Cardiovascular Flashcards
(132 cards)
1
Q
What are the symptoms of an aortic dissection?
A
- Chest pain- sudden, tearing, severe, anterior or interscapular
- Dizziness
- SOB
- Sweating
- Neuro deficit
2
Q
What are the signs of an aortic dissection?
A
Unequal radial pulses
Tachycardia
Hypo/hypertension
Difference in BP between arms >15mmHg
Aortic regurgitation
Pleural effusion
Neurological deficit if carotid artery dissection
3
Q
What urgent investigation would you do for a suspected aortic dissection?
A
Urgent CT aorta
4
Q
What might a CXR show in aortic dissection?
A
Widened mediastinum >8cm (rare)
Irregular aortic knuckle
Small left pleural effusion
5
Q
What is the acute treatment of aortic dissection?
A
Senior help
If HYPOtensive - oxygen, 2x large bore cannulae, Xmatch, IV opioids
If HYPERtensive - keep systolic BP <100mmHg
BOTH - Surgery (Type A, involving ascending aorta) or conservative management (Type B, involving descending aorta only)
6
Q
What are the risk factors for an aortic dissection?
A
Smoking, obesity, diabetes, HTN, high cholesterol, family hx, previous IHD
7
Q
What is the definition of an aneurysm?
A
A permanent and irreversible dilatation of a blood vessel by at least 50% of the normal diameter
8
Q
What are the 2 types of aortic aneurysm and which is most common?
A
Abdominal and thoracic
Abdominal most common
9
Q
What is the normal diameter of the abdominal aorta and what diameter would be classed as a AAA?
A
Normal= 2cm
AAA= 3cm +
10
Q
Where do most AAA’s arise from?
A
Below the level of the renal arteries
11
Q
What are the symptoms/signs of an unruptured AAA?
A
- Most are asymptomatic
- Back/loin/groin pain
- Pulsatile swelling on examination
- Distal embolisation- gives features of limb ischaemia but with easily palpable pulses
- Uterohydronephrosis
- Severe recent onset lumbar pain may indicate impending rupture!
12
Q
What is the monitoring requirement for AAAs? At what diameter would surgery be recommended?
A
3-4.4cm annual US
- 5-5.4cm 3 monthly US
- 5cm or bigger consider surgery
13
Q
What are the surgical options for AAA repair?
A
Open surgery
Endovascular repair: stent-graft introduced through femoral arteries
14
Q
What is the NHS screening for AAA and when/to whom is it offered?
A
One US offered to men aged 65- if negative, rules out AAA for life
15
Q
What are the symptoms of pericarditis?
A
Pleuritic chest pain, worse on lying flat/deep inspiration, better when sat forwards Fever
Recent viral illness
16
Q
What signs may be found in pericarditis
A
None, or pericardial rub
17
Q
What would a saddle shaped ST segment on ECG suggest?
A
Pericarditis
18
Q
What investigations would you do for suspected pericarditis and what would they show?
A
Bedside- temp
Bloods- Raised WCC and CRP, troponin
ECHO- bright pericardium +/- pericardial effusion
19
Q
What is the management of acute pericarditis?
A
Reassurance
Paracemtaol/NSAIDs
If continues >14d, use colchicine/steroids
20
Q
What is constrictive pericarditis?
A
Chronic inflammation of the pericardium resulting in a thickened, scarred pericardium which impairs heart function
21
Q
What are the signs/symptoms of constrictive pericarditis?
A
Similar to R heart failure- SOB, peripheral oedema, raised JVP with Kussmaul’s sign
Pulsatile hepatomegaly (70%)
Pericardial knock
22
Q
What investigation would distinguish constrictive pericarditis from restrictive cardiomyopathy?
A
ECHO
23
Q
What is the management of constrictive pericarditis?
A
Treat cause
Anti-inflammatories
Pericardiectomy
24
Q
What are the causes of cardiac tamponade?
