Cardiovascular Flashcards

Question

What are the immediate management protocols for a STEMI?

Answer 1

- Oxygen: only if SpO2 is <94%, and aim for 94-98% - Analgesia: morphine and sublingual glyceryl trinitrate - Dual antiplatelets: - Aspirin - The choice of the second antiplatelet agent depends on if the person is having PCI or not, and will vary based on local guidance: - Prasugrel or clopidogrel if undergoing PCI - Ticagrelor or clopidogrel if undergoing fibrinolysis

Answer 2

- Lifestyle changes: exercise, diet change, smoking cessation, reducing alcohol intake - Manage cardiovascular risk factors: lipid, diabetes, hypertension management - Antiplatelet therapy: - Aspirin 75mg OD continued indefinitely - The second antiplatelet depends on the one chosen in the acute setting i.e. prasugrel, ticagrelor, or clopidogrel, and is usually continued for 12 months. - Angiotensin-converting enzyme inhibitors (ACEi) and beta-blocker - Statin: usually atorvastatin 80mg - Cardiac rehabilitation: must be offered following myocardial infarction

Answer 3

- Post-MI pericarditis - Cardiac arrest - Bradyarrhythmia's - Ventricular septal defect - Cardiogenic shock - Mitral regurgitation - Left ventricular wall rupture

Answer 4

- Dressler's syndrome - Heart failure - Left ventricular aneurysm

Answer 5

- Type 1: a classic MI and occurs due to atheromatous plaque rupture - Type 2: secondary to ischaemia due to either increased oxygen demand or decreased supply, such as vasospasm, anaemia and sepsis. Management involves treating the underlying cause. - Type 3: Sudden cardiac death or cardiac arrest suggestive of an ischaemic event - Type 4: MI associated with PCI / coronary stenting / CABG

Answer 6

The Global Registry of Acute Coronary Events (GRACE) score is recommended by NICE to risk-stratify patients with unstable angina and non-ST elevation myocardial infarction (NSTEMI).

Answer 7

An antiplatelet: predominantly for COX-1 inhibition and this preventing the synthesis of thromboxane A2

Answer 8

Antiplatelet therapy: inhibit the binding of adenosine diphosphate to its platelet P2Y12 receptor.

Answer 9

Antiplatelets: glycoprotein IIb/IIIa receptor antagonists.

Answer 10

Anticoagulants: activate antithrombin III, this causing the inhibition of clotting factor Xa.

Answer 11

Anticoagulant: reversible direct thrombin inhibitor.

Answer 12

Cardiac output is not able to meet metabolic demands.

Answer 13

- Increasing age - Coronary artery disease - Hypertension - Valvular disease: commonly senile calcifiction of the aortic valve. - Diabetes - Atrial fibrillation - Renal insufficiency

Answer 14

- Cool peripheries - Signs of congestive heart failure: peripheral, pitting oedema and raised JVP - Displaced apex beat - Hypotension - Crackles on auscultation: left-sided failure; usually coarse bi-basal crackles - Third heart sound (S3) - Stony dull percussion: if an effusion is present

Answer 15

- Dyspnoea: due to pulmonary oedema - Often a history of orthopnea and paroxysmal nocturnal dyspnoea - Fatigue and weakness - Cardiogenic wheeze - Symptoms of congestive heart failure: swelling of the peripheries and ascites

Answer 16

- FBCs - U&Es - ABG - BNP or NT-proBNP - ECG - CXR - Transthoracic echocardiogram

Answer 17

- Stabilise the patient: administer oxygen to maintain a SpO2≥94% - Fluid restriction: fluid intake is usually limited to <1.5L/day - IV diuretic: usually a loop diuretic e.g. furosemide to relieve fluid overload - Inotropes or vasopressors e.g. dobutamine: only offer to patients with heart failure and cardiogenic shock (i.e. haemodynamically unstable) - Non-invasive ventilation (NIV): consider NIV if the patient does not stabilise with initial medical management - Continuous positive airway pressure (CPAP) - Intubation and ventilation: if CPAP is unsuccessful

Answer 18

- If acute heart failure is due to aortic stenosis: offer surgical aortic valve replacement - Mechanical assist device: pump that can temporarily help the pumping action of the heart

Answer 19

- ACE-inhibitor e.g. ramipril and a cardioselective β-blocker e.g. bisoprolol - Improved prognosis by slowing, or even reversing, ventricular remodelling - Fluid restriction: fluid intake is usually limited to <1.5L/day - Loop diuretic (e.g. furosemide) for symptomatic relief of oedema

Answer 20

Arrhythmias: can both precipitate acute heart failure and occur as a result of it. Atrial fibrillation is one of the most common arrhythmias associated with heart failure.

Answer 21

- Old age - Hypotension - Male - Ischemia - Renal dysfunction - Previous chronic HF - Low respiratory rate (<30)

Answer 22

Heart cannot supply enough blood to the heart to meet its own demands.

Answer 23

Heart cannot pump hard enough. - Ejection fraction of below 40% (50% and below is borderline). - The stroke volume is decreased.

Answer 24

Heart cannot fill enough during diastole. - Stroke volume is low but the ejection fraction is preserved due to reduced filling (reduced pre-load)

Answer 25

Both right sided and left sided heart failure.

Answer 26

Usually caused by systolic dysfunction. - Usually due to damage to the myocardium. - Cannot contract hard enough.

Answer 27

- Ischemia - Valvular disease - Cardiomyopathy - Left sided heart failure → Biventricular - Atrial septal defect - Ventricular septal defect - AF

Answer 28

- Increased pressure in the pulmonary artery. - Fluid in the interstitial space (congestion)/pulmonary oedema. - Dyspnea and Orthopnea as oxygen cannot enter the alveoli as efficiently when there is fluid build up. - Crackles - when the patient breathes. - S3 heard.

Answer 29

- Jugular venous distention - Hepatosplenomegaly (painful) - Cirrhosis of the liver (cardiac cirrhosis) - Ascites - Pitting oedema (legs when standing and sacrum

Answer 30

- Ischemia - Long standing hypertension - Dilated cardiomyopathy

Answer 31

- Long standing hypertension - Aortic stenosis - Hypertrophic cardiomyopathy - Restrictive cardiomyopathy

Answer 32

- Pulmonary hypertension. - Shunt - Cor Pulmonale

Answer 33

- Hemosiderin-Laden macrophages (LSHF) - ECG - broad QRS complex (LV hypertrophy) - CXR - Alveolar oedema - Kerley B lines - Cardiomegaly - Dilated upper lobe vessels - Pleural effusion - Transthoracic echocardiogram (diagnostic) - LVEF, diastolic function and valvular abnormalities.

Answer 34

- ACEi → dilate blood vessels - Diuretics → reduce fluid build up - Ventricular assist device (VAD) - Heart transplant

Answer 35

Class I (mild) - No limitation for physical activity. Class II (mild) - Slight limitations of physical activity Class III (moderate) - Marked limitation of physical activity Class IV (severe) - Cannot carry out physical l activity without discomfort

Answer 36

An abdominal aortic aneurysm (AAA) describes a dilatation in vessel wall diameter of >50%, which typically means a diameter of >3 cm.

Answer 37

- Degradation of the tunica media and adventitia → vessel dilatation - The most important risk factor for abdominal aortic aneurysms is atherosclerosis. - In atherosclerosis, chronic inflammation results in the release of enzymes called matrix metalloproteinases which degrade the extracellular matrix in the tunica media, weakening the aortic wall. - An AAA most commonly forms below the level of the renal arteries, known as an infra-renal aneurysm. - This is because below this level, the abdominal aorta lacks vasa vasorum (small blood vessels in the adventitial layer that provide nutrients to the aorta). The absence of vasa vasorum in this part of the aorta makes the tunica media particularly susceptible to ischaemia. - Thickening of the intima makes it harder for oxygen to diffuse to the tunica media.

Answer 38

- Gender → Male > Female - Age → >60 years - Atherosclerosis - Smoking - Hypertension - Hyperlipidaemia - Diabetes - Connective tissue disorders: such as Ehlers Danlos and Marfan syndrome, due to changes in the balance of collagen and elastic fibres - Family history

Answer 39

- Pulsatile abdominal mass - Tachycardia and hypotension: red flags signifying ruptured AAA - Grey-Turner’s sign: flank bruising secondary to retroperitoneal haemorrhage - Cullen’s sign: pre-umbilical bruising

Answer 40

- Flank, back or abdominal pain - Pulsating abdominal sensation

Answer 41

Abdominal ultrasound.

Answer 42

- FBC - U&Es - CRP/ESR - Group and save and crossmatch - CT angiogram - MRI

Answer 43

The screening programme in England is offered to all males aged 65 and over as a one-off abdominal ultrasound, and further surveillance is organised if the aneurysm exceeds 3 cm.

