronary embolism, anaemia, arrhythmias, hypertension or hypotension

Question 70

ACS What is troponin a marker for?

Answer 70

Cardiac muscle injury

Question 71

ACS Why do you see increased serum troponin in NSTEMI and STEMI?

Answer 71

The occluding thrombus causes necrosis of cells and so myocardial damage causing troponin to be raised

Question 72

ACS Give 3 signs of unstable angina

Answer 72

1. Cardiac chest pain at rest 2. Cardiac chest pain with crescendo pattern 3. No significant rise in troponin

Question 73

ACS Give 4 symptoms of MI

Answer 73

1. Unremitting and usually severe central cardiac chest pain 2. Pain occurs at rest 3. Sweating, pale, grey 4. Breathlessness 5. Nausea and vomiting

Question 74

ACS Give 3 signs of MI

Answer 74

1. Hypo/hypertension 2. 3rd/4th heart sound 3. Signs of congestive heart failure 4. Ejection systolic murmur

Question 75

ACS Name 3 possible differential diagnoses of MI

Answer 75

1. Pericarditis 2. Stable angina 3. Aortic dissection 4. GORD 5. Pneumothorax

Question 76

ACS What investigations would you do on someone you suspect to have ACS?

Answer 76

1. ECG (within 10 mins) 2. Blood tests - troponin levels and rule out anaemia 3. Coronary angiography 4. Cardiac monitoring for arrhythmias 5. Chest x-ray

Question 77

ACS what other biomarkers can be tested for in MI?

Answer 77

creatine-kinase-MB (CK-MB) myoglobin

Question 78

ACS What might the ECG of someone with unstable angina show?

Answer 78

May be normal, or might show T wave inversion and ST depression

Question 79

ACS What might the ECG of someone with NSTEMI show?

Answer 79

May be normal or might show T wave inversions and ST depression Might also be R wave regression, ST elevation and biphasic T wave in lead V3

Question 80

ACS What might the ECG of someone with STEMI show?

Answer 80

ST elevation in the anterolateral leads After a few hours, T waves inlet and deep, broad, pathological Q waves develop

Question 81

ACS What would the serum troponin level be like in someone with unstable angina?

Answer 81

Normal

Question 82

ACS What would the serum troponin level be like in someone with NSTEMI/STEMI?

Answer 82

Significantly raised - troponin I and T

Question 83

ACS A raised troponin is not specific for ACS. In what other conditions might you see a raised troponin?

Answer 83

1. Gram negative sepsis 2. PE 3. Myocarditis 4. Heart failure 5. Arrhythmias

Question 84

ACS Describe the initial management of ACS

Answer 84

- Analgesia - morphine + sublingual GTN - Oxygen (if SpO2 > 94%) - dual antiplatelets - ALL patients = aspirin 300mg - if PCI = prasugrel or clopidogrel - if fibrinolysis = ticagrelor or clopidogrel MONA

Question 85

ACS What is the overall treatment for STEMI?

Answer 85

PCI - if symptom onset within 12 hours and access to PCI within 120 minutes Thrombolysis e.g. alteplase or tenecteplase - If ineligible for PCI

Question 86

ACS what is the management of an NSTEMI?

Answer 86

- anticoagulation = fondaparinux to most patients, unfractionated heparin if renal failure - use GRACE score to work out if patient requires PCI

Question 87

ACS what is the grace score?

Answer 87

it is used to risk-stratify patients with unstable angina and NSTEMIs it estimates admission to 6 month mortality

Question 88

ACS Describe the secondary prevention therapy for people after having a STEMI

Answer 88

- lifestyle changes - manage CVD risks - 12 months aspirin 75mg + ticagrelor if ACS was medically managed - lifelong aspirin + 12 months ticagrelor/prasugrel if ACS treated with PCI - ACEi

Question 89

ACS Give 5 early complications of MI

Answer 89

- Post MI pericarditis (few days post MI) - cardiac arrest (due to VF) - heart block - cardiogenic shock - VSD - mitral regurgitation - left ventricular wall rupture

Question 90

ACS Give 5 late complications of MI

Answer 90

- dresslers syndrome (2-6 weeks post MI) - heart failure - left ventricular aneurysm

Question 91

DVT What is a DVT?

Answer 91

Blood clot within a blood vessel of the lower limb

Question 92

DVT Give 5 risk factors for DVT

Answer 92

- AGE <40 - IMMOBILITY - surgery, hospitalisation, long-haul travel, bed-bound - TRAUMA - THROMBOPHILIA - MALIGNANCY - SMOKING - PREGNANCY - DRUGS - COCP, HRT, tamoxifen

Question 93

DVT What are the clinical features of DVT?

Answer 93

- unilateral calf pain, redness and swelling - oedema distention of superficial veins rarely phlegmasia cerula dolens (blue and painful leg from both venous and arterial obstruction)

Question 94

DVT What are the causes of DVT?

Answer 94

HYPERCOAGULABILITY - hereditary e.g. facter V leiden, antiphospholipid syndrome - acquired e.g. malignancy, chemo, COCP/HRT, pregnancy, obesity VENOUS STASIS - immobility e.g. surgery, flights - polycythaemia ENDOTHELIAL DAMAGE - surgery - catheter (PICC lines) - trauma - smoking

Question 95

DVT What investigations might be done in order to diagnose a DVT?

Answer 95

1. WELLS score if WELLS >2 DVT likely - duplex ultrasound of leg within 4 hours (if not within 4 hrs, offer anticoagulation) - d-dimer if WELLS <1 DVT unlikely - D-dimer with results within 4 hrs (if not within 4hrs offer anticoagulation) - if D-dimer is raised = duplex USS - if D-dimer normal = no further Ix bloods - FBC, U&Es, LFTs, PT + APTT

Question 96

DVT what is WELLS score?

Answer 96

calculates the risk of DVT and determines how a patient is investigated and treated

Question 97

DVT what are the components of the WELLS score?

Answer 97

- active cancer - bedridden or recent major surgery - calf swelling >3cm compared to other leg - superficial veins present (non-varicose) - entire leg swollen - tenderness along veins - pitting oedema of affected leg - immobility of affected leg - previous DVT - alternative diagnosis likely (-2) all score +1

Question 98

DVT how do you interpret the results of the WELLS score?

Answer 98

>2 = high risk of DVT/likely <1 = low risk of DVT/unlikely

Question 99

DVT What is the treatment for DVT?

Answer 99

- no renal impairment = apixaban/rivaroxaban - renal impairment (CrCl<15ml/min) = LMWH or UFH + warfarin for 5 days, then warfarin alone - active cancer = consider DOAC or warfarin

Question 100

DVT how long should you offer anticoagulation for?

Answer 100

at least 3 months

Question 101

DVT Name the types of DVT

Answer 101

1. Spontaneous 2. Provoked - incidence of recurrence is low if you remove the stimulus

Question 102

DVT How can DVTs and PEs be prevented?

Answer 102

1. Hydration 2. Early mobilisation 3. Compression sticking/pumps 4. Low dose LMW heparin

Question 103

DVT What is low risk thromboprophylaxis treatment?

Answer 103

< 40 years Surgery < 30 mins Early mobilisation and hydration No chemical TED if surgical

Question 104

DVT What is high risk thromboprophylaxis?

Answer 104

Hip, knee, pelvis, malignancy, risk factors, prolonged immobility All immobile medical, many surgical - Dalteparin s/c od

Question 105

DVT what are the complications of a DVT?

Answer 105

Pulmonary embolism Post thrombotic syndrome Increased risk of bleeding Phlegmasia cerula dolens (venous and arterial obstruction resulting in blue painful leg)

Question 106

PE what are the clinical features of PE?

Answer 106

MOST COMMON FEATURES - tachypnoea - crackles - tachycardia - fever SYMPTOMS 1. Breathlessness 2. Pleuritic chest pain 3. signs/symptoms of DVT 4. Cough/haemoptysis SIGNS 1. Tachycardia 2. Tachypnoea 3. pleural rub 4. hypoxia

Question 107

PE What investigations might be done to diagnose a patient with PE?

Answer 107

- CXR (typically normal) - ECG (sinus tachy, S1Q3T3, RBBB + R axis deviation - if WELLS >4 = CTPA (V/Q scan as alternative in severe renal impairment) - if WELLS<4 = D-dimer

Question 108

PE when would a V/Q scan be used over CTPA?

Answer 108

- patients allergic to contrast - severe renal impairment - pregnancy

Question 109

PE what is the WELLS two-level score?

Answer 109

used to determine the probability of PE >4 = high probability <4 = low probability

Question 110

PE what are the components of the WELLs two level score?

Answer 110

- clinical signs + symptoms of DVT (+3) - PE is no.1 diagnosis (+3) - tachycardia <100 (+1.5) - immobilisation for >3 days - previous PE/DVT (+1.5) - haemoptysis (+1) - malignancy with treatment in last 6 months (+1)

Question 111

What is the treatment for a PE?

Answer 111

massive PE = thrombolysis e.g. alteplase non-massive PE = - no renal impairment = apixaban/rivaroxaban - renal impairment (CrCl<15ml/min) = LMWH or UFH + warfarin for 5 days, then warfarin alone - active cancer = consider DOAC or warfarin

Question 112

PE how long would you offer anticoagulation for?

Answer 112

- provoked = 3 months - unprovoked = 6 months

Question 113

PE If a patient can not be placed on anticoagulation following a PE, what alternative treatment should be considered?

Answer 113

IVC filter - prevents more clot travelling from the leg to the lungs surgical embolectomy

Question 114

PE what are the complications?

Answer 114

- cor pulmonale - pulmonary infarction - heparin-associated thrombocytopaenia

Question 115

THROMBUS Define thrombosis

Answer 115

Blood coagulation inside a vessel

Question 116

THROMBUS How would you describe an arterial thrombus?

Answer 116

Platelet rich (a 'white thrombosis')

Question 117

THROMBUS How would you describe a venous thrombosis?

Answer 117

Fibrin rich (a 'red thrombosis')

Question 118

THROMBUS What are the potential consequences of an arterial thrombosis?

Answer 118

1. Coronary circulation = MI 2. Cerebral circulation = Stroke 3. Peripheral circulation = Peripheral vascular disease (e.g. gangrene)

Question 119

THROMBUS What investigations would you do to diagnose an arterial thrombosis?

Answer 119

MI = history, ECG, cardiac enzymes Stoke = History and examination, CT/MRI scan PVD = History and examination, ultrasound, angiogram

Question 120

THROMBUS What is the treatment for arterial thrombosis?

Answer 120

1. Aspirin 2. LMW heparin 3. Thrombolytic therapy: streptokinase tissue plasminogen factor 4. Treat risk factors

Question 121

PHARMACOLOGY How does heparin work?

Answer 121

Inhibits thrombin and factor Xa Indirect thrombin inhibitor - binds to antithrombin and increased its activity

Question 122

PHARMACOLOGY How do you monitor heparin?

Answer 122

Activated partial thromboplastin time Aim ratio: 1.8-2.8

Question 123

PHARMACOLOGY Why is LMW heparin often used instead of normal heparin?

Answer 123

Smaller molecule, less variation in dose and renally excreted

Question 124

PHARMACOLOGY How does warfarin work?

Answer 124

Inhibits production of vitamin K dependent clotting factors (2, 7, 9, 10) Prolongs the prothrombin time

Question 125

PHARMACOLOGY What is warfarin an antagonist of?

Answer 125

Vitamin K

Question 126

PHARMACOLOGY Why is warfarin difficult to use?

Answer 126

Lots of interactions Needs almost constant monitoring Teratogenic

Question 127

PHARMACOLOGY How is warfarin measured?

Answer 127

Using International Noramlised Ratio (derived from prothrombin time) Usual target = 2-3 Higher range = 3-4.5

Question 128

PHARMACOLOGY How does Direct Acting Oral Anticoagulant (DOAC) work?

Answer 128

Directly acts on factor 2 (thrombin) or 10 No blood test or monitoring needed just given od or bd

Question 129

PERICARDITIS How much serous fluid is there between the visceral and parietal pericardium?

Answer 129

50 ml

Question 130

PERICARDITIS What is the function of the serious fluid between the visceral and parietal pericardium?

Answer 130

Lubricant and so allows smooth movement of the heart inside the pericardium

Question 131

PERICARDITIS What is the function of the pericardium?

Answer 131

Restrains the filling volume of the heart

Question 132

PERICARDITIS what is the innervation of the pericardium?

Answer 132

phrenic nerve

Question 133

PERICARDITIS what is the pathophysiology of pericarditis?

