Cardiovascular Flashcards

Question

What is the aetiology of aortic regurgitation?

Answer 1

In developing countries rheumatic heart disease is the most common cause. In developed countries most cases are caused by congenital bicuspid aortic valve and aortic root dilation (connective tissue disorders, aortitis). Aortic root dissection is an acute cause of AR

Answer 2

Chronic AR often begins in the late 50s, documented most frequently in patients >80 years.

Answer 3

Chronic AR: initially asymptomatic. Later, symptoms of heart failure: exertional dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, weakness, fatigue. Chest pain. Occasionally angina. Severe acute AR: sudden cardiovascular collapse. Symptoms related to the aetiology, e.g. chest or back pain in patients with aortic dissection.

Answer 4

Diastolic murmur *Collapsing ‘water-hammer’ pulse Thrusting and heaving displaced apex beat- present in chronic AR with LV hypertrophy Hyperdynamic pulse* Tachypnoea Jugular venous distension (cariogenic shock) Cyanosis (acute AR) Basal lung crepitations (pulmonary oedema)

Answer 5

Visible pulsations on nail-bed

Answer 6

Head nodding in time with pulse

Answer 7

Visible pulsations of the pupils and retinal arteries

Answer 8

Visible pulsation of the uvula

Answer 9

Visible pulsations in neck

Answer 10

1st line: ECG: may show non-specific ST-T wave changes, left axis deviation, left ventricular hypertrophy, or conduction abnormalities CXR: may show cardiomegaly Echo: may indicate the underlying cause (e.g. aortic root dilation, bicuspid aortic valve) or the effects of AR (left ventricular dilation/dysfunction and fluttering of the anterior mitral valve leaflet) Doppler echocardiogram: for detecting AR and assessing severity Other: Cardiac catheterisation: to assess the presence of coronary artery disease or the functional state of the left ventricle

Answer 11

Obstruction of blood flow across the aortic valve from the LV due to pathological narrowing

Answer 12

Rheumatic heart disease (commonest worldwide cause) Calcification of congenital bicuspid aortic valve Calcification or degeneration of a tricuspid aortic valve in the elderly (RF: age > 60 years) Chronic kidney disease

Answer 13

Prevalence in 􏰅3% of 75-year-olds. More common in men than women. Those with bicuspid aortic valve may present earlier (as young adults).

Answer 14

May be asymptomatic initially (Chest pain) Angina (because of " oxygen demand of the hypertrophied ventricles) Syncope or dizziness on exercise Symptoms of heart failure (e.g. dyspnoea)

Answer 15

BP: Narrow pulse pressure. Pulse: Slow-rising. Palpation: Thrill in the aortic area (if severe). Forceful sustained thrusting undisplaced apex beat. Auscultation: Harsh ejection systolic murmur at aortic area, radiating to the carotid artery and apex Second heart sound (A2 component) may be softened or absent (because of calcification) A bicuspid valve may produce an ejection click. *distinguish from aortic sclerosis and hypertrophied obstructive cardiomyopathy*

Answer 16

1st Line: Transthoracic echocardiogram: visualises structural changes int he valve, measure elevated aortic pressure gradient, measurement of valve area and left ventricular ejection function ECG: may demonstrate left ventricular hypertrophy and LBBB (and absent Q waves) Others: Cardiac MRI- demonstrates stenotic aortic valve Cardiac catheterisation: elevated aortic pressure gradient Cardiac angiography: Allows differentiation from other causes of angina, and to assess for concomitant coronary artery disease

Answer 17

an ulcer caused by a reduction in arterial blood flow, leading to decreased perfusion of the tissues and subsequent poor healing.

Answer 18

Atherosclerosis Hypertension Others: smoking, diabetes mellitus, hyperlipidaemia, increasing age, positive family history, and obesity and physical inactivity

Answer 19

Severe pain, particularly at night | Pain is relieved by dependency

Answer 20

likely to give a preceding history of intermittent claudication (pain when they walk) or critical limb ischaemia (pain at night). Severe pain, particularly at night Pain is relieved by dependency Develops over a long period of time with little to no healing

Answer 21

On examination: the limbs will be cold and have reduced or absent pulses. In pure arterial ulcers, sensation is maintained (unlike neuropathic ulcers) Location: distal, dorsum of foot or toes, over bony prominences Characteristics: Irregular edge, poor granulation tissue, dry necrotic base, round or punched-out with sharp demarcation Associated findings: Trophic changes of chronic ischemia, Pale, hair loss, atrophic skin, cool feet, thickened nails, necrotic toes Absence of pulses, prolonged capillary refill (>4–5 s), dependent rubor

Answer 22

Ankle Brachial Pressure Index (ABPI) measurement: (>0.9 = normal; 0.9-0.8 = mild; 0.8-0.5 = moderate; <0.5 = severe) Imaging: duplex ultrasound, CT Angiography, and / or Magnetic Resonance Angiogram (MRA)

Answer 23

Dependent refers to a means of support, i.e., floor, back of chair, armrest.

