Cardiology Flashcards
(321 cards)
1
Q
What is the difference between a true and false aneurysm?
A
True: involves all three layers of artery - intima, media, and adventitia
False: only involves a single layer of fibrous tissue
2
Q
What is the screening program for AAA?
A
65+ men, abdominal ultrasound
3
Q
What causes AAA?
A
- Same risk factors as arterial disease: HTN, smoking, diabetes
- Connective tissue disease: Marfan’s
4
Q
How does connective tissue disease increase the risk of AAA?
A
Disruption of extracellular matrix - change in balance of collagen and elastin fibres
5
Q
How is AAA managed?
A
If symptomatic, or between 5.5-6cm, surgical
If asymptomatic, monitor for growth
6
Q
How is Laplace’s law relevant in AAA?
A
Increase in size correlates with increase in pressure
As size of aneurysm increases, greater likelihood of rupture.
7
Q
Which part of the heart do leads V1-4 correspond to?
A
Anterior
8
Q
Which artery do leads V1-4 correspond to?
A
Left anterior descending artery
9
Q
Which part of the heart do leads II, III, and aVF correspond to?
A
Inferior
10
Q
Which artery do leads II, III, and aVF correspond to?
A
Right coronary artery
11
Q
Which part of the heart do leads I, V5, and V6 correspond to?
A
Lateral
12
Q
Which artery do leads I, V5, and V6 correspond to?
A
Left circumflex
13
Q
What is the initial treatment for ACS?
A
300mg aspirin
14
Q
How does MONAT link to ACS?
A
Morphine only if in severe pain Oxygen only if sats <94% Nitrates with caution if hypotensive Aspirin 300mg Ticagrelor
15
Q
How are nitrates administered in ACS?
A
Sublingually, or IV
16
Q
How are STEMIs managed?
A
Asprin 300mg
If patient has presented within 12 hours, and PCI possible in 120 minutes, PCI
If more than 12 hours, but patient still has symptoms of ongoing MI, consider PCI
If PCI not possible in 120 minutes, fibrinolysis. If ECG changes still present >90 minutes after fibrinolysis, offer PCI
17
Q
If a patient is a candidate for PCI, how would you anticoagulate prior to PCI?
A
Dual antiplatelet therapy with aspirin and prasugrel if the patient is not already on an anticoagulant
18
Q
If a patient is a candidate for PCI, and is already on an oral anticoagulant, how would you anticoagulate prior to PCI?
A
Dual antiplatelet therapy with aspirin and clopidogrel
19
Q
What drug therapy would you give for patients during a PCI procedure using radial access?
A
Unfractionated heparin + bailout glycoprotein IIb/IIIa inhibitor (GPI)
20
Q
What drug therapy would you give for patients during a PCI procedure using femoral access?
A
Bivalirudin without glycoprotein inhibtiors
21
Q
What drugs should be given to patients undergoing fibrinolysis?
A
Antithrombin drugs
22
Q
When should an ECG be repeated following fibrinolysis?
A
60-90 minutes - if persisting myocardial ischaemia, consider PCI
23
Q
How should NSTEMI/unstable angina be managed?
A
Aspirin 300mg and fondaparinux if no immediate PCI planned
24
Q
What are the risk factors for ACS?
A
- Age
- Male
- Family history
- Smoking
- Obesity
- Hypertension
- Hypercholesterolaemia
- Diabetes
25
Describe in 5 steps the pathophysiology behind ACS.
1. Initial endothelial dysfunction triggered by smoking, hypertension, hyperglycaemia
2. Pro-inflammatory changes to endothelium - pro-oxidant state, proliferative, reduced NO bioavailability.
3. Fatty infiltration of the subendothelial space by LDLs
4. Monocytes migrate and differentiate into macrophages. Macrophages phagocytose LDLs and become foam cells. As macrophages die, this can propagate the inflammatory process.
5. Smooth muscle proliferation and migration from the media into the intima results in formation of a fibrous capsule covering the fatty plaque.
26
which risk stratification scoring system is used for NSTEMI to decide whether coronary angiogram?
GRACE score
27
what are the risk factors for AAA?
1. Age (screening in 65+)
2. Male
3. Diabetes
4. Smoking
5. HTN
6. Connective tissue diseases e.g. Marfan's
28
What is the screening program for AAA?
men aged 65 or more - ultrasound measurement of the aneurysm
29
when is CT offered for AAA?
when size reaches 5cm - CT CAP with a view to manage surgically
30
When is surgery offered for AAA?
5.5-6cm
31
what symptoms of AAA
central tearing abdo pain, radiating to back
| pulsatile, expansile mass in abdomen
32
what is the management of AAA
EVAR - endovascular repair
33
what complication of AAA repair using EVAR?
endo-leak - blood still collects in the aneurysm
34
what is the pathophysiology of aortic dissection?
tear in the tunica intima causes blood to pool in the tunica media
35
how is aortic dissection classified?