Answer 133

- Pericardium becomes acutely inflamed, with pericardial vascularisation and infiltration with polymorphonuclear leukocytes - A fibrinous reaction frequently results in exudate and adhesions within the pericardial sac, and a serous or haemorrhagic effusion may develop

Question 134

PERICARDITIS Describe the aetiology of pericarditis

Answer 134

IDIOPATHIC VIRUSES (most common = coxsackie), mumps, EBV, CMV, varicella, HIV less common - autoimmune - TB - trauma - uraemia secondary to kidney disease - post-MI syndrome - dressler syndrome - connective tissue disorders - malignancy - hypothyroidism

Question 135

PERICARDITIS Define acute pericarditis

Answer 135

Acute inflammation of the pericardium with or without effusion

Question 136

PERICARDITIS Give 5 symptoms of pericarditis

Answer 136

1. CHEST PAIN - severe, sharp and pleuritic (worse on inspiration/lying flat - relieved by sitting forward) 2. Dyspnoea 3. Cough 4. Hiccups 5. Skin rash 6. Fever and myalgia 7. peripheral oedema

Question 137

PERICARDITIS Describe the chest pain in acute pericarditis

Answer 137

Severe, sharp, pleuritic, rapid onset, can radiate to arm (trapezius ridge) Relieved by sitting up/leaning forward exacerbated by lying flat may last from hours to days

Question 138

PERICARDITIS Why might someone with pericarditis have hiccups?

Answer 138

Due to irritation to the phrenic nerve

Question 139

PERICARDITIS What is the major differential diagnosis of acute pericarditis?

Answer 139

Myocardial infarction

Question 140

PERICARDITIS Name 3 differential diagnoses for acute pericarditis

Answer 140

1. MI 2. Angina 3. Pneumonia 4. Pleurisy 5. PE 6. GORD 7. pneumothorax

Question 141

PERICARDITIS What investigations might you do on someone who you suspect to have pericarditis?

Answer 141

1. ECG - diagnostic 2. CXR 3. Bloods - FBC, ESR and CRP, Troponin 4. Echocardiogram - usually normal, rule out silent pericardial effusion

Question 142

PERICARDITIS What might the ECG look like in someone with acute pericarditis?

Answer 142

1. Saddle shaped ST elevation 2. PR depression

Question 143

PERICARDITIS What does a raised troponin in acute pericarditis suggest?

Answer 143

Myopericarditis

Question 144

PERICARDITIS How can acute pericarditis be clinically diagnosed?

Answer 144

Patient has to have at least 2 of the following: 1. Chest pain 2. Friction rub 3. ECG changes 4. Pericardial effusion

Question 145

PERICARDITIS where is the pericardial rub heard?

Answer 145

left sternal edge as patient leans forward

Question 146

PERICARDITIS What is the treatment for pericarditis?

Answer 146

idiopathic/viral - 1st line = NSAIDs + colchicine - 2nd line = NSAIDs, colchicine + low-dose prednisolone bacterial - IV antibiotics + pericardiocentesis with washout, cultures

Question 147

PERICARDITIS what are the complications?

Answer 147

- pericardial effusion - cardiac tamponade - myocarditis - constrictive pericarditis

Question 148

PERICARDITIS What is the treatment for chronic constrictive pericarditis?

Answer 148

Surgical excision of thickened pericardium

Question 149

PERICARDITIS What is haemopericaridum?

Answer 149

Direct bleeding from vasculature through the ventricular wall following MI

Question 150

PERICARDIAL EFFUSION What is pericardial effusion?

Answer 150

Abnormal accumulation of fluid in the pericardial cavity It commonly accompanies an episode of acute pericarditis

Question 151

PERICARDIAL EFFUSION What is a complication of pericardial effusion?

Answer 151

Cardiac tamponade

Question 152

PERICARDIAL EFFUSION Why does chronic pericardial effusion rarely cause tamponade?

Answer 152

Parietal pericardium is able to adapt when effusion accumulate slowly and so tamponade is prevented

Question 153

CARDIAC TAMPONADE what is cardiac tamponade?

Answer 153

Cardiac tamponade occurs when a large amount of pericardial fluid restricts diastolic ventricular filling and causes marked reduction in cardiac output

Question 154

CARDIAC TAMPONADE Briefly explain the pathophysiology of cardiac tamponade

Answer 154

Accumulation of pericardial fluid --> increase in intra-pericardial pressure --> poor ventricular filling --> decrease in CO

Question 155

CARDIAC TAMPONADE what are the causes?

Answer 155

idiopathic pericarditis iatrogenic (cardiothoracic surgery) malignancy aortic dissection rheumatological - SLE, RA, scleroderma

Question 156

CARDIAC TAMPONADE What are the signs of Cardiac tamponade?

Answer 156

Beck's triad: 1. low BP but high HR 2. Increased JVP 3. Quiet S1 and S2 - Pulsus paradoxus = pulses fade on inspiration - Kussmaul's sign = rise in jugular venous pressure with inspiration

Question 157

CARDIAC TAMPONADE what are the symptoms?

Answer 157

- shortness of breath - chest discomfort - peripheral oedema - confusion

Question 158

CARDIAC TAMPONADE what are the investigations for cardiac tamponade?

Answer 158

- ECG – tachycardia + electrical alternans - trans-thoracic echo (TTE) is diagnostic – echo-free space around heart - CXR - enlarged heart - bloods - inflammatory markers, troponin

Question 159

CARDIAC TAMPONADE What is the treatment of cardiac tamponade?

Answer 159

Pericardiocentesis (drainage)

Question 160

What is chronic constrictive pericarditis?

Answer 160

Calcification thickens the pericardium and affects cardiac effusion

Question 161

MYOCARDITIS What can cause myocarditis?

Answer 161

most common = coxsackie B others Viral infection - coxsackie B, adenovirus, herpes lyme disease toxoplasmosis autoimmune - SLE, dermatomyositis, sarcoidosis drug-induced - antipsychotics, immunotherapies hypersensitivity reactions

Question 162

MYOCARDITIS what are the risk factors?

Answer 162

peri-partum and post-natal periods Younger age Exposure to certain drugs or allergens Background of autoimmune conditions

Question 163

MYOCARDITIS what are the clinical features?

Answer 163

SIGNS tachycardia fever displaced apex beat S3 gallop peripheral oedema SYMPTOMS chest pain - worse lying flat, improved by sitting forward shortness of breath fatigue syncope palpitations

Question 164

MYOCARDITIS what are the investigations?

Answer 164

- ECG (sinus tachy, T wave inversions) - serum troponin/CK MB - CRP/ESR (may be elevated) - echo

Question 165

MYOCARDITIS what is the management?

Answer 165

- supportive care (bed rest, fluid balance, oxygen) - immunosuppressive therapy if autoimmune - heart failure therapies (ACEi, BB, diuretics)

Question 166

PVD what is the epidemiology of peripheral vascular disease?

Answer 166

Men > women Usually affects the aorta-iliac and infra-inguinal arteries

Question 167

PVD what is the pathophysiology of peripheral vascular disease?

Answer 167

Commonly atherosclerosis leading to claudication of vessels Other (rarer) causes of claudication: - aortic coarctation, - temporal arteritis, - Buerger’s disease. End stage PVD= Critical Limb Ischaemia (6 P’s)

Question 168

PVD Give 5 risk factors for peripheral vascular disease

Answer 168

Smoking Diabetes HTN Sedentary lifestyle Hyperlipidaemia History of CAD Age (>40)

Question 169

PVD what is the clinical presentation of peripheral vascular disease?

Answer 169

- Pain in lower limbs on exercise, relieved on rest- intermittent claudication - Severe unremitting pain in foot (esp at night- hangs foot out of bed) - Leg may be pale, cold, loss of hair, skin changes

Question 170

PVD what are the investigations for peripheral vascular disease?

Answer 170

1st line = ankle brachial pressure index (ABPI), duplex ultrasound < 0.3 = critical ischaemia ECG Bloods - FBX, U&E, random glucose/HbA1c, serum cholesterol, lipid profile

Question 171

PVD what classification is used?

Answer 171

fontaine classification for different stages of PVD

Question 172

PVD what are the different stages of PVD?

Answer 172

1 = asymptomatic 2 = intermittent claudication 3 = critical limb ischaemia 4 = tissue loss (ulceration/gangrene)

Question 173

PVD what is the site of the disease when the claudication is at the following sites? 1. unilateral buttock 2. unilateral thigh 3. unilateral calf

Answer 173

buttock = common iliac thigh = common femoral calf = superficial femoral

Question 174

PVD what are the treatments for peripheral vascular disease?

Answer 174

- exercise control risk factors - stop smoking - diabetes control - HTN control - diet/weight management - statin (atorvastatin 80mg) - antiplatelet (clopidogrel 75mg) surgery - endovascular procedures - bypass surgery

Question 175

CRITICAL LIMB ISCHAEMIA What is critical limb ischaemia?

Answer 175

Critical limb ischaemia is defined as rest or night pain for greater than 2 weeks , with or without tissue loss such as ulceration It is a form of chronic limb ischaemia

Question 176

CRITICAL LIMB ISCHAEMIA what are the risk factors?

Answer 176

- increasing age - PVD - CVD co-morbidities (diabetes, HTN, hypercholesterolaemia, obesity) - family history of vascular disease - smoking - sedentary lifestyle

Question 177

CRITICAL LIMB ISCHAEMIA what are the clinical features?

Answer 177

- nocturnal resting pain for >2 weeks - evidence of aortoiliac disease - cool peripheries SIGNS - non-healing ulcer - surrounded by shiny hairless skin - gangrene - absent/diminished pulses - reactive hyperemia

Question 178

CRITICAL LIMB ISCHAEMIA how is the pain described?

Answer 178

aching pain at rest often nocturnal patients often hang their legs out of the bed to relieve the pain

Question 179

CRITICAL LIMB ISCHAEMIA what is aortoiliac disease?

Answer 179

also known as Leriche syndrome triad of: - claudication of buttocks and thighs - absent or decreased femoral pulses - erectile dysfunction

Question 180

CRITICAL LIMB ISCHAEMIA what are the investigations?

Answer 180

1st line = duplex USS. ABPI 0.5-0.9 = claudication <0.5 = critical limb ischaemia

Question 181

CRITICAL LIMB ISCHAEMIA what is the treatment for critical limb ischaemia?

Answer 181

Revascularisation (e.g. stenting, angioplasty, bypassing) Amputation if unsuitable

Question 182

ACUTE LIMB ISCHAEMIA what is it?

Answer 182

a sudden decrease in perfusion due to arterial occlusion, and can result in rapid ischaemia.

Question 183

ACUTE LIMB ISCHAEMIA What can cause acute ischaemia?

Answer 183

Embolism/thrombosis - AF - MI - valvular vegetations

Question 184

ACUTE LIMB ISCHAEMIA what is the most common site of embolisation?

Answer 184

femoral artery

Question 185

ACUTE LIMB ISCHAEMIA when are different tissues affected by lack of blood?

Answer 185

nerves = after 6 hrs muscles = after 6-10 hrs skin = last to show

Question 186

ACUTE LIMB ISCHAEMIA what are the risk factors?

Answer 186

modifiable - diabetes - smoking - HTN - sedentary lifestyle non-modifiable - family history of CVD - age >40

Question 187

ACUTE LIMB ISCHAEMIA Give 6 symptoms of acute ischaemia

Answer 187

1. Pain 2. Pale 3. Paralysis 4. Paraesthesia 5. Perishing cold 6. Pulseless

Question 188

ACUTE LIMB ISCHAEMIA how can you tell if the cause is embolic or thrombotic?

Answer 188

EMBOLIC - sudden onset - cardiac history - arrhythmia (AF) - cold mottled skin - clear demarkation THROMBOTIC - progressive onset - no cardiac history - peripheral artery disease - no arrhythmias - cool and cyanotic - no clear demarkation

Question 189

ACUTE LIMB ISCHAEMIA what are the investigations?

Answer 189

1st line = duplex USS ABPI ECG contrast-enhanced CT angiogram

Question 190

ACUTE LIMB ISCHAEMIA what is the classification?

Answer 190

rutherford classification 1 = viable 2= threatened 3 = irreversible

Question 191

ACUTE LIMB ISCHAEMIA what is the management?

Answer 191

initially LMWH based on rutherford classification I (viable) = catheter-directed thrombolysis/thrombectomy (within 6-24hrs) IIa = catheter-directed thrombolysis or percutaneous thromboembolectomy IIb = percutaneous/open thromboembolectomy, bypass surgery III = amputation

Question 192

HEART FAILURE Define heart failure

Answer 192

cardiac output struggles to meet the metabolic demands of the body

Question 193

HEART FAILURE what are the different categories of heart failure?

Answer 193

HF with reduced ejection fraction (systolic dysfunction) HF with preserved ejection fraction (diastolic dysfunction) Left sided HF Right sided HF

Question 194

HEART FAILURE what are the causes of HF with reduced ejection fraction (systolic dysfunction)?

Answer 194

damage to myocytes e.g. ischaemic heart disease

Question 195

HEART FAILURE what are the causes of HF with preserved ejection fraction (diastolic dysfunction)?

Answer 195

increased ventricular stiffness e.g. HTN reduced relaxation e.g. constrictive pericarditis

Question 196

HEART FAILURE what are the causes of left sided HF?

Answer 196

increased LV afterload e.g. HTN increased LV preload e.g. aortic regurgitation

Question 197

HEART FAILURE what are the causes of right sided HF?

