Cardiology Flashcards
(120 cards)
1
Q
What are the cardiac differentials for chest pain?
A
- ACS
- Stable angina
- Aortic dissection
- Pericarditis
- Myocarditis
- Cardiac tamponade
- Mitral valve prolapse
- Pulmonary hypertension
- Aortic stenosis
- Arrhythmias
2
Q
What investigations do you want to do for chest pain?
A
- Vital signs
- ECG
- Bloods = FBC, U&E, LFT, clotting screen, troponin ± D dimer, cholesterol, glucose/HbA1c
- CXR
- ABG if hypoxic/PE suspected
3
Q
What are the risk factors for cardiovascular disease?
A
- Race
- Family history
- Overweight/obese and sedentary lifestyle
- Smoking
- Alcohol
- Diabetes, hypertension, hyperlipidaemia
- Stress
Male
4
Q
What are the secondary causes of hypertension?
A
o Renal disease (CKD) from Diabetes
o Pregnancy/pre-eclampsia
o Endocrine causes = Cushing’s, Conn’s, Pheochromocytoma, acromegaly
o Drug therapy = Corticosteroids, cyclosporin, erythropoietin, contraceptive pill, Alcohol, amphetamines, ecstasy and cocaine
o Coarctation of aorta
5
Q
How does hypertension present?
A
- Often asymptomatic = found on screening
- Symptomatic if BP very high = Headaches, Visual disturbance, Seizures
6
Q
What is the Gold Standard investigation to diagnose hypertension?
A
24 hour ambulatory BP monitoring
7
Q
What is the conservative management for hypertension?
A
- Change diet = more fruit and veg, low fat, low salt
- Regular physical exercise
- Reduce alcohol intake
- Lose weight
- Stop smoking
- Stress management
8
Q
What is the first line pharmacological management for hypertension?
A
If under 55 or diabetic = ACEi
If over 55 or black = CCB
If diabetic and black = ARB
9
Q
What is the second line management of hypertension?
A
Add ACEi/ARB or CCB or thiazide-like diuretic (indapamide)
10
Q
How will potassium levels affect the third line treatment of hypertension?
A
- If K+ <4.5 add low-dose spironolactone
- If K+ >4.5 add alpha or beta blocker
11
Q
What are the possible complications of hypertension?
A
- Cardiac = CVD/IHD, MI, CCF, aortic and mitral regurg
- Aortic = aneurysm, dissection
- Renal = proteinuria, chronic renal failure
- Neurological = ischaemic CVA, haemorrhagic CVA, vascular dementia, encephalopathy
- Atherosclerosis = Premature + peripheral vascular disease
- GIT = N+V
- Eyes = retinopathy
- Malignant hypertension
12
Q
What are the subtypes of acute coronary syndrome?
A
- STEMI = Complete occlusion of major coronary artery previously affected by atherosclerosis
- Unstable angina = Angina of recent onset or cardiac chest pain with crescendo pattern
- NSTEMI = Developing complete occlusion of minor or partial occlusion of major coronary artery previously affected by atherosclerosis. No raised troponin
13
Q
How can ACS present?
A
- Acute central chest pain lasting >20 mins May radiate to jaw or left arm
- Sweating
- Nausea and vomiting
- Dyspnoea
- Fatigue
- Palpitations
- Distress and anxiety
- Pallor
- Reduced BP
- Tachy/bradycardia
14
Q
What investigations should you do in ACS?
A
ECG
Troponin (T+I) = Serum levels increase within 3-12 hours from onset of chest pain and peak at 24-48 hours
o If raised repeat in 3h
o If not raised can rule out MI unless pain was <6hrs ago
o If not raised could be unstable angina
15
Q
What will an ECG show in ACS
A
ST elevation/depression + T wave inversion/ Hyperacute (tall) T waves
16
Q
Initial management of ACS
A
Morphine (IV) given if needed but can delay absorption of antiplatelets
Oxygen if sats below 94%
Nitrate unless hypotensive
Aspirin 300mg STAT
17
Q
What is the definitive management of a STEMI?