A
Pericarditis, aortic dissection, haemodialysis, warfarin, trans-septal puncture during cardiac catheterisation, post cardiac biopsy
25
What are the signs of cardiac tamponade?
Tachycardia
Hypotension
Pulsus paradoxus
Raised JVP
Kussmaul's sign
Muffed S1/2
26
What **investigations** would you do for **cardiac tamponade**? What would they show?
CXR: large globular heart
ECG: low voltage QRS +/- electrical alternates
**ECHO is DIAGNOSTIC**: echo-free zone around heart +/- diastolic collapse of right atrium and ventricle
27
What is the management of cardiac tamponade?
Urgent drainage of pericardial effusion
28
What is cardiac tamponade? What is its pathogenesis?
Accumulation of pericardial fluid, resulting in increased intrapericardial pressure causing poor ventricular filling and reduced cardiac output
29
What are the clinical features of pericardial effusion?
SOB
Raised JVP (with prominent x descent)
Bronchial breathing at left base
Signs of cardiac tamponade
30
What is the management of pericardial effusion?
Treat cause
Pericardiocentesis (diagnostic/therapeutic)
31
What would CXR, ECG and ECHO show in pericardial effusion?
CXR: enlarged globular heart
ECG: low voltage QRS and electrical alternans
ECHO: echo-free zone around heart
32
What is the target BP for those without diabetes age \>80 and \<80?
\<80 = \<140/90
\>80 = \<150/90
33
What rise in creatinine/decrease in eGFR is acceptable when on an ACEi?
eGFR decrease up to 25%
or
Creatinine rise up to 30%
34
What 4 things could cause hypertension with low potassium?
Conn's
Cushing's
Renal artery stenosis
Liddle's
35
What is the first line treatment for HTN in a diabetic?
ACEi
36
What is the treatment for resistant hypertension if further diuretics are not tolerated, contraindicated or ineffective?
Consider alpha blocker or beta blocker
37
What should an adult \<80yrs with stage 1 HTN, no end organ damage and a QRisk \>10% but \<20% be treated with?
Lifestyle advice PLUS a statin
38
Antihypertensive drug treatment should be offered to those \<80yrs with stage 1 HTN if they have 1 or more of???
Target organ damage
Established CV disease
Renal disease
Diabetes
10yr CV risk \>20%
39
If HTN is uncontrolled on ACEi, Ca channel blocker and thiazide diuretic what is the next step?
If K+ \<4.5 = spiro
If K+ \>4.5 = increase dose of thiazide
40
What are the sx/signs of idiopathic intracranial HTN?
Headache
Blurred vision
Papilloedema
Enlarged blind spot
+/- 6th nerve palsy
41
What are the risk factors for idiopathic intracranial HTN?
Obesity
Female
Pregnant
Drugs: COCP, steroid, vit A, lithium, tetracycline
42
What is the management of idiopathic intracranial HTN?
Weight loss
Diuretics e.g. acetazolamide
Topiramate
Repeated LPs
Surgery
43
What is aleading cause of sudden cardiac death in young athletes?
Hypertrophic obstructive cardiomyopathy
44
What would an ECHO show in hypertrophic obstrcutive cardiomyopathy?
Mitral regurg
Systolic anterior motion of anterior mitral valve
Asymmetric septal hypertrophy
45
What is the inheritance of HOCM?
Autosomal dominant
46
What are the causes of dilated cardiomyopathy?
Alcohol
Coxsackie B virus
Doxorubicin
Wet beriberi
47
What are the causes of restrictive cardiomyopathy?
Amyloidosis
Post-radiotherapy
Loeffler's endocarditis
48
What is the name for stress-induced cardiomyopathy?
Takotsubo
49
What is the management of Takosubto cardiomyopathy?
Supportive
50
What do new widening QRS complexes and an RSR pattern in v1 suggest?
RBBB
51
What would widened QRS complexes and a notched morphology of the QRS complexes in the lateral leads suggest?