Type A - ascending aorta - 67% cases
| Type B - descending aorta
36
what are the RFs of aortic dissection
1. HTN
2. Connective tissue disorders - EDS, Marfan's
3. Trauma
4. Bicuspid aortic valve
5. Noonan's/Turner's syndrome
6. Pregnancy
7. Syphilis
8. Cocaine
37
What are the symptoms of aortic dissection
Central sharp, tearing chest pain.
Upper back pain if type B
some overlap between site of pain
38
What are the signs of aortic dissection
- HTN
- pulse deficit - weakness in pulse, absent brachial/femoral/carotid pulse
- variation (>20mmHg) in systolic BP between two arms
- aortic regurgitation
39
What are the complications of aortic dissection?
1. Aortic regurgitation
2. False lumen puts pressure on subclavian and renal arteries - renal failure
3. Paraplegia
4. Cardiac tamponade
5. Stroke
6. Myocardial Infarction
40
what murmur might be heard with aortic dissection?
diastolic murmur
41
which branch of coronary arteries is usually affected by aortic dissection and how would this present on ECG
right coronary arteries - inferior ST elevation (II, III, aVF)
42
how is aortic dissection managed
Type A - surgical
| Type B - medical, occasionally surgical repair, but labetalol to prevent further progression
43
what surgical procedure for type b aortic dissection?
thoracic endovascular aortic repair (TEVAR)
44
What are the shockable cardiac arrest rhythms?
VT
| VF
45
what are the non-shockable cardiac arrest rhythms
PEA
| Asystole
46
how is tachycardia treated in an unstable patient?
- 3 synchronised shocks
| - consider amiodarone infusion
47
how is tachycardia classified in a stable patient?
narrow (QRS <0.12s) and broad complex (>012s)
48
what are the three narrow-complex tachycardias
1. AF
2. Atrial flutter
3. SVT
49
Give an example of broad-complex tachycardias
Ventricular tachycardia
50
How is AF rate control achieved
Beta blocker or diltiazem
51
how is atrial flutter rate control achieved
beta blocker
52
how is rate control achieved in SVT
vagal manoeuvres
IV bolus 6mg adenosine (verapamil in asthmatics)
electrical cardioversion
53
give examples of vagal manoeuvres
valsalva
| carotid sinus massage
54
how is ventricular tachy treated
amiodarone infusion
55
what is the pathophysiology of atrial flutter
re-entrant electrical signal from atria loops back on itself and overrides normal sinus rhythm.
This establishes an endless loop of stimulation - tachycardia
56
what are the risk factors for atrial flutter
1. Previous MI
2. Ischaemia
3. HTN
4. Fibrosis
5. Valvular heart disease
6. obstructive sleep apnoea
57
what signs symptoms of atrial flutter
palpitations, chest tightness, heart failure
58
what investigations for atrial flutter
ECG
Echo for valvular disease, HF
TSH levels for hyperthyroidism
59
how is atrial flutter treated
1. if hypertension/hyperthyroidism, treat underlying cause
2. beta blocker for rate control
3. anticoagulate based on chadsvasc
4. radiofrequency catheter ablation
60
explain the pathophys of supraventricular tachy
1. Electrical signal re-enters atria from ventricles
2. Signal travels to AVN, stimulating another ventricular contraction
3. Causes a self-perpetuating electrical loop
4. Results in a narrow complex tachycardia (QRS <0.12s)
61
what is paroxysmal SVT?
remits and recurrs in same patient over time
62
give three causes of svt
1. AV node re-entry tachycardia (re-entry through the AVN)
2. Atrioventricular re-entrant tachycardia - re-entry to ventricles through an accessory pathway (eg WPW syndrome)
3. Atrial tachycardia - ectopic electrical activity generated in the atria, but not from the SAN
63
how is svt treated
1. Vagal manoeuvres (valsalva, carotid massage)
2. IV adenosine, verapamil in asthmatics
3. electrical DC cardioversion
64
what is the long term management of patients with paroxysmal SVT
beta blockers, rate limiting CCB, amiodarone
| radiofrequency catheter ablation
65
explain the pathophysiology of wolff-parkinson white
Congenital accessory pathway connecting atria and ventricles, leading to AVRT.
