Cardio conditions Flashcards
(168 cards)
1
Q
What is an abdominal aortic aneurysm?
A
Pathological dilation of the abdominal aorta
2
Q
What symptoms will someone with an unruptured AAA classically present with?
A
Centrally pulsatile mass
Generalised peritonitis
3
Q
What symptoms will someone with a ruptured AAA classically present with?
A
New onset sudden abdominal or back pain (very severe, feels like a tearing)
Peritonitis- tenderness and rigidity
Abdominal distention
Sudden loss of conciousness
4
Q
What are some risk factors for developing an AAA?
A
Family hx
Smoking
Increased age
Male sex
5
Q
Who is more likely to get an AAA?
A
Older patients
Men in general, but if they present with rupture they are more likely to be a woman
6
Q
What is the first line investigation for an AAA?
A
Bedside aortic ultrasound
7
Q
What is the management for a ruptured AAA?
A
Immediate surgical repair
Post op abx, VTE prophylaxis
8
Q
When should an AAA be operated on?
A
If its ruptured immediately
If its bigger than 5.5cm in diameter
If its bigger than 4cm in diameter and growing fast
9
Q
What are the 2 ways an AAA will present?
A
Ruptured or unruptured
10
Q
What are the 2 types of aortic aneurysm?
A
Abdominal and thoracic
11
Q
When is screening for AAA available and who is eligible?
A
It is available for men over the age of 66
Also available for women over the age of 70 who have risk factors
12
Q
What happens if someone is screened for an AAA and none is found, a small one is found, a medium one is found or a large one is found?
A
None= not invited back for screening Small= invited back once a year for screening Medium= invited back once every 3 months for screening Large= treated asap
13
Q
What does acute coronary syndrome encompass?
A
Unstable angina
Posterior infarct
STEMI
NSTEMI
14
Q
What symptoms will someone with ACS classically present with?
A
Central chest pain that they will describe as crushing
Pain that radiates to their left arm/shoulder and jaw
Pain that lasts for a few mins- half an hours (it will be continuous if they are having an MI
15
Q
Who is more are risk of ACS?
A
Older patients Smokers Patients with diabetes mellitus Patients with dyslipidaemia (atherosclerosis etc) Those with significant family hx
16
Q
When is family history significant for ACS?
A
First degree relative who had an MI/ ACS when they were young (under 50)
17
Q
What are the first line investigations when someone presents with ACS? Explain why each one is done
A
ECG- to figure out what the issue is eg wheres the infarct, what is the arrhythmia etc
Bloods- troponin, ESR, CRP, can do CK-MB
U+Es- to check or imbalance as this can cause arrhythmia
Serum cholesterol
18
Q
What do you need to remember about troponin when interpreting a patient’s results?
A
It may take a few hours to rise
19
Q
What do you need to remember about cholesterol when interpreting a patient’s results?
A
It may fall after an MI and will take a while to restabilise and represent a patient’s usual cholesterol profile
20
Q
What is the acute method of management when a patient has ACS?
A
Start them on a cocktail of drugs which you can remember by using the acronym MONABASH: Morphine/ analgesia Oxygen Nitrates ACE inhibitor Beta blocker Antiplatelets Statin Heparin
If someone has STEMI do an angioplasty immediately and if you can’t then start thrombolysis
21
Q
What long term management is needed for someone with ACS?
A
Lifestyle modification- improve diet, try to do more exercise, smoking cessation, weight loss
Long term ACE inhibitor, statin, aspirin (or other blood thinner)
22
Q
What are the complications of STEMI and how do you remember them?
A
DARTH VADER Death Arrhythmia Rupture (of septum or chamber wall) Tamponade Heart failure Valvular disease Aneurysm Dressler's syndrome (pericarditis a few days- week after MI) Reinfarction
23
Q
Whats the first line treatment for STEMI?
A
Angiography
24
Q
Whats the second line treatment for STEMI?
A
Thrombolysis
25
What is aortic dissection?
A tear in the inner layer of the aorta than causes bleeding into the aorta (or outside it completely)
26
What are the 2 types of aortic dissection and how do they differ?
Type A= only involves the ascending aorta
| Type B= only involves the descending aorta
27
What symptoms will someone with an aortic dissection classically present with?
