Cardiology Flashcards
(191 cards)
1
Q
What is atherosclerosis?
A
Combination of atheromas (fatty deposits in artery walls) and sclerosis (hardening / stiffening of blood vessel walls)
2
Q
Which arteries does atherosclerosis affect?
A
Medium and large arteries
3
Q
What is atherosclerosis caused by?
A
Chronic inflammation and activation of immune system in artery wall (causes deposition of lipids in artery wall followed by development of fibrous atheromatous plaques)
4
Q
What is the result of atheromatous plaques?
A
Stiffening of artery wall leading to hypertension (raised blood pressure) and strain on the heart
Stenosis = reduced blood flow - angina
Plaque rupture giving off thrombus blocking distal vessel leading to ischaemia
5
Q
What are some non-modifiable risk factors for atherosclerosis?
A
Older age
FH
Male
6
Q
What are some modifiable risk factors for atherosclerosis?
A
Smoking
Alcohol consumption
Poor diet (high sugar and trans-fat and reduced fruit and vegetables and omega 3 consumption)
Low exercise
Obesity
Poor sleep
Stress
7
Q
Which medical co-morbidities increase risk of atherosclerosis?
A
Diabetes
HTN
CKD
Inflammatory conditions e.g. Rheumatoid artheritis
Atypical antipsychotics
8
Q
What are the end results of atherosclerosis?
A
Angina
MI
TIA
Stroke
PVD
Mesenteric ischaemia
9
Q
What is the difference between primary prevention and secondary prevention for CVD?
A
Primary - never had CVD in past
Secondary - had angina, MI, TIA, stroke or PVD
10
Q
How to optimise modifiable risk factors for CVD?
A
Advice on diet, exercise and weight loss
Stop smoking
Stop drinking alcohol
Tightly treat any co-morbidities e.g. diabetes
11
Q
What is the QRISK 3 score and when should a statin be offered?
A
Risk that a patient will have a stroke or MI in next 10 years (give atorvastatin 20mg at night)
12
Q
Who else should be offered a statin?
A
Patients with CKD and T1DM for more than 10 years
13
Q
What reduction in non-HDL cholesterol should be aimed for on statin treatment?
A
Check lipids at 3 months and aim for greater than 40% reduction in non-HDL cholesterol (always check adherance before increasing)
14
Q
What bloodsshould becheckedafter starting astatin?
A
LFTs within 3 months and again at 12 months (don’t need to check after that if normal - can cause transient rise in ALT and AST in first few weeks, dont need to stop if rise is less than 3 times upper limit)
15
Q
What is the secondary prevention of CVD?
A
Aspirin (plus second antiplatelet e.g. clopidogrel)
Atorvostatin 80mg
Atenolol (or other beta-blocker commonly bisoprolol) titrated to max dose
Ace inhibitor (commonly ramipril) titrated to max tolerated dose
16
Q
What are some notable side effects of statins?
A
Myopathy (check creatine kinase in patients with muscle pain / weakness)
T2DM
Haemorrhagic stroke (very rarely)
(Atorvastatin = newer statin, mostly well tolerated)
17
Q
What is angina?
A
Narrowing of coronary arteries reducing blood flow to myocardium causing chest pain during periods of high demand e.g. exercise
18
Q
What is the difference between stable and unstable angina?
A
Stable = relieved by rest / glyceryl trinitrate (GTN)
Unstable = symptoms come on randomly (considered an acute coronary syndrome)
19
Q
What is the gold standard investigation for angina?
A
CT Coronary Angiography (injecting contrast and taking CT images timed with heart beat - highlighting narrowing)
20
Q
What other investigations should be performed for angina?
A
Physical examination (heart sounds, signs of heart failure, BMI)
ECG
FBC (for anaemia)
U&Es (prior to ACEi and other meds)
LFTs (prior to statins)
Lipid profile
TFT (check for hypo/hyper thyroid)
HbA1C and fasting glucose (for diabetes)
21
Q
What forms the management of angina?
A
Refer to cardiology (urgently if unstable)
Advise about diagnosis, management and when to call ambulance
Medical treatment (short term / long term)
Procedural or surgical interventions
22
Q
What can be used for immediate symptomatic relief for angina?
A
GTN and repeat after 5 mins (if still pain 5 mins after this then call ambulance)
23
Q
What can be used for long term symptomatic relief of angina?
A
Beta blocker (e.g. bisoprolol 5mg once daily - best if HF)
OR
CCB (e.g. amlodipine 5mg once daily)
(can be used in combo)
Other options (not first line): long acting nitrates (e.g. isosorbide mononitrate - may develop tolerance), ivabradine, nicorandil, ranolazine
don’t use verapamil if HF or with BBs (risk of complete heart block)
24
Q
What can be used for secondary prevention of angina?
A
Aspirin (i.e. 75mg once daily)
Atorvastatin 80mg once daily
ACE inhibitor
Already on beta-blocker for symptomatic relief
25
What **procedural / surgical intervention** can be performed for **stable angina**?
**Percutaneous coronary intervention** (PCI) = **dilating blood vessel with balloon** and / inserting stent - offered to patients with proximal / extensive disease on CT coronary angiography - **catheter** inserted into patient's **brachial** or **femoral artery** (contrast inserted looking for stenosis)
**Coronary artery bypass graft** (CABG) for severe stenosis = open chest **along sternum** causing **midline sternotomy scar** - using graft vein (usually **great saphenous vein**) and sewing it onto affected artery - **recovery slower** and **complication rate** higher than PCI
26
What normally causes **acute coronary syndrome**?
**Thrombus** from **atherosclerotic plaque** blocking **coronary artery** (made up mostly of platelets - anti-platelets are preventative: **aspirin, clopidogrel** and **ticagrelor**)
27
Label the following:
What does the **left coronary artery** become?