A
PCI Within 120 mins
- Give praugrel
Fibrinolysis within 12 hrs of symptom onset if primary PCI cannot be delivered within 120min
18
Q
What is the definitive management of a NSTEMI/ unstable angina?
A
Fondaparinux if no immediate PCI planned
Estimate 6-month mortality with GRACE score
Low risk = give ticagrelor
High risk = PCI within 72 hrs if stable or immediate if unstable. Give prasugrel/ticagrelor + unfractioned heparin
19
Q
What is the secondary prevention of ACS?
A
- Dual antiplatelet therapy: aspirin + Ticagrelor (clopidogrel 2nd line) for 1 year
- Statins (atorvastatin) lifelong
- Beta blockers (Atenolol)
- ACE inhibitors (ramipril)/ ARB
- Diuretic (furosemide) = Heart failure
- Risk factor modification Stop smoking, Lose weight, exercise daily, Healthy diet
- Cardiac rehabilitation programme
- Don’t drive for 1 week if PCI or 4 weeks if no PCI
- 6 weeks off work
20
Q
What are the complications of ACS?
A
- Sudden death (few hours) = ventricular fibrillation
- Arrhythmias (first few days) = VF, AV block
- Persistent pain (12 hrs-few days)
- Heart failure
- Mitral incompetence (few days-later)
- Pericarditis within 48 hrs, Dressler’s syndrome 2-6wks
- Cardiac rupture
- Ventricular aneurysm
- Left ventricular free wall rupture
- Ventricular septal defect
21
Q
If there are ECG changes in leads V1-V4 what artery is affected?
A
Left anterior descending
22
Q
If there are ECG changes in leads II, III, aVF what artery is affected?
A
Right coronary
23
Q
If there are ECG changes in leads I, V5-6 what artery is affected?
A
Left circumflex
24
Q
How does stable angina present?
A
Central chest pain or discomfort = tightness or heaviness
o Provoked by exertion, esp after meal or in cold windy weather or by anger/excitement
o Relieved by rest or GTN spray
o Pain may radiate to one or both arms, neck, jaw or teeth
Nausea, sweatiness
Dyspnoea
Palpitations
Syncope
25
What investigations can be done for angina?
- CT Coronary Angiography
- 12 lead ECG = ST depression?, flat/inverted T waves, past MI
- Treadmill test/Exercise tolerance test + ECG
o If ST depression = sign of late-stage ischaemia
26
What is the management of stable angina?
Modify RF = Stop smoking, Encourage exercise, Weight loss
All patients should take Aspirin and statin
ST symptomatic relief = GTN spray
LT symptomatic relief = Betablockers (bisoprolol) or CCB
Verapamil or diltiazem if CCB monotherapy
Amlodipine or MR nifedipine if combination
Revascularisation = PCI or CABG if failed in 2 antianginals
27
What are the causes of heart failure?
- Ischaemic Heart disease
- Cardiomyopathy
- Hypertension
- Valvular heart disease
- Cor pulmonale (COPD)
- Alcohol excess
- Endocardial and pericardial cases
- Any factor that increases myocardial work = anaemia, arrhythmias, hyperthyroidism, pregnancy, obesity
28
How does heart failure present?
- Dyspnoea when lying flat = orthopnoea
- Paroxysmal nocturnal dyspnoea
- Cough with pink/white frothy sputum Worse at night
- Cardiac wheeze
- Cardiac cachexia (weight loss)
- Bibasal coarse crackles
- Fatigue
- Ankle oedema
- Cold peripheries
- Raised JVP
- Hepatomegaly
- Pansystolic murmur mitral regurg
29
What investigations can be done for heart failure?
- BNP raised
- CXR
- Echocardiography = regional wall motion abnormalities, valvular disease, cardiomyopathies, sign of MI, cardiac chamber distension
- ECG = ischaemia, LV hypertrophy in hypertension or arrhythmia as underlying causes
30
What is shown on a chest XR of someone with heart failure
Alveolar oedema, curly B lines, Cardiomegaly, Dilated upper lobe vessels of lungs, pleural Effusions
31
What classification can be used to stage heart failure?