LBBB
52
What are the risk factors for mitral regurg?
Female
Low BMI
Prior MI/mitral stenosis/valv prolapse
Collagen disorders e.g. Marfans, Ehlers-Danlos
53
What wpuld a pan-systolic blowing murmur heard best at the apex, radiating to the axilla suggest?
Mitral regurgitation
54
Secondary causes of HTN
* Renal disease
* Primary hyperaldosteronism
* Phaeochromocytoma
* Cushing’s
* Acromegaly
* Hyper/hypothyroidism
* Alcohol
* Connective tissue disorders
* OSA
* Coarctation of aorta
* Renal artery stenosis
55
Annual review for HTN
* Check blood pressure
* Check renal function by measuring creatinine, electrolytes and EGFR
* Dip urine to check for proteinuria
* Q risk
56
What is **accelerated hypertension**?
Blood pressure **\>180/110 mmHg** with signs of **papilloedema** and/or **retinal haemorrhage**
57
Complications of hypertension
* Heart Failure
* Coronary artery disease
* Stroke
* Chronic kidney disease
* Peripheral arterial disease
* Vascular dementia
58
Symptoms of postural hypotension
Dizziness
Lightheaded
Blurred vision
Weakness
Fatigue
Nausea
Palpitations
Headache
Less common; syncope, dyspnoea, chest pain, neck/shoulder pain
59
Positive tilt table test
Systolic BP falls below 20mmHg and diastolic BP below 10mmHg of baseline
60
What is the tilt table test for orthostatic hypotension
Tilt testing to an angle between 60 and 80° for three minutes
61
First line drug for orthostatic hypotension
Fludrocortisone
62
Symptoms of hypotensive shock
* Feeling cold, unwell, anxious, faint, short of breath
* Fainting
* Patient may look pale and sweaty
* Tachypnoea
* Tachycardia
* Fall in blood pressure
* Late features include confusion, coma
63
Causes of hypovolaemic shock
* Loss of blood
* Trauma
* Burns
* Severe loss of water and salt from heat, poor intake, diarrhoea and vomiting, inappropriate diuresis
64
Investigations for hypovolaemic shock
Bedside – monitor urine output with catheter, may need CVP monitoring
Bloods – Hb, U&Es, LFTs, group and save, crossmatch, coagulation screen, blood gas
Imaging- ultrasound vena cava to distinguish hypovolaemic vs cardiogenic shock
65
Stages of loss of blood volume
Class 1: 10-15% blood loss; physiological compensation
Class 2: 15-30% blood loss; postural hypotension, generalised vasoconstriction, reduction in UO to 20 to 30ml/hour
Class 3: 30-40% blood loss; hypotension, tachycardia, tachypnoea, UO under 20ml/hour, patient confused
Class 4: 40% blood loss; marked hypotension, tachycardia and tachypnoea, no UO, patient comatose
66
Management of hypovolaemic shock
Oxygen
Venous access
Crystalloid e.g. Hartmann’s, normal saline (or blood if haemorrhage)
IV analgesia if pain
Surgery if bleeding
67
**Complications** of **hypovolaemic shock**
AKI
Gut ischaemia
Hypoxia
Metabolic acidosis
Cardiac arrhythmias/arrest
Haemoconcentration- smudging and venous sinus thrombosis
68
**Virchow’s triad** of risk factors for **thrombophlebitis**
**Damage to vessel wall** (due to infection, inflammation or trauma)
**Stasis** of blood flow
**Hypercoagulability** of blood
69
Risk factors for thrombophlebitis
* Obesity
* Thrombophilia
* Smoking
* Oral contraceptives
* Pregnancy
* IVDU
* IV infusion
70
Signs of thrombophlebitis
**Painful, hard lump**, often with **surrounding erythema**
71
Management of superficial phlebitis
Topical anti-inflammatory
Resolves spontaneously in 10-14 days
72
**Mitral stenosis** murmur
**Mid diastolic** murmur heard best with **patient leaning to left side**
73
Causes of mitral stenosis
**Rheumatic fever**
Degenerative calcification
Congenital
SLE
RA
Carcinoid
Infective endocarditis
Amyloid deposition
74
**Signs** associated with **mitral stenosis**
Malar flush
Raised JVP
Laterally displaced apex beat
RV heave
Loud SI with opening snap in early diastole
A **mid-late diastolic murmur**, heard **best with patient in left lateral position**, with the **bell of the stethoscope**
AF
Signs of RV failure including hepatomegaly, ascites and peripheral oedema
75
What does this ECG show?