**LCA** becomes **circumflex** and **left anterior descending**
28
What does the **right coronary artery** supply?
**Right** atrium
**Right** ventricle
**Inferior** aspect of **left ventricle**
**Posterior septal area**
29
Where does the **circumflex artery supply**?
**Left atrium**
**Posterior aspect of left ventricle**
30
What does the **LAD** supply?
**Anterior aspect** of **left ventricle**
**Anterior aspect** of **septum**
31
What are the **three types** of **ACS**?
**Unstable angina**
**STEMI**
**NSTEMI**
32
What **investigations** for patients with **ACS symptoms**?
Perform an **ECG:**
**ST elevation** / new **LBBB** = **STEMI**
No ST elevation = **troponin blood tests:**
**Raised / if other ECG changes** e.g. **ST depression** or **T wave investion or pathological Q waves** = **NSTEMI**
**Normal levels** and no ECG changes = **unstable angina** / MSK pain
33
What are the **symptoms** of **ACS**?
**Central** **constricting** chest pain associated with:
* **Nausea** and **vomiting**
* **Sweating** and **clamminess**
* Feeling of **impending doom**
* **SoB**
* **Palpitations**
* Pain **radiating** to **jaw** or **arms**
Symptoms should **continue at rest for more than 20 mins** (if settle = angina)
**Diabetic patients** may not experience typical chest pain (**'silent MI'**)
34
What are the **ECG changes** in **STEMI**?
**ST segment elevation** in leads consistent with area of ischaemia
## Footnote
**New LBBB**
35
What are the **ECG** changes in **NSTEMI**?
**ST segment depression** in a region
**Deep T wave inversion**
**Pathological Q waves** (suggesting deep infarct - late sign)
36
Complete the following:
37
How is **ACS** typically diagnosed?
Rise in **serial troponins** (proteins in cardiac muscle): baseline and 6 or 12 hours after onset
38
What are the **alternative causes** of **raised troponin**?
**Chronic renal failure**
**Sepsis**
**Myocarditis**
**Aortic dissection**
**PE**
39
What are the **investigations** for **ACS**?
**_ALL STABLE ANGINA INVESTIGATIONS_**
* **Physical examination** (heart sounds, signs of heart failure, BMI)
* **ECG**
* **FBC** (check for anaemia)
* **U&Es** (prior to ACEi and other meds)
* **LFTs** (prior to statins)
* **TFTs** (check for hypo / hyper thyroid)
* **HbA1C** and **fasting glucose** (for diabetes)
**_PLUS_**
* **CXR** (look for other causes / pulmonary oedema)
* **Echo** (assess functional damage)
* **CT coronary angio**
40
What is the **treatement** of **STEMI** presenting within **_12 hours of onset_**?
**Primary PCI** (if available _within 2 hours of presentation_ - balloons, or aspirate blockage then usually stent)
**Thrombolysis** (if PCI not available)
41
How is **thrombolysis** performed? Give examples?
Injecting **fibrinolytic** medication (**breaks down fibrin**)
Risk of **bleeding**
**E.g.** **streptokinase, alteplase** and **tenecteplase**
42
What is the treatment of **acute NSTEMI**?
**BATMAN**
**B**eta-blockers (unless contraindicated)
**A**spirin 300mg stat dose
**T**icagrelor 180mg stat dose (**clopidogrel** 300mg is alternative)
**M**orphine titrated to control pain
**A**nticoagulant: LMWH at treatment dose (e.g. **enoxaparin** 1mg/kg twice daily for 2-8 days)
**N**itrates (e.g. GTN) to relieve coronary artery spasm
Give **oxygen** only if sats dropping (\<95%)
43
What is the **GRACE Score**?
Assessing for **PCI** in **NSTEMI**:
**Scoring system for 6-month risk of death** / **repeat MI** after NSTEMI
\< 5% low risk
5-10% medium risk
\>10% high risk
If **medium / high** = **early PCI** (within 4 days of admission)
44
What are the **complications** of **MI**?
**D**eath
**R**upture of heart septum / papillary muscles
**E**dema (**heart failure**)
**A**rrhythmia and **A**neurysm
**D**ressler's Syndrome
45
What is **Dressler's syndrome**?
Aka **post MI syndrome**: 2-3 weeks after MI
Caused by **localised immune response** and causes **pericarditis** (less common as management of ACS becomes more advanced)
**Pleuritic chest pain**, low grade fever and **pericardial rub**
**Can cause pericardial effusion** and **pericardial tamponade**
46
How is **Dressler's syndrome** diagnosed?
**ECG** (global ST elevation and T wave inversion)
**Echocardiogram** (pericardial effusion)
**Inflammatory markers** (raised CRP and ESR)
47
What is the **management** of **Dressler's syndrome**?
**NSAIDs** (aspirin / ibuprofen) and in more severe cases **steroids** (prednisolone)
**Pericardiocentesis** (remove fluid from around heart)
48
What form **secondary prevention** following **ACS**?
**A**spirin 75mg once daily
**A**nother antiplatelet e.g. **clopidogrel** or **ticagrelor** for up to 12 months (dual anti platelet duration will vary following PCI procedure depending on type of stent used due to higher risk of thrombus formation with different stents)
**A**torvastatin 80mg once daily
**A**CE inhibitors (e.g. **ramipril** titrated as tolerated to 10mg once daily)
**A**tenolol (or other BB titrated as high as tolerated)
**A**ldosterone antogonist for those with **clinical heart failure** (i.e. **eplerenone** titrated to 50mg once daily)
**Dual antiplatelet** duration varies following **PCI procedures** depending on type of stent (some have higher risks of thrombus)
49
What are the **advisable** **lifestyle changes** following **ACS**?