Answer 44

- Surveillance - Surgical repair - Steroids or immunosuppressants if inflammatory AAA.

Answer 45

Aortic dissection describes the condition when a separation has occurred in aortic wall intima, causing blood flow into a new false channel between the tunica intima and tunica media.

Answer 46

This most commonly occurs around the ascending aorta and aortic arch, but can affect any part of the aorta.

Answer 47

- Hypertension: the most important risk factor - Smoking - Family history of aortic aneurysm or dissection - Coarctation of the aorta: narrowing of vessel - Bicuspid aortic valve - Connective tissue disorders: Marfan and Ehlers-Danlos syndrome - Turner and Noonan syndrome - Trauma - Pregnancy: increased blood plasma volume - Syphilis

Answer 48

- Weak downstream pulses: radio-radial and/or radio-femoral delay - A difference in blood pressure between two arms: >10 mmHg - Hypertension - Tachycardia and hypotension: as condition progresses - Diastolic murmur: due to aortic regurgitation - Involvement of specific arteries - Marfans syndrome signs - Ehlers-Danlos syndrome signs

Answer 49

- Sudden onset, severe ‘tearing’ or ‘ripping’ chest pain that may radiate to the back - Syncope: red flag symptom

Answer 50

- ECG - FBC - Group and save and crossmatch - Chest X-Ray - U&Es - Contrast enhanced CT

Answer 51

Echocardiogram -> transthoracic or transoesophageal should be considered in unstable patients.

Answer 52

- Blood transfusion - Beta blockers - Urgent surgical repair

Answer 53

- Conservative management - Beta blockers - Thoracic endovascular aortic repair

Answer 54

- Aortic regurgitation - MI - Stroke - Renal failure - Tamponade - Haemorrhagic shock

Answer 55

- Hypertension refers to a persistent elevation of arterial blood pressure. - Hypertension is defined as a blood pressure reading of ≥140/90 mmHg (ambulatory blood pressure monitoring ≥135/85 mmHg) and is categorised into primary or secondary hypertension, depending on whether a cause can be identified.

Answer 56

- Primary (essential) hypertension: has no known underlying cause and is responsible for 90-95% of cases of hypertension. Some contributing factors include: - Genetic susceptibility - Excessive sympathetic nervous system activity - Abnormalities of Na+/K+ membrane transport - High salt intake - Abnormalities in renin-angiotensin-aldosterone system

Answer 57

- Secondary hypertension indicates a known underlying cause. Examples include (ROPED): - R - Renal disease: glomerulonephritis, polycystic kidney disease, renal artery stenosis, chronic kidney disease - O - Obesity - P - Pregnancy (pre-eclampsia) - E - Endocrine disorders: primary hyperaldosteronism, phaeochromocytoma, Cushing’s syndrome, hyperthyroidism, acromegaly - D - Drugs: glucocorticoids, ciclosporin, atypical antipsychotics, the combined oral contraceptive pill

Answer 58

- Increasing age - African heritage - Family history

Answer 59

- Obesity - Sedentary Lifestyle - Alcohol excess - Smoking - High Sodium intake - Stress

Answer 60

Stage 1 - >140/90 clinic reading or >135/85 home reading. Stage 2 - >160/100 clinic reading or >150/95 home reading. Stage 3 - >180/120 clinic reading.

Answer 61

- Hypertensive retinopathy - Visual disturbance - Cardiac symptoms e.g. chest pain - Oliguria or polyuria - Weight loss - Sweating - Palpitations

Answer 62

- Asymptomatic: most common presentation - Headaches: classically occipital and worse in the morning

Answer 63

Blood pressure readings.

Answer 64

- Fundoscopy: assess for hypertensive retinopathy - 12-lead ECG: assess for ischaemic changes and evidence of left ventricular hypertrophy - Albumin:creatinine ratio (ACR) and urinalysis: assessing for renal dysfunction, as evidenced by elevated ACR and proteinuria or haematuria on urinalysis - Bloods: HbA1c, U&Es, total cholesterol and HDL cholesterol - It is also important to formally estimate cardiovascular risk using a tool such as QRisk to discuss prognosis and healthcare options.

Answer 65

- Hypertension is confirmed when the following criteria are met: - Clinic blood pressure of 140/90 mmHg or higher and - ABPM daytime average or HBPM average of 135/85 mmHg or higher

Answer 66

A – ACE inhibitor (e.g., ramipril) B – Beta blocker (e.g., bisoprolol) C – Calcium channel blocker (e.g., amlodipine) D – Thiazide-like diuretic (e.g., indapamide) ARB – Angiotensin II receptor blocker (e.g., candesartan) Step 1: Aged under 55 or type 2 diabetic of any age or family origin, use A. Aged over 55 or Black African use C. Step 2: A + C. Alternatively, A + D or C + D. Step 3: A + C + D Step 4: A + C + D + fourth agent (see below)

Answer 67

Step 4 depends on the serum potassium level: Less than or equal to 4.5 mmol/L consider a potassium-sparing diuretic, such as spironolactone More than 4.5 mmol/L consider an alpha blocker (e.g., doxazosin) or a beta blocker (e.g., atenolol)

Answer 68

- <80 years: <140 systolic; <90 diastolic - >80 years: <150 systolic; <90 diastolic

Answer 69

NICE recommend measuring blood pressure every 5 years to screen for hypertension. It should be measured more often in patients that are on the borderline for diagnosis (140/90) and every year in patients with type 2 diabetes.

Answer 70

- Coronary heart disease. - Cerebrovascular accident. - Congestive heart failure. - Chronic kidney disease - Hypertensive retinopathy

Answer 71

While there is not an accepted standard hypotensive value, pressures less than 90/60 are recognized as hypotensive.

Answer 72

Commonly asymptomatic. - Shortness of breath - Irregular heartbeat - Fever - Cough - Vomiting - Dysuria - Fatigue

Answer 73

Commonly asymptomatic. - Dizziness - Syncope - Chest pain - Headache - Stiff neck

Answer 74

- FBC: with TSH, free T4 and cortisol levels. - If patient is in shock then → ECHO immediately with IVC variability test. - Pulse pressure variation measurement. - CT angiogram to rule out saddle embolus pulmonary embolisms.

Answer 75

- The treatment of hypotension should focus on reversing the underlying etiology. - Fluid resuscitation. - Vasopressors may be indicated if the mean arterial pressure is less than 65 mm Hg.

Answer 76

- Benign hypotension - Distributive shock - Cardiogenic shock - Hypovolemic shock - Obstructive shock - Combined-type hypotensive shock

Answer 77

- Sudden cardiac death. - Multi-organ failure.

Answer 78

DVT of the leg is the development of a blood clot in one of the major deep veins in the leg or thigh, which leads to impaired venous blood flow, usually causing leg swelling and pain.

Answer 79

- Cyanosis - Swollen and tended red leg. - Cardiac: Increased HR, AF, Increased JVP. - Chest: Increased RR, pleural rub, pleural effusion. - Pulsus paradoxus.

Answer 80

- Leg pain, which may be along the vein. - Respiratory: SOB, pleuritic chest pain, haemoptysis, cough. - Systemic: dizziness, fever.

Answer 81

- DVT or PE in past medical history. - Immobility - Cancer which effects thrombin (prostate and ovarian heavily linked) - (O)Estrogen which increases fibrinogen, prothrombin and clotting factor levels.

Answer 82

- T - Trauma or Travel - H - Hospitalisation or Hormones - R - Relatives (family history) - O - Old age - M - Malignancy (cancer) - B - Long bone fractures - O -Obesity or Obstetrics - S - Surgery or Smoking - I - Immobilisation - S - other Sickness (Antiphospholipid syndrome, nephrotic syndrome, paroxysmal nocturnal haemoglobinuria)

Answer 83

- 2-level Wells DVT score or 2-level Wells PE score. - Pulmonary embolism rule out criteria (PERC)

Answer 84

- CXR → may show wedge shaped infarct, more often used to rule out other conditions. - ECG → Sinus tach, RV strain (T inversion in V1-V3), S1Q3T3 (prominent S in lead I, Q wave and inverted T wave in lead III), RBBB, right axis deviation. - ABG → Decreased O2, decreased CO2, Increased pH. - Unprovoked VTE → consider thrombophilia.

Answer 85

- Anticoagulation to prevent recurrent VTE (Warfarin or LMW Heparin/Fondaparinux) - DOACs - If O2 <90% then give O2. - Aspirin or other anti-platelet drugs.

Answer 86

- Recurrent risk of VTE. - DVT complications → Cellulitis, Thrombophlebitis, post-thrombotic syndrome.

Answer 87

Pulmonary embolism (PE) refers to obstruction of the pulmonary vasculature, secondary to an embolus.