```
A sudden onset tearing chest pain that radiates to the back
Pale
Sweaty
Clammy
Hyper or hypotension
```
28
What happens to blood pressure when someone has an aortic dissection?
It can either reduce or increase
29
What will you find on examination of a patient with aortic dissection?
Pulse absent in one arm
Difference in pulses between arms >20 mmHg
New onset aortic regurgitation (early diastolic murmur)
Pleural effusion (left sided dull to percussion, reduced chest expansion, reduced breath sounds)
30
What are some risk factors for aortic dissection?
```
Increasing age
Marfan's syndrome
Family hx
Hx of hypertension
Atherosclerosis
Recent valve replacement
```
31
What are the first line investigations for aortic dissection?
```
ECG
Troponin
CRP
ESR
U+Es
FBC
WCC
Erect chest radiograph
Cholesterol
```
32
How are aortic dissections managed?
If type A immediately refer them for emergency surgery
If type B they might be medically managed
Everyone should be given a beta blocker (or CCB if inappropriate) and opioid analgesia
You might want to consider a vasodilator
33
How do type A and type B aortic dissections differ in how they are managed?
Type a= refer for immediate surgery
| Type b= can be medically managed
34
Who do you give beta blockers to and who do you give CCBs to?
Beta blockers= patients who are under 55 or white
| CCB= patients who are over 55 or not white
35
What condition does the management of posterior infarcts follow?
STEMI
36
What is the grace scale?
It is used to stratify the risk of someone with NSTEMI so you can see if they would benefit from an angioplasty
37
What medication will ACS respond well to?
GTN spray
38
How can you differentiate MI from Boerhaave's perforation if there is chest pain and vomiting present in both?
```
Boerhaave's= pain will follow an episode of vomiting
MI= if vomiting is present it will only start after the pain has started
```
39
What is aortic stenosis?
Narrowing of the aortic valve that reduces blood flow from the left ventricle into the aorta
40
What are some risk factors for developing aortic stenosis?
Bicuspid aortic valve
Increasing age
CKD
Rheumatic fever
41
What murmur does aortic stenosis result in?
Ejection systolic murmur (mid systole)
42
What is the pathophysiology underlying aortic stenosis?
It can arise due to calcification or sclerosis
43
What is the first line investigation for aortic stenosis?
Echocardiogram
44
What does ECG stand for?
Electrocardiogram
45
How is aortic stenosis managed?
TAVI= transthoracic aortic valve implantation
Post surgery give lifelong blood thinners- aspirin and if contraindicated then clopidogrel
Also give abx to prevent infective endocarditis
46
What are some complications of aortic stenosis?
Heart failure
Sudden death
Left ventricular hypertrophy
47
What is aortic regurgitation?
Backflow of blood from the aorta into the left ventricle due to intrinsic valve disease or widening of the aortic root
48
What symptoms will someone with aortic regurgitation present with classically?
They usually won't present unless its acute
Diastolic murmur
They may have shortness of breath, chest pain, fatigue etc
49
What are some risk factors for aortic regurgitation?
```
Increasing age
Bicuspid valve
Marfan's syndrome
Rheumatic fever
CKD
```
50
What are the first line investigations for aortic regurgitation?
ECG
Echocardiogram
Erect CXR (may show cardiomegaly)
51
How is aortic regurgitation managed?
TAVI if they present acutely (before surgery give ionotropes and vasodilators to stabilise the patient)
If its mild or moderate assess whether TAVI is beneficial and if not vasodilator therapy
52
What are some complications of aortic regurg?
Chronic heart failure
Left ventricular hypertrophy
Cardiomegaly
53
What murmur is heard with aortic regurgitation? How will it differ if regurgitation is mild vs severe?
Diastolic murmur
If mild= early diastolic murmur
If more severe= the murmur will last longer, but note that it will NOT be more intense (only the duration increases)
54
What happens to an aortic regurgitation murmur as the regurgitation increases in severity?
It becomes longer
55
What is arterial thrombosis?
The formation of a blood clot in an artery
56
What are some ways arterial thrombosis may present?
```
Heart attack
Angina
Stroke
TIA
Peripheral vascular disease
Limb ischaemia
```
57
What are some symptoms patients may experience as a result of arterial thrombosis?