**Stop smoking**
**Reduce alcohol**
**Mediterranean diet**
**Cardiac rehab** (specific exercise regime for patients post MI)
**Optimise treatment** of other medical conditions (e.g. HTN and diabetes)
50
What are the **types of MI**?
**Type 1**: Traditional MI due to acute coronary event
**Type 2**: Ischaemia due to increased demand / reduced supply oxygen (severe anaemia, tachycardia, hypotension)
**Type 3**: Sudden cardiac death / cardiac arrest suggestive of ischaemic event
**Type 4**: MI associated with PCI / coronary stunting / CABG
51
What is the **result of acute left ventricular failure**?
**Pulmonary oedema**
52
What can **trigger** **acute LVF**?
Iatrogenic (e.g. **aggressive IV fluids** in frail elderly patient)
## Footnote
**Sepsis**
**Myocardial infarction**
**Arrhythmias**
53
How does **acute LVF** present?
**Rapid onset breathlessness** (exacerbated by lying flat)
**T1RF** (low O2 with normal CO2)
54
What are the **symptoms** of **acute LVF**?
**SoB**
Looking and **feeling unwell**
**Cough** (frothy white / pink sputum)
55
What may be found **on examination** for **acute LVF**?
**Increased RR**
**Reduced O2 sats**
**Tachycardia**
**3rd heart sound**
**Bilateral basal crackles** (sounding wet on auscultation)
**Hypotension** in severe cases (**cardiogenic shock**)
56
What **signs** of **underlying cause** may be found in **acute LVF**?
**Chest pain** in **ACS**
**Fever** in **sepsis**
**Palpitation** in **arrhythmias**
57
What are the signs of **right sided heart failure**?
Raised **JVP**
**Peripheral oedema** (ankles, legs, sacrum)
58
What may cause an elderly patient who has recieved lots of IV fluid desaturate? What can be prescribed?
**Acute LVF**
**IV furosemide**
59
How to **initally investigate possible acute LVF**?
**History**
**Clinical examination**
**ECG** (to look for ischaemia / arrhythmias)
**ABG**
**CXR**
**Bloods** (routine for infection, kidney function, BNP and consider **troponin**)
60
What are the **investigations** for **acute LVF**?
**B-type natriuretic peptide** (BNP blood test - hormone released from **ventricles** when **myocardium** is stretched too far)
**Echo** - to assess function of LV (**ejection fraction -** should be **\> 50%**) and any structural abnormalities
**CXR** findings:
1. **cardiomegaly** (cardiothoracic ratio \> 50%)
2. **upper lobe venous diversion** (usually when standing erect lower lobe veins contain more blood than upper - in LVF the upper lobe veins also fill = **engorged**)
3. **bilateral pleural effusions**
4. fluid in **interlobar fissures**
5. fluid in septal lines (**Kerley lines**)
61
What is the **action of BNP** and when else can it be released (**sensitive** but **not specific**)
1. **Relax smooth muscle** - reducing systemic vascular resistance
2. Act on **kidneys** to promote excretion of more water
* **Tachycardia**
* **Sepsis**
* **PE**
* **Renal impairment**
* **COPD**
62
What is the standard **management** of **acute LVF**?
**Pour SOD**
**Pour** away (stop IV fluids)
**S**it up (moving fluid to bases)
**O**xygen (if falling \<95% - caution in COPD)
**D**iuretics (IV furosemide 40mg stat) - reducing **circulating volume** meaning heart is less overloaded
**Monitor fluid balance** (fluid intake, urine output, U&E bloods and daily body weight)
63
What are the **further treatment options** in **acute LVF**?
**IV opiates** (e.g. morphine - acts as **vasodilator**)
**NIV** - **CPAP** (or full **intubation** / **ventilation**)
**Inotropes** e.g. infusion of **noradrenaline** - strengthen force of heart contraction (in **local coronary care unit** / high dependency unit / ICU)
64
What is **chronic heart failure** caused by?
**Impaired LV contraction** ('systolic heart failure')
**Impaired LV relaxation** ('diastolic heart failure')
65
How does **chronic heart failure** present?
**Breathlessness** (worse on exertion)
**Cough** - may produce frothy white / pink sputum
**Orthopnoea** (SoB when lying flat)
**Paroxysmal nocturnal dyspnoea** (waking up with severe SoB, cough, wheeze, improves over minutes)
**Peripheral oedema** (swollen ankles)
66
What may cause **PND**?
* Fluid **settles** across **large surface area** (stand up and upper lungs clear)
* During sleep resp centre in brain is **less responsive** so RR / effort doesnt increase in response to reduced O2 sats allowing more **significant pulmonary congection** and **hypoxia** before waking up
* **Less adrenalin** means **myocardium is more relaxed** worsening cardiac output
67
How is **chronic heart failure** **diagnosed**?
**Clinical presentation**
**BNP blood test** (specifically N-terminal pro-B-type natriuretic peptide" - NT - proBNP)
**Echo**
**ECG**
68
What may **cause chronic heart failure**?
**Ischaemic heart disease**
**Valvular heart disease** (commonly aortic stenosis)
**HTN**
**Arrhythmias** (commonly atrial fibrillation)
69
What is the **initial management** of **chronic heart failure**?
**Refer** to specialist (NT-proBNP \> 2,000 = **urgent referral**)
Discussion and explanation
Medical management
Surgical treatment for severe **aortic stenosis** or **mitral regurgitation**
**Heart failure specialist nurse**
In addition: **yearly flu** and pneumococcal vaccine, **stop smoking**, optimise co-morbidities, **exercise** as tolerated
70
What is the **first line medical treatment** for **chronic heart failure**?
