Cardioooooooooo Flashcards
(235 cards)
1
Q
What is an AAA?
A
Localised enlargement of the abdominal aorta where the diameter is 50% larger than normal
2
Q
What are the risk factors for AAA?
A
Atherosclerosis, smoking, male, >60yrs, HTN, hyperlipidaemia, connective tissue disorders, inflammatory disorders
3
Q
What are the symptoms of AAA?
A
Unruptured - None
Ruptured - sudden/severe pain in abdo, back, loin. Syncope, Shock
4
Q
What signs are there of AAA on examination?
A
Pulsatile and lateral expansile mass. Abdo bruit. Retroperitoneal haemorrhage - grey turner’s sign
5
Q
What signs can you do for AAA?
A
Bloods - FBC, clotting screen, renal function, liver function
US, CT w contrast, MRI
6
Q
What is aortic dissection?
A
Tear in aortic intima = blood in aortic wall between inner and outer tunica media = false lumen
7
Q
What are the two types of aortic dissection and how common are they?
A
Type A - ascending aorta (most common)
Type B - Descending aorta (distal to left subclavian artery)
8
Q
What causes aortic dissection? What are some RF’s?
A
Degenerative changes in the smooth muscle of aortic media.
RF’s: HTN, Atherosclerosis, connective tissue disease, coarctation of the aorta, aortitis, iatrogenic, trauma, crack cocaine.
9
Q
What can expansion of the lumen lead to?
A
Obstruction of the subclavian, carotid, coeliac or renal arteries = hypoperfusion of target organs = other symptoms
10
Q
What age group does aortic dissection occur in?
A
Males aged 40-60 yrs
11
Q
What main symptom does aortic dissection present with?
A
Sudden central tearing pain, may radiate to back between shoulder blades.
12
Q
What other symptoms can aortic dissection present with?
A
Carotid - hemiparesis, dysphasia, blackout. Coronary - chest pain/angina/MI Subclavian - ataxia/LOC Anterior spinal artery - paraplegia Coeliac axis - severe abdo pain Renal artery - anuria, renal failure
13
Q
What are signs of aortic dissection?
A
Murmur on the back, HTN, Blood pressure diff between two arms (>20mmHg), wide pulse pressure. (HypOtension may be tamponade)
14
Q
What is a pulsus paradoxus and what does it suggest?
A
Abnormally large decrease in systolic blood pressure + pulse wave amplitude in inspiration. may be: -Tamponade -Pericarditis -Chronic sleep apnoea -Obstructive lung disease
15
Q
What investigations would you do for aortic dissection?
A
1) ECG - ST depression with acute dissection
2) CXR - Widened mediastinum
3) Bloods - FBC, U+E’s - check renal function
4) CT thorax - shows false lumen
5) Echo - transoesophageal allows visualisation
16
Q
What is a DVT?
A
Formation of a thrombus in deep veins - commonly in calf/thigh
17
Q
What causes DVT?
A
Blood stasis, hypercoaguability, damage to endothelium wall
18
Q
What are risk factors for DVT?
A
COP, surgery, long mobilisation, obesity, pregnancy, dehydration, smoking
19
Q
How common are DVTs?
A
Very common esp in hospital pts
20
Q
What symptoms can DVT present with?
A
Swollen limb, may be painless
21
Q
What signs might a DVT present with?
A
- Local erythema, warmth, swelling
- Varicosities
- Skin colour changes
- Homan’s sign - pain on dorsiflexion
22
Q
How would you investigate a potential DVT?
A
1) Wells’ score
2) D-dimer level
3) Duplex ultrasound
4) Whole leg US
5) CXR
23
Q
How would you manage a DVT?
A
1) Anticoagulation (hep then warfarin) + stockings
2) IVC filter
3) Mobilisation, prophylactiv hep
Sidenote: High INR = Longer time to clot, smaller INR = shorter time to clot
24
Q
What are some complications of DVT?
A
- PE
- Venous infarction
- Thrombophlebitis
- Chronic venous insufficiency
25
What is the prognosis of a DVT?
Depends on extent. Below knee - good prognosis. proximal DVT = higher chance of embolisation
26
What are varicose veins?
Veins that are dilated and tortuous, most commonly superficial veins of lower limb.
27
What can cause primary varicose veins?
Primary - Genetic/developmental weakness in vein wall (^elasticity, dilatation and valvular incompetence).
28
What are some secondary causes of varicose veins?
Outflow obstruction:
Pregnancy, malignancy, ovarian cysts, ascites, lymphadenopathy,
```
Valve damage
High flow (arteriovenous fistula)
```
29
What are some risk factors for varicose veins?
Age, female, family history, caucasian, obesity
30
How common are varicose veins?
common and increases with age. 10-15% of men, 20-25% of women.
31
What are some presenting symptoms of these veins?