Answer 24

A fiery to dusky-red coloration visible when the leg is in a dependent position

Answer 25

A surgical emergency

Answer 26

``` Pain Pallor Pulseless Perishing cold Paraesthesia Paralysis ```

Answer 27

Rapid, chaotic and ineffective atrial electrical conduction.

Answer 28

Permanent Persistent Paroxysmal

Answer 29

There may be no identifiable cause (‘lone’ AF) | Secondary causes lead to abnormal atrial electrical pathways that result in AF

Answer 30

Thyrotoxicosis Hypertension Pneumonia Alcohol

Answer 31

``` Mitral valve disease Ischaemic heart disease Rheumatic heart disease Cardiomyopathy Pericarditis Atrial myxoma (benign tumour) ```

Answer 32

Bronchial carcinoma | Pulmonary embolism

Answer 33

Very common in the elderly (􏰄5% of those >65 years) | May be paroxysmal- sudden recurrence or intensification of symptoms

Answer 34

Often asymptomatic Some patients experience palpitations or syncope In secondary cases: symptoms of the cause of AF

Answer 35

Irregularly irregular pulse Difference in apical beat and radial pulse *Look for thyroid disease and valvular heart disease.

Answer 36

- ECG: Uneven baseline (fibrillations) with absent P waves, irregular QRS complexes. - Bloods: Cardiac enzymes, TFTs, lipid profile, U&Es, - Echocardiogram: To assess for mitral valve disease, left atrial dilation, left ventricular dysfunction or structural abnormalities

Answer 37

Saw tooth baseline

Answer 38

1. Rhythm control 2. Rate control 3. Stroke risk stratification

Answer 39

If the AF is >48h from onset, anticoagulate (at least 3–4 weeks) before attempting cardioversion. - DC cardioversion: Synchronized DC shock (2x100 J, 1x200 J) -Chemical cardioversion: Anti-arryhtmic (flecainide or amiodarone)- contraindicated if there is history of ischaemic heart disease and only recommended in dangerous arrythmias Prophylaxis against AF: Sotalol, amiodarone or flecainide.

Answer 40

This is for chronic ‘permanent’ AF: Ventricular rate control with digoxin, verapamil (calcium channel blocker) and/or B- blockers. Aim for rate of 􏰄90/min.

Answer 41

It is a cardiac glycoside that increases the force of myocardial contraction and reduces conductivity within the atrioventricular (AV) node- used to treat AF, atrial flutter and heart failure

Answer 42

K+, Mg2+, Ca2+ | There is a risk of digoxin toxicity if potassium or magnesium are low, or if calcium is high

Answer 43

Low-risk patients: Aspirin | High-risk patients: Require anticoagulation with warfarin

Answer 44

Previous thromboembolic event (s) Age 􏰃75 years with hypertension, diabetes or vascular disease, and/or clinical evidence of valve disease, heart failure or impaired left ventricular function

Answer 45

CHADS-vasc score

Answer 46

Thromboembolism (embolic stroke􏰄, risk with left atrial enlargement or left ventricular dysfunction) Worsens any existing heart failure