**ABAL**
**A**ce inhibitor (e.g. **ramipril** titrated as tolerated up to 10mg once daily)
**B**eta blocker (e.g. **bisoprolol** up to 10mg as tolerated)
**A**ldosterone antagonist if not controlled with A and B (**spirololactone** or **eplerenone**)
**L**oop diuretics improve **symptoms** (e.g. **furosemide** 40mg once daily)
71
What can be **used instead** of **ACE inhibitors** if they're not tolerated?
**Candesartan** titrated up to 32mg OD (avoid ACEi in patients with valvular heart disease)
72
When are **aldosterone antagonists** used?
**Reduced ejection fraction** and symptoms **not controlled** with **ACEi** and **BB**
73
What should be **closely monitored** when on **diuretics**, **ACEi**, and **aldosterone antagonists**?
**U&Es** (all cause **electrolyte disturbances**)
74
What is **cor pulmonale**?
**Right sided** **heart failure** caused by **respiratory disease** (pulmonary hypertension)
75
What are the **respiratory causes** of **cor pulmonale**?
**COPD** - most common
**PE**
**Interstitial** lung disease
**Cystic fibrosis**
Primary **pulmonary hypertension**
76
How does **cor pulmonale** present?
Often **asymptomatic** - main presenting complaint is **SoB** (also SoB from chronic lung disease)
* **Peripheral oedema**
* Increased breathlessness on exertion
* **Syncope** (dizziness and fainting)
* Chest pain
77
What are the **examination signs** of **cor pulmonale**?
**Hypoxia**
**Cyanosis**
**Raised JVP** (due to back-log of blood in **jugular veins**)
Peripheral **oedema**
Third heart sound
Murmurs (e.g. **pan systolic** in **tricuspid regurg**)
**Hepatomegaly** due to back pressure in hepatic vein (pulsatile in **tricuspid regurgitation**)
78
What is the **management** of **cor pulmonale**?
Treat **symptoms** and **underlying cause** (LTOT often used)
Prognosis is poor (unless reversible cause)
79
What BP do NICE suggest **diagnosis of HTN**?
Above **140/90** in clinic or 135/85 with **ambulatory**
80
What are the **causes** of **hypertension**?
**Essential** (95% of HTN)
**_ROPE_**
**R**enal disease (most common cause, BP is very high / no response to treatement = **renal artery stenosis**)
**O**besity
**P**regnancy induced / **pre-eclampsia**
**E**ndocrine (**hyperaldosteronism** - Conns syndrome - **renin:aldosterone ratio** blood test)
Consider these in patients **under 40**
81
What are the **complications** of **HTN**?
**Ischaemic heart disease**
**CVA** (stroke / haemorrhage)
Hypertensive **retinopathy**
Hypertensive **nephropathy**
**Heart failure**
82
How **often** should **BP** be measured?
Every **5 years** to screen (more often in patients on **borderline** - 140/90 and every year in **T2DM**)
If between 140/90 and 180/120 then have **24 hour ambulatory BP** / **home readings** to confirm
Measure in **both arms** if difference is more than 15mmHg then use reading from arm with **higher blood pressure**
83
What is the **white coat effect**?
**More than 20/10 mmHg** difference in blood pressure between **clinic** and **ambulatory** / **home readings**
84
Complete the following:
85
How to **examine** for **end organ damage** in **hypertension**?
**Urine albumin:creatinine ratio** for proteinuria and **dipstick** for microscopic haematuria to assess for kidney damage
**Bloods** for HbA1c, renal function and lipids
**Fundus examination** for **hypertensive retinopathy**
**ECG** for cardiac abnormalities
86
How to **initially manage** **HTN**?
Establish **diagnosis**
**Investigate** for **possible causes** and **end organ damage**
**Advise** on **lifestyle** (healthy diet, stop smoking, reduce alcohol, reduce caffeine and salt intake, take regular exercise)
87
Who is **medically managed** for **HTN**?
All patients with **type 2 HTN**
All patients **under 80** with **stage 1** and **QRISK score \>10%**, **diabetes, renal disease, CVD** or **end organ damage**
88
What is the **medical management of HTN**?
**A**CEi e.g. **ramipril**
**B**eta blocker e.g. **bisoprolol**
**C**alcium channel blocker (e.g. **amlodipine**
**D**iuretic (thiazide-like e.g. **indapamide**)
**AiiRB** e.g. **candesartan** (if not tolerating ACEi - dry cough or black - **not used with ACEi**)
**Step 1**: \< 55 and non black use **A** but if \> 55 or black use **C**
**Step 2**: **A** + **D** or **C** + **D**
**Step 3**: **A + C + D**
**Step 4**: **A + C + D + additional**
Additional = if serum potassium \< 4.5 mmol/l give **potassium sparing diuretic** e.g. **spironolactone** if \> 4.5 then give **alpha blocker** e.g. **doxazosin** or a **beta blocker** e.g. **atenolol**
89
What is **spirolonactone**? How does it work? What is the **risk**?
**"potassium-sparing diuretic****"**working by**blocking**action of**aldosterone**in**kidneys**resulting in**sodium excretion**and**potassium reabsorption**(helpful when**thiazide**diuretics are causing**hypokalaemia**)
**Risk** = **hyperkalaemia** (ACEi also cause this, thiazide-like cause electrolyte disturbances - monitor U&Es regularly)
90
Complete this:
91
What is the **first heart sound** (S1) caused by?
Closing of **AV valves** (tricuspid and mitral) at start of **systolic contraction** of the **ventricles**
92
What is the **second heart sound** (S2) caused by?
Closing of **semilunar valves** (pulmonary and aortic) once systolic contraction is complete
93
When is the **third heart sound heard**?
Roughly **0.1** seconds after **second heart sound** - rapid ventricular filling causing **chordae tendineae** to **pull to their full length** and twang - **normal in young healthy people**, older patients = **heart failure**
94
What is the **fourth heart sound**?