66
how does wpw present on ecg
1. delta waves (slurred upstroke to qrs)
2. broad qrs
3. short pr
4. associated with left-axis deviation
67
how does WPW affect axis-deviation
if accessory pathway is in right atrium, left-axis deviation
| if accessory pathway is in left atrium, right-axis deviation
68
how is WPW treated
radiofrequency ablation
| sotalol, amiodarone, flecainide
69
when would you avoid giving sotalol/beta blockers/antiarrhythmics in WPW
if concurrent AF or atrial fibrillation
70
what conditions are associated with WPW
1. HOCM
2. Ebstein's anomaly
3. Secundum ASD
4. Thyrotoxicosis
5. Mitral valve prolapse
71
what ECG abnormality causes torsades de pointes
long QT
72
which electrolyte abnormalities cause long QT
hypocalcaemia
hypomagnesemia
hypokalaemia
73
how does hypothermia affect QT interval
hypothermia prolongs QT interval
74
list 6 drug groups that commonly cause QT prolongation
1. Erythromycin and macrolides
2. Antiarrhythmics - sotalol, amiodarone, flecainide
3. Tricyclic antidepressants (amitriptyline)
4. Antipsychotics
5. Chloroquine
6. Citalopram
75
What is the management of torsades de pointes acutely
Treat underlying cause
IV mag sulf
defibrillation if VT occurs
76
what is the difference between normal VT and torsades de pointes
normal VT is monomorphic
| Torsades is polymorphic ventricular tachycardia
77
what is the long term management of torsades
1. Beta blockers, but not sotalol
| 2. Pacemaker or implantable defibrillator
78
what are ventricular ectopics
random electrical impulse originating from outside the atria
79
how do ventricular ectopics present on ecg
individual random broad QRS on a background of normal ECG
80
what is bigeminy
ventricular ectopics happen so frequently that there is one for every normal sinus beat
81
what is first degree heart block
Delayed conduction of atrial impulse through AVN. Despite this, every atrial impulse results in a ventricular contraction.
82
How does first degree heart block present on ECG
prolonged PR interval (>0.2s) - 5 small squares/1 big square
83
What is second degree heart block mobitz type 1?
progressively prolonging PR interval until a dropped QRS occurs and the cycle restarts
84
what is second degree heart block mobitz type 2?
PR interval constant, but some atrial impulses fail to conduct, therefore occasional dropped beats occur, with no QRS.
There is usually a set ratio of impulses conducted to those not conducted, e.g. 3:1
85
how do you calculate the ratio for mobitz type 2?
how many P waves for every QRS. so if three p waves for every qrs, ratio of 3:1
86
which mobitz is associated with risk of asystole?
mobitz type 2
87
what is third degree heart block
no relationship between P and QRS - highest risk of asystole
88
which heart blocks are at risk of asystole
mobitz 2, third degree (complete)
89
what treatment for heart blocks at risk of asystole
atropine 500mcg IV
90
how would heart block present?
syncope
heart failure
regular bradycardia
91
what long term treatment for heart block
permanent pacemaker
92
what class of drug is atropine and how does it work
anti-muscarinic - inhibits the parasympathetic nervous system
93
what side effects of atropine (anti-muscarinic)
pupil dilatation
dry eyes
constipation
urinary retention
94
what causes arterial ulcers
insufficient blood supply to the skin due to peripheral artery disease
95
where do arterial ulcers usually occur
distal - toes, dorsum of foot, heel
96
what do arterial ulcers look and feel like?
small, punched out, may be necrotic/gangrenous, pale due to reduced blood supply
painful
97
describe surrounding limb in arterial ulcers
cold, hairless, pulseless
98
what is abpi in arterial ulcers
low ABPI
99
how are arterial ulcers treated
surgical revascularisation
| no beta blockers and no compression
100
how do venous ulcers present
shallow, wide area, poorly defined borders, haemosiderin staining
occur in gaiter area
more likely to bleed than arterial
less painful than arterial
101
how is pain relieved in venous ulcers
pain relieved by elevating the leg
| this is the opposite to arterial ulcers, where pain is relieved by lowering the leg
102
how are venous ulcers treated
compression therapy, analgesia - avoid NSAIDs
103
what ABPI measurement indicates PAD?
ABPI is ratio of systolic in legs to systolic in arms. ratio <1 indicates
104
what swabs if suspecting infection in foot ulcers
charcoal swabs
105
what analgesics must be avoided in venous ulcers
nsaids - can worsen condition
106
what are the three classifications of peripheral artery disease
intermittent claudication
critical limb ischaemia
acute limb-threatening ischaemia
107
what are the the risk factors for peripheral artery disease?
same as atherosclerosis - age, FH, male, smoking, HTN, hyperlipidaemia, alcohol, hyperglycaemia, obesity, sedentary lifestyle
108
how does intermittent claudication present?
leg (particularly calves) cramps when walking
predictably occurs after a certain distance of walking
better at rest
109
how does acute limb ischaemia present (6Ps)
Trophic changes - shiny, hairless shins
- Pain
- Pallour
- Pulseless
- Paraesthesia
- Paralysis
- Perishing cold
110
What sort of pain in critical limb ischaemia, and what symptoms?
Pain at rest
Ulceration
Gangrene
Burning pain, worse at night in bed with legs raised when gravity no longer helps to pull blood into lower limbs.
Pain better when dangling legs off bed
111
what assessments would you do for someone with intermittent claudication
- assess for pulses:
femoral, popliteal, posterior tibialis, dorsalis pedis
- ABPI measurement
- FIRST LINE INVESTIGATION: **duplex ultrasound**
- MR angiography prior to any interventions
112
What is the first line investigation of intermittent claudication
duplex ultrasound
113
what ABPI value suggests critical limb ischaemia?