LBBB
76
**ECG features** in **RBBB**
**QRS duration \>120ms**
An "**M-shaped**" **QRS** complex in **V1** (**rSR** pattern)
**Wide, slurred S wave** in lateral leads (**aVL, V5-6)**
77
**ECG features** in **LBBB**
**QRS duration \>120ms**
**Broad R** wave in **I, aVL** and **V6**
**Lack of septal Q waves** in **I** and **V6**
78
**Causes** of **RBBB**
Normal variant- more common with increasing age
RVH
Cor pulmonale
PE
MI
Atrial septal defect
Cardiomyopathy
Myocarditis
79
**Causes** of **LBBB**
Acute anterior MI
Coronary artery disease
LVH
Heart failure
Idiopathic
Hyperkalaemia
Digoxin toxicity
80
**ECG findings** in **atrial flutter**
* **'sawtooth'** appearance
* as the underlying **atrial rate** is often around **300/min** the **ventricular** or heart **rate** is **dependent on the degree of AV block**. For example if there is 2:1 block the ventricular rate will be 150/min
* flutter waves may be visible following carotid sinus massage or adenosine
81
**Clinical features** of **complete heart block**
* **syncope**
* **heart failure**
* regular **bradycardia** (30-50 bpm)
* **wide pulse pressure**
* JVP: **cannon waves** in neck
* **variable intensity of S1**
82
Describe **atrial flutter** and its **pathophysiology**
Due to **re-entry circuit in the atrium**
**Atria contract at 300-400bpm**
**Refractory period** of **AV node** means **not every P is conducted**
The result is that there are **several P waves** and **then a QRS** which is **conducted regularly** e.g. 3 P waves then a QRS complex is 3:1
83
Describe the **ECG features of** **atrial fibrillation** and its **pathophysiology**
**Supraventricular tachycardia**
**Indiscernable P waves**
**Irregularly irregular** pulse
**Narrow irregular QRS** complex
Due to **uncoordinated atrial activation** resulting in an **irregular ventricular response**
84
**Management** of **atrial fibrillation**
**1st line treatment** is **rate-control** with **beta blocker or rate-limiting calcium channel blocker**
**Assess stroke risk** with **CHA2DS2VASc score**
If 2 or more (F) or 1 ore more (M) need **anticoagulation**
**Assess risk of major bleed** using **HAS-BLED** tool
Anticoagulants: **apixaban, dabigatran, rivaroxaban**, Vit K antagonist (e.g. **warfarin**)
85
**Risks** associated with **AF** and **atrial flutter**
**Ineffective contraction of atria** results in **stasis of blood** and **promotes clot formation**, increasing the risk of **stroke** and other **thromboembolic complications**
86
**Acute** and **long term management** of **atrial flutter**
_Acute:_
**Rate control** with **beta blocker or Ca channel blocker**
**DC cardioversion** for immediate restoration of sinus rhythm- if patient is hypotensive, or 1:1 AV conduction
**Elective restoration of sinus rhythm**: antiarrythmic drug, DC cardioversion or rapoid atrial pacing
_Long term:_
**Anticoagulation** to prevent clots
**Catheter ablation** usually **curative**
87
**Pathophysiology** of **ectopic beats** (ventricular ectopics/premature beats)
* **Ectopic firing of a focus within the ventricles bypasses the His-Purkinje system and depolarises the ventricles directly.**
* This **disrupts the normal sequence of cardiac activation**, leading to **asynchronous activation of the two ventricles**.