Heart **directly before S1** - always abnormal and relatively rare - **indicates stiff / hypertrophic ventricle** - caused by **turbulent flow** from **atria** contracting **against non-compliant ventricle**
95
What side of the **stethoscope** do you use?
**Bell** = low pitched sounds
**Diaphragm** = high pitched
96
Where can you **listen to the different valves**?
**Pulmonary:** 2nd I.C.S left sternal boarder
**Aortic:** 2nd I.C.S right sternal boarder
**Tricuspid:** 5th I.C.S left sternal boarder
**Mitral:** 5th I.C.S mid clavicular line (apex area)
97
Where is the best area for listening to **heart sounds**?
**Erb's point** (**3rd** intercostal space on **left sternal border**)
98
What can be done to **emphasise** the **murmur heard** in **mitral stenosis**?
**Patient** on **lhs**
99
How can **murmur** in **aortic regurgitation** be exaggerated?
**Sit patient up**
**Lean forward**
**Hold exhalation**
100
How to **assess a murmur**?
**_SCRIPT_**
**Site**: where is it loud?
**Character:** soft / blowing / crescendo / decrescendo
**Radiation:** hear murmur over carotids (AS) or left axilla (MR)
**Intensity**: what grade is murmur
**Pitch**: high / low pitched (indicates velocity)
**Timing**: systolic / diastolic
101
How to **grade a murmur**? (quite subjective)
1. Difficult to hear
2. Quiet
3. Easy to hear
4. Easy to hear with a palpable thrill
5. Can hear with stethoscope barely touching chest
6. Can hear with stethoscope off the chest
102
Give an **example script** for describing a **murmur**?
“This patient has a **harsh / soft / blowing, Grade** …, **systolic / diastolic murmur**, heard **loudest in the aortic / mitral / tricuspid / pulmonary area**, that **does not / radiates to the carotids / left axilla**. It is **high / low pitched** and has a **crescendo / decrescendo / crescendo-decrescendo shape**. This is suggestive of a diagnosis of **mitral stenosis / aortic stenosis**”
103
What is the **difference** between **hypertrophy** and **dilatation**?
**Hypertrophy** = thickening both outwards and into chambeer
**Dilatation** = thinning and expanding
104
What changes to **myocardium** does **mitral stenosis** and **aortic stenosis** cause?
**Mitral stenosis** = left atrial hypertrophy
**Aortic stenosis** = left ventricular hypertrophy
105
What changes to the **myocardium** does **mitral regurgitation** and **aortic regurgitation** cause?
**Mitral regurgitation** = left atrial dilatation
**Aortic regurgitation** = left ventricular dilatation
106
What causes **mitral stenosis**?
**Rheumatic heart disease**
**Infective endocarditis**
107
What kind of **murmur** does **mitral stenosis** cause?
**Mid-diastolic**, **low pitched**"rumbling" murmur due to a low velocity of blood flow
**Loud S1** due to thick valves requiring a **large systolic force** to shut then **shutting suddenly**
**Palpate** a **tapping apex beat** due to loud S1
108
What is **mitral stenosis** associated with?
**Malar flush** - due to **back-pressure** of blood into pulmonary system causing rise in CO2 and vasodilation
**AF** - caused by **left atrium** struggling to push blood through stenotic valve causing **strain**, **electrical disruption** and resulting **fibrillation**
109
What is **mitral regurgitation**?
Incompetent **mitral valve** allows blood to leak back through during **systolic contraction** of the **left ventricle** - causing **congestive cardiac failure** (leaking valve causes **reduced ejection fraction**)
Causing **pan-systolic, high pitched**"whistling" murmur due to high velocity blood flow though leaky valve
**Radiates to left axilla** (may hear 3rd heart sound)
110
What are the **causes** of **mitral regurg**?
**Idiopathic weakening of valve** with age
**IHD**
**Infective endocarditis**
**Rheumatic heart disease**
**Connective tissue disorder** e.g. **Ehlers Danlos syndrome** or **Marfan syndrome**
111
Describe the **murmur** in **aortic stenosis**?
**Ejection-systolic**, **high-pitched** murmur
**Crescendo-decrescendo** due to speed of blood during different periods of systole
112
What are the **other signs** in **aortic stenosis**?
**Radiates** to **carotids** as turbulence continues up neck
**Slow rising pulse** and **narrow pulse pressure**
**Exertional syncope** (light headedness and fainting when exercising) due to **difficulty maintaining good flow to brain**
113
What are the **causes** of **aortic stenosis**?
**Idiopathic age related calcification**
**Rheumatic heart disease**
114
What is the **murmur** heard in **aortic regurgitation**?
**Early diastolic**, **soft murmur** (assoicated with **Corrigan's pulse** - collapsing pulse - blood pumped out by ventricles then immediately flows back)
115
What does **aortic regurgitation result in**?
**Heart failure**
116
What other **murmur** can **aortic regurgitation** result in?
**Austin-flint** - heard at **apex** and is **early diastolic**'**rumbling**' murmur - caused by **blood flowing back through aortic valve** and over mitral causing vibrations
117
What are some **causes** of **aortic regurgitation**?
Idiopathic **age related weakness**
**Connective tissue disorder** e.g. **Ehlers Danlos syndrome** or **Marfan syndrome**
118
What **scar** will **patients** who have had **valve replacement** have?
**Midline sternotomy scar** - down middle of sternum (**mitral** or **aortic valve replacement** or **CABG**)
**Right sided mini-thoracotomy** (minimally invasive mitral valve replacement)
119
What are the **different types of** replacement **valves**?
**Bioprosthetic** (e.g. **porcine** from a pig) - last for 10 years
**Mechanical valves** - over 20 years - **require lifelong** anticoagulation with **warfarin** (target INR = 2.5 - 3.5)
120
What are the **types** of **mechanical heart valves**?