Answer 88

- Emboli typically originate in the lower extremities, most commonly secondary to a deep vein thrombosis (DVT) in the calf: - Once the clot has formed, the increased pressure in the vein can cause a part of the main clot to break free, becoming a thromboembolism which can travel downstream towards the heart and gets into the right atrium, and then into the right ventricle to get pumped into the lungs where it can get lodged. - When a pulmonary embolism happens, a blockage in any of the arteries leads to a decrease in blood flow to lung tissue downstream. - If there is no blood flowing past an alveoli, then this means that the alveoli getting ventilated with fresh air but not getting perfused with blood. This is called a ventilation perfusion mismatch or a V/Q mismatch. The body needs oxygenated blood to function and can therefore only tolerate a bit of a V/Q mismatch, before the lungs are no longer able to meet the needs of the body. - After some hours, the non-perfused lung no longer produces surfactant resulting in alveolar collapse which in turn exaggerates hypoxaemia.

Answer 89

- Virchow's triad causing clots: - Hypercoagulability - Venous Stasis - Endothelial cell damage .

Answer 90

- Hypoxia - Cyanosis may be present - Deep vein thrombosis: swollen, tender calf - Pyrexia may be present - Tachypnoea and tachycardia - Crackles - Hypotension: SBP <90 mmHg suggests a massive PE - Elevated JVP: suggests cor pulmonale - Right parasternal heave: suggests right ventricular strain

Answer 91

- Pleuritic chest pain - Dyspnoea - Cough +/- haemoptysis - Fever - Fatigue - Syncope: a red flag symptom

Answer 92

- Wells Two-Level score, in conjunction with clinical judgement, is utilised to determine the probability of PE. - > 4: high probability of PE - ≤ 4: low probability of PE

Answer 93

- CXR - rule out an alternative pathology. - ECG (sinus tachy, RBBB, S1Q3T3) - CT pulmonary angiogram - D-Dimer (fibrin breakdown products) - All patients with unprovoked PE should have FBC for suspected cancer.

Answer 94

- ABG - quantify the degree of hypoxia. - V/Q scan - Pulmonary angiography (gold standard, but more invasive and has higher complications)

Answer 95

- Cor pulmonale - Pulmonary infarction - Sudden death - Respiratory alkalosis - Embolic stroke - Heparin-associated thrombocytopenia

Answer 96

- Compression stockings - Frequent calf exercises during long periods of sitting still - Prophylactic treatment with low molecular weight heparin

Answer 97

- Admission to hospital - Oxygen, as required - Analgesia, if required - Adequate monitoring for any deterioration

Answer 98

- Thrombolysis e.g. alteplase: injecting a fibrinolytic medication that rapidly dissolves clots. - Anticoagulation therapy - Inferior vena cava filter - Surgical embolectomy

Answer 99

Peripheral arterial disease (PAD) is a major circulatory disorder characterised by arterial obstruction, leading to reduced blood supply and ischaemia in the lower limbs.

Answer 100

- Age → Higher risk when older. - Gender → Male > Female - Smoking: the single greatest risk factor and is thought to confer more than a 4-fold increased risk of PAD - Diabetes mellitus - Hypercholesterolaemia - Hypertension - Chronic kidney disease - High serum homocysteine

Answer 101

PVD. - Stage I - Asymptomatic - Stage 2 - Intermittent claudication - Stage 3 - Critical limb ischemia - Stage 4 - Tissue loss: ulceration or gangrene

Answer 102

- Common iliac: unilateral buttock - Common femoral: unilateral thigh - Superficial femoral: unilateral calf - Aortoiliac (Leriche syndrome) may cause the triad of: - Bilateral buttock and thigh claudication - Absent or decreased femoral pulses - Erectile dysfunction

Answer 103

- History - Ankle-brachial pressure index (ABPI) - Duplex ultrasound - Assessment of cardiovascular risk factors (ECG, FBC, U&E, random glucose or HbA1c, serum cholesterol, and lipid profiles)

Answer 104

- Exercise ABPI: for people in whom the diagnosis is uncertain on the basis of resting ABPI - Computed tomography angiography - Magnetic resonance angiography

Answer 105

- Exercise - Management of cardiovascular risk factors: smoking cessation, HbA1c control, BP control, diet and weight management, lipid modification (statins), antiplatelet agents (e.g. clopidogrel) - Surgical intervention - Consideration of naftidrofuryl oxalate: vasodilator

Answer 106

- Critical limb ischaemia and acute limb ischaemia - Ulceration and gangrene - Infection and poor tissue healing - Amputation - Multiorgan dysfunction may occur, especially in people with acute limb ischaemia

Answer 107

- Pericarditis is inflammation of the pericardium. - Pericardial effusion is a condition in which extra fluid collects between the heart and the pericardium.

Answer 108

- Gender → Male > Female - 20-50 years of age - Previous MI - Viral or bacterial infection - Systemic autoimmune disorders

Answer 109

- Pericardial rub - Heard at the left sternal edge as the patient leans forward - Extra heart sound of a to-and-fro character - High-pitched or squeaky - Diminished heart sounds: if there is large effusion - Tachycardia - Tachypnoea

Answer 110

Acute pericarditis generally lasts just a few weeks, whereas chronic pericarditis lasts longer, usually more than 6 months.

Answer 111

- Chest pain - Sudden onset, sharp, central and pleuritic - Relief upon sitting up or leaning forward - Exacerbated by lying flat - May last from hours to days - Fever and myalgia - Shortness of breath - Hiccups: if phrenic involvement - Low BP and light headedness: if effusion is large - Peripheral oedema: suggests right-sided heart failure secondary to constrictive pericarditis - Prodromal viral illness: e.g. upper respiratory tract infection

Answer 112

- ECG: - Pericarditis: widespread saddle-shaped ST-elevation (highly sensitive) and PR depression (highly specific) followed by T-wave flattening and eventual T-wave inversion. - Pericardial effusions: low QRS complex voltage or electrical alternans (QRS complexes have different heights) - Chest X-ray: may demonstrate an associated pericardial effusion showing “water-bottle heart” as there is pooling of fluid at the bottom of the heart - Transthoracic echocardiogram: pericardial effusion shows a 'dancing' heart as it moves around in the fluid - ESR and CRP: elevated secondary to inflammation

Answer 113

- Troponin: elevated in 35-50% of patients - Urea: elevated levels indicate a uraemic cause

Answer 114

- 1st line: NSAIDs and colchicine are often both used together - 2nd line: NSAIDs, colchicine and low-dose prednisolone

Answer 115

IV antibiotics and pericardiocentesis (removal of fluid) with washout, culture and sensitivities

Answer 116

Pericardectomy may be considered for refractory cases of pericarditis unresponsive to medical therapy

Answer 117

- Myocarditis - Constrictive pericarditis

Answer 118

- Idiopathic - Viral - Bacterial - Dressler syndrome - Uraemia secondary to kidney disease - Systemic autoimmune disorders - Connective tissue disorders - Hypothyroidism - Trauma - Malignancy - Certain medications such as penicillin or anticonvulsants

Answer 119

- Coxsackievirus - Mumps - Epstein-Barr virus (EBV) - Cytomegalovirus (CMV) - Varicella-Zoster virus (VZV) - HIV

Answer 120

- Tuberculosis

Answer 121

- Kussmaul’s sign: rise in jugular venous pressure and increased neck vein distension during inspiration - Pulsus paradoxus - Diffuse heart sounds - Right heart failure signs - Ascites - Oedema - Atrial dilatation

Answer 122

- CXR: small heart with/without pericardial calcification - ECG: low voltage QRS - ECHO: thickened calcified pericardium restricting the heart’s movement; small ventricular cavities

Answer 123

- May require complete resection of the pericardium; pericardiectomy

Answer 124

- Congestive heart failure.

Answer 125

- Cardiac tamponade describes a reduction in cardiac output due to a raised intrapericardial pressure secondary to a pericardial effusion.

Answer 126

- Idiopathic - Viral - Bacterial - Dressler syndrome - Uraemia secondary to kidney disease - Systemic autoimmune disorders - Hypothyroidism - Trauma - Malignancy - Aortic dissection - Rheumatological

Answer 127

- Beck's triad - Hypotension - Kussmaul's sign - Muffled heart sounds - Tachycardia - Cool peripheries - Pulsus paradoxus - Prolonged capillary refill time

Answer 128

- Dyspnoea - Coughing - Chest discomfort - Lightheadedness: if large effusion - Peripheral oedema: heart failure - Confusion: decreased CNS perfusion

Answer 129

- ECG: tachycardia, low QRS complex voltage and electrical alternans (QRS complex varies in amplitude as the heart moves in the fluid) - Bloods (inflammatory markers and troponin) - Imaging (ECHO, chest X-ray)

Answer 130

Pericardial fluid analysis - obtained through a pericardiocentesis.