- Cosmetic appearance
- Aching in legs
- worse at the end of day
- Swelling, itching, bleeding, infection, ulceration
32
What signs does varicose veins present with?
```
Inspection for veins, palpate the veins (ask to cough), tap test (a tap @ saphenofemoral junction= impulse felt distally, would not happen if valves were competent)
Palpation of thrill/auscultation of bruit = AV fistula.
Trendelenburg test (localisation of sites of valvular incompetence)
Signs of venous insufficiency (ulcers, oedema, lipodermatosclerosis etc)
```
33
What investigations would you do for varicose veins?
1) Duplex US - locates site of incompetence
| 2) excludes DVT
34
How would you manage varicose veins?
Conservative - exercise, elevation, support stockings
Venous telangiectasia + reticular veins - laser sclerotherapy, microinjection sclerotherapy.
Surgical - saphenofemoral ligation, stripping of long saphenous vein
35
What are some complications of varicose veins?
Venous pigmentation, eczema, lipodermatosclerosis, superficial thrombophlebitis, venous ulceration, treatment complications
36
What is the prognosis for varicose veins?
Slowly progressive, high recurrence rates
37
What are venous ulcers?
Large, shallow ulcers superior to medial malleoli caused by incompetent valves -> venous stasis + ulceration
38
What causes venous ulcers?
Incompetent valves in lower limbs
39
What are risk factors for venous ulcers?
Obesity, immobility, recurrent DVT, varicose veins, surgery to leg, age
40
How common are venous ulcers?
very common and increase with age
41
What are symptoms of venous ulcers?
Large, shallow relatively painless ulcer. Irregular margin.
42
What are some signs of venous ulcers?
symptoms
others:
- Stasis eczema, lipodermatosclerosis (inverted champagne bottle if severe), haemosiderin deposition
43
What investigations would you do for venous ulcers?
1) ABPI
2) Measure surface area of ulcer - to monitor progress
3) Swab for microbiology
4) Biopsy
44
How do you manage a venous ulcer?
Graduated compression, debridement and cleaning, antibiotics, topical steroids
45
What are some potential complications of venous ulcers?
Recurrence, infection
46
What is the prognosis for venous ulcers?
Good esp if they are mobile w few comorbidities
47
What is ischaemic heart disease?
Decreased blood supply to heart muscle resulting in chest pain (angina pectoris). May present as stable angina or ACS
48
What is ACS divided into?
Unstable angina, NSTEMI and STEMI
49
How common is ischaemic heart disease?
common. >2%. males. 5/1000 in UK
50
What causes ischaemic heart disease?
oxygen demand > supply
51
What are risk factors of ischaemic heart disease?
Male, DM, FH, HTN, Hyperlipidaemia, smoking
52
What symptoms does ichaemic HD present with?
ACS - acute onset, central, heavy, tight, crushing, radiates to arms, neck, jaw, at rest, breathlessness, sweating, N+V.
Stable angina - pain on exertion
53
What signs may ischaemic heart disease present with?
Pale, sweating, restless, low grade pyrexia, rule out aortic dissection, arrhythmias, new heart murmurs, signs of complications
54
What investigations would you do for ischaemic heart disease?
Bloods - FBC, U+Es, CRP, glucose, lipid profile, cardiac enzymes, amylase (rule out pancreatitis), TFTs, AST/LDH - raised 24hrs and 48hrs respectively.
ECG -
Unstable angina or NSTEMI - may show ST depression or T wave inversion
STEMI - Hyperacute T waves, ST elevation, new onset LBBB, T wave inversion.
CXR
Exercise ECG
Echo
55
How can you manage stable angina?
Minimise risk factors, immediate symptom relief (GTN spray), beta-blockers, percutaneous coronary intervention, CABG
56
How would you manage unstable angina/NSTEMI?
MONABASH
| Morphine, Oxygen, Nitrates ,Anticoags, beta-blockers, ACE inhibitors, statins, hep
57
How would you treat a STEMI?
Similar to UA/NSTEMI. see laz's notes.
58
What are complications of Ischaemic heart disease? (DARTH VADE)
^risk of MI or other vascular disease.
```
Death
Arrhythmias
Rupture
Tamponade
Heart failure
```
Valve disease
Aneurysm
Dressler's syndrome
Embolism
59
What's the prognosis of patients with ischaemic heart disease?
TIMI score or Killip classification give indications for likelihood of cardiac events or evidence of heart failure
60
Define hypertension
systolic >140mmHg, diastolic >90mmHg on 3 separate occasions.
61
How common is HTN?
Very common. 10-20% adults - in the west
62
What are the causes of HTN?
Primary - >90% of cases
Secondary -
Renal - Renal artery stenosis, chronic glomerulonephritis, chronic pyelonephritis, polycystic kidnet disease, chronic renal failure.
Endo- DM, Hyperthyroidism, cushing's disease, Conn's syndrome etc
CVS - coarctation of aorta
Drugs, pregnancy
63
What are symptoms of HTN?