Answer 197

increased RV afterload e.g. pulmonary HTN increased RV preload e.g. tricuspid regurgitation

Question 198

HEART FAILURE what are the risk factors for heart failure?

Answer 198

1. >65 y/o 2. African descent 3. Men 4. Obesity 5. Previous MI - previous MI - HTN - valvular disease - arrhythmias - cor pulmonale - T2DM - renal failure

Question 199

HEART FAILURE Why are men more commonly effected by heart failure than women?

Answer 199

Women have 'protective hormones' meaning they are less at risk of developing HF

Question 200

HEART FAILURE Describe the pathophysiology of heart failure

Answer 200

When the heart fails, compensatory mechanisms attempt to maintain CO As HF progresses, these mechanism are exhausted and become pathophysiological

Question 201

HEART FAILURE What are the compensatory mechanisms in heart failure?

Answer 201

1. Sympathetic system 2. RAAS 3. Natriuretic peptides 4. Ventricular dilation 5. Ventricular hypertrophy

Question 202

HEART FAILURE What are the 3 cardinal symptoms of heart failure?

Answer 202

1. SOB 2. Fatigue 3. Peripheral oedema

Question 203

HEART FAILURE what are the clinical signs of left heart failure?

Answer 203

1. Pulmonary crackles 2. S3 and S4 and murmurs 3. Displaced apex beat 4. Tachycardia 5. fatigue

Question 204

HEART FAILURE what are the clinical features of right HF?

Answer 204

1. Raised JVP 2. Ascites 3. peripheral oedema

Question 205

HEART FAILURE what are the clinical features of heart failure?

Answer 205

SOFA PC - shortness of breath - orthopnea - fatigue - ankle swelling - pulmonary oedema (due to backflow from decreased CO; produced cough with pink frothy sputum) - cold peripheries Raised JVP End respiratory crackles

Question 206

HEART FAILURE what is the classification system for heart failure?

Answer 206

New York heart association (NYHA)

Question 207

HEART FAILURE What investigations might you do initially do in someone who you suspect has HF?

Answer 207

1. ECG 2. CXR 3. BNP - brain natriuretic peptide 4. Trans-thoracic echo (TTE)

Question 208

HEART FAILURE What 4 signs might you see on a CXR taken from someone with HF?

Answer 208

ABCDE A - alveolar oedema (bat wing shadowing) B - Kerley B lines C - cardiomegaly D - dilated upper lobe vessels E - effusions (pleural)

Question 209

HEART FAILURE what is the management for chronic HF?

Answer 209

1st line = BB + ACEi (started one at a time) If ACEi not tolerated, try ARB or hydralazine with nitrate 2nd line = aldosterone antagonist (SPIRONOLACTONE) 3rd line = cardiac resynchronisation therapy (CRT) or ICD insertion, digoxin (particularly in AF) or ivabradine other options: - fluid restriction - loop diuretics (for symptom management) - annual flu + pneumococcal vaccine

Question 210

Give an example of an ACEi that is commonly used in HF

Answer 210

Ramipril

Question 211

What is cor pulmonale?

Answer 211

Right sided heart failure caused by chronic pulmonary arterial hypertension

Question 212

Name 3 BB that are used in treatment of HF

Answer 212

1. Propranolol 2. Bisoprolol 3. Atenolol 4. Carvedilol

Question 213

HEART FAILURE what is the treatment for acute HF?

Answer 213

- treat any underlying causes - oxygen if SpO2<94% - fluid restriction <1.5L - IV diuretic (furosemide) - inotropes/vasopressors (dobutamine)

Question 214

What might you give to someone with hypertension if they are ACE inhibitor intolerant?

Answer 214

Angiotensin receptor blocker (ARB) - losartan, valsartan, candesartan

Question 215

HEART FAILURE How can chronic HF be prevented?

Answer 215

Stop smoking Eat more healthy Exercise Avoid large meals Vaccinations Treat underlying cause - dysarrhythmias or valve disease

Question 216

HTN What is the clinical definition of hypertension?

Answer 216

BP > 140/90 mmHg

Question 217

HTN Name 4 conditions that hypertension is a major risk factor for

Answer 217

1. Stroke 2. MI 3. HF 4. Chronic renal failure 5. Cognitive decline 6. Premature death

Question 218

HTN What are the blood pressure readings for someone to be diagnosed with Stage 1 hypertension?

Answer 218

Clinic BP = 140/90 ABPM = 135/85

Question 219

HTN What are the blood pressure readings for someone to be diagnosed with Stage 2 hypertension?

Answer 219

Clinic BP = 160/100 ABPM = 150/95

Question 220

HTN What are the blood pressure readings for someone to be diagnosed with severe hypertension?

Answer 220

Systolic BP = >180 Diastolic BP = >110

Question 221

HTN Name the 2 types of hypertension

Answer 221

1. Essential (primary) hypertension 2. Secondary hypertension

Question 222

HTN What causes essential hypertension?

Answer 222

Unknown cause - multifactorial involving: - genetic susceptibility - Excessive sympathetic nervous system activity - Abnormalities of Na+/K+ membrane transport - High salt intake - Abnormalities in renin-angiotensin-aldosterone system

Question 223

HTN Give 5 causes of secondary hypertension

Answer 223

ROPE R - renal disease O - obesity P - pregnancy E - endocrine (Conn's, Cushing's, pheochromocytoma) most common = primary hyperaldosteronism - Conn's syndrome

Question 224

HTN Name 3 endocrine disease that can cause secondary hypertension

Answer 224

1. Conn's syndrome - hyperaldosteronism 2. Cushing's syndrome - excess cortisol --> increase BP 3. Phaemochromocytoma - adrenal gland tumour, excess catecholamines --> high BP 4. hyperthyroidism 5. acromegaly

Question 225

HTN Name 5 risk factor for hypertension

Answer 225

Modifiable: - alcohol intake - sedentary lifestyle - diabetes mellitus - sleep apnoea - smoking Non-modifiable: - Increasing age - family history - ethnicity - afro-Caribbean

Question 226

HTN What is the clinical presentation of hypertension?

Answer 226

Usually asymptomatic Found on screening headaches - occipital, worse in morning

Question 227

HTN what is the clinical presentation of malignant hypertension?

Answer 227

hypertensive retinopathy visual disturbance cardiac symptoms e.g. chest pain oliguria or polyuria

Question 228

HTN Why might you examine the eyes of someone with hypertension?

Answer 228

Very high BP can cause immediate damage to small vessels --> seen in the eyes --> retinopathy

Question 229

HTN What investigations might you do in someone with hypertension?

Answer 229

1. 24 hour ambulatory blood pressure monitoring --> confirm diagnosis 2. ECG and Bloods --> identify secondary causes - urinalysis - protein, albumin:creatine ratio, haematuria - blood tests - serum creatinine, eGFR, glucose - fundoscopy - retinal haemorrhage, papillodema - ECG - left ventricular hypertrophy

Question 230

HTN What is the treatment target for hypertension for the following: a) People aged <80? b) People aged >80?

Answer 230

a) < 140/90 mmHg b) < 150/90 mmHg

Question 231

HTN What are the 2 main types of treatment for hypertension?

Answer 231

1. Lifestyle modifications - reduce salt, loss weight, reduce alcohol 2. Drug therapy = ACD

Question 232

HTN Describe the pharmacological intervention for someone with hypertension

Answer 232

IF <55 OR T2DM 1. ACEi/ARB 2. ACEi/ARB + CCB or ACEi/ARB + thiazide-like diuretic (indapamide) 3. ACEi/ARB + CCB + thiazide-like diuretic 4. if K+<4.5 add spironolactone, if K+>4.5 add alpha/beta-blocker IF >55 + NO T2DM OR BLACK 1. CCB 2. CCB + ACEi/ARB* or CCB + thiazide like diuretic 3. CCB + ACEi/ARB* + thiazide-like diuretic 4. if K+<4.5 add spironolactone, if K+>4.5 add alpha/beta-blocker *note ARB is preferred in african-caribbean/black ethnicities

Question 233

HTN what is the first line for patients <55 or T2DM?

Answer 233

ACEi if afro-caribbean + T2DM, ARB more preferable

Question 234

HTN what is the first line therapy for >55 or afro-caribbean (any age)

Answer 234

CCB

Question 235

HTN What other pharmacological interventions might you give to someone with hypertension (except ACD)?

Answer 235

Beta blockers - bisoprolol statins - simvastatin

Question 236

HTN Will anti-hypertensives make someone feel better?

Answer 236

No, usually treating hypertension doesn't relive symptoms except headache

Question 237

HTN Write an equation for BP

Answer 237

BP = CO x TPR

Question 238

PHARMACOLOGY Name 2 systems that are targeted pharmacologically in the treatment of hypertension

Answer 238

1. RAAS 2. Sympathetic nervous system

Question 239

PHARMACOLOGY Give 4 functions of angiontensin II

Answer 239

1. Potent vasoconstrictor 2. Activated sympathetic nervous system - increased NAd 3. Activates aldosterone - Na+ retention 4. Vascular growth, hyperplasia and hypertrophy

Question 240

PHARMACOLOGY Give 3 ways in which the Sympathetic nervous system (NAd) leads to increased BP

Answer 240

1. Noradrenaline is a vasoconstrictor = increase TPR 2. NAd has positive chronotropic and inotropic effects 3. It can cause increase renin release

Question 241

PHARMACOLOGY In what diseases are ACE inhibitors clinically indicated?

Answer 241

1. Hypertension 2. Heart failure 3. Diabetic nephropathy

Question 242

PHARMACOLOGY Name 3 ACE inhibitors

Answer 242

1. Ramipril 2. Enalapril 3. Perindopril 4. Trandolapril 5. Lisinopril

Question 243

PHARMACOLOGY what are the side effects of ACE inhibitors?

Answer 243

1. Hypotension 2. Hyperkalaemia 3. Acute renal failure 4. Teratogenic 5. cough - from build up of kinin

Question 244

PHARMACOLOGY You see a patient who is taking ramipril. They say that since starting the medication they have had a dry and persistent cough. What might have caused this?

Answer 244

ACE inhibitors lead to a build up of kinin One of the side effects of this is a dry and chronic cough

Question 245

PHARMACOLOGY What are ARBs?

Answer 245

Angiotensin II receptor blockers

Question 246

PHARMACOLOGY At which receptor do ARB's work?

Answer 246

AT-1 receptor - prevent angiotensin II binding

Question 247

PHARMACOLOGY In what diseases are ARBs clinically indicated?

Answer 247

1. Hypertension 2. Heart failure 3. Diabetic nephropathy

Question 248

PHARMACOLOGY Name 3 ARBs

Answer 248

1. Candesartan 2. Valsartan 3. Losartan

Question 249

HTN A patient with hypertension has come to see you about their medication. You see in their notes that ACE inhibitors are contraindicated. What might you prescribe them instead?

Answer 249

An ARB e.g. candesartan

Question 250

PHARMACOLOGY Give 4 potential side effect of ARBs

Answer 250

1. Hypotension 2. Hyperkalaemia 3. Renal dysfunction 4. Rash Contraindicated in pregnancy

Question 251

PHARMACOLOGY In what diseases are calcium channel blockers clinically indicated?

Answer 251

1. Hypertension 2. IHD 3. Arrhythmia

Question 252

PHARMACOLOGY Name 2 calcium channel blockers

Answer 252

1. Amlopipine 2. Felodipine 3. Diltiazem 4. Verapamil

Question 253

PHARMACOLOGY Name 2 dihydropyridines and briefly explain how they work

Answer 253

Class of CCBs Amlodipine and felodipine Arterial vasodilators

Question 254

PHARMACOLOGY Name a calcium channel blocker that acts primarily on the heart

Answer 254

Verapamil Negatively chronotropic and inotropic (reduce HR and force of contraction)

Question 255

PHARMACOLOGY Name a CCB that acts on the heart and on blood vessels

Answer 255

Diltiazem

Question 256

PHARMACOLOGY On what channels do CCB work?

Answer 256

L type Ca2+ channels

Question 257

PHARMACOLOGY Give 3 potential side effects that are due to the vasodilatory ability of CCBs

Answer 257

1. Flushing 2. Headache 3. Oedema 4. Palpitations

Question 258

PHARMACOLOGY Give 2 potential side effects that are due to the negatively chronotropic ability of CCBs

Answer 258

1. Bradycardia 2. Atrioventricular block 3. Postural hypotension

Question 259

PHARMACOLOGY Give a potential side effect that is due to the negatively inotropic ability of CCBs

Answer 259

Worsening cardiac failure

Question 260

PHARMACOLOGY Give 4 potential side effects of verapamil

Answer 260

1. Worsening of cardiac failure (-ve inotrope) 2. Bradycardia (-ve chronotrope) 3. Atrioventricular block (-ve chronotrope) 4. Constipation

Question 261

PHARMACOLOGY A patient comes to see you who has recently started taking calcium channel blockers for their hypertension. They complain of constipation. What calcium channel blocker might they be taking?

Answer 261

Verapamil

Question 262

PHARMACOLOGY In what diseases are beta blockers clinically indicated?