Answer 131

- Conservative management: repeat echocardiograms and monitor blood pressure - NSAIDs or colchicine if the underlying cause is suspected pericarditis - Pericardiocentesis: may be required for larger effusions

Answer 132

- Urgent pericardiocentesis: a needle is inserted between the xiphisternum and left costal margin and directed towards the left shoulder. This can be done under ultrasound guidance. Pericardial fluid can be aspirated to relieve intrapericardial pressure - Urgent surgical drainage is usually indicated in cases related to neoplasia, a purulent effusion, or hemopericardium (e.g. trauma)

Answer 133

- Cardiac arrest - Constrictive pericarditis

Answer 134

Bradycardia is defined as a heart rate below 50 beats per minute, which can either be physiological or due to sinus node or atrioventricular (AV) node conduction dysfunction.

Answer 135

First-degree AV block: occurs where there is delayed atrioventricular conduction through the AV node but every atrial impulse leads to a ventricular contraction.

Answer 136

Atrial inputs becomes gradually weaker until it does not pass through the AV node. After failing to stimulate a ventricular contraction the atrial impulse returns to being strong.

Answer 137

Usually due to disease of the His-Purkinje system which causes intermitted failure or interruption of AV conduction. This results in missing QRS complexes. There is usually a set ratio of P waves to QRS complexes.

Answer 138

Complete heart block. This is no observable relationship between P waves and QRS complexes.

Answer 139

- Increasing age. - Hypothyroidism - Electrolyte imbalances - Recent MI - Hypothermia - Drugs - Drugs: e.g. beta-blockers, non-dihydropyridine calcium channel blockers, digoxin, adenosine and amiodarone

Answer 140

Cushings triad - Bradycardia - Hypertension - Irregular respirations (apnoea) - JVP

Answer 141

- Dizziness - Fatigue - Shortness of breath - Syncope

Answer 142

- First-degree AV block: PR interval >0.2s - Mobitz type I / Wenckebach: increasing PR interval culminating in a dropped QRS complex. The PR interval resets and the cycle repeats. - Mobitz type II: the PR interval remains constant, but with intermittent dropped QRS complexes (2:1, 3:1, etc). - Third-degree AV block: P wave and QRS complex are completely dissociated

Answer 143

- TFTs - U&Es - Serum digoxin - Holter monitoring - Tilt-table test - ECHO

Answer 144

If stable - observe.

Answer 145

- First line: atropine 500mcg IV - If no improvement: - Atropine 500mcg IV repeated - Other inotropes (such as noradrenalin) - Transcutaneous cardiac pacing (using a defibrillator)

Answer 146

- Temporary transvenous cardiac pacing - Permanent implantable pacemaker when available

Answer 147

- Syncope - Arrhythmias: some patients may go on to develop asystole, ventricular tachycardia or ventricular fibrillation - Congestive heart failure: due to poor cardiac output

Answer 148

- Infective endocarditis (IE) is an infection of the endocardium (including the valvular structures, the chordae tendineae, sites of septal defects etc). - Endocarditis typically affects valves - native valves or prosthetic valves.

Answer 149

- Staphylococcus aureus - Staphylococcus epidermidis - Streptococcus bovis - Viridans streptococci - Streptococcus mitis and sanguinis

Answer 150

- Male gender: men are 2.5 times more prone to endocarditis than women - Previous infective endocarditis - Prosthetic heart valves or implantable cardiac device - Congenital heart disease especially affecting the valves - Rheumatic heart disease causing damage to the valves - Poor dental hygiene/ dental treatment: a way of microbes entering - Intravenous drug use (IVDU) typically affects tricuspid valve - Intravenous catheter - Immunosuppression

Answer 151

- Heart murmur: due to turbulent blood flow - Splinter haemorrhages: red-plum lines under the nails due to microemboli deposition - Janeway lesions: painless plaques on palms and soles due to septic microemboli deposition - Osler’s nodes: painful nodules on fingers or toes due to immune complex deposition - Roth’s spots: white centred retinal haemorrhages due to immune complex deposition - Signs of glomerulonephritis: due to immune complex deposition in kidneys - Mild splenomegaly

Answer 152

- Fever or chills - Headache - Shortness of breath - Night sweats, malaise, fatigue, weight loss - Joint pain: may be due to septic emboli

Answer 153

- inflammatory markers (WCC, Neutrophilia) - CRP/ESR - 3 x blood cultures 1 hour apart - ECHO - confirms diagnosis (transthoracic is first line, transoesophageal if clinical suspicion remains) - Chest X-ray - 12-lead ECG - Urinalysis

Answer 154

The Modified Duke Criteria requires 2 major criteria, or 1 major and 3 minor criteria, or 5 minor criteria for a diagnosis of infective endocarditis.

Answer 155

IV antibiotics: generally for 4-6 weeks. Patients usually require a central line or peripherally inserted central catheter (PICC)

Answer 156

- Surgery: aim to remove infected tissue and repair or replace affected valves - Indications include: decompensated heart failure, resistance to antibiotic therapy, severe sepsis, perivalvular abscess, intracardiac fistulae, prosthetic valve endocarditis

Answer 157

- Regurgitation - Congestive HF - Septic embolisation - Valvular rupture - Aortic rot abscess

Answer 158

Acute rheumatic fever is an autoimmune condition triggered by group A β-haemolytic Streptococcus pyogenes infection (rheumatic fever usually follows strep throat)

Answer 159

- Childhood and adolescence: peak age 5-17 years old - Developing world: rheumatic fever is considered a disease of poverty, with lower rates in the developed world due to improvements in antibiotic use and hygiene - Malnutrition - Overcrowding - Family history of rheumatic fever - HLA class II

Answer 160

- Heart murmur (mitral stenosis and aortic regurgitation) - Tachycardia or bradycardia - Pericardial rub on auscultation - Palpitations - Tender joints: usually not swollen - Erythema marginatum - Subcutaneous nodules - Pan-carditis

Answer 161

- Recent sore throat or scarlet fever (occurs 2-4 weeks before chest pain) - Chest pain: pleuritic - Shortness of breath - Fever and rigors - Non-pruritic rash - Joint pain: oligo- or poly-arthritis - Severe pain - Often involves the lower limbs - Migratory - Sydenham’s chorea

Answer 162

- Throat swab - Anti-streptococcal antibodies (ASO) titres - Chest X-ray: cardiomegaly and/or evidence of congestive heart failure may be seen - Echocardiogram: may demonstrate mitral and aortic valvular pathology, as well as the presence of pericarditis or a pericardial effusion - Blood cultures: if the patient is pyrexial - Raised WCC - Raised ESR and CRP

Answer 163

Jones Criteria is used to diagnose rheumatic fever and is dependent on evidence of recent streptococcal infection in addition to 2 major criteria, or 1 major and 2 minor criteria: - Major criteria: - J – Joint arthritis - O – Organ inflammation, such as carditis - N – Nodules - E – Erythema marginatum rash - S – Sydenham chorea - Minor criteria - Fever - ECG Changes (prolonged PR interval) without carditis - Arthralgia without arthritis - Raised inflammatory markers (CRP and ESR)

Answer 164

- Conservative: bed rest, analgesia, immobilise joints in severe arthritis - Antibiotic therapy: benzylpenicillin IV STAT, followed by oral phenoxymethylpenicillin for 10 days - Aspirin and steroids: used to treat carditis - Haloperidol or diazepam: if severe Sydenham’s chorea is present

Answer 165

- All patients should be put on long-term, regular antibiotics to lower chance of developing chronic rheumatic heart disease - Antibiotics: IM benzylpenicillin. The duration will vary depending on patient factors (e.g. could be for 10 years or life-long)

Answer 166

- Rheumatic heart disease: occurs in 30-50% of patients, most commonly affecting the mitral valve, followed by the aortic valve. - Heart failure: may occur in chronic or recurrent cases - Infective endocarditis: previous rheumatic heart disease increases the risk of infective endocarditis - Atrial fibrillation

Answer 167

- Aortic stenosis (AS) represents obstruction of blood flow across the aortic valve due to pathological narrowing. - It can be supra-valvular (e.g. fibrous ridge above valve), sub-valvular (e.g. fibrous ridge is below valve) or valvular.

Answer 168

The aortic valve is normally made up of three leaflets: the left, the right, and the posterior leaflet. It opens during systole to allow blood to be ejected to the body. During diastole, it closes to allow the heart to fill with blood and get ready for another systole.

Answer 169

- Mechanical stress over time. - Bicuspid valve. - Other congenital variations of the valve. - Chronic rheumatic fever.