**Starr-Edwards valve** - bell in cage, very successful but no longer used, **highest risk of thrombus** formation
**Tilting disc valve** - single tilting disc
**St Judes valve** - two tilting metal discs, **bileaflet valve**, least risk of thrombus formation
121
What are the **major complications** of **mechanical heart valves**?
**Thrombus** formation (blood stagnates and clots)
**Infective endocarditis**
**Haemolysis** (blood churns in valve)
122
What **type of click** does **mechanical heart valve** cause?
**S1 click** for metallic mitral valve
**S2 click** for metallic aortic valve
123
What is the surgical **treatment for severe aortic stenosis**?
**TAVI** (transcatheter aortic valve implantation)
Local / general anaesthetic - catheter inserted to **femoral artery** and under **x-ray guidance** going to the **aortic valve** - inflating balloon to stretch valve and implanting **bioprosthetic valve** in the location of the aortic valve
**Long term outcome** = still not clear (relatively new procedure) - typically **do not require warfarin** as valve is bioprosthetic
124
What is a complication with **surgical valve replacement**? What organisms are implicated normally?
**Infective endocarditis** (2.5% of patients)
Gram +be cocci organisms:
* **Staphylococcus**
* **Streptococcus**
* **Enterococcus**
Used to take **abx** for **routine dental procedures** - no longer case
125
What is the **result** of **atrial fibrillation**?
**Irregularly irregular** ventricle contractions
**Tachycardia**
**Heart failure** due to **poor filling** of the ventricles during **diastole**
Risk of **stroke** (blood collects in **atria** and forms blood clots)
126
How does **atrial fibrillation present**?
**Asymptomatic usually**
* Palpitations
* SoB
* Syncope (dizziness or fainting)
* Symptoms of associated conditions (e.g. stroke, sepsis, or thyrotoxicosis)
127
What are the **two differential diagnoses** of an **irregularly irregular pulse**?
**Atrial fibrillation**
**Ventricular ectopics** (disappear when HR gets over certain threshold - if regular during exercise = ventricular ectopics)
Differentiated using ECG
128
How does **AF** appear on an **ECG**?
**Absent P** waves
Narrow **QRS** Complex Tachycardia
**Irregularly irregular ventricular rhythm**
129
What is **valvular AF**?
Patients with **AF** who have **moderate / severe** **mitral stenosis** or **mechanical heart valve**
130
What are the **most common causes of AF**?
**S**epsis
**M**itral valve pathology (stenosis / regurgitation)
**I**schaemic heart disease
**T**hyrotoxicosis
**H**ypertension
131
What are the **two principles** of **treating AF**?
**Rate** or **rhythm** control
**Anticoagulation** to prevent stroke
132
What should patients with **AF** have first line?
**Rate control** unless:
* **Reversible** cause of AF
* **New onset** (within last 48 hrs)
* AF causing **heart failure**
* Remain **symptomatic** despite effective rate control
133
What can be given for **rate control** in **AF**?
**Beta blocker** (e.g. atenolol 50-100mg OD)
**CCB** (e.g. diltiazem - not in HF)
**Digoxin** (only in sedentary people, needs monitoring and risk of toxicity)
134
When is **rhythm control** given to patients with AF?
What are the **two options**?
**Reversible** cause
**New** onset (48rs)
Causing **heart failure**
**Symptomatic** despite rate control
* **Single cardioversion** event that puts the patient back into sinus rhythm or **long term medical rhythm control**
135
What are the **two choices** for timing of **cardioversion**?
**Immediate** - present for less than 48 hrs / severely haemodynamically unstable
**Delayed** - present for more than 48 hrs and haemodynamically stable (should be **anticoagulated** for 3 weeks prior to cardioversion - may have developed a blood clot in atria and cardioversion mobilises causing stroke, should have **rate control** whilst waiting)
136
What are the **two options** for **cardioversion**?
**Pharmacological** (first line) - flecanide, amiodarone (choice in structural heart disease)
**Electrical** - shock heart back into sinus rhythm involving **sedation** / **GA** and using defibrillator
137
What are the options for **long term medical rhythm control**?
**Beta blockers** - rhythm control
**Dronedarone** - second line for maintaining normal rhythm where successful cardioversion
**Amiodarone** - if HF or left ventricular dysfunction
138
What is **warfarin** and how does it work?
**Warfarin** is a **vitamin K antagonist** (needed for clotting factors)
Prolonging **PT** (time for blood to clot)
139
What does an **INR** of 2 mean?
**Prothrombin time** twice that of a normal healthy adult
140
What is the target INR in AF? When is warfarin given?
2-3
Given in **evening** in hosp (6pm) and INR taken before
141
What foods affect warfarin / **cytochrome P450** (and as such metabolism)?
Those containing **vitamin K** e.g. **leafy green vegetables**
Those that affect P450 e.g. **cranberry juice** and **alcohol**
142
What is the **half life** of **warfarin** and how can it be reversed?
1-3 days (reversibel with **vitamin K** in event INR is very high / bleeding)
143
What are NOACs now known as? Give some examples? What are they reversed with?
NOvel AntiCoagulants are now known as Direct acting Oral AntiCoagulants (**DOACs**)
E.g.
**Apixaban**, **rivaroxaban (Andexanet Alfa)**
**Dabigatran (Idarucizumab)**
Currently on patent so more expensive than warfarin (e.g. £27 versus £1, apixaban comes off in 2022)
144
How are DOACs taken?
**Apixaban** and **dabigatran** are taken **twice daily**
**Rivaroxaban** is taken once daily
No way to reverse effect however lower blleding risk and short half life (7-15 hours)
145
What are the **advantages** of **DOACs** compated to warfarin?