Answer 262

1. IHD 2. Heart failure 3. Arrhythmia 4. Hypertension

Question 263

PHARMACOLOGY Name 3 beta blockers

Answer 263

1. Bisoprolol (beta 1 elective) 2. Atenolol 3. Propranolol (beta 1/2 nonselective)

Question 264

PHARMACOLOGY Give 5 potential side effects of beta blockers

Answer 264

1. Fatigue 2. Headache 3. Sleep disturbances/nightmares 4. Bradycardia 5. Hypotension 6. Cold peripheries 7. Erectile dysfunction 8. Bronchospasm

Question 265

PHARMACOLOGY Give 3 conditions in which Beta blockers can worsen them

Answer 265

1. Asthma or COPD 2. PVD 3. Heart failure

Question 266

PHARMACOLOGY In what diseases are diuretics clinically indicated?

Answer 266

1. Heart failure 2. Hypertension

Question 267

PHARMACOLOGY Name 4 classes of diuretics

Answer 267

1. Thiazides 2. Loop 3. Potassium sparing 4. Aldosterone antagonists

Question 268

PHARMACOLOGY Where in the kidney do thiazide diuretics work?

Answer 268

The distal tubule

Question 269

PHARMACOLOGY Name a thiazide

Answer 269

Bendroflumethethiazide

Question 270

PHARMACOLOGY Name a loop diuretic

Answer 270

Furosemide Bumetanide

Question 271

PHARMACOLOGY Name a potassium sparing diuretic

Answer 271

Spironolactone Eplerenone

Question 272

PHARMACOLOGY Why are potassium sparing diuretics especially effective?

Answer 272

They have anti-aldosterone effects too

Question 273

PHARMACOLOGY Give 5 potential side effects of diuretics

Answer 273

1. Hypovolaemia 2. Hypotension 3. Reduced serum Na+, K+, Mg+, Ca2+ 4. Increased uric acid --> gout 5. Erectile dysfunciton 6. Impaired glucose tolerance

Question 274

HTN You see a 45 y/o patient who has recently been diagnosed with hypertension. What is the first line treatment?

Answer 274

ACE inhibitors e.g. ramapril or ARB e.g. candesartan

Question 275

HTN You see a 65 y/o patient who has recently been diagnosed with hypertension. What is the first line treatment?

Answer 275

Calcium channel blockers (as this patient is over 55) e.g. amlodipine

Question 276

HTN You see a 45 y/o patient who has recently started taking ACE inhibitors for their hypertension. Unfortunately their hypertension still isn't controlled. What would you do next for this patient?

Answer 276

You would combine ACE inhibitors or ARB with calcium channel blockers

Question 277

HTN You see a 45 y/o patient who has been taking ACE inhibitors and calcium channel blockers for their hypertension. Following several tests you notice that their blood pressure is still high. What would you do next for this patient?

Answer 277

You would combine the ACEi/ARB and calcium channel blockers with a thiazide-like diuretic e.g. indapamide

Question 278

PHARMACOLOGY What is the counter regulatory system to RAAS?

Answer 278

Atrial Natriuretic Peptide/BNP (ventricular natriuretic peptide) hormones

Question 279

PHARMACOLOGY Where are ANP and BNP produced?

Answer 279

The heart

Question 280

PHARMACOLOGY What metabolises ANP and BNP?

Answer 280

Neprilysin (NEP)

Question 281

PHARMACOLOGY What are the functions of ANP and BNP?

Answer 281

1. Increased renal excretion of Na+ and water 2. Vasodilators 3. Inhibit aldosterone release

Question 282

PHARMACOLOGY Why can Neprilysin (NEP) inhibitors work for heart failure treatment?

Answer 282

NEP metabolises ANP and BNP NEP inhibitors therefore increase levels of ANP and BNP in the serum

Question 283

PHARMACOLOGY In what diseases are nitrates clinically indicated?

Answer 283

1. IHD 2. Heart failure

Question 284

PHARMACOLOGY Name 2 nitrates that are used pharmacologically

Answer 284

1. GTN spray (short acting) 2. Isosorbide mononitrate (long acting)

Question 285

PHARMACOLOGY How do nitrates work in the treatment of heart failure?

Answer 285

They are venodilators so reduce preload and therefore BP

Question 286

PHARMACOLOGY Give 2 potential side effects of nitrates

Answer 286

1. Headache 2. GTN syncope 3. Tolerance

Question 287

PHARMACOLOGY How do anti-arrhythmic drugs work?

Answer 287

Interfere with the action potential of the heart in different phases

Question 288

PHARMACOLOGY What classification is used to group anti-arrhythmic drugs?

Answer 288

Vaughan Williams classification

Question 289

PHARMACOLOGY Name two class 1 drugs of the Vaughan Williams classification

Answer 289

Class 1 are Na+ channel blockers 1a = disopyramide, quinidine 1b = lidocaine 1c = flecainide (tachycardias)

Question 290

PHARMACOLOGY Name three class 2 drugs of the Vaughan Williams classification

Answer 290

Class 2 are Beta blockers Propranolol Atenolol Bisoprolol

Question 291

PHARMACOLOGY Name a class 3 drug of the Vaughan Williams classification

Answer 291

Class 3 rugs prolong the action potential Amiodarone Side effects are likely with these

Question 292

PHARMACOLOGY Name two class 4 drugs of the Vaughan Williams classification

Answer 292

Class 4 drugs are calcium channel blockers (but NOT dihydropyridines as they don't effect the heart) Verapamil Dilitiazem

Question 293

PHARMACOLOGY How does digoxin work?

Answer 293

Inhibits the Na+/K+ pump therefore making the action potential more positive and ACh is released from parasympathetic nerves

Question 294

PHARMACOLOGY What are the main effect of digoxin?

Answer 294

1. Bradycardia 2. Reduced atrioventricular conduction 3. Increased force of contraction (positive inotrope)

Question 295

PHARMACOLOGY Give 3 potential side effects of digoxin

Answer 295

1. Nausea 2. Vomiting 3. Diarrhoea 4. Confusion Also has a narrow therapeutic range

Question 296

PHARMACOLOGY In what disease is digoxin clinically indicated?

Answer 296

1. Atrial fibrillation 2. Severe heart failure

Question 297

PHARMACOLOGY What does furosemide block?

Answer 297

The Na+/K+/2Cl- transporter

Question 298

PHARMACOLOGY Why are beta blockers good in chronic heart failure?

Answer 298

They block reflex sympathetic responses which stress the failing heart

Question 299

PHARMACOLOGY How does amiodarone work?

Answer 299

Prolongs action potential by delaying depolarisation

Question 300

PHARMACOLOGY Name 4 potential effects of amiodarone

Answer 300

1. QT prolongation 2. Interstitial lung disease 3. Hypothyroidism 4. Abnormal liver enzymes

Question 301

ABNORMAL ECGS What aspect of the heart is represented by leads II, III and aVF?

Answer 301

Inferior aspect

Question 302

ABNORMAL ECGS What might ST elevation in leads II, II and aVF suggest?

Answer 302

RCA blockage Leads represent inferior aspect of heart, RCA supplies inferior aspect

Question 303

ABNORMAL ECGS Give 3 effects hyperkalaemia on an ECG

Answer 303

GO - absent P wave GO TALL - tall T wave GO long - prolonged PR GO wide - wide QRS

Question 304

ABNORMAL ECGS Give 2 effects of hypokalaemia on an ECG

Answer 304

1. Flat T waves 2. QT prolongation 3. ST depression 4. Prominent U waves

Question 305

ABNORMAL ECGS Give an effect go hypocalcaemia on an ECG

Answer 305

1. QT prolongation 2. T wave flattening 3. Narrowed QRS 4. Prominent U waves

Question 306

ABNORMAL ECGS Give an effect of hypercalcaemia on an ECG

Answer 306

1. QT shortening 2. Tall T wave 3. No P waves

Question 307

ARRHYTHMIAS What controls the sinus node discharge rate?

Answer 307

Autonomic nervous system

Question 308

ARRHYTHMIAS Define sinus rhythm

Answer 308

A P wave precedes each QRS complex

Question 309

ARRHYTHMIAS Define cardiac arrhythmia

Answer 309

Abnormality of cardiac rhythm

Question 310

ARRHYTHMIAS Give 3 potential consequences of arrhythmia

Answer 310

1. Sudden death 2. Syncope 3. Heart failure 4. Chest pain 5. Palpitations May also be asymptomatic

Question 311

ARRHYTHMIAS Define bradycardia

Answer 311

< 60 bpm

Question 312

TACHYCARDIA Define tachycardia

Answer 312

> 100 bpm

Question 313

BRADYCARDIA Give 2 causes of bradycardia

Answer 313

1. Conduction tissue fibrosis 2. Ischaemia 3. Inflammation/infiltrative disease 4. Drugs

Question 314

BRADYCARDIA what are the adverse clinical features for bradycardia?

Answer 314

- shock (hypotension, pallor, sweating, cold, clammy, confusion or impaired consciousness) - syncope - MI - HF

Question 315

BARDYCARDIA what is the emergency management?

Answer 315

LIFE-THREATENING FEATURES - 1st line = atropine 500 micrograms IV - if response unsatisfactory repeat 500 micrograms atropine (up to max 3mg), or adrenaline 2-10 micrograms IV, - arrange transvenous pacing NO LIFE-THREATENING FEATURES - if risk of asystole treat as above - if not at risk of asystole, observe

Question 316

BRADYCARDIA what are the risk factors for asystole in bradycardia?

Answer 316

- complete heart block with broad QRS - recent asystole - Mobitz type II AV block - ventricular pause > 3 seconds

Question 317

TACHYCARDIA Give 2 broad categories of tachycardia

Answer 317

1. Supraventricular tachycardias 2. Ventricular tachycardias

Question 318

TACHYCARDIA What are the signs of unstable tachycardia?

Answer 318

- shock (hypotension, pallor, sweating, cold, confusion) - syncope - MI - heart failure

Question 319

TACHYCARDIA what is the emergency management?

Answer 319

ADVERSE SIGNS PRESENT - 1st line = synchronised DC cardioversion (up to 3 shocks) treat according to whether SVT or VT

Question 320

SVT what is it?

Answer 320

any tachyarrhythmia arising above the Bundle of His AVNRT is the most common type

Question 321

SVT what are the different types?

Answer 321

ATRIAL + REGULAR - sinus tachycardia - atrial tachycardia - atrial flutter ATRIAL + IRREGULAR - AF AV NODE - AVRT (including Wolff-Parkinson-White syndrome) - AVNRT - junctional tachycardia

Question 322

SVT are the QRS complexes broad or narrow in SVT?

Answer 322

narrow (<0.12s)

Question 323

SVT what are the risk factors?

Answer 323

- increasing age - female - hyperthyroidism - smoking - excessive caffeine or alcohol - stress - medication (salbutamol, atropine, decongestants) - recreational drug use (cocaine, methamphetamines)

Question 324

SVT what are the clinical features?

Answer 324

SYMPTOMS - may be asymptomatic - palpitations - SOB - dizziness - life-threatening (chest pain, syncope, confusion, sweating) SIGNS - tachycardia - tachypnoea - life threatening (hypotension, pallor, cold + clammy, pulmonary oedema, raised JVP)

Question 325

SVT what are the life-threatening features?

Answer 325

shock (hypotension, pallor, sweating, cold extremities) syncope myocardial ischaemia (chest pain) heart failure (pulmonary oedema, raised JVP)

Question 326

SVT what are the investigations?

Answer 326

12 lead ECG = regular, narrow complex tachycardia, 151-250 bpm to consider - TFTs = hyperthyroidism - U&Es + metabolic panel

Question 327

SVT what is the management?

Answer 327

UNSTABLE - synchronised DC shock (up to 3 attempts) - if unsuccessful, 300mg amiodarone IV + repeat shock STABLE - 1st line = vagal manoeuvres (Valsalva, carotid sinus massage) - 2nd line = adenosine 6mg, if unsuccessful give 12mg then 18mg - 3rd line = verapamil or BB - long term = catheter ablation

Question 328

SVT what are the complications?

Answer 328

- syncope - congestive heart failure - life-threatening arrhythmias - sudden death

Question 329

WPW what is Wolff-Parkinson-White syndrome?

Answer 329

a congenital pre-excitation syndrome that occurs due to presence of an accessory electrical pathway between atria and ventricles

Question 330

WPW what are the clinical features of Wolff-Parkinson-White syndrome?

Answer 330

- often asymptomatic - palpitations - dizziness - syncope

Question 331

WPW what are the investigations?

Answer 331

12 LEAD ECG - delta waves (slurred upstroke in QRS) - short PR interval (<120ms) - broadened QRS if a re-entrant circuit has developed, there will be narrow complex tachycardia BLOODS - TFTs IMAGING - echocardiogram - cardiac catheterisation

Question 332

WPW what is the management?