* The consequent interventricular conduction delay produces **QRS complexes with prolonged duration and abnormal morphology**.
88
**ECG features** of **premature ventricular ectopics**
* **Broad QRS complex** (≥ 120 ms) with abnormal morphology.
* **Premature** — i.e. occurs earlier than would be expected for the next sinus impulse.
* **Discordant ST segment and T wave changes.**
* Usually followed by a full **compensatory pause**.
* **Retrograde capture** of the atria may or may not occur.
89
What is **cardiogenic shock**?
Occurs when there is **failure of the pump action of the heart**, resulting in a **decrease in cardiac output** causing **reduced end-organ perfusion**. This leads to **acute hypoperfusion and hypoxia of the tissues and organs**, despite the presence of an adequate intravascular volume.
_Defined as:_
* **Sustained hypotension** (systolic blood pressure (BP) \<90 mm Hg for more than 30 minutes)
* **Tissue hypoperfusion** (cold peripheries, or oliguria \<30 ml/hour, or both)
(Despite adequate LV filling pressure)
90
Most **common cause** of **cardiogenic shock**
MI
91
**Symptoms** of **varicose veins**
**aching legs**
**discomfort or itching** over the veins
**swollen feet and ankles**
92
**Management** of **varicose veins**
Weight loss, light activity
93
Most **common cause** of **infective endocarditis**
Staph aureus
94
**Valves** most **commonly affected** by i**nfective endocarditis**
Mitral
Aortic
Mitral + aortic
Tricuspid
Pulmonary (rare)
95
**Signs** and **symptoms** of **infective endocarditis**
_Signs:_
* Heart **murmur** (may be new)
* **Splinter haemorrhages**
* **Osler's nodes** (small tender red-purple nodules on terminal phalanges)
* **Janeway's lesions** (irregular painless erythematous macules on thenar and hypothenar eminence)
* **Roth's spots** (retinal haemorrhages with pale centres)
* **Cerebrovascular accident**
* **Arthritis**
* **Splenomegaly** (long standing disease)
* **Meningism**
_Symptoms:_
* **Infection** e.g. fatigue, fever, flu-like symptoms, pain, anorexia, weight loss
* May present as an acute rapidly progressive infection
96
**Risk factors** for **infective endocarditis**
Valvular heart disease
Valve replacement
Structural congenital heart disease
Previous infective endocarditis
Hypertrophic cardiomyopathy
Drug abuse
Invasive vascular procedures
97
**Investigations** for **endocarditis**
Bloods- CRP, FBC
**Blood cultures**
CXR
ECG
**ECHO** (TTE is initial investigation of choice)
98
**Diagnostic criteria** for **infective endocarditis**
2 major *or* 1 major + 3 minor *or* 5 minor criteria
_Major criteria:_
* **Positive blood cultures**
* Evidence of endocardial involvement (e.g. positive ECHO)
_Minor criteria:_
* Predisposition: predisposing heart condition or intravenous drug use.
* Fever: temperature \>38°C.
* Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial haemorrhage, conjunctival haemorrhages and Janeway's lesions.
* Immunological phenomena: glomerulonephritis, Osler's nodes, Roth's spots and rheumatoid factor.
* Microbiological phenomena: positive blood culture but does not meet a major criterion as noted above or serological evidence of active infection with organism consistent with IE.
* PCR: broad-range PCR of 16S (polymerase chain reaction using broad-range primers targeting the bacterial DNA that codes for the 16S ribosomal subunit).
* Echocardiographic findings consistent with IE but do not meet a major criterion as noted above.