Asymptomatic. Symptoms of complications or cause.
| headaches, seizures, N+V could be malignant HTN
64
What signs does HTN present with?
high BP on 2-3 occasions. Hypertensive retinopathy, renal artery bruit, radiofemoral delay (coarc of aorta distal to left subclavian)
65
What investigations should you do for hypertension?
Bloods - U+E's, glucose, lipids
Urine - blood and protein
ECG - left ventricular hypertrophy, ischaemia, Ambulatory bp monitoring
66
How can you treat hypertension?
Conservative, treat secondary causes
| Medical: ACE inhibitors or ARBs, CCBs, Beta blockers.
67
What are some complications of htn?
heart failure, coronary artery disease, PVD, Emboli, HTN retinopathy
68
What's the prognosis for HTN?
Good prog if well controlled
69
What is cardiac failure?
Inability of heart to meet body's demand despite normal venous pressures
70
What causes low output cardiac failure?
(decreased cardiac output)
LHF: IHD, HTN, Cardiomyopathy, Aortic valve disease, Mitral regurg
RHF: 2nd to LHF, infarction, cardiomyopathy, pulmonary HTN/embolus/valve disease, chronic lung disease, tricuspid regurgitation, constrictive pericarditis/pericardial tamponade.
Biventricular: arrhythmia, cardiomyopathy, myocarditis, drug toxicity
71
What are some causes of high output cardiac failure?
(Increased demand)
| Anaemia, beri-beri, pregnancy, paget's disease, hyperthyroidism, ateriovenous malformation
72
What people does cardiac failure effect?
10% of >65 year olds
73
What symptoms does LHF present with?
Left symptoms caused by pulmonary congestion
Main symptom is dyspnoea and is classified with New York Heart association classification.
Others: orthopnea, PND, fatigue
Acute LHF: Dyspnoea, wheeze, cough, pink frothy sputum
74
What are symptoms of RHF?
Swollen ankles, fatigue, increased weight from oedema, decreased exercise tolerance, anorexia, nausea
75
What signs will LHF present with?
Tachycardia, tachypnoea, displaced apex beat, bilateral basal crackles, third heart sound, pansystolic murmur
Acute: cyanosis, peripheral shutdown, pulsus alternans, gallop rhythm, wheeze, fine crackles throughout lungs
76
What are signs of RHF?
^JVP, hepatomegaly, ascites, ankle/sacral oedema, functional tricuspid regurg
77
What investigations would you do for cardiac failure?
Bloods: FBC, U+E's, LFT's, CRP, Glucose, TFTs
CXR - cardiomegaly, pleural effusion, Kerley B lines
12 lead ECG, Echocardiogram to assess ventricular contraction
78
How would you manage acute cardiac failure?
Cardiogenic shock - Inotropes (dopamine/dobutamine) + manage in ITU
Pulmonary oedema - 60-100% O2 (consider CPAP). give venodilators and dieuretics to decrease fluid load.
79
How would you treat chronic LHF?
Treat cause and treat exacerbating factors.
80
What drugs are good for chronic LHF?
ACE-inhibitors, B-blockers, Loop diuretics, aldosterone antagonists, ARBs
81
What are 3 complications of cardiac failure?
Resp failure, cardiogenic shock, death
82
What's the prognosis of heart failure?
50% of severe heart failure die in 2 years
83
What is pulmonary hypertension?
Consistently increased pulmonary arterial pressure (>20mmHg)
84
What causes pulmonary HTN?
Primary: Idiopathic
Secondary: LHD, chronic lung disease, recurrent PE, ^pulmonary blood flow (ASD, VSD, patent ductus arteriosus), connective tissue disease, drugs
85
Who usually gets P. HTN?
Young females
86
What symptoms does P HTN present with?
Dyspnoea, chest pain, syncope, tiredness, symptoms of underlying cause
87
What signs does pulmonary HTN present with?
Increased JVP,
Left parasternal heave (right ventricular hypertrophy)
Auscultation - Loud S2, s3/s4 maybe, early diastolic murmur (pulmonary regurg if present), signs of underlying condition
88
What investigations would you do P HTN?
CXR - cardiomegaly (right enlargment), prominent main pulmonary arteries, signs of cause
ECG - RV hypertrophy, low voltage in limb leads = COPD
Echo - visualise right ventricular hypertrophy/dilation
Lung function tests
89
What is hyperlipidaemia?
Elevation of one or more plasma lipid fractions
90
What are causes of hyperlipidaemia?
Primary - familial
Secondary -
^Cholesterol - hypothyroidism, nephrotic syndrome, cholestatic liver disease
^Triglycerides - DM, drugs, alcohol, obesity, chronic renal disease, hepatocellular disease
91
What % of people are affected by high cholesterol?