Answer 332

CONSERVATIVE - if asymptomatic, may be monitored MEDICAL - amiodarone - sotalol INTERVENTIONAL AND SURGICAL - radiofrequency ablation EMERGENCY TREATMENT - if unstable = synchronised DC cardioversion - stable + narrow QRS, 1st line = vagal manoeuvres, 2nd line = adenosine - stable + broad QRS 1st line = procainamide or flecainide, 2nd line = DC cardioversion

Question 333

WPW which drugs are contraindicated in WPW syndrome?

Answer 333

any drugs that block AVN activity could cause dangerous arrhythmias - digoxin - adenosine - non-dihydropyridine CCBs (verapamil and diltiazem)

Question 334

ATRIAL FIBRILLATION Define atrial fibrillation

Answer 334

Chaotic irregular atrial rhythm at 300-600 bpm AV node responds intermittently – irregular ventricular rate

Question 335

ATRIAL FIBRILLATION what are the risk factors?

Answer 335

- increasing age - DM - hyperthyroidism - HTN - congestive heart failure - valvular heart disease - coronary artery disease - dietary + lifestyle (excessive caffeine, alcohol, smoking, medication use (thyroxine or beta-agonists))

Question 336

ATRIAL FIBRILLATION what are the different types?

Answer 336

- first episode - paroxysmal ( recurrent episodes that stop on their own in <7 days) - persistent (recurrent episodes last >7days) - permanent (continuous AF that is refractory to treatment)

Question 337

ATRIAL FIBRILLATION what is the clinical presentation of atrial fibrillation?

Answer 337

SYMPTOMS - palpitations - dyspnoea - chest pain (red flag) - syncope (red flag) SIGNS - irregularly irregular pulse - hypotension (red flag) - evidence of HF (red flag)

Question 338

ATRIAL FIBRILLATION what are the causes of atrial fibrillation?

Answer 338

PIRATES Pulmonary - PE, COPD Ischaemic heart disease Rheumatic heart disease Anaemia, Alcohol, Advancing age Thyroid disease (hyperthyroid) Electrolyte disturbance (hypo/hyperkalaemia) Sepsis, Sleep apnoea

Question 339

ATRIAL FIBRILLATION Briefly describe the pathophysiology of atrial fibrillation

Answer 339

continuous rapid activation of the atria with no organised mechanical action at 300-600bpm

Question 340

ATRIAL FIBRILLATION what are the investigations?

Answer 340

- ECG (irregular QRS complexes, absent P waves + chaotic baseline) - serum electrolytes including magnesium, calcium + phosphate - TFTs to consider - troponin - CXR - transthoracic echo

Question 341

ATRIAL FIBRILLATION Describe 2 characterics of an ECG taken from someone with atrial fibrillation

Answer 341

1. Absent P waves 2. Irregular and rapid QRS complexes 3. Fine oscillation of the baseline 'Irregularly irregular'

Question 342

ATRIAL FIBRILLATION What score can be used to calculate the risk of stroke in someone with atrial fibrillation?

Answer 342

CHA2D2 VAS

Question 343

ATRIAL FIBRILLATION What does the CHA2DS2 VASc score take into account

Answer 343

CHD HTN Age (>75) = 2 points DM Stroke (previous) = 2 points Vascular disease Age 65-74 Sex (female) Score >1 = anticoagulation

Question 344

ATRIIAL FIBRILLATION what features would suggest the need for synchronised DC cardioversion?

Answer 344

- shock (HTN, pallor, sweating, col, clammy extremities, confusion or LOC) - syncope - MI - Heart failure (pulmonary oedema +/- raised JVP)

Question 345

ATRIAL FIBRILLATION Describe the treatment for atrial fibrillation

Answer 345

HAEMODYNAMICALLY UNSTABLE - 1st line = synchronised DV cardioversion STABLE onset <48hrs - 1st line = rate control (BB or CCB)* - 2nd line = rhythm control (flecanide or amiodarone) onset >48hrs - 1st line = rate control (BB or CCB)* + anticoagulation for at least 3 weeks, then offer rhythm control if appropriate *consider digoxin 1st line in patients with AF + HF, those who do no exercise or other drugs excluded avoid CCB in HF avoid non-selective BB (e.g. propranolol) in asthma

Question 346

ATRIAL FIBRILLATION which medications are used for rate control?

Answer 346

1st line = beta-blocker (bisoprolol) or CCB (diltiazem/verapamil) consider digoxin 1st line when AF + HF 2nd line = combination therapy with any two - beta-blocker (bisoprolol) - diltiazem - digoxin

Question 347

ATRIAL FIBRILLATION what medications are used for rhythm control?

Answer 347

if no structural/ischaemic heart disease = flecainide or amiodarone if structural/ischaemic heart disease = amiodarone

Question 348

ATRIAL FIBRILLATION What is the long term treatment for atrial fibrillation?

Answer 348

Catheter ablation

Question 349

ATRIAL FIBRILLATION if a patient undergoes ablation, do you stop anticoagulation?

Answer 349

do not stop anticoagulation even if AF is no longer detectable only stop after consulting CHADSVASC and HASBLED

Question 350

ATRIAL FIBRILLATION what are the complications of atrial fibrillation?

Answer 350

- increased risk of stroke - due to static blood in the atria - the blood pools and it remains still, causing it to clot and embolise

Question 351

ATRIAL FLUTTER What is atrial flutter?

Answer 351

Fast but organised waves in the atrium Atrial rate 250-350 bpm it is a type of AV re-entry tachycardia (AVRT)

Question 352

ATRIAL FLUTTER Describe the ECG pattern taken from someone with atrial flutter

Answer 352

1. Narrow QRS 2. Saw tooth flutter (F) waves

Question 353

ATRIAL FLUTTER Describe the pathophysiology of atrial flutter

Answer 353

the P wave produces a sawtooth pattern with regular conduction to the ventricles - Wave of contraction around the atria causing the repolarisation of the AV node

Question 354

ATRIAL FLUTTER what are the risk factors for atrial flutter?

Answer 354

- atrial fibrillation

Question 355

ATRIAL FLUTTER what are the causes of atrial flutter?

Answer 355

more likely to occur with pulmonary disease: - COPD - obstructive sleep apnoea - PE - pulmonary hypertension other causes: - ischaemic heart disease - sepsis - alcohol - cardiomyopathy - thyrotoxicosis

Question 356

ATRIAL FLUTTER what is the clinical presentation of atrial flutter?

Answer 356

Palpitations Breathlessness chest pain Dizziness Syncope fatigue

Question 357

ATRIAL FLUTTER what is the management for atrial flutter?

Answer 357

- Cardioversion - Give a LMWH - Shock with defibrillator - Catheter ablation = definitive treatment – creates a conduction block - IV Amiodarone – restore sinus rhythm

Question 358

VENTRICULAR TACHYCARDIA what is it?

Answer 358

a broad-complex tachycardia originating from ventricles has potential to precipitate ventricular fibrillation (VF) so requires urgent treatment

Question 359

VENTRICULAR TACHYCARDIA what are the risk factors?

Answer 359

- electrolyte abnormalities (hypokalaemia, hypomagnesaemia) - structural heart disease (previous MI, cardiomyopathies) - drugs causing QT prolongation (clarithromycin, erythromycin) - inherited channelopathies

Question 360

VENTRICULAR TACHYCARDIA what are the different types?

Answer 360

- monomorphic VT (commonly caused by MI) - polymorphic VT (commonly caused by prolonged QT, example = torsade de pointes)

Question 361

VENTRICULAR TACHYCARDIA what is the management of pulsed VT?

Answer 361

IF ADVERSE FEATURES PRESENT (HF, MI, shock syncope) - 1st line = synchronised DC cardioversion (up to 3 attempts) - 2nd line = amiodarone 300mg IV over 10-20 mins IF NO ADVERSE FEATURES PRESENT - 1st line = amiodarone 300mg IV - 2nd line = synchronised DC cardioversion if drug therapy fails - ICD implanted

Question 362

TORSADES DE POINTES what is it?

Answer 362

a form of polymorphic VT associated with prolonged QT

Question 363

TORSADES DE POINTES what are the causes?

Answer 363

- congenital - antiarrhythmics (amiodarone, sotalol) - tricyclic antidepressants - antipsychotics - chloroquine - erythromycin - electrolyte abnormalities (hypocalcaemia, hypokalaemia, hypomagnesaemia) - myocarditis - hypothermia - subarachnoid haemorrhage

Question 364

TORSADES DE POINTES what is the management?

Answer 364

IV magnesium sulphate

Question 365

ARRHYTHMIAS What are ectopic beats?

Answer 365

Non sustained beats arising from ectopic regions of atria or ventricles Very common, generally benign arrhythmias caused by premature discharge

Question 366

LONG QT SYNDROME what are the causes of long QT syndrome?

Answer 366

1. Congenital 2. hypokalaemia, 3. hypocalcaemia 4. Drugs - amiodarone, tricyclic antidepressants 5. bradycardia 6. Acute MI 7. diabetes

Question 367

LONG QT SYNDROME what is the clinical presentation of long QT syndrome?

Answer 367

SYMPTOMS - syncope - dizziness - palpitations - dyspnoea - collapse or sudden cardiac death SIGNS - sensorineural deafness (congenital)

Question 368

LONG QT SYNDROME which abnormal heart rhythm are people with long QT syndrome at risk of developing?

Answer 368

torsades de pointes

Question 369

LONG QT SYNDROME what is the management?

Answer 369

conservative - avoid precipitating factors beta-blocker (propranolol) to prevent ventricular arrhythmia ICD may be considered

Question 370

HEART BLOCK Where can heart blocks occur?

Answer 370

1. Block in either AVN or bundle of His = AV block 2. Block lower in conduction system = Bundle Branch Block

Question 371

HEART BLOCK Describe a first degree heart block

Answer 371

Fixed prolongation of the PR interval due to delayed conduction to the ventricles - PR interval >0.22s - asymptomatic

Question 372

HEART BLOCK Describe a second degree heart block

Answer 372

There are more P waves to QRS complexes because some atrial impulses fail to reach the ventricles

Question 373

HEART BLOCK Describe a Mobitz type 1 second degree heart block

Answer 373

PR interval gradually increases until AV node fails and no QRS is seen PR interval returns to normal and the cycle repeats

Question 374

HEART BLOCK Describe a Mobitz type 2 second degree heart block

Answer 374

Sudden unpredictable loss of AV conduction and so loss of QRS PR interval is constant but every nth QRS is missing wide QRS

Question 375

HEART BLOCK Describe a third degree heart block

Answer 375

Atrial activity fails to conduct to the ventricles P waves and QRS complexes occur independently ventricular contractions are maintained by spontaneous escape rhythm originating below the block

Question 376

HEART BLOCK What are the treatments for heart blocks?

Answer 376

1st = asymptomatic, watch and wait --> atropine Mobitz 1 = no pacemaker if asymptomatic, pacemaker if symptomatic Mobitz 2 = pacemaker even if asymptomatic 3rd = transcutaneous pacing followed by permanent pacemaker

Question 377

HEART BLOCK what are the causes of heart block?

Answer 377

Athletes Sick sinus syndrome IHD – esp MI Acute myocarditis Drugs Congenital Aortic valve calcification Cardiac surgery/trauma

Question 378

BUNDLE BRANCH BLOCK What kind of heart block is associated with wide QRS complexes with an abnormal pattern?

Answer 378

Right bundle branch block (RBBB) and Left bundle branch block (LBBB)

Question 379

BUNDLE BRANCH BLOCK Explain the pathophysiology of a BBB

Answer 379

Lack of simultaneous ventricular contractions LBBB = R before L RBBB = L before R

Question 380

BUNDLE BRANCH BLOCK What changes would you see on an ECG from someone with a LBBB?

Answer 380

WiLLiaM slurred S wave in V1 (resembles W) R wave in V6 (resembles M) wide QRS with notched top in V6

Question 381

BUNDLE BRANCH BLOCK What changes would you see on an ECG from someone with a RBBB?

Answer 381

MaRRoW R wave in V1 (resembles M) slurred S wave in V6 (resembles W) wide QRS RSR pattern in V1

Question 382

ARRHYTHMIAS Cardiac arrhythmias: what is the treatment of choice in a patient who is hemodynamically unstable due to the underlying rhythm?

Answer 382

DC cardioversion

Question 383

VALVE DISEASE Name 4 valvular heart diseases

Answer 383

1. Aortic stenosis 2. Mitral regurgitation 3. Mitral stenosis 4. Aortic regurgitation

Question 384

VALVE DISEASE Why does medical intervention have a limited role in aortic and mitral stenosis treatment?

Answer 384

Aortic and mitral stenosis are mechanical problems

Question 385

AORTIC STENOSIS what is it?

Answer 385

Narrowing of the aortic valve resulting in obstruction to left ventricular stroke volume

Question 386

AORTIC STENOSIS Name the 3 types of aortic stenosis

Answer 386

1. Surpavalvular 2. Subvalvular 3. Valvular = most common

Question 387

AORTIC STENOSIS What are the causes of aortic stenosis?