Chest pain/ angina
Stroke
Pain in limbs
58
What is the cause of arterial thrombosis?
Atherosclerosis (the build up of fats in arteries)
59
What are the stages of atherosclerosis?
Fatty streak
Atheroma
Fibroatheroma
Complicated lesion
60
What are some risk factors for developing arterial thrombosis?
```
Smoking
Hypertension
Alcohol misuse
Diet high in fat and salt
Sedentary lifestyle
Diabetes mellitus
```
61
How is arterial thrombosis managed
Medications- blood thinners like warfarin, antiplatelets like aspirin or clopidogrel, ACE inhibitors to reduce blood pressure
Surgery- coronary angiography, CABG, carotid endartectomy
Lifestyle advice- good diet low in sat fats and salt, adequate exercise, stop smoking, reduce alcohol intake etc
62
What is coronary angiography?
When a tube is placed inside one of the coronary vessels to hold it open
63
What are some investigations you might do when you suspect arterial thrombosis?
ECG, troponin etc if you suspect MI/ angina
| Non contrast head CT for stroke/ TIA
64
What is an arterial ulcer?
An area of the skin that has broken down (often after minor injury) and is slow to heal due to inadequate blood supply
65
What symptoms will someone with an arterial ulcer classically present with?
Ulcer that looks like skin thats been punched out
Often located in the lower legs or feet
Episode of previous minor trauma to the area
Painful, pain worse at night
Minimal bleeding even when knocked or touched
Borders well defined
66
What is the first line investigation for an arterial ulcer?
Nothing, diagnosis is usually clinical
Capillary refill can be done
Foot pulses may be checked
67
Why do arterial ulcers arise?
Due to atherosclerosis leading to poor blood supply to an area which means when there is trauma blood supply is inadequate for healing
68
How are arterial ulcers managed?
Wound care to optimise healing and reduce chances of infection (abx to prevent infection are not routinely given)
Surgical intervention to allow healing is usually required and consists of bypass, angiography or skin grafts
Lifestyle intervention- stop smoking, improve diet by reducing fats, sugar etc
69
What are the 3 types of arterial ulcer?
Acute
Chronic
Recurrent
70
What is cardiac arrest?
Loss of circulation due to sudden loss of cardiac systolic function
71
What are the symptoms of cardiac arrest?
Loss of consciousness
Lack of breathing
Loss of pulses
72
What are the common causes of cardiac arrest?
Ischaemic heart disease
Cardiovascular disease
Arrhythmia
73
What investigations are done if a patient undergoes cardiac arrest?
Continuous heart monitoring
ECG
Bloods- FBC, U+Es, cardiac biomarkers
ABG
74
How is cardiac arrest managed?
First line CPR
May give adrenaline during CPR
May give adjuncts eg magnesium if due to torsade des pointes (caused by hypomagnesium)
75
What are some complications of cardiac arrest?
Death
Anoxic brain injury
Organ injury due to ischaemia
Rib and sternal fractures
76
What are the 4 cardiac rhythmn disturbances that can cause cardiac arrest?
V fib
Pulseless ventricular tachycardia
Pulseless electrical activity
Asystole
77
What is heart failure?
When the heart is unable to sustain a cardiac output that is sufficient to meet the demands of the body
78
What symptoms will someone with heart failure classically present with?
```
Dyspnoea (worse on exertion)
Orthopnoea
Fatigue
Pleural effusion (crackles at base of lungs)
Swelling of legs and feet
S3 gallop
```
79
Who is more at risk of cardiac failure?
```
Increasing age
Smoking
Female
Hypertension
Ischaemic heart disease
Diabetes mellitus
Overweight
```
80
What are the first line investigations for someone with heart failure?
ECG
BNP levels- a hormone released by ventricular cells in heart failure so if not raised heart failure is unlikely
Bloods- FBC, glucose (check for anaemia etc)
Lipid profile
LFTS
Thyroid function- can be a cause of contributing factor
U+Es- need to be checked if theres fluid overload and if you want to start a diuretic
Creatinine
81
What is BNP and when is it useful to measure it?
A hormone released by ventricular cells during heart failure, it can be used to rule out heart failure as if it isn't raised heart failure is unlikely
82
How is heart failure managed?