Answer 47

Chronic AF in a diseased heart does not usually return to sinus rhythm

Answer 48

Acute cessation of cardiac function

Answer 49

``` 4 Hs and 4Ts: Hypokalaemia Hypothermia Hypovolaemia Hypoxia ``` Tamponade Tension pneumothorax Thromboembolism Toxins

Answer 50

Unconscious Patient is not breathing Absent carotid pulses

Answer 51

Ventricular fibrillation (VF) Pulseless ventricular tachycardia (VT) Pulseless electrical activity Asystole

Answer 52

Cardiac monitor: Classification of the rhythm directs management Bloods: ABG, U&Es, FBC, cross-match, clotting, toxicology screen, glucose.

Answer 53

Safety: approach with caution, defibrillators and oxygen are hazards- call for help A: Clear and maintain airway with head tilt (if no spinal injury), jaw thrust and chin lift. B: Assess breathing by look, listen and feel. If not breathing, give two effective breaths immediately. C: Assess circulation at carotid pulse for 10 s. If absent, give 30 chest compressions at rate of 􏰄100/min􏰆. Continue cycles of 30 compressions for every two breaths. Proceed to advanced life support as soon as possible.

Answer 54

1. Attach cardiac monitor and defibrillator | 2. Assess the rhythm

Answer 55

Ventricular tachycardia | Ventricular fibrillation

Answer 56

1. Defibrillate once 2. Resume CPR immediately for 2 min, and then defibrillate 3. Administer adrenaline (1 mg IV) after second defibrillation and again every 3–5 min. 4. If ‘shockable rhythm’ persists after third shock, administer amiodarone 300 mg IV bolus (anti-arrhythmic)

Answer 57

Pulseless electrical activity | Asystole

Answer 58

1. CPR for 2 min, and then return to assessing rhythm 2. Administer adrenaline (1 mg IV) every 3–5 min. 3. Atropine (3 mg IV, once only) if asystole or PEA with rate <60/min􏰆

Answer 59

Hypothermia: Warm slowly Hypo- or hyperkalaemia: Correction of electrolytes Hypovolaemia: IV colloids, crystalloids or blood products Hypoxia: oxygen Tamponade: Pericardiocentesis under xiphisternum up and leftwards Tension pneumothorax: Needle into second intercostal space, mid-clavicular line Thromboembolism: management for PE, MI Toxins: antidotes

Answer 60

Irreversible hypoxic brain damage, death

Answer 61

Resuscitation is less successful in the arrests that occur outside hospital. Duration of inadequate effective cardiac output is associated with poor prognosis.

Answer 62

Restrictive

Answer 63

Inability of the cardiac output to meet the bodys demands despite normal venous pressures

Answer 64

``` Left heart failure: -Ischaemic heart disease -Hypertension -Cardiomyopathy -Aortic valve disease -Mitral regurgitation Right heart failure: -Secondary to left heart failure -Infarction -Cardiomyopathy -Pulmonary hypertension/embolus/valve disease -Chronic lung disease -Tricuspid regurgitation -Constrictive pericarditis/pericardial tamponade Biventricular failure: -Arrhythmia -Cardiomyopathy (dilated or restrictive) -Myocarditis -Drug toxicity ```

Answer 65

``` (High demand) Anaemia Beriberi (vitamin B-1 deficiency- thiamine deficiency) Pregnancy Pagets disease Hyperthyroidism Arteriovenous malformation ```

Answer 66

10% of > 65-year-olds

Answer 67

``` Left (symptoms caused by pulmonary congestion): Dyspnoea (New York Heart Association classification): 1. no dyspnoea 2. dyspnoea on ordinary activities 3. dyspnoea on less than ordinary activities 4. dyspnoea at rest Orthopnoea Paroxysmal nocturnal dyspnoea Fatigue ```

Answer 68

``` Swollen ankles Fatigue Increased weight (resulting from oedema) Reduced exercise tolerance Anorexia Nausea ```

Answer 69

Tachycardia Tachypnoea Displaced apex beat Bilateral basal crackles Third heart sound (gallop rhythm: rapid ventricular filling) Pansystolic murmur (functional mitral regurgitation)

Answer 70

Symptoms: Dyspnoea, wheeze, cough and pink frothy sputum Signs: Tachypnoea, cyanosis, tachycardia, peripheral shutdown, pulsus alternans (strong and weak beats), gallop rhythm, wheeze cardiac asthma, fine crackles throughout the lung

Answer 71

``` Raised JVP Hepatomegaly Ascites Ankle/sacral pitting oedema Signs of functional tricuspid regurgitation ```