50% of UK population have level high enough for CHD
92
What symptoms does High lipids present with?
asymptomatic, symptoms of CVS complications , diabetes, FH, smoking, HTN
93
What signs may high lipids present with?
Signs of lipid deposits - xanthelasmas, xanthomas, lipidaemia retinalis
Signs of complications - decreased peripheral pulses, carotid bruit, other CVS factors associated with high BP
94
What investigations would you do for high lipids?
Fasting lipid profile, glucose, TFT, LFT, U+E's.
Cardiovascular risk assessment
95
How would you manage dyslipidaemia?
Advice - exercise, lose weight, stop smoking, lower BP, diabetes control, alcohol
Lipid-lowering drugs - HMG coA reductase inhibitors (statins). Ezetimibe
96
What are some complications of high cholesterol?
coronary artery disease, MI, peripheral vascular disease, stroke
97
What's the prognosis of high cholesterol?
Depends on early diagnosis.
98
Define aortic stenosis
Narrowing of left ventricular outflow at level of the aortic valve
99
What are 2 causes of aortic stenosis?
1) Stenosis secondary to rheumatic heart disease
| 2) Calcification - either of congenital bicuspid aortic valve or tricuspid in the elderly
100
How common is aortic stenosis?
Prevalence of 3% of 75yr olds, males more than females. may present earlier if bicuspid calcification
101
What symptoms does aortic stenosis?
May be asymptomatic, angina, syncope, symptoms of HF. Presents initially when exercising
102
What examinations findings will there be?
Narrow pulse pressure, slow rising pulse, thrill in aortic area is severe, ejection systolic murmur radiating to carotid. Distinguish from aortic sclerosis and HOCM
103
What investigations can you do for aortic stenosis?
1) Transthoracic echo - elevated aortic pressure gradient; measurement of valve area and left ventricular ejection function
2) ECG - may demonstrate left ventricular hypertrophy and absent Q waves, AV block, hemiblock, or bundle branch block
104
What is aortic regurgitation?
Reflux of blood from aorta into LV during diastole. aka aortic insufficiency
105
What causes aortic regurg?
Aortic valve leaflet damage/abnormalities - bicuspid aortic valve, infective endocarditis, rheumatic fever, trauma
Aortic root dilation - HTN, aortic dissection, aortitis, connective tissue disorders, arthritides
106
What causes a collapsing puse and wide pulse pressure?
Reflux of blood into the LV during diastole results in left ventricular dilation and ^end-diastolic
volume and ^ stroke volume. The combination of ^ stroke volume and low end-diastolic
pressure in the aorta may explain the collapsing pulse and the wide pulse pressure.
107
When does AR usually start and what age of patients does it usually affect?
chronic often begins in late 50s and documented most in >80yrs
108
What symptoms does AR present with?
symptoms of HF
acute AR - sudden cardiovascular collapse
Symptoms of the cause
109
What signs does aortic regurg present with?
Collapsing 'water-hammer' pulse, wide pulse pressure, thrusting and heaving displaced apex beat. Early diastolic murmur at lower left sternal edge. systolic pulsations see as various signs around body
110
What investigations would you do for aortic regurgitation?
1) ECG - may show non-specific ST-T wave changes, left axis deviation, or conduction abnormalities
2) CXR - Cardiomegaly
3) Echocardiogram- visualisation of the origin of regurgitant jet and its width; detection of cause of aortic valve pathology
111
What is mitral regurg?
Retrogade fow of blood from LV to left atrium during systole
112
What causes mitral regurg?
Rheumatic disease, infective endocarditis, mitral valve prolapse, papillary muscle rupture/dysfunction, chordal rupture/floppy mitral valve secondary to connective tissue disease, ventricular dilation
113
How common is mitral regurg?
affects 5% of adults. mitral valve prolapse common in young females.
114
What symptoms does mitral regurg present with?
symptoms of left HF, palps if there's AF, fatigue.
115
What signs might mitral regurg present with?
if AF - irregularly irregular pulse. Apex beat may be laterally displaces and thrusting, pansystolic murmur, loudest at apex, radiating to axilla, maybe s3 sound, signs of LHF, Mid-systolic click and late systolic murmur
116
What investigations would you do for mitral regurg?
Transthoracic Echo - presence and severity of MR; other structural and flow abnormalities
ECG - may show underlying arrythmia or prior infarction
117
What is mitral stenosis?
Mitral valve narrowing causing obstruction of blood flow from left atrium to left ventricle
118
What causes mitral stenosis?
Rheumatic heart disease (90%). congenital mitral stenosis, SLE, rheumatoid, endocarditis, atrial myxoma
119
How common is mitral stenosis?
Decreased incidence of rheumatic fever = declining incidence in industrialised countries
120
What symptoms does mitral stenosis present with?
Asymptomatic, fatigue, SOB on exertion
121
What signs will mitral stenosis present with?
peripheral or facial cyanosis (malar flush)
Pulse - thready or irregularly irregular (AF)
Palpation - apex beat undisplaced/tapping. parasternal heave.