Answer 170

- Aortic stenosis refers to when the aortic valve doesn't fully open, making it harder for blood to be pumped out. Usually, the aortic valve opens to about 3-4 cm^2, but with stenosis it can become less than 1 cm^2. - The valve doesn't open as easily but as the left ventricle contracts, it creates a high pressure that eventually pushes on the valve until it finally snaps open, causing a characteristic “ejection click.” - As the blood has to flow through a narrow opening, there’s turbulence which creates a murmur - initially gets louder as more blood flows past the opening, and then becomes quieter as the amount of blood flowing subsides (crescendo-decrescendo murmur). - As the left ventricle has to generate higher pressures, it undergoes concentric hypertrophy. Despite this, enough blood may still not leave the heart. This leads to symptoms of heart failure which will vary depending on which organ is affected e.g. brain = syncope

Answer 171

- Hypercholesterolaemia - Hypertension - Smoking - Diabetes - Rheumatic heart disease - Bicuspid aortic valve

Answer 172

Mild aortic stenosis can be completely asymptomatic, discovered as an incidental murmur during routine examination. - Ejection systolic murmur - Ejection click - Soft / ascent S2 - Fourth heart sound (s4) - Palpable thrill during systole - Pulsus tarsus - Left ventricular hypertrophy on imaging

Answer 173

Mild aortic stenosis can be completely asymptomatic, discovered as an incidental murmur during routine examination. - Fatigue - Shortness of breath - Angina - Dizziness - Fainting - Epistaxis and bruising Symptoms may be worse on exertion.

Answer 174

- ECHO (gold standard) - left ventricular size and valve area

Answer 175

Aortic regurgitation (AR) is the diastolic leakage of blood from the aorta into the left ventricle.

Answer 176

- Patients with aortic regurgitation will have an early decrescendo diastolic murmur, caused by the blood flowing back through the valve. - As blood leaks back from the aorta into the left ventricle, the left ventricular blood volume increases, which increases the stroke volume. More blood pumped out of the heart per squeeze requires more pressure, so systolic blood pressure increases. During diastole, though, there’s less blood volume in the aorta so diastolic blood pressure decreases. A high systolic pressure and low diastolic pressure is known as hyperdynamic circulation. - Patients with a hyperdynamic circulation have bounding pulses, or water-hammer pulses, as the blood slams against the walls of the arteries with each heartbeat. - Over time, the increase in blood volume in the left ventricle causes it to undergo eccentric ventricular hypertrophy. - Aortic regurgitation can be acute or chronic. Chronically, there can be compensation (LV hypertrophy). However, acutely valvular incompetence develops and blood starts to back up in the atria → pulmonary system etc

Answer 177

- Aortic root dilation: most are idiopathic but can also be caused by aortic dissection, aneurysms, syphilis, connective tissue disorders and aortitis. - Valvular damage e.g. due to infective endocarditis or rheumatic fever: chronic inflammation leads to fibrosis, but instead of fusing the valve leaflets together, it makes it so that they don’t form a strong seal, and instead let blood leak through. - Congenital causes: e.g. bicuspid or quadcuspid valve

Answer 178

- Infective endocarditis - Rheumatic fever - Congential abnormalities e.g. bicuspid valve - Connective tissue disorders - Aortic dissection - Aortic aneurysms - Gender → Male > Female

Answer 179

- Early decrescendo murmur: due to blood flowing back into LV - Soft S1 and S2 - Apex beat is displaced laterally - Wide pulse pressure: due to high systolic pressure and low diastolic pressure - Bounding pulses/ water-hammer pulse - de Musset’s: head bobbing with each beat due to severe bounding pulses - Quincke’s sign: pulsation of capillary beds in fingernails due to bounding pulses - Traube’s: pistol shot femoral pulses - Duroziez’s: to and fro murmur heard when stethoscope compresses femoral vessels. - Müller’s: pulsation of uvula. - Raised JVP: if acute regurgitation as blood backs up - LV hypertrophy seen on imaging

Answer 180

- Dyspnoea - Chest pain - Palpitations - Syncope In chronic regurgitation, patients remain asymptomatic for a long time.

Answer 181

ECHO: gold standard investigation; allows visualisation of the origin of regurgitant jet and its width, detection of aortic valve pathology and compensatory changes e.g. LV hypertrophy and function

Answer 182

- BP - ECG: left ventricular hypertrophy (deep S-waves in V1 and V2, tall R-waves in V5 and V6) in chronic AR - CXR: may show a dilated ascending aorta; may show cardiomegaly if chronic AR - MRI: can be used to show regurgitant fraction - CT: can show aortic dilation and maximum diameter; LV hypertrophy - Angiography: can be done prior to surgery to look for concomitant coronary artery disease

Answer 183

Serial echocardiograms to monitor progression.

Answer 184

- Vasodilators e.g. ACE-inhibitors (ramipril) will improve stroke volume and reduce regurgitation (only if patient is symptomatic or has hypertension) - Root replacement, if needed - Replacement of the valve: can be mechanical or bioprosthetic - Infective endocarditis prophylaxis no longer recommended

Answer 185

Mitral stenosis is a narrowing of the mitral valve orifice, making it difficult for blood to flow from the left atria to the left ventricle.

Answer 186

- The mitral valve has two leaflets: the anterior leaflet and the posterior leaflet. Together, they separate the left atrium from the left ventricle. During systole the valve closes, which means blood is ejected out of the aortic valve and into circulation. During diastole, the mitral valve opens and lets blood fill into the ventricle. - It is supported by the chordae tendineae and papillary muscles.

Answer 187

- As the volume of blood in the left atrium increases it causes higher pressures in the left atrium. Higher pressures flowing through the fibrotic valve make a “snap” sound when the valve opens, which is followed by a diastolic rumble as the blood is forced through the smaller opening. - A constant elevation in both blood volume and pressure in the left atrium causes it to dilate, and can allow blood to back up into the pulmonary circulation (pulmonary congestion and pulmonary oedema). This can ultimately result in pulmonary hypertension and right sided heart failure. - As the left atrium dilates, the muscle walls stretch and the pacemaker cells become more irritable, increasing the risk of atrial fibrillation. - The dilated atria may also press on nearby structures, causing certain symptoms.

Answer 188

- Rheumatic fever. - Congenital MS - Mitral annular calcification - Radiation associated MS - Carcinoid associated valve disease - Fabry's disease

Answer 189

- Loud S1 snap - Atrial fibrillation - Mitral facies (malar flush) - Signs of RSHF - Signs of pulmonary hypertension - Mid-diastolic murmur - the more severe the stenosis the longer the diastolic murmur and the closer the opening snap is to S2

Answer 190

- Dyspnoea - Fatigue - Haemoptysis - Angina - Dysphagia - Ortner syndrome Usually there are no symptoms until the valve orifice is moderately stenosed i.e. area is less than 2cm^2

Answer 191

- ECG - atrial fibrillation; p-mitrale signifying enlarged atria; right axis deviation and tall R-waves in V1 if right ventricular hypertrophy - CXR: left atrial enlargement - double right heart border, splayed trachea, prominent atrial appendage; pulmonary oedema and congestion; calcified mitral valve - Transthoracic ECHO (gold standard) - both the valve area and trans-mitral gradient can be assessed

Answer 192

- Transoesophageal ECHO: performed to look for left atrial thrombosis either after an embolic episode (e.g. stroke) or prior to percutaneous mitral commissurotomy. - Stress testing e.g. exercise stress echo or dobutamine stress test.

Answer 193

- Beta-blockers e.g. atenolol and digoxin: control heart rate and prolong diastole for improved diastolic filling - Valve repair or surgical replacement of the valve. Options include: - Percutaneous mitral commissurotomy (PMC): balloon enters via right femoral vein. Balloon is inflated to alleviate the stenosis. - Open surgery - Diuretics: for fluid overload - Anticoagulation/ Vitamin K antagonist: due to risk of thrombus formation

Answer 194

- Mitral valve prolapse - Damage to the papillary muscles post MI - Dilated and hypertrophic cardiomyopathy - LSHF - Infective endocarditis - Medications - ergotamine, bromocriptine, pergolide

Answer 195

Mitral regurgitation refers to when the mitral valve doesn't completely shut allowing blood to leak back into the left atria from the left ventricle.

Answer 196

- Associated with females - Advanced age - Connective tissue disease e.g. Marfans syndrome or Ehlers-Danlos syndrome - Prior MI - Infective endocarditis - Rheumatic fever - Cardiomyopathies - Certain medications e.g. ergotamine, bromocriptine, pergolide

Answer 197

- Mid-systolic click - Pan-systolic murmur - Soft S1 - Additional S3 sound - Apex beta displaced laterally - Systolic thrill - Tachycardia - Signs of HF

Answer 198

- When squatting down, the click comes later and the murmur is shorter - Squatting increases venous return, which fills the left ventricle with slightly more blood and the left ventricle gets larger. Therefore, the larger leaflets have more space, and as the ventricle contracts it takes just a little longer for the leaflet to get forced into the atrium.

Answer 199

- When standing or doing a valsalva maneuver, the click comes sooner and the murmur lasts longer - Standing reduces venous return so there’s a little less blood in the ventricle and so less room for the valve leaflets. This results in the leaflets being forced out earlier during contraction.