99
**Management** of **infective endocarditis**
**Empirical antibiotics** whilst awaiting cultures:
native valve, indolent presentation- amoxicillin
native valve and sepsis- vancomycin AND gentamicin
prosthetic valve- vancomycin + gentamicin + rifampicin
**Staphylococcal endocarditis- flucloxacillin IV 4 weeks**
Streptococcal- benzylpenicillin or ceftriaxone
**Surgery if heart failure or inadequate response to antibiotic treatment**
100
**Management** of **MI** (**long-term**)
_Lifestyle advice:_
* **Stop smoking**
* **Cardioprotective diet** (salt \<6g/d, minimise refined sugars, wholegrain, 4-5 30g portions nuts/seeds per week, fish 2x per week, 5 a day, olive oil, reduce fat and sat fat)
* **Regular exercise**- ideally 150mins per week of moderate intensity aerobic activity and muscle strength on 2 or more days per week
* **Weight loss** if overweight
* **\<14 units alcohol** per week
* **Cardiac rehabilitation programme**
* Annual **influenza vaccine**
_Medication:_
* **ACEi**
* **Dual antiplatelet therapy** (aspirin + clopidogrel *or* ticagrelor)
* **Beta-blocker**
* **Statin**
Source: [https://cks.nice.org.uk/mi-secondary-prevention#!scenario](https://cks.nice.org.uk/mi-secondary-prevention#!scenario)
101
**Management** of **acute myocardial infarction**
**M**orphine 10mg IV (+metoclopramide IV)
**O**xygen (to keep O2 sats \>94%)
**N**itrates
* sublingual GTN (2 sprays) if not hypertensive, then prn
* IV GTN/IV isosorbide dinitrate
**A**spirin 300mg loading *then 75mg OD lifelong*
**C**lopidogrel 300mg loading *then 75mg for 12 months* OD/Ticagrelor/Prasugrel\*
+ LMWH or fondaparinux
+ beta blockers (if no contra-indications)
+ statin
If **STEMI**- refer for **PCI or** **thrombolysis** (if PCI not possible within 90mins, give thrombolysis plus LMWH/fondaparinux)
102
**Investigations** for **ACS**
* **12 lead ECG** (then continuous cardiac monitoring)
* Bloods: usual bloods (**FBC, U&Es, LFTs, CRP, glucose**) plus **cardiac enzymes** (STAT and again at 10-12 hours post- pain onset), **magnesium, phosphate, lipid profile**
* **Chest X-ray** (LVF signs?)
103
**Symptoms** suggestive of **ACS**
**Pain in chest** (or arms/back/jaw) lasting **\>15mins**
Associated with **nausea & vomiting**, **sweating**, or **breathlessness**
Associated with **haemodynamic instability**
Pain is **new-onset**, **or an abrupt deterioration** of stable angina
104
**ECG features** indicative of **ischaemia/previous MI**
**Pathological Q waves**
**LBBB**
**ST-segment and T-wave abnormalities**
*\*a normal ECG _does not_ confirm or exclude a diagnosis of ACS\**
105
When is serum troponin normally detectable after a myocardial infarction?
Within 3-6 hours
106
What is the **definition** of **angina**?
**Chest pain** (or **constricting discomfort**) caused by an **insufficienct blood supply** to the **heart muscle**
107
The **3 types of angina** and their definitions
**Stable**- occurs with **exertion or stress**, **relieved** within minutes of **rest** or with **GTN spray**.
**Unstable**- **new onset** angina, **or abrupt deterioration in stable angina**, often occuring at rest. Requires immediate admission.
**Prinzmetal's variant** (aka coronary artery vasospasm)- rare angina due to **narrowing/occlusion of proximal coronary arteries due to spasm**. Occurs **at rest, not during exercise**. Tends to occur at the same time each day, most often during the night and early morning.