Answer 387

- Calcification and fibrosis of normal trileaflet aortic valve = 80% of cases - congenital bicuspid valve - rheumatic fever (rare, seen in developing countries)

Question 388

AORTIC STENOSIS what are the risk factors?

Answer 388

- advancing age - congenital bicuspid valve (turners syndrome + coarctation of aorta) - rheumatic fever - chronic kidney disease - HTN - Smoking - mediastinal radiotherapy

Question 389

AORTIC STENOSIS Describe the pathophysiology of aortic stenosis

Answer 389

Obstruction to left ventricular emptying results in left ventricular hypertrophy Increased myocardial oxygen demand, relative ischaemia of the myocardium and consequent angina and arrhythmias Left ventricular systolic function typically conserved

Question 390

AORTIC STENOSIS what are the symptoms of aortic stenosis?

Answer 390

Occur when valve area is 1/4 of normal (normal - 3-4 cm2) - exertional dyspnea (SOB) - chest pain (angina-like) - exertional syncope - fatigue

Question 391

AORTIC STENOSIS what are the signs of aortic stenosis?

Answer 391

MURMUR - ejection systolic murmur over aortic area - radiating to carotids and apex - crescendo-decrescendo - thrill if severe - left ventricular heave ASSOCIATED FEATURES - diminished S2 - slow rising pulse - narrow pulse pressure - S4 heart sound FEATURES OF HF - crackles - raised JVP - peripheral oedema

Question 392

AORTIC STENOSIS What investigation might you do in someone who you suspect to have aortic stenosis?

Answer 392

ECG - L axis deviation - ST depression - increased R wave amplitude and S wave depth TTE (trans-thoracic echo) - aortic valve are reduced BLOODs - BNP raised if HF CXR - rule out respiratory pathology

Question 393

AORTIC STENOSIS what murmur is heard with aortic stenosis?

Answer 393

- ejection systolic murmur over aortic area - radiating to carotids and apex - crescendo-decrescendo - thrill if severe - left ventricular heave

Question 394

AORTIC STENOSIS Describe the management for someone with aortic stenosis

Answer 394

valve replacement via open heart surgery (SAVR) or transcatheter (TAVI) can have balloon valvuloplasty to stretch valve

Question 395

AORTIC STENOSIS what factors affect treatment choice?

Answer 395

SAVR (open-surgery) - young - few comorbidities - need additional procedures e.g. CABG TAVI (trans-catheter) - older - multi-morbid - high operative risk

Question 396

AORTIC STENOSIS what factors affect valve choice (bioprosthetic or mechanical)?

Answer 396

MECHANICAL - younger (mechanical valves are more durable) - suitable for anticoagulation BIOPROSTHETIC - older patients (>65) - anticoagulation contraindicated

Question 397

AORTIC STENOSIS What are the indications for valve replacement

Answer 397

- severe aortic stenosis and symptomatic - severe aortic stenosis and asymptomatic but have one of the following - heart failure - symptoms on exercise testing

Question 398

AORTIC STENOSIS what are the complications?

Answer 398

- heart failure - complications from surgery - endocarditis - valve thrombus - haemolysis - aortic regurgitation

Question 399

MITRAL REGURGITATION What is mitral regurgitation?

Answer 399

Backflow of blood from the LV to the LA during systole LV volume overload

Question 400

MITRAL REGURGITATION What can cause mitral regurgitation?

Answer 400

1. Myxomatous degeneration (mitral valve prolapse) - most common cause 2. Ischaemic mitral valve 3. Rheumatic heart disease 4. IE 5. dilating left ventricle

Question 401

MITRAL REGURGITATION Describe the pathophysiology of mitral regurgitation

Answer 401

Circulatory changes depend on speed on onset and severity Long standing MR produces little increase in left atrial pressure – accommodated by large LV In acute MR an increased in LA pressure increases pulmonary venous pressure and pulmonary oedema Left ventricle dilates but more so in chronic MR

Question 402

MITRAL REGURGITATION what are the risk factors?

Answer 402

- history of cardiac infection e.g. rheumatic fever, endocarditis - cardiac trauma - history of ischaemic heart disease e.g. MI - congenital heart disease - cardiomyopathy - HTN - structural heart disease - dopaminergic drugs e.g. cabergoline, pergolide

Question 403

MITRAL REGURGITATION what are the symptoms of mitral regurgitation?

Answer 403

- Exertional dyspnoea - Reduced exercise tolerance - Fatigue - Paroxysmal nocturnal dyspnoea - Palpitations

Question 404

MITRAL REGURGITATION what are the signs of mitral regurgitation?

Answer 404

MURMUR - Pan-systolic murmur - Radiates to left axilla - blowing at apex - S3 heart sound - Quiet S1 - displaced apex towards axilla

Question 405

MITRAL REGURGITATION what is the murmur?

Answer 405

- Pan-systolic murmur - Radiates to left axilla - blowing at apex

Question 406

MITRAL REGURGITATION What investigations might you do in someone who you suspect to have mitral regurgitation?

Answer 406

1. ECG 2. CXR 3. Echo 4. doppler and colour flow doppler to measure severity

Question 407

MITRAL REGURGITATION What is the management of mitral regurgitation?

Answer 407

ACUTE SEVERE 1st line = emergency surgery to repair/replace CHRONIC SEVERE, SYMPTOMATIC - if LVEF <60% or LV end-systolic diameter >40mm = surgery to repair/replace - if LVEF >60% or LV end-systolic <40mm = watchful waiting CHRONIC SEVERE, ASYMPTOMATIC - if suitable for surgery = surgical repair/replace - if unsuitable for surgery = Transcatheter replacement, optimise HF meds, consider cardiac resynchronisation therapy

Question 408

MITRAL REGURGITATION what are the complications?

Answer 408

- AF - pulmonary hypertension - LV dysfunction and HF - post-op endocarditis - prosthesis failure

Question 409

AORTIC REGURGITATION What is aortic regurgitation?

Answer 409

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

Question 410

AORTIC REGURGITATION What causes aortic regurgitation?

Answer 410

acute - infective endocarditis - rheumatic fever - aortic dissection chronic - rheumatic disease - bicuspid aortic valve - aortic endocarditis

Question 411

AORTIC REGURGITATION what is the pathophysiology of aortic regurgitation?

Answer 411

- Chronic regurgitation volume loads the left ventricle and results in hypertrophy and dilation - SV increases so increased pulse pressure and myriad of clinical symptoms - Contraction of ventricle deteriorates – LV failure - Adaptations to the volume load entering the LV do not occur in acute AR and patients present with pulmonary oedema and reduced SV

Question 412

AORTIC REGURGITATION what are the risk factors?

Answer 412

- male sex - advancing age - congenital heart disease - bicuspid valve - previous rheumatic heart disease - previous endocarditis - aortic root disorders (marfan, ankylosing spondylitis)

Question 413

AORTIC REGURGITATION Give 3 symptoms of aortic regurgitation

Answer 413

- exertional dyspnoea - fatigue - palpitations - orthopnoea - paroxysmal nocturnal dyspnoea

Question 414

AORTIC REGURGITATION what are the signs of aortic regurgitation?

Answer 414

MURMUR - early diastolic murmur - decrescendo - soft, high-pitched - collapsing (waterhammer) pulse - wide pulse pressure - displaced apex OTHER SIGNS - austin flint murmur = rumbling mid-diastolic murmur, loudest at apex, suggests severe disease - corrigans sign = visible distension + collapse of carotid arteries - millers sign = visible pulsation of uvula - Quinckes sign = visible pulsations in nail bed when compressed - De Mussets sign = heartbeat associated with head bobbing - Traubes sign = pistol shot sound over femoral arteries - Duroziezs sign = audible systolic + diastolic murmur on compression of femoral artery

Question 415

AORTIC REGURGITATION what is the murmur?

Answer 415

- early diastolic murmur - decrescendo - soft, high-pitched - collapsing (waterhammer) pulse - wide pulse pressure - displaced apex

Question 416

AORTIC REGURGITATION What investigations might you do in someone who you suspect to have aortic regurgitation?

Answer 416

CXR - cardiomegaly, aortic root enlargement ECHO - assess severity ECG - left ventricular hypertrophy cardiac catheterisation

Question 417

AORTIC REGURGITATION Describe the management for someone with aortic regurgitation

Answer 417

MILD - MODERATE - lifestyle modifications - ACEi (ramipril) - Beta-blockers (bisoprolol) SEVERE DISEASE - loop diuretic (furosemide) - aortic valve repair/replacement

Question 418

AORTIC REGURGITATION what are the complications?

Answer 418

- LV dysfunction + HF - AF - sudden cardiac death - recurrence of endocarditis

Question 419

MITRAL STENOSIS What is mitral stenosis?

Answer 419

Obstruction of LV inflow that prevents proper filling during diastole

Question 420

MITRAL STENOSIS Name 3 causes of mitral stenosis

Answer 420

1. Rheumatic heart disease 2. IE 3. Mitral annular calcification - rarer

Question 421

MITRAL STENOSIS Describe the pathophysiology of mitral stenosis

Answer 421

Thickening and immobility of the valve leads to obstruction of blood flow from left atrium to left ventricle Left atrial pressure increases – left atrium dilation and hypertrophy Pulmonary venous, arterial and right heart pressure increases

Question 422

MITRAL STENOSIS what are the symptoms of mitral stenosis?

Answer 422

1. progressive dyspnoea 2. Haemoptysis (coughing up blood) 3. palpitations (AF) 4. chest pain

Question 423

MITRAL STENOSIS what are the signs of mitral stenosis?

Answer 423

rumbling mid-diastolic murmur with opening snap - decrescendo-presystolic crescendo 1. malar flush 2. AF 3. tapping apex beat 4. low volume pulse 5. loud snapping S1

Question 424

MITRAL STENOSIS what is the murmur?

Answer 424

rumbling mid-diastolic murmur with opening snap - decrescendo-presystolic crescendo

Question 425

MITRAL STENOSIS What investigations might you do in someone who you suspect to have mitral stenosis?

Answer 425

1. ECG - AF, left atrial hypertrophy causes bifid P wave 2. CXR - large L atrium, pulmonary oedema 3. Echo - gold standard for diagnosis

Question 426

MITRAL STENOSIS Describe the management for mitral stenosis

Answer 426

lifestyle optimise HF meds valve repair/replacement percutaneous balloon dilation

Question 427

VALVE DISEASE In what type of valvular heart disease would you hear a mid-diastolic murmur and a 1st heart sound snap?

Answer 427

Mitral stenosis

Question 428

VALVE DISEASE In what type of valvular heart disease would you hear a pan systolic murmur?

Answer 428

Mitral regurgitation

Question 429

VALVE DISEASE In what type of valvular heart disease would you hear an ejection systolic murmur?

Answer 429

Aortic stenosis

Question 430

VALVE DISEASE In what type of valvular heart disease would you see a wide pulse pressure and hear an early diastolic blowing murmur and systolic ejection murmur?

Answer 430

Aortic regurgitation

Question 431

INFECTIVE ENDOCARDITIS What is infective endocarditis?

Answer 431

an infection of the endocardium or vascular endothelium of the heart

Question 432

INFECTIVE ENDOCARDITIS what are the different types of infective endocarditis

Answer 432

acute - develop over days to weeks (s.aureus) subacute - develops over weeks to months (s.viridans) non-bacterial thrombotic - associated with malignancy or SLE

Question 433

INFECTIVE ENDOCARDITIS Which type of infective endocarditis is more likely to spread systemically?

Answer 433

Left sided IE - more likely to cause thrombo-emboli (Right sided IE could spread to the lungs)

Question 434

INFECTIVE ENDOCARDITIS what are the risk factors for infective endocarditis?

Answer 434

- IV drug use - poor dental hygiene - skin and soft tissue infections - dental treatment - IV cannula - cardiac surgery - pacemaker - immunocompromised

Question 435

INFECTIVE ENDOCARDITIS Which bacteria are most likely to cause infective endocarditis?

Answer 435

1. Staphylococcus aureus = MOST COMMON 2. Streptococcus viridian's (alpha haemolytic) 3. Staphlococcus epidermidi (coagulase negative staph)

Question 436

INFECTIVE ENDOCARDITIS which bacteria is associated with IV drug use?

Answer 436

staph aureus

Question 437

INFECTIVE ENDOCARDITIS which bacteria are associated with prosthetic valves?

Answer 437

s. aureus s. epidermidis

Question 438

INFECTIVE ENDOCARDITIS which bacteria are associated with colon cancer?

Answer 438

strep bovis

Question 439

INFECTIVE ENDOCARDITIS which bacteria is associated with infection of native valves?

Answer 439

strep viridans

Question 440

INFECTIVE ENDOCARDITIS which bacteria is associated with poor dental hygiene and infection following dental procedures?

Answer 440

strep viridans

Question 441

INFECTIVE ENDOCARDITIS which bacteria is most commonly associated with pregnancy?