New York heart classification
1. no symptoms, no limitation
2. mild symptoms, slight limit of physical activity
3. moderate symptoms, marked limitation of physical activity
4. severe symptoms, unable to carry out physical activity without discomfort
32
What vaccines does someone with heart failure need?
Annual influenza vaccine and one off pneumococcal vaccine
33
Pharmacological treatment of heart failure
Take all 4 of: ACEi, BB, spironolactone, SGLT-2 inhibitor
All patients on aspirin and statin if ischaemic
34
What surgical options for heart failure are there?
o Cardiac resynchronisation therapy +/- defibrillator
o Revascularisation = PCI stenting
o Repair surgery = aortic/mitral valve repair/replace, LV re-modelling
o Heart transplant
35
What are the complications of heart failure?
- Renal dysfunction
- Rhythm disturbances = AF, AfI, VT, VF, LBBB, bradycardia
- Systemic thromboembolism DVT and PEs
- Hepatic dysfunction
- Neurological and psychological complications
36
What is acute pericarditis?
Acute inflammation of pericardium with or without effusion lasting less than 4-6 wks
37
What are the possible causes of pericarditis?
- Viral = EBV, adenoviruses, mumps, varicella, HIV, echovirus
- Bacterial = TB, lyme disease, pneumonia, rheumatic fever
- Fungal = histoplasma. Spp
- Autoimmune = Sjogren’s syndrome, RA, SLE
- Neoplastic = secondary metastatic tumours (lung/breast, lymphoma), Dressler’s syndrome
- Metabolic = uraemia, myxoedema, hypothyroidism, anorexia nervosa
- Traumatic/iatrogenic = pericardial injury syndromes
- Drugs = procainamide, hydralazine, penicillin, chemo
- Other = amyloidosis, aortic dissection, malignancy, MI, radiotherapy
38
How does acute pericarditis present?
- Sudden pleuritic chest pain, Worse on inspiration or lying flat = relieved by sitting forward, Radiates to arm
- Dyspnoea
- Non-productive Cough
- Fever
- Hiccups = phrenic involvement
- Skin rash
- Joint pain
- Eye Symptoms
- Weight loss
- Flu-like symptoms
39
What can be heard on auscultation in acute pericarditis?
Pericardial friction rub
40
What is beck's triad?
Hypotension
Elevated JVP
Quiet heart sounds
41
What can be seen on an ECG in acute pericarditis?
Widespread concave-upwards (Saddle-shaped ST elevation)
PR depression
42
What investigation must be done in suspected acute pericarditis?
Transthoracic echo
43
What is the management of acute pericarditis?
Can be managed as outpatient but if temp >38 or elevated trop then admit
Restrict physical activity until resolution of symptoms and see improvement in ECG and CRP
Acute idiopathic or viral pericarditis give NSAID and colchicine
44
What is a pericardial effusion?
Collection of fluid within potential space of serous pericardial sac (10-50ml)
45
What can cause a pericardial effusion?
- Pericarditis
- Myocardial rupture
- Aortic dissection
- Pericardium filling with pus
- Malignancy
46
How does a pericardial effusion present?
- Dyspnoea
- Chest pain
- Hiccups = compressed phrenic nerve
- Nausea = compressed diaphragm
- Soft and distant heart sounds
- Apex beat obscured
- Raised JVP
- Ewart’s sign = bronchial breathing at left base due to compressed L lower lobe
47
What are the investigations for pericardial effusion?
- CXR = Large globular heart if effusion >300ml
- ECG = Low-voltage QRS complexes, Sinus tachycardia
- Echocardiogram = Echo-free zone surrounding heart
- Pericardial fluid = culture and cytology, ZN stain/TB culture
48
What is the management for a pericardial effusion?
- Find and treat underlying cause if possible
- Most pericardial effusions resolve spontaneously
- May re-accumulate most often due to malignancy
- Require pericardial fenestration = window in pericardium created to allow slow release of fluid into surrounding tissues
49
What is cardiac tamponade?