Answer 72

Bloods: - Elevated BNP (B type natriuretic peptide, associated with reduced LVEF) - FBC (anaemia, high lymphocytes) - U&Es baseline (decreased sodium, altered potassium) - Serum creatinine: normal to elevated - LFTs: normal to elevated (reflects abdominal congestion) - TFTs: screening for hypo and hyperthyroidism - Others: CRP, glucose, lipids CXR: - Cardiomegaly (heart >50 % of thoracic width) - Pulmonary vascular congestion (vascular redistribution, Kerley B lines-interstitial oedema) - Pleural effusion (usually right-sided but often bilateral) ECG: May be normal. May show underlying coronary artery disease, left ventricular hypertrophy, or atrial enlargement Echocardiogram: To assess ventricular contraction - If left ventricular ejection fraction (LVEF) <40%: systolic dysfunction - Diastolic dysfunction: reduced compliance leading to a restrictive filling defect Swan–Ganz catheter (right heart catheterisation): Allows measurements of right atrial, right ventricular, pulmonary artery, pulmonary wedge and left ventricular end-diastolic pressures (any pulmonary or systemic resistance) Exercise stress testing/exercise tolerance: Assess patient's functional exercise limitation and haemodynamic response to exercise

Answer 73

Bloods: -FBC (anaemia) -ABG -Troponin: elevated -Brain natriuretic peptide (BNP): elevated suggests the diagnosis of cardiac failure *A low plasma BNP rules out cardiac failure (90% sensitivity) ECG: arrhythmia (20% are AF) , ischaemic ST and T wave changes CXR: - Cardiomegaly - Pulmonary congestion - Pleural effusion - Valvular or pericardial calcification Echocardiogram: -Abnormal systolic and diastolic function (EF) Cardiac catheterisation: abnormal coronary artery flow and left ventricular function

Answer 74

Cardiogenic shock: Severe cardiac failure with low BP requires the use of inotropes (e.g. dopamine, dobutamine) and should be managed in ITU *inotropes: increase the force contractility of the heart Pulmonary oedema: Sit up patient, 60–100% O2 and consider CPAP. Other first-line therapies are diamorphine (venodilator and anxiolytic effect), GTN infusion (reduces preload), IV furo- semide if fluid overloaded (venodilator and later diuretic effect) Monitor BP, respiratory rate, sat. O2, urine output, ECG. Treat the cause, e.g. myocardial infarction, arrhythmia

Answer 75

Treat the cause, e.g. hypertension Treat exacerbating factors, e.g. anaemia 1. ACE-inhibitors (e.g. enalapril, perindopril, ramipril): Inhibit intracardiac renin-angiotensin system which may contribute to myocardial hypertrophy and remodelling. ACE inhibitors slow progression of the heart failure and improve survival 2. b-Blockers (bisprolol or carvedilol): Block the effects of chronically activated sympathetic system, slow progression of the heart failure and improve survival. The benefits of ACE inhibitors and b-blockers are additive* 3. Loop diuretics (e.g. furosemide) and dietary salt restriction to correct fluid overload. 4. Aldosterone antagonists (spironolactone or, if not tolerated, eplerenone) improve survival. May be used to assist in the management of diuretic-induced hypokalaemia 5. Angiotensin receptor blockers (ARB) (e.g. candesartan): May be added in patients with persistent symptoms despite ACE inhibitors and b-blockers. 6. Hydralazine and a nitrate: May be added in patients (particularly in Afro-Caribbeans) with persistent symptoms despite therapy with an ACE inhibitor and b-blocker 7. Digoxin: Positive inotrope, reduces hospitalization, but does not improve survival 8. Cardiac resynchronization therapy (CRT): Biventricular pacing improves symptoms and survival in patients with LVEF 􏰅 35%. Most patients who meet these criteria are also candidates for an implantable cardiac defibrillator (ICD) and receive a combined device *Avoid drugs that can adversely affect patients with heart failure due to systolic dysfunction, e.g. NSAIDs, non-dihydropyridine calcium channel blockers (i.e. diltiazem and verapamil)

Answer 76

Respiratory failure, cardiogenic shock, death

Answer 77

50% of patients with severe heart failure die within 2 years

Answer 78

Primary disease of the myocardium | Cardiomyopathy may be dilated, hypertrophic or restrictive

Answer 79

The majority are idiopathic, the different types have different aetiologies

Answer 80

Post-viral myocarditis Alcohol, drugs (e.g. doxorubicin, cocaine) Familial (􏰄25% of idiopathic cases, usually autosomal dominant) Thyrotoxicosis Haemochromatosis Peripartum

Answer 81

Up to 50% of cases are genetic (autosomal dominant) with mutations in b-myosin, troponin T or a-tropomyosin

Answer 82

Amyloidosis, sarcoidosis, haemochromatosis

Answer 83

Prevalence of dilated cardiomyopathy and hypertrophic cardiomyopathy is 􏰄0.05–0.20% *Restrictive cardiomyopathy is rare

Answer 84

Symptoms of heart failure Arrhythmias Thromboembolism Family history of sudden death.