Answer 441

group B strep

Question 442

INFECTIVE ENDOCARDITIS Give 3 groups of people who are at risk of infective endocarditis

Answer 442

more common in developing countries males > females 1. Elderly 2. IV drug users 3. Those would prosthetic valves 4. Those with rheumatic fever 5. Young with congenital heart disease

Question 443

INFECTIVE ENDOCARDITIS Describe the pathophysiology of infective endocarditis

Answer 443

- Usually the consequence of the presence of organisms in the blood and abnormal cardiac endothelium that facilitates adherence and growth - A mass of fibrin, platelets and infectious organisms form vegetations along the edges of the valve - Virulent organisms destroy the valve, producing regurgitation and worsening heart failure

Question 444

INFECTIVE ENDOCARDITIS What is the hallmark of infective endocarditis?

Answer 444

Vegetation - lumps of fibrin hanging of heart valves

Question 445

INFECTIVE ENDOCARDITIS Name 2 sites where vegetation is likely in infective endocarditis

Answer 445

1. Atrial surface of AV valves 2. Ventricular surface of SL valves

Question 446

INFECTIVE ENDOCARDITIS what are the symptoms of infective endocarditis?

Answer 446

Fever Headache Rigors Night sweats Malaise Weight loss

Question 447

INFECTIVE ENDOCARDITIS what are the signs of infective endocarditis

Answer 447

1. Splinter haemorrhages - on nails 2. Osler's nodes - on hands 3. Janeway lesions - on hands 4. Roth spots - in eyes 5. embolic skin lesions - skin 6. petechiae - skin 7. Heart murmurs anaemia splenomegaly clubbing valve disease

Question 448

INFECTIVE ENDOCARDITIS Name the criteria that is used in the diagnosis of infective endocarditis

Answer 448

Duke's criteria

Question 449

INFECTIVE ENDOCARDITIS Give the 2 major points in the Duke's criteria that if presence can confirm a diagnosis of infective endocarditis

Answer 449

1. Two positive blood cultures 2. Positive echo showing endocardial involvement

Question 450

INFECTIVE ENDOCARDITIS what is the minor criteria for Modified Dukes criteria?

Answer 450

- predisposing heart condition or IVDU - fever >38 - immunological phenomenon (glomerulonephritis, osler nodes, roths spots, rheumatoid factor) - microbiological evidence not meeting major criteria - vascular abnormalities

Question 451

What investigations might you do in someone who you suspect to have infective endocarditis?

Answer 451

BLOODS - raised WCC, neutrophilia, raised CRP + ESR BLOOD CULTURES - 3 sets, 1 hour apart, ideally before initiating abx ECHO - to confirm dx CXR - rule out other causes ECG URINALYSIS

Question 452

INFECTIVE ENDOCARDITIS what are the pros and cons of a trans-thoracic echo (TTE)?

Answer 452

Advantages: 1. Safe 2. Non-invasive, no discomfort Disadvantage: 1. Poor images

Question 453

INFECTIVE ENDOCARDITIS what are the pros and cons of a trans-oesophageal echo (TOE)?

Answer 453

Advantage: 1. Excellent images Disadvantage: 1. Discomfort 2. Small risk of perforation or aspiration

Question 454

INFECTIVE ENDOCARDITIS Describe the treatment for infective endocarditis

Answer 454

BLIND THERAPY (when organism not known) - native valve = amoxicillin (+/- gentamicin) - pen allergy/MRSA = vancomycin (+/- gentamicin) - prosthetic valve (vancomycin + rifampicin + gentamicin) NATIVE VALVE S.AUREUS - 1st line = flucloxacillin - 2nd line = vancomycin + rifampicin PROSTHETIC VALVE S.AUREUS - 1st line = flucloxacillin + rifampicin + gentamicin STREP VIRIDANS - 1st line = benzylpenicillin - 2nd line = vancomycin + gentamicin HACEK - 1st line = ceftriaxone

Question 455

INFECTIVE ENDOCARDITIS Give 4 indications for surgery in IE

Answer 455

1. Antibiotics not working 2. Complications 3. To remove infected devices 4. To replace valve after infection cured 5. To remove large vegetations before they embolism

Question 456

INFECTIVE ENDOCARDITIS Why is it important to remove large vegetations?

Answer 456

To prevent them embolising and causing a stroke, MI etc

Question 457

INFECTIVE ENDOCARDITIS Why might blood cultures be negative in a person with IE?

Answer 457

They may have previously received antibiotics

Question 458

PHARMACOLOGY What additional property makes propranolol the most useful beta blocker to help control the arrhythmias which occur immediately following a heart attack?

Answer 458

It can also block sodium channels

Question 459

PULMONARY STENOSIS What is pulmonary stenosis?

Answer 459

Narrowing of the RV outflow tract

Question 460

PULMONARY STENOSIS How does a patient present with pulmonary stenosis?

Answer 460

Right ventricular failure Collapse Poor pulmonary blood flow right ventricular hypertrophy Tricuspid regurgitation

Question 461

PULMONARY STENOSIS How is pulmonary stenosis treated?

Answer 461

Ballon valvuloplasty Open valvotomy Open trans-annular patch Shunt (to bypass blockage)

Question 462

VALVE DISEASE What are 3 problems with a bicuspid aortic valve?

Answer 462

1. Degenerate quicker than normal valves 2. Become regurgitant earlier than normal valves 3. Associated with coarctation and dilation of ascending aorta

Question 463

MITRAL STENOSIS Why does mitral stenosis cause AF?

Answer 463

Increased LA pressure Stretches myocytes in the atria and irritates pacemaker cells --> AF

Question 464

PERICARDITIS What is Dressler's syndrome?

Answer 464

Myocardial injury stimulates formation of autoantibodies against the heart Cardiac tamponade may occur Dressler's is a secondary form of pericarditis

Question 465

PERICARDITIS Give 3 symptoms of Dressler's syndrome

Answer 465

1. Fever 2. Chest pain 3. Pericardial rub Occurs 2-10 weeks after MI

Question 466

EQUATIONS Write an equation for mAP

Answer 466

mAP = DP + 1/3PP

Question 467

EQUATIONS Give the equation for stroke volume

Answer 467

SV = EDV - ESV

Question 468

CHRONIC ISCHAEMIA What is a consequence of peripheral arterial occlusion?

Answer 468

Gangrene

Question 469

CHRONIC ISCHAEMIA Give 2 diseases that result from stress induced ischaemia

Answer 469

1. Exercise induced angina 2. Intermittent claudication

Question 470

CHRONIC ISCHAEMIA Give 2 disease that result from ischaemia due to structural/functional breakdown

Answer 470

1. Critical limb ischaemia 2. Vascular dementia

Question 471

CHRONIC ISCHAEMIAGive an example of infarction

Answer 471

Gangrene

Question 472

CHRONIC ISCHAEMIA What is intermittent claudication?

Answer 472

A symptom describing muscle pain that is caused by moderate ischaemia Intermittent claudication occurs when exercising (stress induced) and is relieved with rest

Question 473

CHRONIC ISCHAEMIA What can intermittent claudication lead on to if left untreated?

Answer 473

Critical ischaemia

Question 474

CHRONIC ISCHAEMIA Intermittent claudication: is O2 supply normal or low at rest and when you begin exercise?

Answer 474

Normal Intermittent claudication is stress induced so at rest and when you begin exercise O2 supply is able to meet demand

Question 475

CHRONIC ISCHAEMIA Intermittent claudication: is O2 supply normal or low when you do moderate/hard exercise?

Answer 475

Low O2 supply is unable to meet demand --> anaerobic respiration --> lactic acid

Question 476

CHRONIC ISCHAEMIA Intermittent claudication: is O2 supply normal or low after a short rest?

Answer 476

Low It takes longer to recover as you're getting rid of the lactic acid After a long rest = normal

Question 477

CHRONIC ISCHAEMIA Give a symptom of intermittent caludication

Answer 477

Muscle cramps

Question 478

CHRONIC ISCHAEMIA Name 2 diseases that are due to moderate ischaemia

Answer 478

1. Angina 2. Intermittent claudication

Question 479

ANEURYSM Name 3 causes of an aneurysm

Answer 479

1. Atherosclerotic (most common) 2. Ateriomegaly 3. Collagen disease - Marfans, vascular Ehlers Danlos 4. tobacco smoking

Question 480

ANEURYSM Name 2 types of aortic aneurysm

Answer 480

1. Abdominal aortic aneurysm (AAA) 2. Thoracic abdominal aneurysm (TAA)

Question 481

ANEURYSM What classifies as an Abdominal aortic aneurysm?

Answer 481

> 3 cm Dilation affects all 3 layers of the vascular tunic

Question 482

ACS what are the risk factors for acute coronary syndromes?

Answer 482

age male family history smoking hypertension diabetes mellitus obesity and sedentary lifestyle

Question 483

HEART FAILURE what does the level of brain natriuretic peptide (BNP) tell you?

Answer 483

- levels are directly correlated to ventricular wall stress and the severity of heart failure - the levels are increased in those with heart failure

Question 484

HEART FAILURE what additional investigations should be undertaken for acute heart failure?

Answer 484

- serum troponin - D-dimer

Question 485

COR PULMONALE what are the causes of cor pulmonale?

Answer 485

- chronic lung disease - pulmonary vascular disorders - neuromuscular and skeletal diseases

Question 486

COR PULMONALE what are the signs of cor pulmonale?

Answer 486

- cyanosis - tachycardia - raised JVP - RV heave - pan-systolic murmur due to tricuspid regurgitation - hepatomegaly - oedema

Question 487

COR PULMONALE what are the symptoms of cor pulmonale?

Answer 487

- dyspnoea - fatigue - syncope

Question 488

COR PULMONALE what investigations should be undertaken for cor pulmonale?

Answer 488

arterial blood gas - hypoxia - sometimes shows hypercapnia

Question 489

COR PULMONALE what is the management for cor pulmonale?

Answer 489

- treat the underlying cause - oxygen - diuretics - venesection if haematocrit >55 - heart-lung transplant in young patients

Question 490

HTN what is malignant hypertension?

Answer 490

markedly raised diastolic BP usually over 120mmHg and progressive renal disease usually evidence of acute haemorrhage and papilledema

Question 491

HTN what are the consequences of malignant hypertension?

Answer 491

- cardiac failure (LVH) - blurred vision (papilledema) - haematuria - due to fibrinoid necrosis of glomeruli - severe headache and cerebral haemorrhage

Question 492

ACS what are the risk factors of MI?

Answer 492

Age, male, history of CVD, FHx Premature menopause DM, smoking, hypertension, hyperlipidaemia, obesity, sedentary lifestyle

Question 493

AORTIC DISSECTION what is the epidemiology of aortic dissection?

Answer 493

- men>female - 40-60yrs - 65% occur in ascending aorta

Question 494

AORTIC DISSECTION what is an aortic dissection?

Answer 494

- there is a tear in the tunica intima , and blood then splits the vessel wall and dissects through the tunica media . - a false lumen is created as the blood in the media layer propagates both proximally and distally. Abnormal flow through this false lumen can occlude flow through the branches of the aorta.

Question 495

AORTIC DISSECTION Describe the pathophysiology of an aortic dissection

Answer 495

Tear in intimal lining of aorta --> column of blood under pressure enters aortic wall forming haematoma --> separates intima from adventitia --> false lumen False lumen extends --> intimal tears

Question 496

AORTIC DISSECTION what are the risk factors of aortic dissection?

Answer 496

Hypertension- most common risk factor Trauma Vasculitis Cocaine use Connective tissue disorders- Turners + noonans

Question 497

AORTIC DISSECTION what are the clinical features of aortic dissection?

Answer 497

-Sudden and severe tearing pain in chest radiating to back -Hypotension -Asymmetrical blood pressure -Syncope - Aortic regurgitation, coronary ischaemia, cardiac tamponade - Peripheral pulses may be absent

Question 498

AORTIC DISSECTION what is the classification system for aortic dissections?

Answer 498

Stanford - type A - ascending aorta +/- aortic arch - type B - descending aorta only

Question 499

AORTIC DISSECTION what are the investigations of aortic dissection?

Answer 499

-ECG/cardiac enzymes - rule out MI -Chest x-ray - widening mediastinum -CT scanning- definitive imaging - echo - TTE/TOE - bloods - FBC, U&Es, group and save, crossmatch - gold standard = CT angiography

Question 500

AORTIC DISSECTION what is the management of aortic dissection?

Answer 500

TYPE A - blood transfusion - IV labetalol - urgent surgical repair TYPE B - conservative management (bed rest + analgesia) - IV labetalol - thoracic endovascular aortic repair (TEVAR)

Question 501

BUNDLE BRANCH BLOCK what are the causes of RBBB?

Answer 501

- normal variant (more common with increasing age) - right ventricular hypertrophy - PE - MI - Atrial septal defect - cardiomyopathy or myocarditis

Question 502

BUNDLE BRANCH BLOCK what is the pathophysiology of RBBB?

Answer 502

Right bundle doesn’t conduct Impulse spreads from left ventricle to right Late activation of RV

Question 503

BUNDLE BRANCH BLOCK what is the clinical presentation of RBBB?