<0.6
114
what ABPI value suggests intermittent claudication
<0.9
115
what does a high ABPI (>1.3) indicate
calcification of arteries, making them difficult to compress
| more common in diabetic patients
116
what is the management of intermittent claudication
- lifestyle changes - stop smoking, lose weight, exercise
- exercise training
- pharmacological: statin, clopidogrel, naftidrofuryl oxalate
- endovascular angioplasty + stenting
- endarterectomy
- bypass graft surgery
117
what is the management of critical limb ischaemia
Urgent referral to vascular team for revascularisation
- endovascular angioplasty + stenting
- endarterectomy
- bypass graft surgery
- limb amputation if irreversible ischaemia
118
what is the management of acute limb-threatening ischaemia
urgent referral to on-call vascular team
- endovascular thrombolysis
- endovascular thrombectomy
- surgical thrombectomy
- endovascular angioplasty
- endarterectomy
- bypass graft surgery
- limb amputation if irreversible ischaemia
119
what are the two causes of acute limb threatening ischaemia. explain the pathophys of each
thrombus: rupture of atherosclerotic plaque in previously atherosclerotic peripheral artery
embolus: originating from elsewhere eg AF
120
what factors would suggest thrombus causing acute limb ischaemia
- pre-existing claudication with sudden deterioration
- no obvious source for emboli (AF, recent MI)
- reduced/absent pulses in contralateral limb
- evidence of widespread vascular disease (MI, stroke, TIA, previous vascular surgery)
121
what factors would suggest embolus causing acute limb ischaemia
- sudden onset painful leg
- no pre-existing claudication/PAD
- present pulses in contralateral limb
- source of embolus identified - AF, recent MI
- evidence of proximal aneurysm - abdominal/popliteal
122
what analgesic for acute limb ischaemia pain
IV opiates
123
what pharmacological management for PAD
statin - atorvastatin 80
clopidogrel
naftidrofuryl oxalate - vasodilator
124
what causes leriche syndrome
occlusion of distal aorta or proximal common iliac artery
125
what is leriche syndrome triad
- buttock/thigh claudication
- absent femoral pulse
- male impotence
126
what is aortic stenosis caused by
- degenerative calcification
- bicuspid aortic valve
- william's syndrome - postvalvular aortic stenosis
- post-rheumatic disease
- subvalvular: HOCM
127
what are the symptoms of aortic stenosis
chest pain
dyspnoea
syncope/presyncope (exertional dizziness)
murmur - Ejection systolic murmur
128
what are the signs of aortic stenosis
```
narrow pulse pressure
absent S2
slow rising pulse
thrill
S4 heart sound?
```
129
what complication of aortic stenosis
left ventricular hypertrophy/failure
130
how is aortic stenosis managed
if asymptomatic, observe
if symptomatic - valve replacement
if asymptomatic with valve pressure >40mmHg - consider for surgery
131
how is aortic stenosis investigated
echocardiogram
132
where does ejection systolic murmur from aortic stenosis radiate
carotids
133
what are the two branches of causes of aortic regurgitation
aortic valve disease
| aortic root disease
134
what are the aortic valve disease causes of aortic regurgitation
rheumatic fever
infective endocarditis
connective tissue disease (SLE/RA)
bicuspid aortic valve
135
what are the aortic root disease causes of aortic regurgitation
```
aortic dissection
spondyloarthritidies (ank spond)
HTN
syphilis
Marfan's
Ehler Danlos syndrome
```
136
what are the symptoms of aortic regurg
```
exertional dyspnoea
orthopnoea
paroxysmal nocturnal dyspnoea
palpitations
angina
cyanosis if acute
```
137
what are the signs of aortic regurg
```
early diastolic murmur
collapsing pulse
wide pulse pressure
Quincke's sign (nailbed pulsation)
De Mussett's sign (headbobbing)
```
138
what is arterial thrombosis
formation of thrombus in an artery, often due to atherosclerotic plaque rupture causing thrombus formation
can also occur as a result of thrombus formation in heart, e.g. in AF
139
what is arterial embolism
when arterial thrombus travels downstream and causes blockage of artery
140
what are the complications of arterial thrombosis
```
MI
stroke
acute limb ischaemia
acute mesenteric ischaemia
hepatic artery thrombosis
```
141
what investigation for mesenteric ischaemia
bloods may show raised lactate, WCC
CT scan
angiography
142
what treatment for mesenteric ischaemia
revascularisation - thrombectomy
| if necrotic, remove dead bowel
143
explain the pathophys of heart failure briefly
impaired left ventricular contraction or left ventricular relaxation causes chronic backpressure of blood in the left ventricles
blood backs up in the left ventricle, left atrium, and pulmonary veins
144
what symptoms of HF
```
dyspnoea
cough productive of frothy white/pink sputum
orthopnoea
paroxysmal nocturnal dyspnoea
peripheral oedema
cardiac wheeze
cardiac cachexia
```
145
what signs of right sided HF
raised JVP
ankle oedema
hepatomegaly
146
what are the mechanisms behind paroxysmal nocturnal dyspnoea
1. lying flat at night - fluid settles across large surface of lungs
2. respiratory centre less responsive to hypoxia at night
3. less circulating adrenaline overnight, decreased cardiac function overnight, worse heart failure
147
what are the causes of heart failure
```
ischaemic heart disease
cardiomyopathies
valvular heart disease (aortic stenosis)
hypertension
arrhythmias (AF)
anaemia
alcohol
thyrotoxicosis
pulmonary hypertension
```
148
what is first line treatment of heart failure
ACEi and beta blocker
ramipril and bisoprolol
149
what is second line treatment of heart failure
spironolactone/eplerenone
monitor K, esp as in conjunction with ACEi (first line HF treatment)
consider ARB in afro-caribbean
150
what is third line treatment of HF
cardiac resynchronisation therapy
| digoxin
151
what NT-proBNP level warrants urgent referral to cardiology
>2000
152
what alternative loop diuretic to furosemide
bumetanide
153
which medication for HF should be avoided in valvular heart disease until seen by a specialist?