108
**Management** of **stable angina**
_Lifestyle advice:_
* Stop smoking
* Weight loss
* Exercise
* Limit alcohol
_Medication:_
* Sublingual **GTN**
* **Beta-blocker or calcium-channel blocker** 1st line
* 2nd line= isosorbide mononitrate, nicorandil, ivabradine or ranolazine
* **Secondary prevention of CV events**:
* Consider antiplatelet therapy (**aspirin** 75mg OD)
* **Statin**
* ACEi if co-existing HTN, heart failure, CKD or previous MI. Consider ACEi if diabetic
* **Anti-hypertensive** treatment if required as per NICE guidelines
109
In **which type of angina** are **beta blockers contra-indicated**? What is the **alternative**?
**Prinzmetal's angina**
use **rate-limiting calcium-channel blocker** e.g. verapamil or diltiazem
110
**Causes** of **cardiac failure**
**Myocardial disease** e.g. CAD, HTN, cardiomyopathies
**Valvular heart disease** e.g. aortic stenosis
**Pericarditis/pericardial effusion**
**Congenital heart disease**
**Arrythmias** e.g. AF/other tachyarrythmias
**High output states** e.g. anaemia, thyrotoxicosis, phaeochromocytoma, sepsis, liver failure, AV shunts, Paget's disease, thiamine deficiency
**Volume overload**
**Obesity**
**Drugs** incl. alcohol, cocaine, NSAIDs, beta blockers, calcium channel blockers
111
**New York** Heart Association **classification of heart failure**
(4 classes)
**Class I- no limitation** of physical activity
**Class II**- Slight limitation (**ordinary activity** results in **breathlessness/fatigue/palpitations**)
**Class III**- Marked limitation (**less than ordinary physical activity** results in **breathlessness/fatigue/palpitations**)
**Class IV**- **unable to carry out any activity without discomfort**. Symptoms at rest may be present.
112
**Complications** of **chronic heart failure**
Arrythmias (AF most common)
Depression
Cachexia
CKD
Sexual dysfunction
Sudden cardiac death
113
Typical **symptoms** of **heart failure**
* **Breathlessness** — on exertion, at rest, on lying flat (**orthopnoea**), nocturnal cough, or waking from sleep (**paroxysmal nocturnal dyspnoea**).
* **Fluid retention** (ankle swelling, bloated feeling, abdominal swelling, or weight gain).
* **Fatigue**, decreased exercise tolerance, or increased recovery time after exercise.
* **Light headedness** or history of **syncope**.
114
**Clinical features** of **chronic heart failure**
**Tachycardia, abnormal rhythm**
**Laterally displaced apex beat, murmur, and 3rd/4th HS** (gallop rhythym)
**HTN**
**Raised JVP**
**Enlarged liver** (due to engorgement)
**Dependent oedema/ascites**
115
**Management** of **confirmed heart failure** with **reduced ejection fraction**
Stop drugs which may cause/worsen heart failure
**Loop diuretic** e.g. bumetanide, furosemide, torasemide (to relieve sx of fluid overload)
Prescribe an **ACEi** and **beta-blocker** e.g. bisoprolol, carvedilol, nebivolol (but start *_one_* at a time)
* Consider antiplatelet if artherosclerotic disease*
* Consider statin if indicated*
Manage causes/comorbidites/precipating factors
**Annual inflenza vaccine** and **once-only pneumococcal vaccines**
Screen for depression and anxiety
Supervised exercise-based group rehab programme
116
**Management** of **heart failure** with **preserved ejection fraction**
Stop drugs which may cause/worsen heart failure
**Loop diuretic**- up to 80mg **furosemide** or equivalent (to relieve sx of fluid overload)
Consider antiplatelet if artherosclerotic disease
Consider statin if indicated
Manage causes/comorbidites/precipating factors
**Annual influenza vaccine** and **once-only pneumococcal vaccine**
Screen for depression and anxiety
Supervised exercise-based group rehab programme
117
**Investigations** for **suspected chronic heart failure**
**Admit if severe symptoms/pregnant**
If **previous MI, refer urgently** (seen within 2wks)
If has not had previous MI, **measure BNP or NT-pro-BNP**:
*BNP \>400pg/mL refer for ECHO + specialist assessment within 2 weeks
BNP 100-400 refer within 6 weeks
BNP \<100*