Answer 503

Asymptomatic syncope/presyncope

Question 504

BUNDLE BRANCH BLOCK what is the treatment for RBBB?

Answer 504

Pacemaker CRT – cardiac resynchronisation therapy Reduce blood pressure

Question 505

BUNDLE BRANCH BLOCK what is the clinical presentation of LBBB?

Answer 505

Asymptomatic syncope/presyncope

Question 506

BUNDLE BRANCH BLOCK what is the pathophysiology of LBBB?

Answer 506

Left bundle doesn’t conduct Impulse spreads from right ventricle to left Late activation of LV

Question 507

BUNDLE BRANCH BLOCK what is the treatment for LBBB?

Answer 507

Pacemaker CRT – cardiac resynchronisation therapy Reduce blood pressure

Question 508

BUNDLE BRANCH BLOCK what are the causes of LBBB?

Answer 508

A new LBBB is always pathological IHD Aortic valve disease

Question 509

HEART BLOCK what are the investigations for heart block?

Answer 509

ECG

Question 510

HEART BLOCK what is the treatment for heart block?

Answer 510

Cardioversion - Give a LMWH - Shock with defibrillator Catheter ablation – creates a conduction block IV Amiodarone – restore sinus rhythm

Question 511

HEART BLOCK what is the presentation of first degree heart block?

Answer 511

asymptomatic

Question 512

HEART BLOCK what is the clinical presentation of Mobitz type 1 second degree heart block?

Answer 512

light-headedness dizziness syncope

Question 513

HEART BLOCK what is the clinical presentation of Mobitz type 2 second degree heart block?

Answer 513

SOB postural hypotension chest pain

Question 514

HEART BLOCK what is the clinical presentation of third degree heart block?

Answer 514

dizziness blackouts

Question 515

AORTIC ANEURYSM what is the epidemiology abdominal aortic aneurysm?

Answer 515

- incidence increases with age - men > females - most commonly occur below renal arteries

Question 516

AORTIC ANEURYSM what are the risk factors for abdominal aortic aneurysm?

Answer 516

- Smoking- MAJOR - Family history - Connective tissue disorders- Marfan’s, Ehlers-Danlos - Age - Atherosclerosis - Male

Question 517

AORTIC ANEURYSM what is the clinical presentation of an unruptured abdominal aortic aneurysm?

Answer 517

- often asymptomatic - causes symptoms if expanding rapidly - pain in abdomen, loin or groin - pulsatile abdominal swelling - bruit on ascultation

Question 518

AORTIC ANEURYSM what is the clinical presentation of a ruptured abdominal aortic aneurysm?

Answer 518

- intermittent/continuous abdominal pain - radiates to back, iliac fossa or groin - painful pulsatile mass - hypovolaemic shock - syncope - nausea, vomiting - profound anaemia - sudden death

Question 519

AORTIC ANEURYSM what are the investigations for abdominal aortic aneurysm?

Answer 519

- Abdominal ultrasound – can assess aorta to degree of 3mm - CT or MRI angiography scans

Question 520

AORTIC ANEURYSM what is the management for abdominal aortic aneurysm?

Answer 520

- ruptured = urgent repair (do not wait for imaging) - symptomatic = repair indicated regardless of diameter - asymptomatic AAA = surveillance until high risk of rupture - 5.5cm in men and 5.0cm in women

Question 521

AORTIC ANEURYSM what are the complications of abdominal aortic aneurysm?

Answer 521

- rupture of AAA - thromboembolisms - fistula formation

Question 522

ENDOCARDITIS what antibiotics are used for endocarditis?

Answer 522

INITIAL BLIND THERAPY - native valve = amoxicillin (consider gentamicin) - pen allergy = vancomycin + gentamicin NATIVE S.AUREUS - flucloxacillin - pen allergy = vancomycin + rifampicin PROSTHETIC VALVE S.AUREUS - flucloxacillin + rifampicin + gentamicin - pen allergy = vancomycin + rifampicin + gentamicin FULLY SENSITIVE STREP (S.VIRIDANS) - benzylpenicillin - pen allergy = vancomycin + gentamicin LESS SENSITIVE STREP - benzylpenicillin + gentamicin - pen allergy = vancomycin + gentamicin

Question 523

ENDOCARDITIS how can endocarditis be prevented?

Answer 523

- good oral health - no IV drug use - educate surgery patients on symptoms

Question 524

MI ECG ECG changes in which regions indicates a lateral MI?

Answer 524

lead I aVL V5 V6

Question 525

MI ECG ECG changes in which regions indicates an inferior MI?

Answer 525

lead II lead III aVF

Question 526

MI ECG ECG changes in which regions indicates a septal MI?

Answer 526

V1 V2

Question 527

MI ECG ECG changes in which regions indicates an anterior MI?

Answer 527

V3 V4

Question 528

MI ECG ECG changes in lateral regions are caused by which artery in an MI?

Answer 528

lateral = circumflex

Question 529

MI ECG ECG changes in inferior regions are caused by which artery in an MI?

Answer 529

inferior = RCA

Question 530

MI ECG ECG changes in anterior regions are caused by which artery in an MI?

Answer 530

anterior = LAD

Question 531

MI ECG A blockage in the LAD will cause ECG changes in which regions?

Answer 531

anterior - V3, V4 septal - V1, V2

Question 532

MI ECG A blockage in the RCA will cause ECG changes in which regions?

Answer 532

inferior - leads II, III, aVF

Question 533

MI ECG A blockage in the circumflex artery will cause ECG changes in which regions?

Answer 533

lateral - lead I, aVL, V5, V6

Question 534

RISK SCORE which tool is used to estimate the risk of developing a heart attack or stroke in the next 10 years?

Answer 534

QRISK3

Question 535

PHARMACOLOGY what is the mechanism of action for apixaban?

Answer 535

DOAC - inhibits factor Xa

Question 536

HYPERTROPHIC CARDIOMYOPATHY what is hypertrophic cardiomyopathy?

Answer 536

genetic disorder characterised by left ventricular hypertrophy -> causes diastolic ventricular malfunction

Question 537

HYPERTROPHIC CARDIOMYOPATHY what is the pathophysiology of hypertrophic cardiomyopathy?

Answer 537

thickened septum below aortic valve causes outflow tract obstruction -> causes left ventricular hypertrophy

Question 538

HYPERTROPHIC CARDIOMYOPATHY what are the clinical features?

Answer 538

most = asymptomatic - SOB - fatigue - dizziness - syncope - chest pain - palpitations

Question 539

HYPERTROPHIC CARDIOMYOPATHY what are the examination findings?

Answer 539

- ejection systolic murmur at lower left sternal border - 4th heart sound - thrill at lower left sternal border

Question 540

HYPERTROPHIC CARDIOMYOPATHY what are the investigations?

Answer 540

- ECG - LV hypertrophy - CXR - usually normal, can show pulmonary oedema - echo - genetic testing

Question 541

HYPERTROPHIC CARDIOMYOPATHY what is the management?

Answer 541

- beta blockers - surgical myectomy - ICD - heart transplant

Question 542

CARDIOMYOPATHY what are the different types?

Answer 542

- hypertrophic - dilated - restrictive - arrythmogenic right ventricular

Question 543

HTN what is the most common cause of secondary hypertension?

Answer 543

primary hyperaldosteronism - Conn's syndrome

Question 544

PERCARDITIS What are the side effects of colchicine?

Answer 544

Diarrhoea and nausea

Question 545

ARTERIAL ULCER what are the features?

Answer 545

- symmetrical shape - well-defined borders - punched out appearance - loss of hair surrounding (shiny) - pale, dry, gangrenous with cool surrounding skin - minimal bleeding when knocked/touched - painful, particularly at night

Question 546

ARTERIAL ULCER what are the common locations?

Answer 546

lower legs tops of feet or toes

Question 547

ARTERIAL ULCERS what are the investigations?

Answer 547

- doppler USS - ABPI

Question 548

ARTERIAL ULCER what is the management?

Answer 548

- analgesia - wound management (maintain moist environment) no compression bandages

Question 549

VENOUS ULCERS where are they most commonly found?

Answer 549

around medial and lateral malleolus

Question 550

VENOUS ULCERS what is the appearance?

Answer 550

- shallow - irregular borders - oedema, erythema + brown pigment - warm skin surrounding

Question 551

VENOUS ULCER what are the investigations?

Answer 551

- doppler USS - venous duplex USS - venous pressure assessment

Question 552

VENOUS ULCERS what is the management?

Answer 552

- lifestyle modifications - leg elevation - compression bandages - emollient use

Question 553

CARDIAC ARREST what is it?

Answer 553

sudden loss of heart function

Question 554

CARDIAC ARREST what are the 4 arrest rhythms?

Answer 554

- pulseless electrical activity (PEA) - asystole - ventricular fibrillation - pulseless ventricular fibrillation

Question 555

CARDIAC ARREST which of the arrest rhythms are shockable rhythms?

Answer 555

ventricular fibrillation pulseless ventricular fibrillation

Question 556

CARDIAC ARREST which of the arrest rhythms are non-shockable?

Answer 556

pulseless electrical activity asystole

Question 557

CARDIAC ARREST what are the reversible causes of cardiac arrest?

Answer 557

4Hs + 4Ts - hypoxia - hypovolaemia - hypo/hyperkalaemia - hypothermia - thrombosis - toxins - tension pneumothorax - tamponade (cardiac)

Question 558

CARDIAC ARREST what are the signs?

Answer 558

- unresponsive - absence of pulse - fixed, dilated pupils - absent breath sounds - pallor/cyanosis

Question 559

CARDIAC ARREST what are the symptoms that commonly precede cardiac arrest?

Answer 559

chest pain SOB nausea

Question 560

CARDIAC ARREST what are the investigations?

Answer 560

- pulse check - attach manual/automatic defib - ABG

Question 561

CARDIAC ARREST what are the investigations post-ROSC?

Answer 561

- echo - blood tests

Question 562

CARDIAC ARREST what is the management for all cardiac arrests?

Answer 562

- call for assistance - commence CPR 30:2 ratio - defib assessment - rhythm check every 2 mins - treat reversible causes - manage airway

Question 563

CARDIAC ARREST what is the management for shockable rhythms?

Answer 563

- shock ASAP then resume CPR - rhythm check - give 1mg adrenaline after 3rd shock + after alternating shocks - give 300mg amiodarone after 3rd shock + 150mg after 5th shock

Question 564

CARDIAC ARREST what is the management for non-shockable rhythms?

Answer 564

- no shocks given - rhythm check - adrenaline 1mg ASAP and after alternating cycles of CPR

Question 565

CARDIAC ARREST what is the management post-ROSC?

Answer 565

- intensive care support - induced hypothermia - manage underlying cause

Question 566

CARDIAC ARREST what are the complications?

Answer 566

brain damage kidney failure heart failure death

Question 567

VARICOSE VEINS what is it?

Answer 567

superficial veins dilated and tortuous are visible and palpable are an indicator of superficial lower extremity venous insufficiency

Question 568

VARICOSE VEINS what is the pathophysiology?

Answer 568

leaky valves cause retrograde blood flow, resulting in increased pressure on distal valves superficial veins are thin-walled so cannot withstand increased pressure. This results in dilatation and tortuosity.

Question 569

VARICOSE VEINS what are the risk factors?

Answer 569

genetics/family history increasing age female obesity pregnancy history of DVT prolonged sitting or standing

Question 570

VARICOSE VEINS what are the clinical features?

Answer 570

SYMPTOMS - discomfort (dull ache, worse after prolonged standing) - itching - night cramps - restless legs SIGNS - visible + palpable dilated veins - oedema - signs of chronic venous insufficiency (ulceration, venous eczema, telangiectasia)

Question 571

VARICOSE VEINS what are the investigations?

Answer 571

primary - duplex USS - ABPI

Question 572

VARICOSE VEINS what is the management?

Answer 572

1st line = endothermal ablation 2nd line = foam sclerotherapy 3rd line = surgery conservative - compression hoisery - lifestyle (wt loss, exercise, leg elevation when resting)

Question 573

MI COMPLICATIONS what is the most common cause of death following MI?

Answer 573

ventricular fibrillation (cardiac arrest)

Question 574

MI COMPLICATIONS what type of MI most commonly causes acute mitral regurgitation?

Answer 574

infero-posterior MI

Question 575

MI COMPLICATIONS what is the pathophysiology of acute mitral regurgitation following MI?

Answer 575

ischaemia or rupture of papillary muscle

Question 576

MI COMPLICATIONS how does acute mitral regurgitation after MI present?

Answer 576

- acute hypotension - pulmonary oedema - early-to-mid systolic murmur

Question 577

MI COMPLICATIONS how does a ventricular septal defect following MI present?

Answer 577

usually occurs in first week following MI - pansystolic murmur - acute heart failure

Question 578

MI COMPLICATIONS how does a left ventricular free wall rupture present?

Answer 578

occurs 1-2 weeks after - acute HF - cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds)

Question 579

MI COMPLICATIONS which MI region most commonly causes atrioventricular blocks and bradyarrhythmia?

Answer 579

inferior MI