Answer 200

- Dyspnoea and orthopnoea: due to pulmonary hypertension - Fatigue and malaise: due to reduced cardiac output - Palpitations: due to initial compensation and increased stroke volume - Peripheral oedema: if right sided heart failure

Answer 201

- ECHO - confirmation of an incompetent valve, assessment of the severity and identification the underlying cause. - CXR: left sided enlargement; pulmonary oedema in acute MR - ECG: may reflect recent MI; p-mitrale suggestive of left atrial enlargement; may be AF; signs of LV hypertrophy

Answer 202

- Exercise testing - Cardiac MRI - Cardiac catheterisation: used for evaluation of the coronary vessels prior to valvular surgery. Right sided catheterisation can be used to confirm pulmonary hypertension.

Answer 203

- Vasodilators e.g. ACE-inhibitors (Ramipril or hydralazine) - Diuretics e.g. furosemide or spiranolactone: for fluid overload - Beta blockers e.g. atenolol/ calcium channel blockers/ digoxin: for heart rate control - Cardiac resynchronisation therapy (CRT) used when appropriate - Anticoagulation in atrial fibrillation and flutter: to prevent thrombus formation - Valve repair or surgical replacement of the valve. - Other surgical measures include: ventricular assist devices, cardiac restraint devices and heart transplantation.

Answer 204

- Serial echocardiography: - Mild: 2-3 years - Moderate: 1-2 years - Severe: 6-12 months

Answer 205

- Left sided heart failure - Pulmonary congestion, hypertension and right sided heart failure: in acute MR - Cardiogenic shock: as cardiac output isn't maintained - Atrial fibrillation: due to enlarged atria - Thrombus formation: due to atrial fibrillation

Answer 206

Hypertrophic cardiomyopathy (HCM) is a genetic disorder characterised by left ventricular hypertrophy (LVH).

Answer 207

- Autosomal dominant trait: genetic missense mutation in one of the genes that encode proteins in the sarcomere of heart muscle. - Beta-myosin heavy chain mutation is the most common, but it could also be mutations in the myosin binding protein C and Troponin T. - 50% of mutations are sporadic

Answer 208

- Family history - Friedreich's Ataxia (autosomal recessive neurodegenerative disease): patients with Friedreich's ataxia often develop hypertrophic cardiomyopathy

Answer 209

- Ejection systolic murmur: crescendo-decrescendo character due to blood flowing through the obstructed left ventricular outflow tract. - Bifid pulse: two pulses due to mitral valve moving towards outflow tract mid-systole and causing further obstruction - S4 sound: due to atria contracting and pushing blood into a non-compliant ventricular wall during diastole. - Systolic thrill may be felt - Arrhythmias - Hypertrophy seen on imaging

Answer 210

- *When squatting vascular resistance increases, which makes it harder to eject blood out and increases afterload. This means that the ventricle has more blood stretching it out, so it becomes less obstructed, and the murmur becomes less intense.* - *When standing or doing a valsalva maneuver, venous return decreases. This decreases preload so less blood is stretching out the ventricle before ejection. The obstruction gets larger and the murmur’s intensity increases.*

Answer 211

- Dyspnoea - Palpitations - Chest pain - Dizziness - Syncope - Sudden death, may be first manifestation

Answer 212

- ECG: shows signs of left ventricular hypertrophy with progressive T wave inversion and deep Q waves; may also be AF, WPW syndrome, ventricular ectopics, VT - Echocardiogram: shows ventricular hypertrophy and a small left ventricular cavity; mid-systolic closure of aortic valve; anterior movement of mitral valve mid-systole

Answer 213

- MRI - Exercise test - Genetic analysis can confirm diagnosis since most cases are autosomal dominant and familial

Answer 214

- Beta blockers or calcium channel blockers: control heart rate. - Digoxin is contraindicated because it tends to increase force of contraction, which can increase the obstruction. - Anti-arrhythmic medication e.g. amiodarone - Consider defibrillator if at high risk of arrhythmias - Anticoagulation: if AF is present as there is higher risk of thrombus formation - Septal myectomy: surgery to remove part of septum causing obstruction

Answer 215

- Left ventricular outflow obstruction - Heart failure - Arrhythmias: as there is disarray of cardiac myocytes as well as due to the heart becoming ischaemic - Sudden death: due to fast arrhythmias

Answer 216

Dilated cardiomyopathy refers to when all 4 chambers of the heart dilate (but don't get thicker).

Answer 217

- Most often idiopathic - Autosomal dominant - familial - Certain genetic conditions e.g. Duchenne Muscular Dystrophy and haemochromatosis - Infection e.g. coxsackievirus B or Chagas disease, a protozoal infection - Alcohol abuse: alcohol and its metabolites have a direct toxic effect on the myocardium - Chemotherapy drugs e.g. doxorubicin and daunorubicin - Drugs e.g. cocaine - Thyroid disorder - Wet beriberi: Vitamin B1 deficiency - Peripartum cardiomyopathy: dilated cardiomyopathy can develop in the third trimester of pregnancy or in the weeks following delivery. About half of patients recover following pregnancy.

Answer 218

- Family history - Certain conditions e.g. haemochromatosis - Alcohol abuse - Drug abuse - Chemotherapy - Certain infections - Thyroid disorders - Increased BP

Answer 219

- Larger heart seen on imaging - Systolic murmur: due to regurgitation - S3 gallop: due to blood rushing hitting the dilated ventricular wall during diastole - Increased pulse - Decreased BP - Displaced and diffuse apex - Arrhythmias - Signs of heart failure e.g. pulmonary oedema, increased JVP

Answer 220

- Fatigue - Dyspnoea

Answer 221

- Bloods: BNP elevated; low Na+ implies poor prognosis - CXR: cardiac enlargement; pulmonary oedema - ECG: tachycardia, non-specific T wave changes and poor R-wave progression; may be AF or VT - ECHO: shows dilated heart and low ejection fraction

Answer 222

- Bed rest - Diuretics: to deal with oedema - Beta blockers: to control heart rate - ACE inhibitors: dilate vessels to improve blood flow - Anticoagulation: due to increased risk of thrombus - Biventricular pacing - ICD - Left ventricular assist device (LVAD): mechanical pump that assists the heart in distributing blood - Heart transplant, in extreme cases

Answer 223

- Heart failure - Mitral and tricuspid valve regurgitation - Arrhythmias - Risk of thromboembolism - Sudden death

Answer 224

Restrictive cardiomyopathy describes when the heart muscle becomes stiffer and less compliant.

Answer 225

- Idiopathic - Amyloidosis - Sarcoidosis - Endocardial fibroelastosis - Loffler syndrome - Haemochromatosis - Scleroderma - Radiation

Answer 226

- 3rd and 4th heart sounds - Signs of heart failure - Increased JVP - Elevation of venous pressure with inspiration - Oedema - Hepatomegaly

Answer 227

- Dyspnoea - Fatigue - Embolic symptoms

Answer 228

- ECG: low amplitude QRS - ECHO - CXR - MRI - Cardiac catheterisation helps diagnosis The others are all abnormal but not specific enough to be diagnostic

Answer 229

- Treat underlying cause e.g. removing excess iron in case of haemochromatosis - Heart transplant

Answer 230

Heart failure.

Answer 231

Atrial flutter is usually an organised atrial rhythm with an atrial rate typically between 250-350bpm

Answer 232

Type 1 (typical) - Single reentrant circuit, from the right atrium. - Cavotricuspid isthmus dependent - Circulates tricuspid annulus usually counterclockwise (from below) Type 2 (atypical) - Less common - Right or left atrium (exact location is less defined. - Isthmus independent. - Associated with underlying diseases e.g. ischemia.

Answer 233

- Idiopathic (30%) - Coronary heart disease - Obesity - Hypertension - Cardiomyopathy - Heart failure - Thyrotoxicosis - COPD - Pericarditis - Acute excess alcohol intoxication

Answer 234

- Previous MI - Heart Failure - Hypertension - Diabetes - Valvular Heart Disease - Obstructive Sleep Apnoea

Answer 235

- Previous MI - Heart Failure - Hypertension - Diabetes - Valvular Heart Disease - Obstructive Sleep Apnoea

Answer 236

- Palpitations - Tachycardia - Breathlessness - Chest pain - Dizziness - Syncope - Fatigue

Answer 237

- ECG: regular sawtooth-like atrial flutter waves (F waves) with P-wave after P-wave (diagnostic) - FBC - in all patients - Serum electrolytes - Renal function test - TSH → To exclude thyroid problems - Transthoracic ECHO: Evaluate the size of the left and right ventricles, heart disease and assess the ejection fraction. - CXR

Answer 238

- Treat the reversible underlying condition (e.g. hypertension or thyrotoxicosis) - Radiofrequency ablation of the re-entrant rhythm - Anticoagulation based on CHA2DS2VASc score - IV Amiodarone to restore sinus rhythm - Beta blocker e.g. Bisoprolol to suppress further arrhythmias - Electrical cardioversion with anticoagulant (LMW-heparin) such as Enoxaparin - Dalteparin if acute (in last 48 hours)

Answer 239

- Heart Failure - Thromboembolic events - Atrial Fibrillation

Answer 240

Atrial fibrillation (AF) is a chaotic irregular atrial arrhythmia and is considered a type of supraventricular tachycardia (SVT).