Pericardial effusion that raises intrapericardial pressure, reducing ventricular filling and dropping cardiac output
50
How does cardiac tamponade present?
- Beck’s triad = falling BP, rising JVP, muffled heart sounds (1 and 2)
- Dyspnoea
- Tachycardia
- Kussmaul’s sign = rise to JVP and increased neck vein distension during inspiration
- Pulsus paradoxus = exaggeration in normal variation in pulse pressure seen with inspiration
51
Investigations for cardiac tamponade?
- CXR = Big globular heart
- ECG = Low voltage QRS +/- electrical alternans
- Echocardiogram = Echo-free zone around heart
o Late diastolic collapse of RA
o Early diastolic collapse of RV
52
Management for cardiac tamponade
- Keep heart = Fast, full and strong
- Require urgent drainage via pericardiocentesis
- Send fluid for culture, Ziehl-Nielsen stain and cytology
53
What is constrictive pericarditis?
Pericardium becomes so inelastic it interferes with diastolic filling of heart
54
Risk factors for abdominal aortic aneurysm
- FHx
- Severe atherosclerotic damage
- Tobacco smoking
- Hypertension
- COPD
- Trauma
- Hyperlipidaemia
- Ehlers Danlos type 1
- Marfan’s syndrome
55
Presentation of AAA
- Can be asymptomatic if unruptured
- Pain in abdomen, back, loin or groin (radiates to back, iliac fossa or groin)
- Pulsatile abdominal swelling
- Rupture collapse, hypotension, tachycardia, profound anaemia, sudden death
56
Investigation of AAA
Abdo US
57
Screening for AAA
All men aged 65 offered single abdo US
58
Aortic dissection Risk factors
- Hypertension
- Trauma = shearing stresses in road traffic accident
- Bicuspid aortic valve
- Marfan’s syndrome, Ehlers-Danlos syndrome
- Turner’s and Noonan’s syndrome
- Pregnancy
- Syphilis
59
Presentation of aortic dissection
- Sudden onset of severe and central tearing chest pain
Pain radiates to back and down arms
Pain maximal from time of onset
- Hypertension
- Peripheral pulses may be absent
- Variation in systolic blood pressure between arms
- Paraplegia
- Limb ischaemia
60
Red Flags for aortic dissection
o Tearing pain radiating to back
o Differing BPs/pulses between limbs
o Pain refractory to morphine
o Evidence of aortic regurgitation
o Known dilated aorta or evidence on CXR
o Evidence of right coronary occlusion (inferior ECG changes
o Subcutaneous bruising
61
Stanford classification of aortic dissection
o Type A = ascending aorta
o Type B = descending aorta, distal to let subclavian origin
62
DeBakey classification of aortic dissection
o Type 1 = originates in ascending aorta, propagates to at least aortic arch and possibly beyond
o Type 2 = originates in and confirmed to ascending aorta
o Type 3 = originates in descending aorta, rarely extends proximally but extends distally
63
Investigations of aortic dissection
- Transoesophageal echocardiography/MRI for unstable patients
- CXR = Widened mediastinum
- Urgent CT angiography of chest, abdo, pelvis
64
Management of aortic dissection
- Urgent antihypertensive medication (if hypertensive) BB (IV metoprolol) or vasodilators (IV GTN)
- Adequate analgesia (morphine)
- Surgery to replace aortic arch if Type A
- Endovascular intervention with stents
65
Complications of aortic dissection
- Aortic regurgitation
- Coronary ischaemia
- Cardiac tamponade
- Acute kidney failure
- Acute lower limb ischaemia
66
Normal ECG variants
- Sinus bradycardia
- Junctional escape rhythm
- First degree heart block
- Mobitz type 1 (Wenckebach phenomenon)
- Right axis deviation in tall thin individuals
- Left axis deviation in short, obese individuals
67
Differentials for ST elevation
- Myocardial infarction