ACEi
154
briefly describe the nyha classification
class 1: no symptoms, no interference with daily activities
class 2: mild symptoms, ordinary activity results in fatigue, palpitations, dyspnoea
class 3: marked limitation in physical activity, less than ordinary activity results in symptoms
class 4: symptoms present at rest, unable to carry out any physical activity without discomfort
155
what is first line investigation of heart failure?
NT-proBNP
156
dysfunction of which organ can cause raised BNP
kidney, eGFR <60 causes raised
157
what are the actions of BNP?
vasodilator
diuretic and natriuretic
suppresses RAAS and sympathetic tone
158
explain the pathophys of cor pulmonale
1. Respiratory disease causes pulmonary hypertension.
2. Right ventricle unable to pump blood effectively to the pulmonary arteries
3. This leads to a back pressure of blood in the right atrium, the vena cava, and the systemic venous system
159
what are the most common resp causes of cor pulmonale
1. COPD
2. Interstitial lung disease
3. Cystic fibrosis
4. Pulmonary embolism
5. Primary pulmonary hypertension
160
what are the symptoms of cor pulmonale
1. breathlessness
2. peripheral oedema
3. syncope
4. chest pain
161
what signs of cor pulmonale
cyanosis
raised JVP
peripheral oedema
hepatomegaly (pulsatile if tricuspid regurg)
third heart sound
pansystolic murmur due to tricuspid regurgitation
162
what causes pulsatile hepatomegaly
tricuspid regurg
163
what type of murmur is tricuspid regurg
pansystolic
164
how is cor pulmonale treated
LTOT, poor prognosis unless reversible underlying cause
165
how does cor pulmonale present on CXR
right ventricular hypertrophy
prominent pulmonary arteries
right atrial dilation
166
what might you see on ECG of cor pulmonale
P pulmonale - characteristic peaked P wave
167
briefly explain pathophys of VTE
thrombosis formation in venous system secondary to stagnation of blood and a hypercoagulable state
168
what are the major risk factors for VTE
```
immobility
long haul flights
recent surgery
pregnancy
HRT, COCP
malignancy
polycythaemia
SLE
thrombophilia
```
169
what are the two main causes of thrombophilia
anti phospholipid syndrome
| factor V leiden
170
how does antiphospholipid present and how is it investigated
recurrent VTE, recurrent miscarriages
anti-phospholipid antibodies
171
what is used for VTE prophylaxis
LMWH eg enoxaparin
| compression stockings
172
when is VTE prophylaxis contraindicated
active bleeding
existing anticoag with warfarin/DOAC
compression stocking contraindicated in PAD
173
how does DVT present
- calf/leg swelling
- oedema
- dilated superficial veins
- colour changes
- calf tenderness
174
where should calf circumference be measured, what difference is significant
10 cm below tibial tuberosity
>3 cm is significant
175
what symptoms of PE?
shortness of breath
pleuritic chest pain
palpitations
176
how is DVT investigated
- D-Dimer to exclude (positive in preg)
| - Doppler ultrasound, if negative, repeat in 6-8 days
177
how is PE diagnosed
CTPA or V/Q scan
178
when would V/Q scan be used instead of CTPA
contrast allergy
| renal impairment
179
what treatment for DVT
rivarox/apixaban
| catheter directed thrombolysis if ileofemoral
180
what treatment for DVT if clinical suspicion but unable to get scan
treat as if DVT with rivarox/apix. treatment may be stopped once ruled out with scan
181
what long term anticoagulation for DVT/PE
DOAC
Warfarin
LMWH
182
which form of long term anticoagulation for antiphospholipid syndrome
Warfarin and initially LMWH
183
what is first line anticoagulant for DVT/PE in pregnancy
LMWH
184
how long is long term anticoagulation in provoked DVT/PE
3 months
185
how long is long term anticoagulation in unprovoked DVT/PE
6 months, same for in active cancer
186
what investigations for patients with unprovoked DVT?