Answer 241

- Increasing age: AF affects approximately 5% of patients aged 70-75 years, and 10% of patients aged 80-85 years - Diabetes mellitus - Hyperthyroidism - Hypertension - Congestive heart failure - Valvular heart disease - Coronary artery disease - Dietary and lifestyle factors: excessive caffeine intake, alcohol abuse, obesity, smoking, medication use (e.g. thyroxine or beta-agonists)

Answer 242

- Irregular irregular pulse - Hypotension: red flag; suggest haemodynamic instability - Evidence of heart failure: red flag; such as pulmonary oedema

Answer 243

- Palpitations - Dyspnoea - Chest pain: red flag - Syncope: red flag

Answer 244

The presence of adverse features guides the decision to undergo DC cardioversion. - Shock: hypotension (systolic blood pressure <90 mm Hg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness - Syncope: transient loss of consciousness - Myocardial ischaemia: typical ischaemic chest pain and/or evidence of myocardial ischaemia on 12-lead ECG - Heart failure: pulmonary oedema and/or raised jugular venous pressure

Answer 245

- ECG: irregularly irregular QRS complexes with absent P waves and chaotic baseline (gold standard) - 24-hour ambulatory ECG monitoring is recommended for those with paroxysmal AF in the community - Serum electrolytes, urea and creatinine: in addition to standard electrolytes, magnesium, calcium and phosphate should also be assessed - TFTs: hyperthyroidism is a secondary cause of AF - FBC in all patients

Answer 246

- Cardiac biomarkers: request troponin if chest pain is present as this may reflect an MI - Chest x-ray: if there is suspicion of heart failure to assess for pulmonary oedema - Transthoracic ECHO: consider if there is a suspicion of underlying structural or functional heart disease; usually performed prior to cardioversion in chronic cases

Answer 247

Unstable - Emergency electrical synchronised DC cardioversion Stable - Onset of AF < 48 hours: 1) rate control or 2) rhythm-control - Onset of AF > 48 hours / unknown onset: offer rate-control and anticoagulation for at least 3 weeks, then offer rhythm control if appropriate e.g. if rate control is unsuccessful or the patient remains symptomatic

Answer 248

- First line: beta-blocker (e.g. bisoprolol) or a rate-limiting calcium-channel blocker (e.g. verapamil) - Digoxin: may be considered first-line in patients with AF and heart failure - Second line: if refractory then consider combination therapy

Answer 249

- Pharmacological: - Flecainide or amiodarone: if no evidence of structural/ischaemic heart disease - Amiodarone: if structural/ischaemic heart disease is present - Electrical cardioversion: rapidly shock the heart back into sinus rhythm

Answer 250

- Stroke - Myocardial infarction - HF - Reduced quality of life

Answer 251

Used to calculate stroke risk when considering anticoagulation

Answer 252

Estimates the risk of major bleeding for patients on anticoagulation to assess risk-benefit in AF care

Answer 253

- Congestive heart failure (1) - Hypertension (1) - Age (1 - 65-74, 2 - >75) - Diabetes (1) - Stroke (2) - Vascular disease (1) - Sex (1 - Female)

Answer 254

- Hypertension (1 - uncontrolled) - Abnormal renal/liver function (1 each) - Stroke history (1) - Bleeding history (1) - Liable to INR (1) - Elderly (>65 = 1) - Drugs (1)

Answer 255

- Delayed AV conduction through AV node - Every atrial impulse still leads to one ventricular contraction. - Prolonged PR interval seen on ECG (>200ms) - No treatment required

Answer 256

- Some impulses do not make it through the AV node. - Some P waves do not lead to QRS complexes. - Atrial impulse become gradually weaker until they do not pass through the AV node and repeats. - ECG → Longer PR (>200ms) until no QRS and then repeats. - No treatment required.

Answer 257

- Some impulses do not make it through the AV node. - Some P waves do not lead to QRS complexes. - Intermittent conduction of P waves to QRS complex. - Conduction ratio of 2:1 is untypable as cannot tell if there is progressive PR prolongation. - High grade 2nd degree heart block is when two successive P wave fail to conduct to the ventricles. - P waves are regular. - High risk of progression to 3rd degree so pacemaker required.

Answer 258

- Complete heart block. - No transmission of P waves into ventricles. - QRS usually wide, occasionally the bundle of His takes over and can become narrow. - Requires pacemaker.

Answer 259

ECG - QRS complex becomes wider. >120ms. - LBBB - W shape seen in V1 and notched M in V6 - RBBB - Terminal R wave (M) in V1 and W shaped in V6

Answer 260

- If acquired through heart disease then a cardiac resynchronisation pacemaker can be inserted. - This paces the chambers at the same time and improves cardiac function.

Answer 261

Tetralogy of Fallot (TOF) is a congenital cardiac malformation. It is the most common form of congenital cyanotic heart disease.

Answer 262

- Pulmonary infundibular stenosis - Right ventricle hypertrophy - Overriding Aorta - Ventricular Septal Defect

Answer 263

- Neonates and babies: typically manifests at around 1-2 months of life - Family history of congenital heart disease - Rubella infection - Increased age of the mother (over 40 years) - Alcohol consumption in pregnancy - Diabetic mother - Down syndrome: trisomy 21 - DiGeorge syndrome: chromosome 22q11 deletion - Edwards’ syndrome: trisomy 18 - Patau syndrome: trisomy 13

Answer 264

- Ejection systolic murmur: due to pulmonary stenosis - Reduced SpO2, particularly when distressed - Respiratory distress - Cyanosis - Clubbing

Answer 265

- Poor weight gain or ‘failure to thrive’ - Difficulty feeding - Hyper-cyanotic or ‘Tet’ spells: cyanosis, breathlessness and syncope, particularly when crying or feeding - Squatting posture

Answer 266

- ECG: evidence of right ventricular hypertrophy, such as right axis deviation - Echocardiogram + doppler flow studies: definitive investigation and will reveal right ventricular outflow obstruction, right ventricular hypertrophy, a ventricular septal defect and an overriding aorta - Chest X-ray: demonstrates a characteristic ‘boot-shaped’ heart due to RV hypertrophy, right-sided aortic arch is seen in 25% of patients

Answer 267

- FBC: secondary polycythaemia may be seen (raised Hb and haematocrit) due to hypoxia-driven erythropoietin release from the kidney - Hyperoxia test: the infant is given high flow oxygen and an ABG is performed to measure pO2. In cyanotic heart disease, the pO2 will fail to rise significantly due to deoxygenated blood being shunted away from the lungs.

Answer 268

- Conservative: ensure the infant is kept calm and their knees are placed to their chest to reduce the right to left shunt - Supplementary oxygen is essential in hypoxic children as hypoxia can be fatal - Beta blockers can relax the right ventricle and improve flow to the pulmonary vessels - IV fluids can increase pre-load, increasing the volume of blood flowing to the pulmonary vessels - Morphine can decrease respiratory drive, resulting in more effective breathing - Sodium bicarbonate can buffer any metabolic acidosis that occurs - Phenylephrine infusion can increase systemic vascular resistance

Answer 269

Prostaglandin e.g. alprostadil: used in symptomatic babies at birth to maintain a ductus arteriosus, thus allowing shunting of deoxygenated blood into the pulmonary circulation - - Blalock-Taussig (BT) shunt: a temporary palliative measure performed for patients that remain persistently cyanotic whilst awaiting definitive surgery. It increases pulmonary arterial blood flow. - Definitive surgery: all patients eventually need surgical correction of the abnormality, which involves closure of the VSD with a patch and reconstruction of the right ventricular outflow tract.

Answer 270

- Cardiovascular: - Hyper-cyanotic (‘Tet’) spells - severe spells can lead to reduced consciousness, seizures and potentially death - Congestive cardiac failure - Paradoxical emboli - Post-surgical: - Atrial and ventricular arrhythmias: increased long-term risk - Pulmonary regurgitation

Answer 271

Transposition of the great arteries refers to the switching of places of the pulmonary artery and the aorta.