- Pericarditis/myocarditis
- Normal variant high take-off
- Takotsubo cardiomyopathy (Broken heart syndrome)
- Left ventricular aneurysm
- Prinzmetal angina
- Subarachnoid haemorrhage (rare)
68
Causes of Atrial Fibrillation
- Alcohol
- Thyrotoxicosis
- Rheumatic heart disease (mitral stenosis/regurg)
- Ischaemia (MI)
- Atrial myoxoma
- Lung (PE, emphysema, lung cancer)
- Failure of the heart
- Infection (Sepsis)
- Blood pressure (Hypertension)
- Diabetes
69
Presentation of atrial fibrillation
- May be asymptomatic (especially if elderly)
- Palpitations
- Dyspnoea and/or chest pains
- Fatigue
- Syncope
- Apical pulse rate is greater than radial rate
- 1st heart sound is variable intensity
- Tachycardia
- Heart failure
70
ECG findings of AF
Absent P waves, narrow QRS complex, irregularly irregular ventricular rhythm
71
Management of unstable AF
Cardioversion and amiodarone
72
Management of stable AF
Rate and rhythm control
o If <48 hrs: rate or rhythm control
o If >48 hrs or uncertain: rate control
1st line Rate control = bisoprolol
2nd line verapamil
3rd line Digoxin
Rhythm control = amiodarone/flecanide
73
CHA2DS2-VaSc score
Risk of stroke/TIA in someone with AF
o Congestive heart failure
o Hypertension
o Age>75 (2 points) 65-74 (1 point)
o Diabetes
o Stroke/TIA previously (2 points)
o Vascular disease
o Sex (female)
74
ORBIT score
Bleeding risk
Hb <130 for males, or <120 for female
o Age >74
o Bleeding history
o Renal impairment
o Treatment with antiplatelet agents
75
Complications of AF
- Stroke
- Myocardial infarction
- Congestive cardiac failure
- Cardiac tamponade
- Pulmonary vein stenosis
- Amiodarone = hypo/hyperthyroidism, corneal deposits, liver fibrosis, pulmonary fibrosis, peripheral neuropathy, slate-grey appearance, bradycardia, QTc prolongation
76
ECG of atrial flutter
o Regular atrial flutter (F) waves between QRS complexes (continuous atrial depolarisation)
o Sawtooth baseline
o Atrial rate = 300bpm
77
Management of atrial flutter
- Electrical cardioversion but anticoagulated before
- Catheter ablation = Conduction block to try and restore rhythm and block offending re-entrant wave
- IV amiodarone to restore sinus rhythm
- BB (propranolol) to suppress further arrhythmias
78
First degree AV block
Every atrial depolarisation is followed by conduction to ventricles but with delay
Prolongation of PR interval > 0.22s
No treatment required
79
Causes of 1st degree AV block
hypokalaemia, myocarditis, inferior MI, BB, CCB, digoxin
80
2nd degree AV block
o Mobitz I = Progressive PR interval prolongation until beat is ‘dropped’ and p wave fails to conduct
o Mobitz II = PR interval is constant and QRS interval is dropped
81
Treatment of 2nd degree AV block
Treatment
o Mobitz I = only requires pacemaker if poorly tolerated
o Mobitz II = high risk of developing sudden complete AV block pacemaker
82
Causes of 2nd degree AV block
acute MI, AVN blocking drugs, SLE, Lyme disease
83
3rd degree AV block
o Complete heart block occurs when all atrial activity fails to conduct to ventricles
o Ventricular contractions are sustained by spontaneous escape rhythm which originates below block
84
Causes of 3rd degree AV block
structural heart disease, ischaemic heart disease, hypertension, endocarditis
85
ECG of 3rd degree AV block
P waves completely independent of QRS complex
86
Management of 3rd degree AV block
o Narrow-complex escape rhythm = IV atropine pacemaker
o Broad-complex escape rhythm = Permanent pacemaker
87
Management of Ventricular Tachycardia
- Immediate cardioversion if adverse signs (systolic BP <90, chest pain, heart failure)