Auscultation - loud s1 with opening sound, mid-diastolic murmur, pulmonary oedema if decompensated
122
What investigations would you do for mitral stenosis?
1. ECG - atrial fibrillation; left atrial enlargement; right ventricular hypertrophy
2. CXR - double right heart border indicating an enlarged left atrium; prominent pulmonary artery; Kerley B lines
3. Echo - hockey stick-shaped mitral deformity
123
Define tricuspid regurgitation
backflow of blood from right ventricle to right atrium in systole
124
What can cause tricuspid regurg?
| congenital, functional + other
Congenital - Ebstein anomaly (malpositioned tricuspid valve), cleft valve.
Functional: right ventricular dilation, valve prolapse
Rheumatic heart disease, infective endocarditis, trauma
125
How common is tricuspid regurg? What is the most common cause?
differs with cause. most common cause is infective endocarditis
126
What are symptoms of tricuspid regurg?
fatigue, breathlessness, palps, headaches, nausea, anorexia, epigastric pain
127
What are signs of tricuspid regurg?
AF - irregularly irregular pulse
^JVP, parasternal heave, pansystolic murmur @ lower left sternal edge. Loud p2 part of 2nd heart sound.
Palpable liver, ascites. Pitting oedema.
128
What investigations can you do for tricuspid regurg?
1) Echo - assessment of left and right heart ejection fraction/dilation, valve morphology/function; evidence of pericardial disease, constrictive/restrictive physiology, may show regional wall motion abnormalities
2) ECG - may show atrial flutter/fibrillation; presence of previous myocardial infarction
129
Define atrial fibrillation/flutter
| What are the three types of AF?
Rapid, chaotic and ineffective atrial electrical conduction:
Permanent, persistent and paroxsymal
130
What causes AF?
| Group into systemic, heart and lung causes
Systemic: thyrotoxicosis, HTN, alcohol.
Heart: Mitral valve disease, Ischaemic HD, rheumatic HD, cardiomyopathy, pericarditis, sick sinus syndrome, atrial myxoma.
Lung causes: bronchial carcinoma, PE
131
How common is AF?
Very common, present in 5% over 65 yrs old.
132
What are symptoms of AF?
Palps, syncope, symptoms of cause
133
What are signs of AF?
Irregularly irregular pulse, difference in apical and radial beat, signs of thyroid/valcular disease
134
What investigations would you do for AF?
1) ECG - uneven baseline with absent P waves, atrial flutter - saw tooth
2) Bloods - cardiac enzymes, TFTs, U+E's, Mg2+, Ca2+
3) Echocardiogram
135
How would you manage an AF patient?
1) treat any reversible causes.
2 components of AF management:
1) Rhythm control
>48hrs after AF - anticoag for 3-4 weeks before cardioversion
<48hrs since AF - DC cardioversion or chemical cardioversion. Prophylaxis against AF - sotalol, amiodarone, flecainide.
2) Rate control -
chronic (permanent) AF - Digoxin, verapamil, beta-blockers
136
What score assess stroke risk in AF pt's?
CHADS-Vasc score
Low risk pt's managed with aspirin
High risk managed with warfarin
137
What are some complications of AF?
Thromboembolism, worsening of existing HF
138
What's the prognosis for AF?
Chronic AF does not usually return to sinus rhythm
139
What is a supraventricular tachycardia?
Regular narrow-complex tachycardia. No p-waves. originates in atria.
140
What are the 3 types of SVT? And what are they?
AF,
AVNRT - Re-entrant circuit around AV node
AVRT - Re-entrant circuit between atria and ventricles due to accessory pathway (Bundle of Kent)
141
What are risk factors for developing a SVT?
Nicotine, alcohol, caffeine, previous MI, Digoxin toxicity
142
How common are they and in what gender?
VERY common, 2x more common in females
143
What symptoms can SVT's present with?
Syncope, palps, light-headedness, fatigue, dyspnoea
144
What signs does an SVT present with?
AVNRT - Normal except tachycardia
AVRT (WPW syndrome) - secondary cardiomyopathy (S3 gallop, RV heave, displaced apex beat)
145
What investigations can you do
1) ECG - regular tachycardia that does not vary in rate; P waves may have an unusual axis, such as being inverted in the inferior leads
2) Cardiac enzymes - check for features of MI
3) Digoxin toxicity - check levels
146
How would you manage an SVT if the pt is haemodynamically unstable?
DC cardioversion
147
What would you do for an SVT if patient is haemodynmically stable?
vagal manouevres + chemical cardioversion. If this fails - adenosine 6mg bolus (can increase to 12mg). if unresponsive sedate and synchronised DC cardioversion.
148
What is the ongoing management of an SVT?