**12-lead ECG**
**Consider tests for other conditions/aggravating factorse** e.g. CXR, bloods (U&Es, eGFR, FBC, TFTs, LFTs, HbA1c, fasting lipids), urine dip (blood and protein), lung function tests
118
**Investigations** for **new suspected acute heart failure**
**BNP**
If BNP raised, do **TTE**
119
**Treatment** of **acute heart failure**
_Initial treatment:_
*Pharmacological:*
* **IV diuretics** (if already on diuretic then increase dose)
*Non-pharmacological:*
* Consider NIV if cardiogenic pulmonary oedema and severe dyspnoea and acidaemia
* Consider invasive ventilation if heart failure is (despite treatment) leading to respiratory failure, decreased consciousness or physical exhaustion
_After stabilisation:_
* Beta blocker if acute heart failure due to left ventricular systolic dysfunction, once IV diuretics are no longer needed
* ACEi and an aldosterone antagonist if acute heart failure and reduced ejection fraction
_Long-term management:_
* As per chronic heart failure
* **Surgical aortic valve replacement if heart failure due to severe aortic stenosis** (or transcatheter aortic valve implantation if unfit for surgery)
120
**Causes** of **acute heart failure/decompensation** of chronic heart failure
* Further/worsening **ischaemia**
* **Myocardial infarction**
* Additional **valvular or diastolic dysfunction**
* **Infections**
* **Arrhythmias** - commonly atrial fibrillation (AF).
* **Electrolyte imbalance**
* **Worsening comorbidities** - eg, anaemia, thyroid dysfunction, pulmonary disease, renal dysfunction, diabetes
* New **medications**
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**Ejection systolic** murmur
**Crescendo-decrescendo**
Commonly heard in **2nd right intercostal space**
**Aortic stenosis**
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**Slow rising pulse** is associated with which murmur?
**Aortic stenosis**
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**Symptoms** of **aortic stenosis**
May be asymptomatic
SOBOE
Dizziness
Chest pain/angina
Syncope
Swollen ankles
124
**Diagnostic** investigation for **aortic stenosis**
ECHO
125
**Managament** of **aortic stenosis**
Avoid heavy exertion
Modify atherosclerotic risk factors
Treat HTN
Maintain sinus rhythm
**Surgery or transcatheter aortic valve implantation if symptomatic**
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**Early diastolic murmur**
Best heard in **aortic area** with **patient sat forward in expiration**
Soft S1
Collapsing pulse/wide pulse pressure
**Aortic regurgitation**
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**Causes** of **aortic regurgitation**
Most common cause worldwide- **rheumatic heart disease**
Commonest cause in developed countries- **congenital and degenerative valve abnormalities** e.g. bicuspid aortic valve, endocarditis, collagen vascular diseases
**Transcatheter aortic valve replacement**
128
**Management** of **aortic regurgitation**
**Surgery** if **symptomatic** or **asymptomatic with deteriorating left ventricular function** (valve replacement or repair)
129
**Pansystolic** murmur
Heard **loudest over tricuspid** region
Loudest during **inspiration**
Large **v waves** in JVP
**Hepatic pulsations**
Signs of **right sided heart failure**
Tricuspid regurgitation
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**Ejection systolic** murmur
**Loudest** over **pulmonary area in inspiration**
**Radiates to left shoulder**
"**a waves**" in JVP
**Widely split S2**
Pulmonary stenosis
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**Early decrescendo** murmur
**Loudest** over **left sternal edge during inspiration**
Usually due to pulmonary hypertension
Pulmonary regurgitation
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**Mid-diastolic** murmur (rarely audible)
**Loudest at 3rd/4th intercostal space, left sternal edge, during inspiration**
Signs of **right atrial enlargment** (raised JVP with giant a waves, peripheral oedema, ascites)
Tricuspid stenosis