**No monitoring** is required
**No major interaction** problems
Equal / **better** than **warfarin** at **preventing strokes** in AF
Equal / **less risk** of **bleeding** than warfarin
146
What is the **tool** for assessing whether to **initiate** anticoagulation? (risk of **stroke** / **TIA**)
CHA2DS2-VASc (if **one or more** then **consider / start**)
**C**ongestive heart failure
**H**ypertension
**A**ge \> 75 (scores 2)
**D**iabetes
**S**troke / TIA / MI previously (score 2)
**V**ascular disease
**A**ge 65-74
**S**ex (female)
147
What is the **assessment tool** for assessing risk of **major bleed** whilst on **anticoagulation**?
**HAS-BLED** (don't need to know inside out - usually risk of stroke outweighs risk of bleeding)
**H**ypertension
**A**bnormal renal and liver function
**S**troke
**B**leeding
**L**abile INRs (whilst on warfarin)
**E**lderly
**D**rugs or alcohol
148
What are the **four** **cardiac arrest rhythms**?
**Shockable**: VT, VF
**Non-shockable**: PEA (including sinus rhythm without pulse), asystole
149
What is the treatment of **tachycardia** in **unstable** / **stable** (broad / narrow)
**Unstable**: consider 3 syncronised shocks / amiodarone infusion
**Stable**:
_Narrow complex (QRS \< 0.12s)_
**Atrial fibrillation** - rate control with BB / diltiazem
**Atrial flutter** - control rate with BB
**Supraventricular tachycardias** - treat with vagal manoeuvres and adenosine
_Broad complex (QRS \> 0.12s)_
**Ventricular tachycardia** or unclear - amiodarone
If known **SVT with BBB** treat as normal SVT
If irregular may be AF variation - seek expert help
150
What causes **atrial flutter** how does it **appear on ECG**?
**Re-entrant rhythm** in either atrium (re-circulates in **self perpetuating loop** due to **extra electrial pathway**)
Atria contract at **300bpm** - signal is conducted every second lap due to refractory period at AV node (150bpm)
**Sawtooth** **appearance** on ECG with P wave after P wave
151
Which **conditions** are **associated** with **atrial flutter**?
**Hypertension**
**Ischaemic heart disease**
**Cardiomyopathy**
**Thyrotoxicosis**
152
What is the **treatment** of **atrial flutter**?
**Similar to AF**:
* **Rate / rhythm control** with BB / cardioversion
* Treat **underlying condition** e.g. hypertension / thyrotoxicosis
* **Radiofrequency ablation** of the re-entrant rhythm
* **Anticoagulation** based on CHA2DS2VASc
153
What is a **supraventricular tachycardia** caused by?
How does it appear?
**Electrical signals re-entering atria** from ventricles (normally can only go from atria to ventricles)
Causing fast **narrow complex tachycardia** (QRS \< 0.12)
QRS followed by T followed by QRS followed by T...
154
What is **paroxysmal SVT**?
**SVT** reoccurs and remits in same patient over time
155
What are the **three main types of SVT**? (based on source of electrical signal)
**Atrioventricular nodal re-entrant tachycardia** (re-entry back through AV node)
**Atrioventricular re-entrant tachycardia** (re-entry is an accessory pathway - Wolff-Parkinson-White syndrome)
**Atrial tachycardia** - electrical signal originates in atria somewhere other than SAN node (ectopic electrical activity causes atrial rate of \>100bpm)
156
What can be done to **acutely manage SVT**?
**Valsalva manoeuvre** - blow hard against resistance e.g. into plastic syringe
**Carotid sinus massage** - on one side with two fingers
**Adenosine**
Alternative to adenosine is **verapamil**
**Direct current cardioversion** (if all other treatment fails)
^ try in stepwise fashion
157
How does **adenosine** work?
"Resets rhythmn"
Slows cardiac conduction through **AV node** (interrupting AV node / accessory pathway during **SVT** - needs to be given as rapid bolus to ensure reaches heart with enough impact - causes **brief period of asystole** / **bradycardia** - quickly metabolised)
158
When to **avoid** **adenosine**?
What to warn about?
If patient has **asthma** / **COPD** / **heart failure** / **heart block** / **severe hypotension**
Feeling of **dying** / **impending doom**
159
How to give **adenosine**?
Fast **IV** bolus into **antecubital fossa** (initially **6mg**, then **12mg** then futher **12mg** if no improvement between doses)
160
What can be given to **manage** **SVT**?
Medication (**beta blocker**, **CCB**, or **amiodarone**)
## Footnote
**Radiofrequency ablation**
161
What is **Wolff-Parkinson White syndrome**?
Extra electrical pathway connecting **atria** and **ventricles** (normally only AV node connects)
(Often called **bundle of kent**)
162
What is the **definitive treatment** of **WPW syndrome**?
**Radiofrequency ablation** of the **accessory pathway**
163
What are the **ECG** changes on **WPW syndrome**?
**Short PR interval** (\<0.12 seconds)
**Wide QRS complex** (\>0.12)
**Delta wave** - slurred upstroke of QRS
164
What is the **risk with AF** / **atrial flutter** and **WPW**?
Electrical activity can pass through accessory pathway causing **polymorphic wide complex tachycardia**
**Antiarrhythmic medications** (e.g. **BB**, **CCB** and **adenosine**) increase risk by reducing contraction through AV node and promoting through accessory (**contraindicated** in patients with WPW who develop AF / flutter)
165
How does **radiofrequency ablation** work?
**Catheter ablation** performed in **cath lab** (local / GA) interting catheter into **femoral veins** and guiding to heart under **xray guidance** (placed against different areas of heart looking for electrical signals) - **radiofrequency ablation** (heat) used in abnormal areas of electrical activity leaving **scar tissue**
166
What is **radiofrequency ablation** used for?