cancer screen
- physical examination for evidence of cancer, baseline bloods
CT CAP if over 40
Mammogram in women >40
187
what is budd chiari syndrome
thrombosis of hepatic vein usually due to hypercoagulable states
188
what causes of budd-chiari syndrome
polycythaemia
thrombophilia
pregnancy
COCP
189
what symptoms of budd chiari
sudden onset abdo pain
tender hepatomegaly
ascites
190
how is budd chiari investigated
ultrasound with doppler flow studies
191
what are some causes of secondary HTN
```
CROP
Conn's disease (primary hyperaldosteronism)
Renal disease
Obesity
Pregnancy, pre-eclampsia
```
192
What are the complications of HTN
- IHD
- stroke
- hypertensive retinopathy
- hypertensive nephropathy
- heart failure
193
what investigations for newly diagnosed HTN
- urine albumin: creatinine ratio for proteinuria and urine dipstick for microscopic haematuria
- bloods for HbA1C, renal function, lipids
- fundus examination for retinopathy
- ECG
194
what treatment for HTN if under 55/diabetic of any age
1. ACEi
2. ACEi + CCB
3. ACEi + CCB + Diuretic
4. Add either alpha/BB or spiro depending on K levels
195
what treatment for HTN if afro-caribbean/over 55
1. CCB
2. CCB + ARB
3. CCB + ARB + diuretic
4. Add either alpha/BB or spiro depending on K levels
196
what symptoms of very raised HTN (>200/120)?
headache
seizures
visual disturbance
197
what lifestyle modifications for HTN
- low salt diet <6g/day
- reduce caffeine intake
- stop smoking, drink less alcohol, lose weight, exercise, balanced diet
198
what is HTN based on ABPM
>135/85
199
what is HTN based on clinic BP readings
>140/90
200
what BP target for >80
<150/90 - abpm less
201
what BP target for <80
<140/90 - abpm less
202
what drugs can cause secondary hyperlipidaemia
thiazides
beta blockers
oestrogens
203
what conditions can lead to hyperlipidaemia
hypothyroidism
renal failure
alcohol consumption
nephrotic syndrome
204
what risk factors for hyperlipidaemia
- diet
- age
- obesity
- physical inactivity
- genetic influence
- liver disease
- unopposed oestrogen
205
what are some complications of hyperlipidaemia
atherosclerosis - IHD, PAD
stroke
pancreatitis
cholelithiasis
206
what symptoms of hyperlipidaemia
xanthomata
| corneal arcus
207
how is hyperlipidaemia managed primary vs secondary prevention
```
primary = atorva 20mg
second = atorva 80mg
```
208
what causes of hyperCholesterolaemia
nephrotic syndrome
cholestasis
hypothyroidism
209
what are the RFs of infective endocarditis
- previous infective endocarditis
- prosthetic valves
- rheumatic heart disease
- congenital heart defects
- IVDU
- recent piercings
- poor dentition
210
what is most common microorganism implicated in infective endocarditis
staph aureus, also most common in IVDU
211
which microorganisms are implicated in poor dentition in IE
streptococcus mitis
streptococcus sanguinis
both are strep viridans
212
what microorganism most commonly causes IE in prosthetic valves
staph epidermidis (particularly <2 months)
213
which microorganism most commonly associated with colorectal cancer in IE
strep. bovis
| strep gallolyticus
214
what symptoms of infective endocarditis
fever
new heart murmur
septic emboli cause:
- splinter haemorrhages
- janeway lesions
- osler nodes
- roth spots
- glomerulonephritis
215
how is infective endocarditis investigated
blood cultures to find causative organism
| echo to visualise infected heart valves
216
how is infective endocarditis managed
antibiotics
| surgery, esp if congestive heart failure/abscess
217
how would aortic abscess present on ECG in IE
lengthening PR interval
218
what criteria for infective endocarditis
modified Duke criteria
219
what are the complications of infective endocarditis
aortic abscess formation
congestive heart failure
septic emboli
valvular incompetence
220
what is gold standard investigation for angina
CT coronary angiogram
221
what management for angina attack
GTN spray. repeat in 5 minutes
| if after 5 minutes pain still there, call an ambulance
222
what long term meds for angina
beta blocker or calcium channel blocker
statin
aspirin
ACEi
223
what second line treatment for angina
add both BB+CCB
224
what third line treatment for angina
isosorbide mononitrate
ivabradine
nicorandil
ranolazine
225
what surgical interventions for angina
PCI with coronary angioplasty
| CABG
226
how to differentiate between NSTEMI and unstable angina
unstable angina - no raised troponins, may show ST depression
NSTEMI - troponins raised + ST depressionram
227
what investigation for aortic dissection
CT aortic angiogram
228
what is third heart sound associated with
dilated cardiomyopathy
229
what murmur associated with dilated cardiomyopathy
third heart sound
230
if patient has AF with low CHADSVasc, what investigation must be performed before deciding not to anticoagulate
echo to exclude valvular heart disease - if valvular - anticoag must be given regardless of chadsvasc score
231
what grace score in nstemi indicates PCI within 72 hrs of hospital admission
>3%
232
what ecg abnormality can be caused by macrolides
long QT syndrome and torsades de pointes
233
what side effects of GTN spray
hypotension
tachycardia
headache
234
what treatment for torsades de pointes
IV magsulf
235
what drug has visual disturbance as side effect and what is it used for
ivabradine - angina third line?