- Absence of adverse signs use antiarrhytmics
o Amiodarone
o Licocaine
o Procainamide
- If antiarrhytmics fail, electrical cardioversion with synchronised DC shocks
- Alternatives to drug: electrophysiological study, implantable cardioverter-defibrillator
88
ECG of RBBB
o Deep s wave in leads I and V6
o Tall late R wave in lead V1
o Looks like marrow = QRS looks like M in lead V1 and W in V5/6
o Causes wide physiological splitting of 2nd heart sound
89
ECG of LBBB
o deep S wave in lead V1
o Tall late R wave in leads I and V6
o Abnormal Q waves
o Looks like William = QRS looks like W in leads V1/2 and M in V4-6
o Causes reverse splitting of 2nd heart sound
90
AVNRT ECG
o Sometimes in QRS complexes will show typical BBB
o P waves not visible or seen immediately before/after QRS complex = due to simultaneous atrial and ventricular activation
91
Management of AVNRT
- ABCDE
- If haemodynamically unstable sedate and DC cardioversion
- Carotid massage
- Valsalva manoueve
- IV 6mg Adenosine bolus
92
Associations of Wolff-Parkinson-White syndrome
- HOCM
- Mitral valve prolapse
- Ebstein’s anomaly
- Thyrotoxicosis
- Secundum ASD
93
ECG of WPW syndrome
o Pre-excitation = Short PR interval
o Wide QRS complex that begins as slurred part known as delta wave
o Left axis deviation if right-sided accessory pathway
o Right axis deviation if left-sided accessory pathway
94
Management of WPW syndrome
- Radiofrequency ablation of accessory pathway
- Sotalol, amiodarone, flecainide
- Emergency cardioversion
o Patients with haemodynamic instability (hypotension and pulmonary oedema)
- If stable, then vagal manoeuvres
o Breath-holding
o Carotid massage
o Valsalva manoeuvre = abrupt voluntary increase in intra-abdominal and intrathoracic pressure by straining
95
Drugs that cause prolonged QT syndrome
o Amiodarone and
o tricyclic antidepressants (amitriptyline)
o antipsychotics
o chloroquine
o terfenadine
o erythromycin
96
Management of prolonged QT syndrome
- Treat underlying cause
- If acquired long QT then give IV isoprenaline = contraindicated for congenital long QT
- IV magnesium sulphate
97
Causes of aortic stenosis
- Idiopathic age-related calcification
- Rheumatic Heart disease
- Congenital bicuspid aortic valve (BAV) predominant in males
- William’s syndrome
- Subvalvular: HOCM
98
Examination findings in aortic stenosis
- High pitched ejection systolic murmur
o crescendo-decrescendo character
o Murmur radiates to carotids
o Murmur decreased following Valsalva manoeuvre
99
Examination findings in severe disease of aortic stenosis
o Slow rising carotid pulse and
o narrow pulse pressure
o Soft or absent 2nd heart sound
o Prominent 4th heart sound = left ventricular hypertrophy
o Thrill
o Left ventricular hypertrophy or failure
o Delayed ESM
100
Investigations of aortic stenosis
Echo
ECG
CXR
101
Management of aortic stenosis
- If asymptomatic then observe
- Surgical aortic valve replacement
- Transcutaneous Aortic Valve Implantation (TAVI)
- Balloon valvuloplasty
- Rigorous dental hygiene/care
102
Causes of aortic regurg
Acute
o Infective endocarditis
o Aortic dissection
Chronic
o Congenital bicuspid aortic valve
o Rheumatic fever
o Connective tissue disorders = SLE, Marfan syndrome, Ehlers-Danlos syndrome
o Calcific valve disease
o Spondylarthropathies
o Hypertension
o Syphilis
o Idiopathic age-related weakness
103
Presentation of aortic regurg
- May be asymptomatic for many years before symptoms develop
- Exertional dyspnoea
- Palpitations
- Angina
- Syncope
- Wide pulse pressure
- Apex beat displaced laterally
- Early diastolic soft blowing murmur at left sternal border (‘Austin-Flint murmur)