**Atrial fibrillation**
**Atrial flutter**
**SVT**
**WPW syndrome**
167
What is **Torsades des pointes**?
**Polymorphic** (multiple shape) **ventricular tachycardia** - looks like **normal VT** on ECG but **variable QRS heights**
Occurs in patients with **prolonged QT interval**
168
How does **torsades de pointes** progress?
**Terminate spontaneously**
If progress into **ventricular tachycardia** leading to cardiac arrest
169
What are some **causes of prolonged QT**?
**Long QT syndrome** (inherited)
Medications (**antipsychotics**, **citalopram**, **flecainide**, **sotalol**, **amiodarone**, **macrolide antibiotic**)
Electrolyte disturbance (**hypokalaemia**, **hypomagnesaemia**, **hypocalaemia**)
170
What is the **acute management of Torsades de pointes**?
**Correct the cause** (electrolyte disturbances / medications)
**Magnesium infusion** (even if normal serum magnesium)
**Defibrillation** if **VT occurs**
171
What is the **long term management of prolonged QT syndrome**?
**Avoid medications** that **prolong QT**
**Correct electrolyte disturbance**
**BB** (not sotalol)
**Pacemaker** / **implantable defibrillator**
172
What are **ventricular ectopics**?
**Premature ventricular beats** caused by random electrical discharge from outside the atria = random brief palpitations (**relatively common at all ages** and in healthy patients - more common in **pre-existing heart conditions** (e.g. ischaemic heart disease / heart failure)
173
How do **ventricular ectopics** appear on an ECG?
Appear as **individual random, abnormal, broad QRS complexes** on a background of normal ECG
174
What is **bigemy**?
Ventricular ectopics occur so frequently (after every sinus beat)
**ECG looks like** normal sinus beat followed immediately by ectopic, then normal beat and so on
175
What is the **management** of **ventricular ectopics**?
Check bloods for **anaemia, electrolyte disturbance** and **thyroid abnormalities**
Reassurance & no treatment in otherwise healthy people
**Expert advise** if heart conditions / concerning features (chest pain, syncope, murmur, FH of sudden death)
176
What is **first degree heart block**?
**Delayed AV condition** (every P wave has a QRS complex)
**PR interval** \> 0.20 seconds (5 small or 1 big square)
177
What is **second degree heart block**? What are the types?
Some atrial impulses **don't make it through AV node**:
**Mobitz type 1** (Wenckebach's phenomenon) = atrial impulses become gradually weaker until it doesn't pass - ECG shows increasing PR intervals until QRS complex is missed
**Mobitz type 2** = Intermitted failure of AV conduction - usually ratio e.g. 3:1 (3 p's to each QRS) risk of **asystole**
**2:1 block** = caused by mobitz type 1 / 2 (difficult to tell which)
178
What is **third degree heart block**?
Aka **complete heart block** (no relationship between P waves and QRS) significant **risk of asystole** with 3rd degree heart block
179
What is the **treatment of bradycardias** / **AV node blocks**?
What is an **unstable / risk of asystole** rhythmn?
**Stable** = observe
**Unstable / risk of asystole** (Mobitz type 2, complete heart block / previous asystole) =
**Atropine** 500mcg (first line)
Repeat atropine up to 6 times (total 3mg)
Other **inotropes** (e.g. noradrenaline)
**Transcutaneous cardiac pacing** (using defib)
**Temporary transvenous cardiac pacing** (if high risk of asystole - electrode on wire inserted into vein and fed through venous system to right atrium to **stimulate directly**)
**Permanent implantable pacemaker** when available
180
What is **atropine**? What are the **side effects**?
**Antimuscarinic** - **inhibits** the **parasympathetic nervous system** causing **pupil dilatation** / **urinary retention** / **dry eyes** / **constipation**
181
What are the **components** to a **pacemaker**?
**Pulse generator** (pacemaker box)
**Pacing leads** (carry electrical impulses to heart)
182
Where is the **pacemaker** **implanted**?
**Left anterior chest wall** / **axilla** and wires implanted into relevant chambers of heart
183
How **long** do pacemaker **batteries** last? When are they **contraindicated**?
**5 years**
**MRI scans** (due to powerful magnets - some are MRI compatible) and **electrical interventions** e.g. **TENS machines** and **diathermy**
184
When should **pacemakers** be removed at death?
**Prior** to **cremation** - on "cremation form" the most important task is to state if it's been removed
185
When is **pacemaker** indicated?
**Symptomatic bradycardia**
**Mobitz Type 2 AV block**
**Third degree heart block**
**Severe heart failure** (biventricular pacemakers)
**Hypertrophic obstructive cardiomyopathy** (ICDs)
186
How do **single-chamber pacemakers** work?
**Leads** in a **single chamber** either **right atrium** or **right ventricle**
Placed in **right atrium** if problem with **SA node** (AV conduction is normal) or **right ventricle** if AV conduction is abnormal
187
How do **dual chamber** pacemakers work?
Leads in **both right atrium** and **right ventricle** allowing **pacemaker** to syncronise
188
What is a **biventricular (triple-chamber) pacemaker**? When is it given? What are they also called?
Leads in **right atrium**, **right ventricle**, and **left ventricle**
Usually in **heart failure**
**Cardiac resynchronisation therapy** (CRT) pacemakers
189
What are **implantable cardioverter defibrillators** (ICDs)?
Monitor heart and apply **defib** **shock** to **cardiovert** patient back to sinus rhythmn
190
Describe the **ECG changes with**:
Single chamber pacemakers
Dual chamber pacemakers
191
When should a statin not be prescribed?
**Pregnant**
**Ceased during macrolide meds** (increased risk of rhabdomyolysis)