AVNRT - radiofrequency ablation of slow pathway, beta blockers or chemical cardioversion
AVRT - rediofrequency ablation
Sinus tachycardia - exclude secondary cause, Beta-blockers, rate limiting CCB
149
What are some complications of aN SVT?
Haemodynamic collapse, DVT, systemic embolism, cardiac tamponade
150
What is the prognosis for an SVT?
Depends on if they have a underlying structural heart disease. If structure is normal - good prognosis.
151
What is WPW syndrome?
Congenital abnormality resulting in SVT using an accessory pathway. pre-excitation syndrome
152
What is the accessory pathway called? What heart abnormalities is this syndrome associated with?
bundle of kent
Associated with:
- Congenital cardiac defects
- Ebstein's anomaly
- Mitral valve prolapse
- Cardiomyopathies
153
How common is WPW?
Relatively common - most common of ventricular pre-excitation syndromes. more common in young and decreases w age
154
What are some signs and symptoms of WPW?
SVT may occur in early childhood, palps, light headedness, syncope, polyuria (atrial dilation - > ANP release)
155
What investigations would you do for WPW?
1) ECG - Short PR interval,
Broad QRS complex, Slurred upstroke producing a delta wave
2) Echo for structural defects
156
What are the three levels of heart block?
1st degree - prolonged conduction through the AV node
2nd degree -
Mobitz type 1 - progressive prolongation of conduction at AVN culminating in one atrial impulse failing to go through.
Mobitz type 2-regular failure of AVN conduction, define by number of normal conduction per failed conduction (e.g 2:1, 3:1)
3rd degree - no relationship between atria and ventricle
157
How common is heart block?
250,000 pacemakers a year and most are for heart block
158
What causes heart block?
MI or ischaemia heart disease (most common), Infection (rheumatic fever, infective endocarditis), Drugs (digoxin), metabolic (hyperkalaemia), infiltration of conducting system (sarcoidosis), degeneration of conducting system.
159
What symptoms do the different heart blocks present with?
1st degree - asymptomatic
2nd degree type 1 - usually asymptomatic
2type 2 and 3rd degree - stokes-adams attacks - syncope from ventricular asystole, maybe dizziness, palps, chest pain, HF
160
What signs does heart block present with?
often normal.
3rd degree - large volume pulse, JVP may show cannon a waves - which occur when atria and ventricles contract simultaneously
mobitz t2 + 3rd degree - signs of reduced cardiac output
161
What investigations do you do for heart block?
ECG (see laz for examples)
| Bloods - TFTs, digoxin, cardiac enzymes, troponin, CXR, Echo
162
How would you manage heart block?
Chronic - pacemaker for 3rd degree, Mt2 and symptomatic mt1.
Acute - IV atropine and temporary pacemaker
163
What are complications of heart block?
Asystole, cardiac failure, heart failure, complications of pacemaker
164
What is the prognosis for Heart block?
mt2 and 3rd degree usually indicate serious underlying issue
165
What is ventricular tachycardia?
Regular broad complex tachycardia originating from the venticles. rate of >120bpm
166
What causes a ventricular tachycardia?
Electrical impulses from a ventricular ectopic focus
167
What are risk factors for ventricular tachycardia?
coronary heart disease, structural heart disease, electrolyte deficiencies (k, ca and mg), use of stimulant drugs (caffeine, cocaine)
168
How common are VT's?
Fairly common, it's one of the shockable rhythms seen in cardiac arrest pts. peaks in middle decades of life.
169
What symptoms arise with VT?
Chest pain, palps, dyspnoea, syncopoe
170
What signs can VT present with?
Respiratory distress, bibasal crackles, raised JVP, hypotension, anxiety, agitation, lethargy, coma
171
What investigations are done for a VT?
ECG - can be hard to distinguish with SVT, if in doubt treat as VT.
Rate - >100bpm. Broad QRS complex, AV dissociation.
Electrolytes, digoxin levels, cardiac enzymes
172
What would you check first to manage a VT patient?
ABC approach. check if patient has a pulse,
173
How would you manage a pulseless VT and an unstable VT?
Pulseless - follow advanced life support algorithm.
Unstable - reduced cardiac output - synchronised cardioversion, correct electrolyte abnormalities, amiodarone.
174
How would you treat a stable VT?
They do not experience symptoms of haemodynamic compromise. Correct electrolyte abnormalities, amiodarone. synchronised DC shock if above steps are unsuccessful.
175
What are some complications of ventricular tachycardia?
Congestive heart failure, cardiogenic shock, VF
176
What's the prognosis of ventricular tachycardia?
Good if treated rapidly, long term depends on underlying cause
177
Define ventricular fibrillation
Irregular broad complex tachycardia that can cause cardiac arrest and sudden cardiac death
178
What causes VF?
Ventricular fibres contract randomly causing failure of ventricular function - occurs usually in pts with underlying heart disease
179
What are risk factors for VF?