First line ACE inhibitor and if not tolerated then angiotensin II receptor blocker
Beta blocker
CCB
Loop diuretic if heart failure is mild
Lifestyle advice eg low salt diet and fluid restriction (if in hospital)
If there is acute hyperkalemia give sodium zirconium cyclosilicate
83
What are some complications of cardiac failure?
```
Pleural effusion
Sudden decompensation
CKD
AKI
Anaemia
```
84
What is deep vein thromobsis?
Formation of a blood clot deep to the muscular layer, often in the leg
85
What symptoms will someone with a DVT classically present with?
Painful and swollen leg
Localised pain along the nerve
It may be cold, may also be warm and red
86
What scoring criteria is used to assess the risk of someone having a DVT? What score is positive
Well's score
| Score of 2 or more is positive
87
What are some risk factors for developing DVT?
```
Pregnant
Female sex
Increasing age
Recent surgery
Recent trauma or fracture
Hereditary thrombophilia
Being sedentary (hospital bedbound for more than 3 days or otherwise)
Certain drugs
Cancer (thats active)
```
88
What is the first line investigation for DVT?
If Well's score is positive, immediate first line proximal leg vein ultrasound within 4 hours. If risk is not very high can be done in 24 hours with interim anticoagulation
Bloods- FBC, renal function, LFTs, PT and APTT
89
How is DVT managed?
Anticoagulation: interim use apixaban, long term use DOAC or warfarin
Monitor them, assess risk of causes eg follow up if you suspect cancer etc
90
What are some complications of DVT?
```
Pulmonary embolism
Bleeding due to treatment
Heparin induced thrombocytopenia
Osteoporosis due to heparin
Bleeding due to long term anticoagulation
```
91
What is the definition of hypertension?
A systolic blood pressure over 140 and a diastolic blood pressure over 90 mmHg
92
What symptoms might someone with hypertension present with classically?
```
Headache
Visual changes
Retinopathy
Dyspnoea
Chest pain
Sensory or motor deficit
```
93
What are some risk factors for developing hypertension?
```
Family hx of hypertension or coronary artery disease
Increasing age
Black ancestry
Inadequate exercise
Diet high in fats or sodium
Diabetes mellitus
Obesity
```
94
Who is more likely to have hypertension?
Someone living in a low or middle income country
Men if they are under 65 years
Women if they are over 65 years
People with black ancestry
95
What is the first line investigation for hypertension?
Measuring blood pressure
If its over 140/90 in clinic, do it again and take the lowest reading of 3
Measure it after making the patient stand for 1 min to check for postural hypertension
If over 140/90 and under 180/120 offer ambulatory or home blood pressure monitoring before a final diagnosis of hypertension
```
Also do
Bloods- FBC, Hba1c
Renal function
Creatinine
Urine dip- albuminuria and haematuria (check for kidney damage
U+Es
12 lead ECG
```
96
What tool is used to assess a patient's cardiovascular risk?
Q risk tool
97
When you suspect hypertension, apart from measuring blood pressure what other investigations do you need to do? Explain why you do them
Bloods- FBC, Hba1c- check for anaemia and diabetes
Creatinine
U+Es- check for electrolyte imbalance
Renal function- check for kidney damage
Urine dip (check for haematuria and albuminuria)
12 lead ECG- check for cardiac abnormalities
Opthalmoscopy- check for retinopathy
98
How is hypertension managed?
```
Lifestyle advice:
Stop smoking
Adequate exercise
Reduce alcohol intake
Reduce caffeine intake
Reduce sodium intake
```
Medication:
First line= if they are under 55 and not black offer ACE inhibitor and if not tolerated, ARB (angiotensin II receptor blocker). If they are over 55 or black, offer CCB and if not tolerated, thiazide diuretic
Second line= if on ACE inhibitor/ARB offer CCB and vice versa (if someone is on CCB and black, ARB is prefered as second line instead of ACE inhibitor
Third line= if on ACE inhbitor/ARB and CCB offer thiazide diuretic
99
How often is hypertension reviewed?
Annually
100
What are some complications of hypertension?
```
Coronary artery disease
Cerebrovascular event
Chronic kidney disease
Retinopathy
Left ventricular hypertrophy
Congestive heart failure
Peripheral arterial disease
```
101
What is infective endocarditis?