- Collapsing pulse (Corrigan’s pulse)
- Quincke’s sign = capillary pulsation in nail beds
- De Musset’s sign = head nodding with each heartbeat
- Pistol shot femoral = sharp bang heard on auscultation
104
Management of aortic regurg
- Consider infective endocarditis prophylaxis
- Vasodilators = ACE-inhibitors (ramipril)
o Only if patient is symptomatic or has hypertension
- Surgery for valve replacement (if worsening)
o Symptomatic patients with severe AR
o Asymptomatic patients with severe AR who have LV systolic dysfunction
105
Risk factors for mitral regurg
Lower BMI
Renal dysfunction
Prior MI
Infective endocarditis
Rheumatic heart disease
Connective tissue disorders
106
What murmur is found in mitral regurg
High pitched pan systolic whistling murmur at apex radiating to axilla
107
Management of mitral regurg
- Vasodilators = ACE-inhibitors (Ramipril or hydralazine)
- Beta-blockers (atenolol), CCBs, digoxin = Heart rate control for AF
- Anticoagulation in AF and atrial flutter
- Diuretics for fluid overload = furosemide
- Serial echocardiography
- Surgical valve replacement
108
Murmur for mitral stenosis
Low pitched mid-diastolic rumbling murmur
109
Management of mitral stenosis
- Warfarin
- BB (bisoprolol) and digoxin = control HR, improved diastolic filling
- Diuretics (furosemide) = fluid overload
- Asymptomatic = monitor with regular echo
- Symptomatic:
o Percutaneous mitral balloon valveotomy
o Mitral valve replacement
110
Presentation of lower limb ischaemia
- Cramping induced by exercise and relieved by rest
- Pain distal to atheroma
- Pulselessness = Absent femoral, popliteal or foot pulses
- Pallor
- Perishingly cold
- Paraesthesia
- Paralysis
111
Investigations of lower limb ischaemia
1st line = colour duplex US
Severity indicated be ankle/brachial pressure index
MRI/CT angiography to assess extent and location of stenoses
112
Management of lower limb ischaemia
- Exercise training
- Atorvastatin and Clopidogrel
- Peripheral vasodilator (Naftidrofuryl oxalate)
- Cilostazol (phosphodiesterase III inhibitor)
- Surgery = angioplasty and stenting
- Critical limb ischaemia
o Analgesia
o Urgent revascularisation = angioplasty and stenting, bypass surgery
- Amputation
113
What is the most common cause of sudden cardiac death in the young?
Hypertrophic cardiomyopathy
114
How does hypertrophic cardiomyopathy present?
- Often asymptomatic
- Exertional dyspnoea
- Angina
- Syncope (Typically following exercise)
- Palpitations
- Dizziness
- Sudden death = may be first manifestation
- Ejection systolic murmur or pansystolic murmur
- Jerky carotid pulse
- Large a waves
- Double apex beat
115
What conditions is hypertrophic cardiomyopathy associated with?
Friedreich's ataxia
Wolff-Parkinson White
116
Management of hypertrophic cardiomyopathy
- Amiodarone
- Beta-blocker or verapamil
- Cardioverter defibrillator
- Dual chamber pacemaker
- Endocarditis prophylaxis
- Avoid nitrates, ACEi, inotropes
117
What is the most common cardiomyopathy?
Dilated cardiomyopathy
118
Risk factors of cardiomyopathy
- Family history of cardiomyopathy (autosomal dominant)
- High BP
- Obesity
- Diabetes
- Previous MI
- Ischaemia
- Alcohol
- Thyroid disorder
119
Presentation of dilated cardiomyopathy
- Shortness of breath at first and fatigue
- Dyspnoea
- Sudden death
- Increased jugular venous pressure
120
Presentation of restricted cardiomyopathy
- Dyspnoea
- Fatigue
- Embolic symptoms
- Elevated jugular venous pressure with diastolic collapse
o Elevation of venous pressure with inspiration
- Hepatic enlargement
- Ascites
- Dependent oedema
- 3rd and 4th heart sounds