236
which beta blocker causes long QT syndrome
sotalol
237
what medication must be stopped 36 hours before starting sacubitril valsartan
ACEi due to bradykinin
| ARB due to valsartan also ARB
238
if patient unable to undergo CT aortic angiography for aortic dissection what investigation
transoesophageal echo
239
which anti-anginal causes ulceration in GI tract
nicorandil
240
what arrest rhythm can be caused by tension pneumothorax
pulseless electrical activity
241
what is kussmaul's sign and what has it to do with constrictive pericarditis
JVP rises on inspiration
242
where does furosemide work
ascending loop of henle
243
what murmur is associated with heart failure (left sided)
third heart sound
244
why are CCBs contraindicated in HF, and which is the only CCB licensed for used in HF
CCBs exacerbate heart failure symptoms
Amlodipine is licensed for use in HF
245
if someone has stage 4 ckd, what investigation for PE
V/Q scan
246
what is the most common mitral valve disease?
mitral regurgitation
247
explain the pathophysiology behind mitral regurgitation
blood leaks back to left atrium through mitral valve during systole. this means that less blood is pumped to the body with each contraction.
over time, this can lead to left ventricular myocardial thickening. eventually, the left ventricle become less efficient, and heart failure develops
248
what are the RFs for mitral regurg
- mitral stenosis/prolapse
- female sex
- connective tissue disease
- previous MI
- infective endocarditis
- rheumatic fever
- age
- renal dysfunction
- low BMI
249
how does MI cause mitral regurg
if papillary muscles/cordae tendiniae are affected in an MI, this causes mitral valve disease as a result of damage to its supporting structures
250
how does infective endocarditis cause mitral regurg
vegetations growing on the valve prevent valve from closing fully
251
how does rheumatic fever cause mitral regurg
inflammation of valve
252
what symptoms of mitral regurg
asymptomatic until heart failure develops, then HF symptoms:
- dyspnoea
- oedema
- fatigue
253
what murmur for mitral regurg. describe s1 and s2 in mitral regurg
pansystolic blowing murmur heard at apex and radiating to axilla
quiet S1 and widely split S2
254
What ecg findings for mitral regurg
broad P wave due to atrial enlargement
255
what CXR findings for mitral regurg
cardiomegaly as enlarged L atrium and L ventricle
256
what gold standard investigation for mitral regurg
echo
257
what is medical management of mitral regurg in acute cases
nitrates
diuretics
positive inotropes
intra-aortic balloon pump
258
what treatment of HF associated with MRegurg
same as normal HF
| ACEi, BB, spironolactone
259
what treatment if acute severe MRegurg
surgery - repair or replacement with prosthetic/pig
260
explain the pathophys of mitral stenosis
obstruction of blood flow across the mitral valve from left atrium to left ventricle
increased pressure in left atria, pulmonary vasculature, and right side of the heart
261
what is the most common cause of mitral stenosis and what are some other causes
rheumatic fever is most common cause
- mucopolysaccharidoses
- endocardial fibroelastoses
- carcinoid
262
what would you hear on auscultation of mitral stenosis
mid-late diastolic murmur
| loud s1 opening snap
263
what signs of mitral stenosis
malar flush
atrial fibrillation
low volume pulse
264
what are the features of severe mitral stenosis
length of murmur increases
| opening snap becomes closer to S2
265
what investigations of mitral stenosis
CXR - atrial enlargement
| echo
266
what management of mitral stenosis for:
AF
asymptomatic
symptomatic
if AF - requires anticoag regardless of chadsvasc, wafarin
asymptomatic - monitor
symptomatic - percutaneous balloon mitral valvotomy, mitral valve surgery
267
What are the complications of MI darth vader
DARTH VADER
```
Death
Arrhythmia
Rupture - free ventricular wall, septum, pap muscles
Tamponade
Heart failure (both acute and chronic)
```
```
Valve disease
Aneurysm of ventricle
Dressler's syndrome
Embolism (thrombo)
Recurrence / Mitral Regurgitation
```
268
what are the other complications of MI (not darthvader)
- cardiac arrest due to ventricular fibrillation
- cardiogenic shock
- AVN block following inferior MI
- pericarditis
269
what is beck's triad of acute cardiac tamponade NOT PERICARDITIS
- hypotension
- raised JVP
- muffled heart sounds
other signs:
pulsus paradoxus
kussmaul's sign
270
what ecg finding in tamponade
electrical alternans - variable QRS amplitude
271
how does dressler syndrome present
fever
| pericarditis pain
272
list some causes of myocarditis
viral: coxsackie, HIV
bacterial: diphtheria, clostridia
autoimmune
spirochaetes - lyme disease
protozoa - chagas disease, toxoplasmosis
drugs - doxorubicin
273
how does myocarditis present
chest pain - acute history
dyspnoea
palpitations
arrhythmias
274
what investigations for myocarditis
RAISED:
inflammatory markers
cardiac enzymes
BNP
ECG:
tachycardia
arrhythmia
ST elevation, T wave inversion
275
how is myocarditis managed
treat underlying cause - Abx if bacterial
| supportive - treat arrhythmias, HF
276
what are the complications of myocarditis
arrhythmias - lead to sudden death
heart failure
dilated cardiomyopathy
277
how does pericarditis present?