Infection of the endocardial surfaces of the heart
102
What symptoms will someone with infective endocarditis classically present with?
```
Fever
Weight loss
Night sweats
Headache
Cardiac murmur
Chills
Shortness of breath
Signs might include janeway lesions, oslers nodes and splinter haemorrhages
```
103
What are some risk factors for developing infective endocarditis?
```
Valve replacement
Recent vascular access eg central venous catheter
IV drug use
Congenital structural heart disease
Implantation of cardiac device
Previous infective endocarditis
Hypertrophic cardiomyopathy
```
104
What is the first line investigation for infective endocarditis? What will they show?
Blood culture- try to take 3 sets in 30 mins before abx unless they are septic then start abx immediately
Creatinine
U+Es- urea may be high
Echocardiogram
ECG- there may be abnormalities if heart block develops
LFTs
Urinalysis
105
How is infective endocarditis managed?
IV abx- broad spectrum if they are septic to start with then specific once cultures come back
Surgical intervention may be needed if the valves become damaged, if there is chronic infection where an abscess etc develops
106
What are some complications of infective endocarditis?
Systemic heart failure
Systemic embolism
Valvular damage
AKI
107
What is coronary heart disease?
Narrowing of the blood vessels due to atherosclerosis
108
What are some other names for coronary heart disease?
Coronary artery disease
| Ischaemic heart disease
109
What are some symptoms someone with ischaemic heart disease will classically present with?
```
Chest pain/ angina (worse on exertion)
Shortness of breath
Dizziness
Nausea
Feeling sick
Neck pain
Stomach pain
```
110
What are some risk factors for ischaemic heart disease?
```
Smoking
Hypertension
Diabetes mellitus
Family hx
Increasing age
Inadequate exercise/ sedentary lifestyle
Poor diet (high in fat or glucose)
```
111
What is the first line investigation for ischaemic heart disease?
```
Bloods- lipid profile, Hba1c, FBC etc
ECG
Coronary angioplasty
CT/MRI
Stress test (treadmill etc)
```
112
How is ischaemic heart disease managed?
First line lifestyle advice (exercise, low fat/glucose diet, weight loss, stop smoking)
Second line medication (ACE inhibitor, beta blocker, CCB, statin, metformin etc)
Surgery can also be used eg CABG, coronary angiography, percutaneous coronary intervention
113
What are some complications of ischaemic heart disease?
```
Cardiac arrest
Acute coronary syndrome- unstable angina, MI
Cardiac failure
Arrhythmia
Cardiogenic shock
```
114
What are the types of ischaemic heart disease and how do they differ?
Obstructive= blood vessels more than 50% blocked
Non obstructive= blood vessels inner lining is damaged which causes spasm
Microvascular= spasm of the small blood vessels
115
What are the 3 types of ischaemic heart disease?
Obstructive
Non obstructive
Microvascular
116
What is myocarditis?
Inflammation of the myocardium without chronic or acute ischaemia
117
What symptoms will someone with myocarditis classically present with?
```
Chest pain
Dyspnoea
Orthopnoea
Fatigue
S3 gallop
Palpitations
Atrial or ventricular fibrillation
```
118
Who is more likely to get myocarditis?
```
Those under 50
Those with a prodromal viral episode eg fever, myalgia
Those with an autoimmune condition
Those with an infection (eg HIV)
Those who have has the smallpox vaccine
```
119
What are the first line investigations for myocarditis? Explain why you do each one
12 lead ECG- to look for any dangerous abnormality and structure management
Serum troponin and CK-MB- should be done if MI is suspected
CXR- to look for fluid, dilated cardiomyopathy etc
BNP- will be raised if ventricular cells are affected
120
How is myocarditis managed?
Treat the underlying cause if manageable
Steroids if autoimmune
ACE inhibitors, beta blockers, diuretics if needed
To improve cardiac output give ionotropes or vasoldilators/nitrate
121
What are some complications of myocarditis?
AF
| Ventricular dilation
122
How is myocarditis different from IHD or CAD?
There is no chronic or acute ischaemia
123
What is pericarditis?
Inflammation of the pericardium
124
What symptoms will someone with pericarditis classically present with?