Coronary artery disease, AF, hypoxia, ischaemia, Pre-excitation syndrome
180
How common is VF?
Most common arrhythmia in cardiac arrest pts. Parallels the incidence of IHD
181
What are the signs and symptoms of VF?
History of chest pain, fatigue, palps. likely to have pre-existing conditions.
182
What investigations would you do for VF?
1) ECG
2) Cardiac enzymes, electrolyes, drug levels, TFTs
3) Coronary angiography - if pt survives VF to check integrity of Coronary arteries
183
What would you do to manage VF?
Urgent defib and cardioversion. Most survivors need an ICD (assesses rhythm and applies shock if needed)
184
What are some complications of VF?
Brain injury, MI, arrhythmias, aspiration pneumonia, skin burns, death
185
What is the prognosis of VF?
Depends on time between VF and intervention - Ideally best within 4-6 mins. Anoxic encephalopathy is major VF outcome
186
What is infective endocarditis?
Infection of intracardiac endocardial structures - mainly valves
187
What causes infective endocarditis?
Streptococci, staphylococci, enterococci.
Oragnisms deposit on heart valves - can destroy them. activate the immune system ->immune complexes which deposit.
188
What are risk factors?
Abnormal valves, prosthetic heart valves, turbulent blood flow, recent dental work/poor dental hygiene
189
How common is infective endocarditis?
16-22/1 million.
190
What symptoms does infective endocarditis present with?
Fevers w sweats, chills, rigors, malaise, arthralgia, myalgia, confusion, skin lesion. ask about recent dental surgery or IV drug use.
191
What symptoms does infective endocarditis present with?
pyrexia, tachycardia, signs of anaemia, clubbing, new murmur.
Vasculitic lesions:
roth spots, janeway lesions, splinter haemorrhages. Osler nodes (autoimmune complexes)
192
What investigations would you do for Infective endocarditis?
Bloods -
FBC: anaemia, leukocytosis
Urinalysis - Proteinuria, pyuria, RBC casts, WBC casts (glomerulonephritis)
blood culture and sensitivity. - bacteraemia, fungaemia
Echo - valvular mobile vegetations
ECG
193
How would you treat infective endocarditis?
On clinical suspicion give empirical treatment of gentamicin, benzylpenicillin. antibiotics vary for each organism. on for 4-6 weeks. surgery to replace valves if poor response to antibiotics.
194
What are some complications of infective endocarditis?
Valve incompetence, intracardiac fistulae/abscesses, aneurysm, heart failure, renal failure, glomerulonephritis, arterial amboli from vegetations shooting to brain, kidneys, lungs, spleen
195
What's the prognosis of infective endocarditis?
Fatal if untreated, 15-30% even with treatment
196
What is rheumatic fever?
Inflammatory multisystem disorder occurring following group a strep infection
197
What is the underlying cause of rheumatic fever?
strep pharyngeal infection -> molecular mimicry and attack on heart tissue. (antibodies
directed against GAS antigens cross-react with host antigens).
198
Where is rheumatic fever common and at what age?
more common in far east/middle east/eastern europe/south america.
5-15 yrs old is peak incidence
199
What symptoms does Rheumatic fever present with?
2-5 weeks after GAS infection.
General: fever, malaise, anorexia.
Joints: painful, swollen, decreased movement/function. cardiac: breathlessness, chest pain, palps
200
What criteria can you use for rheumatic fever?
Duckett jones - +ve diagnosis if there's 2 major criterua or one major plus two minor. See RM for criteria.
201
What investigations can you do for rheumatic fever?
1) ESR/CRP
2) WBC
3) throat swab - culture for GAS
4) ECG/ECHO
202
What is pericarditis?
Inflammation of the pericarditis - may be acute, subacute or chronic
203
How common is pericarditis?
uncommon, <1/100 hospital admissions, more common in males
204
What causes pericarditis?
IDIOPATHIC.
infective causes - coxsackie B, Echovirus, mumps, strept, fungi, TB, Staph.
Connective tissue disease (sarcoidosis, SLE)
Post-MI
dresseler's syndrome
Malignancy, radiotherapy, thoracic surgery, drugs
205
What symptoms does pericarditis present with?
Chest pain, sharp and central, may radiate to neck or shoulders. worse coughing or deep inspiration (pleuritic pain). relieved sitting forward.
206
What signs do you get with pericarditis?
Fever, pericardial friction rub, faint heart sounds may be due to pericardial effusion, cardiac tamponade signs (raised JVP, low BP, muffled heart sounds), tachycardia, pulsus paradoxus.
207
What investigations would you do for pericarditis?
1) ECG - upwards concave ST-segment elevation globally with PR depressions
2) Echo - pericardial effusion
3) Bloods - FBC, U+E's, ESR/CRP, cardiac enzymes
208
How would you manage pericarditis?