- chest pain relieved on sitting forward, may be pleuritic
- dyspnoea, non-productive cough
- pericardial friction rub
- tachypnoea
- tachycardia
278
list some causes of pericarditis
```
viral - coxsackie
TB
uraemia
trauma
post-MI
connective tissue disease
hypothyroidism
malignancy
```
279
what are the ECG changes for pericarditis
PR depression
| saddle shaped ST elevation
280
What investigation aside from ECG should all patients with pericarditis get?
Transthoracic echo
281
how is pericarditis managed
NSAIDs and colchicine
| treat underlying cause
282
what can cause constrictive pericarditis
any cause of pericarditis, but especially TB
283
how does constrictive pericarditis present
- dyspnoea
- right heart failure
- raised JVP
- oedema
- hepatomegaly
- kussmaul's sign
- pericardial knock - S3 loud
284
how would constrictive pericarditis appear on cxr
pericardial calcification
285
how does cardiac tamponade typically present - triad
beck's triad
- muffled heart sounds
- hypotension
- raised JVP
286
what are some other features of cardiac tamponade aside from beck's triad
kussmaul's sign
pulsus paradoxus
dyspnoea
tachycardia
287
what ECG finding of cardiac tamponade
electrical alternans
288
how is cardiac tamponade managed
urgent pericardiocentesis
289
which valve is most commonly affected with infective endocarditis in IVDU
tricuspid
290
AF and heart failure. what do you do
synchronised DC cardioversion
291
what effect may beta blockers have on peripheries
cold peripheries. especially bisoprolol NOT atenolol
292
what is most common cause of death following MI
ventricular fibrillation
293
what is the difference between aortic sclerosis and stenosis
sclerosis is thickening and calcification of valve without actually affecting function
ejection systolic murmur would be present but not radiate to carotids
294
how would left ventricular aneurysm present after an MI
blood stagnates in left ventricle - clotting - embolus forms - can present as stroke
295
which valve problem is associated with narrow pulse pressure
aortic stenosis
296
what cardioversion in AF
amiodarone if structural abnormality
| flecainide if no structural abnormality
297
how long must patient be anticoagulated for to receive cardioversion in AF
3 weeks
298
how to decide between electrical or pharma cardioversion for AF
if AF has persisted for more than 48 hours - electrical cardioversion
299
how to differentiate between constrictive pericarditis and cardiac tamponade
kussmaul's sign - constrictive pericarditis (JVP rises on inspiration)
300
what drugs should be avoided in HOCM with left ventricular outflow obstruction
ACEi - they can reduce afterload and thus reduce the LVOT gradient idk
301
what target INR for VTE despite taking warfarin
3-4
302
how would atrial myxoma present
benign tumour commonly in left atrium
presents with triad:
- mitral valve obstruction
- systemic embolisation
- constitutional symptoms - weight loss, fever, dyspnoea
303
what would you see on echo of atrial myxoma
pedunculated heterogeneous mass in left atrium
304
how would posterior MI present
tall R waves in V1 and V2
305
what is mechanism of action of fondaparinux
activates antithrombin III
306
when to discontinue treatment with statin if hepatic dysfunction
if enzymes over 3x upper limit of normal
307
what condition would result in an absent limb pulse
takayasu arteritis - large vessel vasculitis
308
what class of drug are statins and how do they work?
HMG-CoA reductase inhibitor
inhibit intrinsic cholesterol synthesis
309
what to do if acute heart failure not responding to treatment with IV furosemide
CPAP
310
what heart sounds are associated with HOCM and DCM
DCM - S3
| HOCM - S4
311
what is mechanism of action of alteplase
activates plasminogen to form plasmin
312
what condition would cause severe worsening of renal function when starting an ACEi
bilateral renal artery stenosis
313
which murmurs are louder on inspiration/exhalation
RILE
Right sided louder on Inspiration
Left sided louder on Expiration
314
what side effect of indapamide
erectile dysfunction
315
what drugs are contraindicated in hypotension in ACS
nitrates
316
what antiplatelets for conservative management of NSTEMI
aspirin + either
clopidogrel if high risk
ticagrelor if low risk
317
how is amiodaron administered
into a central vein to reduce the risk of thrombophlebitis
318
when should warfarin be stopped before surgery
5 days
319
when should heparin be stopped before surgery
6-12 hours before
320
what sort of sputum can mitral stenosis cause and why
haemoptysis - rupture of bronchial veins caused by left atrial pressure
321
what are the CXR findings of HF
```
ABCDE
Alveolar oedema
Kerley B lines
Cardiomegaly
Dilated upper lobe vessels
Pleural Effusion
```