Chest pain- it will be a constant retrosternal pain for weeks, it will be sharp/stabbing in nature, it will also be relieved by sitting up or bending forward
Pericardial rub- this will sound like a crunch like when someone steps on fresh snow that can be heard on auscultation of the left sternal border
If effusion has developed features of cardiac tamponade may be present
125
Who is more likely to get pericaditis?
```
20-50 years old
Male sex
Transmural MI
Recent infection
Systemic autoimmune condition
Uraemia
Dialysis
Cardiac surgery
Neoplasm
```
126
What are the first line investigations for pericarditis? Describe why each one is done
12 lead ECG- there will be abnormalities
UEs- check for uraemia as a cause
CK-MB and serum troponin- do in everyone with suspected MI
LFTs- check because if there is development of cardiac tamponade there will be liver congestion
CXR- to check for effusion
127
What is a pericardial rub? Where should you listen for it? What does it sound like? When may it not be present?
It is a sound that can be heard in a patient with pericarditis
You should auscultate for it at the left sternal border
It will sound like a crunch like when someone steps on fresh snow
It may not be present in a patient with pericarditis if they have developed an effusion as the layers of the pericardium will be separated
128
What are the different types of pericarditis?
Fibrinous (dry)
| Effusive (purulent, serous or haemorrhagic)
129
What are the 3 types of effusive pericarditis?
Serous
Purulent
Haemorrhagic
130
How is pericarditis managed?
If there is evidence of cardiac tamponade an immediate pericardocentesis needs to be done to drain it
Otherwise give them NSAIDs for 2-4 weeks high dose and a PPI with it (always give PPI with high dose NSAIDs)
Give colchicine to prevent recurrence unless they have TB pericarditis
You may want to consider corticosteroids
131
What are some complications of pericarditis?
Cardiac tamponade
| Chronic pericarditis
132
What is the time frame for acute pericaditis?
It must be within 2-4 weeks
133
How is chest pain in pericarditis differentiated from pain in MI?
In pericarditis pain is: retrosternal, constant, onset was weeks ago, sharp/stabbing in nature, relieved by sitting up or sitting forward, not associated with nausea/vomiting/sweating/breathlessness
In MI pain is: central and may radiate to arms/jaw, onset is sudden ie minutes/hours ago, crushing and tight in nature, associated with nausea/vomiting, sweating and breathlessness
134
What is peripheral vascular disease?
A circulatory disorder wherein there is narrowing, blockage or spasm of blood vessels outside the heart and brain
135
What vessels does peripheral vascular disease affect? Which ones most commonly?
Blood vessels outside the heart and brain, most commonly in the legs
136
What symptoms will someone with peripheral vascular disease classically present with?
```
Intermittent claudication- pain in the lower legs which is worse after exercise
Thinning of skin
Red or blue skin
Wounds or ulcers that won't heal
Loss of pulses
```
137
Who is most likely to get peripheral vascular disease?
```
Older patients
Male sex
Those with hx of heart disease
Hypertension
Hyperlipidaemia
Sedentary lifestyle
Obesity
Smoking
Diabetes mellitus
```
138
Why does peripheral vascular disease arise?
```
Athersclerosis
Spasm
Infection
Trauma
Irregular anatomy
```
139
What are the first line investigations for peripheral arterial disease?
Angiography
Ankle brachial index
Doppler ultrasound
140
How is peripheral vascular disease managed?
First line lifestyle advice: healthy diet, increased exercise, weight loss, stop smoking
Medical: tight control of underlying conditions eg diabetes, hypertension. Can also give antiplatelets to reduce the risk of blood clots
141
What are some complications of peripheral vascular disease?
Infection of ulcers/wounds
Amputation
Gangrene
Restricted mobility
142
What is vasovagal syncope
The common faint- a sudden and temporary loss of consciousness
143
Why does vasovagal syncope occur?
Insufficient cerebral perfusion due to a systemic fall in arterial blood pressure that results from vasodilation
144
What are some causes of vasovagal syncope?
```
Pain
Fear
Hot environment
Prolonged periods of standing
Anaemia
Pregnancy
Arrhythmia/heart block
Dehydration
Adrenal insufficiency
PE
MI
```
145
What symptoms will someone with vasovagal syncope present with?