Acute - pericardiocentesis
Medical - treat underlying causes, NSAIDs for pain and fever relief
Recurrent - low-dose steroids, immunosuppressants, colchicine
Surgical - pericariectomy if constrictive
209
What are 3 possible complications of pericarditis?
Pericardial effusion, cardiac tamponade, cardiac arrhythmias.
210
What's the prognosis of pericarditis?
depends on cause, viral usually good. malignant poor.
211
What is constrictive pericarditis?
chronic inflammation of the pericardium with thickening and scarring.
212
What causes constrictive pericarditis?
can occur after any pericardial disease process. Idiopathic, viral, TB, mediastinal irraditation, post-surgical, connective tissue disorder. difficult to distinguish from restrictive cardiomyopathy so often underdiagnosed
213
How common is constrictive pericarditis?
rare, all ages, 9% of acute pericarditis get constrictive pericarditis. TB has highest incidence. more common in males.
214
What are the signs and symptoms of constrictive pericarditis?
gradual onset. early symptoms are vague.
| Fever, chest pain, lower heart sounds, decreased cardiac output - SOB, low BP, lightheadedness.
215
What investigations would you do for constrictive pericarditis?
1) ECG - upwards concave ST-segment elevation globally with PR depressions
2) Echo - pericardial effusion
3) Bloods - FBC, U+E's, ESR/CRP, cardiac enzymes
216
What is cardiomyopathy?
Primary disease of the myocardium.
217
What causes the three types of cardiomyopathy?
Majority of causes are idiopathic.
1) Dilated - Post-viral myocarditis, alcohol, drugs (chemo, cocaine), thyrotoxicosis, haemochromatosis, peri-partum
2) Hypertrophic - 50% of cases are genetic (autosomal dominant)
3) Restrictive: amyloidosis, sarcoidosis, haemochromatosis.
218
How common are the three types of cardiomyopathy?
dilated and hypertrophic have prevanlence of ~0.05-0.2%. restrictive is rare.
219
What symptoms do each of them present with?
Dilated - symptoms of heart failure, arrhythmias, thromboembolism
Hypertrophic - usually none, syncope, angina, arrhythmias, family history of sudden death.
Restrictive - dyspnoea, fatigue, arrhythmia, ankle swelling or abdo swelling.
220
What signs will you get on examination for each of the cardiomyopathies?
dilated: ^JVP, displaced apex beat, functional mitral and tricuspid regurgitations, 3rd heart sounds
Hypertrophic: jerky carotid pulse, double apex beat, ejection systolic murmur.
Restrictive - ^JVP, palpable apex beat, 3rd heart sound, ascites, ankle oedema, hepatomegaly.
221
What investigations would you do for cardiomyopathy?
CXR - may show cardiomegaly + signs of heart failure
| ECG
ECHO
results see laz
222
What is myocarditis?
Acute inflammation and necrosis of cardiac muscle
223
What causes myocarditis?
Usually idiopathic. Viruses (Coxsackie b), bacteria, fungus etc
Non-infective - systemic disorders (SLE, sarcoidosis, polymyositis)
Drugs (Chemo)
224
How common is myocarditis?
unknown incidence bc not many detected at the time of acute illness. Coxsackie B common cause in europe and north america. Chagas common cause in south america
225
What symptoms does myocarditis present with?
Flu-like illness, fever, malaise, fatigue, lethargy. SOB. palps. sharp chest pain.
226
What signs does myocarditis present with?
Signs of concurrent pericarditis or complications: heart failure, arrhythmia
227
What investigations would you do for myocarditis?
1) 12 lead ECG - most commonly displays non-specific ST-segment and T-wave abnormalities; however, ST-segment elevation and depression frequently occur
2) CXR - frequently reveals bilateral pulmonary infiltrates in the setting of myocarditis-induced CHF
3) Bloods - including cardiac enzymes.
228
What is PVD?
Occurs due to stenosis of arteries from atheroclerosis, embolus or functional PVD (spasms)
229
What are the different types of PVD?
Intermittent claudication (calf pain on exercise), critical limb ischaemia (pain at rest), acute limb ischaemia (sudden decrease in arterial perfusion in a limb), arterial ulcers, gangrene
230
What are risk factors for PVD?
Smoking, diabetes, HTN, hyperlipidaemia, physical inactivity, obesity
231
Who is affected by PVD?
4-15% of 55-70 yrs old.
15-20% of 70+yrs.
males and incidence increases with age
232
What symptoms does PVD present with?
Intermittent claudication - cramping pain in the calf, thigh or buttock after exertion, relieved by rest.
233
What are some features of critical limb ischaemia?
Ulcers, gangrene, rest pain, night pain
234
What are the 5 steps of fontaine classification?
asymptomatic, intermittent claudication, rest pain, ulceration, gangrene
235
What signs does PVD present with?
Pain, pale, pulseless, paralysis, parasthesia, perishingly cold. atrophic skin, hairless, punched-out ulcers, colour change when raising leg.