Answer 272

Cause is idiopathic but risk factors include the expecting mother having: - Diabetes - Rubella - Poor nutrition - Alcohol consumption - Being over 40 years old

Answer 273

- Cyanosis - Tachycardia

Answer 274

- Respiratory distress - Poor feeding - Poor weight gain - Sweating

Answer 275

- The defect is often diagnosed during pregnancy with antenatal ultrasound scans. - ECHO

Answer 276

- Close monitoring during the pregnancy and arrangements should be made so that the woman gives birth in a hospital capable of managing the condition after birth. - Babies are given prostaglandin E to keep ductus arteriosus open (short term solution) - Balloon septostomy: insert a catheter into the foramen ovale via the umbilicus, and inflating a balloon to create a large atrial septal defect. - Open heart surgery: definitive management. A cardiopulmonary bypass machine is used to perform an “arterial switch” procedure within a few days of birth. If present, a VSD or ASD can be corrected at the same time.

Answer 277

Congestive heart failure. The right ventricle pumps out to the higher-pressure systemic circuit, even though it’s built for low-pressure systems, and the left ventricle pumps out to the lower pressure pulmonary circuit, even though it’s built for high pressure systems. So, in response, the right ventricle can hypertrophy and the left ventricle might atrophy. This can lead to heart failure.

Answer 278

Coarctation of the aorta is defined as a narrowing in the aorta. There is an infant (70%) and an adult form (30%).

Answer 279

- Turner syndrome.

Answer 280

- Weak femoral pulses - - Tachypnoea - Left ventricular heave due to left ventricular hypertrophy - Cyanosis of lower extremities: seen in infantile coarctation - Bruits over the scapulae and back from collateral vessels - May be a systolic murmur heard below the left clavicle and below the left scapula - Hypertension: as reduced kidney perfusion activated RAAS - Underdeveloped left arm where there is reduced flow to the left subclavian artery: in infantile form - Underdevelopment of the legs: in infantile form - Signs of aneurysm and dissection in adult form - Rib notching seen on CXR

Answer 281

- Poor feeding - Grey and floppy baby - Claudication in lower extremities - Headaches and nose bleeds: due to hypertension

Answer 282

- CXR: dilated aorta indented at the site of the coarctation - ECG: left ventricular hypertrophy - CT: accurately demonstrates the coarctation and quantify flow

Answer 283

Management depends on severity - Infantile coarctation: prostaglandin E is used keep the ductus arteriosus open while waiting for surgery Surgical options: - Balloon dilation: used to widen the aorta - Surgical removal of the narrowed area of the aorta - Infantile coarctation: surgical ligation of ductus arteriosus

Answer 284

- Ventricular septal defect refers to when the ventricular septum has a gap in it. - This can vary in size from tiny to the entire septum, forming one large ventricle.

Answer 285

- Foetal alcohol syndrome - Turner syndrome - Down syndrome - Other cardiac deformities

Answer 286

- Pansystolic murmur at the lower left sternal border - May be a systolic thrill on palpation - Cyanosis: due to deoxygenated blood in systemic circulation - Tachypnoea

Answer 287

Small VSDs may be asymptomatic while large VSDs may present early. - Dyspnoea - Poor feeding - Failure to thrive

Answer 288

- May be picked up on antenatal scans or when a murmur is heard during the newborn baby check. - CXR: may show large heart or normal heart depending on size of VSD - ECHO

Answer 289

- Watch and wait: for small VSD as they can close spontaneously - Surgical closure of VSD - Trans-catheter closure - Open heart surgery - Antibiotic prophylaxis: should be considered due to increased risk of infective endocarditis

Answer 290

- Right sided heart failure: due to left to right shunt and right sided overload - Pulmonary hypertension: as blood is shunted from left to right

Answer 291

An atrial septal defect describes when there’s an opening in the heart between the right and left atria.

Answer 292

- Down syndrome: associated with ostium primum defects - Foetal alcohol syndrome - Affects Females > Males

Answer 293

- Mid-systolic, crescendo-decrescendo murmur loudest at the upper left sternal border - Splitting S2 sound: due to pulmonary valve closing after the aortic valve - Cyanosis: if reversal of shunt

Answer 294

Can often be asymptomatic in childhood, and first presentation in adulthood can sometimes be stroke or heart failure. - Dyspnoea - Difficulty feeding - Poor weight gain - Lower respiratory tract infections

Answer 295

- Atrial septal defects are often picked up through antenatal scans or newborn examinations. - CXR: large pulmonary arteries; may show large heart - ECG: may show right bundle branch block due to right ventricle dilatation - ECHO: hypertrophy and dilation of right side of heart and pulmonary arteries

Answer 296

- Watch and wait: for small ASD as it may spontaneously resolve - Surgical closure of ASD - Trans-catheter closure - Open heart surgery - Anticoagulants: used to reduce the risk of clots and stroke in adults

Answer 297

- Stroke - Pulmonary hypertension - Atrial fibrillation - Eisenmenger syndrome

Answer 298

As right sided pressure increases and blood is shunted from right to left = deoxygenated blood in the systemic circulation

Answer 299

Patent ductus arteriosus (PDA) describes the persistent opening of a foetal structure, known as the ductus arteriosus, after birth.

Answer 300

- Maternal infections e.g. rubella - Prematurity

Answer 301

- Continuous crescendo-decrescendo “machinery” murmur: due to blood moving from the aorta to the pulmonary artery - Bounding pulse - Cyanosis of lower extremities: initially acyanotic but progresses into being cyanotic as shunt reverses - Tachycardia

Answer 302

A small PDA can be asymptomatic, cause no functional problems and close spontaneously. - Shortness of breath - Difficulty feeding - Poor weight gain - Lower respiratory tract infections

Answer 303

ECHO + doppler flow studies: can confirm diagnosis. Can assess the size and characteristics of the left to right shunt. May also show right ventricular hypertrophy.

Answer 304

- Monitor with ECHO until 1 years of age: may close spontaneously - Indomethacin: NSAID that inhibits prostaglandin E2 so PDA can close - Trans-catheter closure of PDA - Surgical ligation of PDA

Answer 305

- Chronic heart failure - Eisenmengers syndrome

Answer 306

- Tachycardia - Tachypnoea - Pulse pressure is reduced → MAP may be maintained until a very large volume of blood is lost. - Skin is flushed → Warm shock - Skin is cold → Cold shock - Reduced urine output - Confusion - Collapse - Coma - Weakness

Answer 307

- Cold and clammy skin - Confusion and drowsiness - Increased sympathetic tone - Tachycardia or bradycardia → depending on the stage. - Initially weak pulse pressure until compensation → weak pulse when compensation fails.

Answer 308

Signs of heart failure. Raised JVP, Pulmonary oedema.

Answer 309

- Warm and flushed skin - Pyrexia and rigors - Nausea and vomiting - Bounding pulse

Answer 310

- Warm and flushed skin - Itching - Sweating - May be breathlessness and wheeze - Hypotensive - Tachycardia - Pulmonary oedema

Answer 311

- Assess using ABCDE. - Capillary refill time: takes more than 3 seconds to turn pink after 5 seconds of compression → easliest and most accurate sign of shock. - Investigate suspected underlying cause → CXR, Troponin, ECG.

Answer 312

- Treatment depends on the cause. - ABC - Airway → Intubation of necessary. - Breathing → give O2. - Circulation → Establish IV access, raise legs if hypovolaemic, fluid resuscitation and blood transfusion if necessary, ensure haemostasis. - Medications that increase heart contractility, cause vasocontriction, and retail fluid. - Manage underlying causes: - Septic → Antibiotics - Anaphylactic chock → remove causative agent, give adrenaline, chlorphenamine and hydrocortisone. - Cardiogenic chock → Revascularisation

Answer 313

- Organ failure due to prolonger hypotension: - Kidney - Acute tubular necrosis. - Lungs - ARD’s. - Heart - Ischemia and MI. - Brain - Confusion, Irritability, Coma.

Answer 314

Acute, febrile, self-limiting, systemic vasculitis of unknown origin. Mainly affects coronary arteries.

Answer 315

There is no clear cause. May be related to infection, autoimmune reactions and genetics

Answer 316

- Mnemonic - CRASH - C - Conjunctivitis - R - Rash - erythema and desquamation (skin peeling) - A - Adenopathy - enlarged lymph nodes - S - “Strawberry tongue” (red tongue with prominent papillae) - H - Hand and feet issues - swelling and rash - Other: - Persistent high fever > 5 days

Answer 317

- Bloods - Anaemia - Increased WCC - Increased CRP - Increased ESR - Increased liver enzyme - Increased platelets - Urinalysis - Mononuclear white blood cells in urine without bacteria - Echocardiogram - Check for complications - Diagnostic Criteria - Patient's must meet 4/5 of the CRASH signs

Answer 318

Aspirin and IV immunoglobulins - Monitor due to aspirin administration in children

Answer 319

Coronary artery aneurysms - leading to MI and ischaemia

Cardiovascular Flashcards

(343 cards)