```
A faint- sudden and temporary
Provocative event precipitating the faint
Nausea
Pallor
Palpitations
Diaphoresis- sweating and clamminess
Postural instability during the faint
```
146
What are the first line investigations for vasovagal syncope? Describe why each one is done
12 lead ECG- rule out heart block, asystole etc
```
You might also want to do:
HCG- to rule out pregnancy
UEs- to rule out dehydration
D dimer- to rule out PE
FBC- to rule out anaemia
Serum cortisol- to rule out adrenal insufficiency
Cardiac enzymes- to rule out MI
```
147
How is vasovagal syncope managed?
Tell the patient to avoid triggers, maintain good fluid intake, teach them techniques to help postural stability to reduce injury risk and possibly advise increased salt intake
Medication may include that which improves fluid retention of due to dehydration as well as medically treating underlying causes
148
What are some complications of vasovagal syncope?
Injury/fracture
| Subdural or extradural haemorrhage
149
What make should you differentiate vasovagal syncope from?
Seizure
150
What are some features of a seizure that differentiate it from vasovagal syncope?
```
No provocative factors
Same type each time an episode occurs
Tongue biting
Head tilts to one side
Confusion after the episode
No postural instability
Limb jerking
```
151
What are varicose veins?
Dilated, tortuous superficial veins most commonly in the legs
152
What symptoms will someone with varicose veins classically present with?
Visibly dilated veins in the leg (bigger than 3mm)
Leg pains, aches, itches
Leg pain worse when standing and better with elevation, not present in the morning
Skin changes- eczema etc
Nocturnal leg cramps
Restless eg syndrome
153
Why do varicose veins arise?
There is valvular dysfunction which causes backflow and pooling of blood resulting in vein dilation
154
Who is more likely to get varicose veins?
```
Older patients
Those who have had DVT, previous varicose veins, vascular surgery
Trauma
Ulceration
Pregnant women
Female sex
Increasing no of births
```
155
What is the first line investigation for varicose veins?
None- clinical assessment is sufficient, they should be larger than 3mm
Doppler ultrasound may be useful
156
How are varicose veins managed?
Lifestyle advice: weight loss, mild/moderate exercise
Compression stockings- do not give these to people with arterial insufficiency, test this by doing ankle brachial pressure index
Refer to vascular team if pain is high, if there are skin changes, if there is leg ulcer (active or healed)
157
What is the main complication of varicose veins?
Chronic venous insufficiency
158
What is atrial fibrillation?
A supraventricular tachyarrhythmia where uncoordinated atrial electrical impulses lead to ineffective atrial contractions
159
What signs and symptoms will someone with AF present with?
```
Palpitations
SOB
Dizziness
Syncope
Chest discomfort/ tightness
```
160
What are the RF for AF?
```
Increasing age
Valvular disease
CAD
Previous arrhythmia
Heart failure
Hypertension
Obesity
OSA
```
161
What is the first line investigation for AF, what will you see?
12 lead ECG- you will see absent p waves and an irregularly irregular R-R interval
162
How is AF managed?
Admit if haemodynamically unstable- high HR, low BP, worsening SOB, constant dizziness/ syncope
If <48hrs of episode immediately cardiovert (electrical or medical) then rate control
If >48 hrs of episode 3 weeks of anticoagulation then cardioversion and rate control
Long term anticoagulation
163
How is cardioversion performed in someone with AF?
Electrical- DCCV
| Pharmacological- flecanide first line, if they have IHD amiodarone
164
How is rate controlled in someone with AF?
First line beta blocker
165
What long term anticoagulation is given to those with AF?
First line DOAC
| If not warfarin but for first 2 weeks give LMWH
166
What are some complications of AF?
Stroke
TIA
Heart failure
167
What is the CHADSVASC score used for and what score is needed?
It is used to calculate the risk of a cardiovascular event in someone with AF in the next year so can be used to decide whether they require long term anticoagulation and how much
A score of 1 or above for a man or 2 or above for a women displays need for long term anticoag
168
What is the ORBIT score used for and what score is needed?
It is used to calculate the risk of someone with AF bleeding
Score 0-2= low risk
3= medium risk
4-7= high risk