Answer 85

``` Usually none Syncope Angina Arrhythmias Family history of sudden death ```

Answer 86

*Dyspnoea *Fatigue Arrhythmias Ankle or abdominal swelling Family history of sudden death

Answer 87

(similar to heart failure) Raised JVP Displaced apex beat Functional mitral and tricuspid regurgitations Third heart sound *auscultation of the lungs: crackles, indicating pulmonary congestion

Answer 88

Jerky carotid pulse Double apex beat Ejection systolic murmur *auscultation of the lungs: crackles, indicating pulmonary congestion

Answer 89

Raised JVP (Kussmauls sign: further increase on inspiration) Palpable apex beat Third heart sound Ascites Ankle oedema Hepatomegaly *auscultation of the lungs: crackles, indicating pulmonary congestion

Answer 90

Bloods:FBC,LFTs,TFTs, BNP (elevated), cardiac enzymes CXR: May show cardiomegaly, and signs of heart failure (pulmonary oedema) ECG: All types: Non-specific ST changes, conduction defects, arrhythmias -Hypertrophic: Left-axis deviation, signs of left ventricular hypertrophy -Restrictive: Low voltage complexes Echocardiography: - Dilated: Dilated ventricles with ‘global’ hypokinesia - Hypertrophic: Ventricular hypertrophy (disproportionate septal involvement) - Restrictive: Non-dilated non-hypertrophied ventricles * IN AMYLOIDOSIS: Atrial enlargement, preserved systolic function, diastolic dysfunction, granular or ‘sparkling’ appearance of myocardium Others: Cardiac catheterization: May be necessary for measurement of pressures Endomyocardial biopsy: May be helpful in restrictive cardiomyopathy (RARE)

Answer 91

Inflammation of the pericardium, may be acute, subacute or chronic

Answer 92

New-onset inflammation lasting <4-6 weeks

Answer 93

Can be idiopathic or due to an underlying systemic condition (e.g., systemic lupus erythematosus) As many as 90% of cases are either idiopathic or due to viral infections or systemic autoimmune conditions

Answer 94

Viral or bacterial infection (viral is most common): -Commonly coxsackie B, echovirus, mumps virus, streptococci, fungi, staphylococci, TB Systemic autoimmune conditions e.g. rheumatoid arthritis and SLE Malignancy Metabolic disorders Cardiac surgery (4 weeks after coronary artery bypass graft) Transmural MI: -post-myocardial infarction (24–72 h) -Dresslers syndrome (weeks to months after acute MI)

Answer 95

Acute pericarditis is more common in adults (typically between 20 to 50 years old) and in men Uncommon- the clinical incidence is <1 in 100 hospital admissions

Answer 96

Chest pain (most common- 85% of cases) -Sharp, stabbing, pleuritic, or aching, and can mimic the pain of myocardial ischaemia or infarction **Almost all patients report relief of pain with sitting up or leaning forward -Pain radiates to neck or shoulders -Aggravated by coughing, deep inspiration and lying flat Others: Dyspnoea, nausea

Answer 97

Fever Pericardial friction rub (best heard lower left sternal edge, with patient leaning forward in expiration) Heart sounds may be faint in the presence of an effusion

Answer 98

Raised JVP with inspiration (Kussmauls sign) Pulsus paradoxus: an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration (<10 mmHg) Hepatomegaly Ascites Oedema Pericardial knock (rapid ventricular filling) AF

Answer 99

Impedes (delays) normal diastolic filling and can be a medium to late complication of acute pericarditis

Answer 100

*ECG: Widespread ST elevation that is saddle-shaped (most useful diagnostic test) Bloods: -Troponin: elevated -ESR and CRP: elevated consistent with inflammation -Urea: elevated suggest a urea cause -FBC: elevated leukocytes Pericardial fluid/blood culture: positive if infectious cause (and viral serology, ANA, rheumatoid factor) CXR: Usually normal unless a large pericardial effusion is present >300 mL effusion: water-bottle-shaped enlarged cardiac silhouette Chest CT: Pericardial calcification can be seen in constrictive pericarditis: -pericardial thickness, calcification -deformed ventricular contours -dilatation of the inferior vena cava -angulation of the ventricular septum (lateral CXR or CT)

Answer 101

An invasive diagnostic procedure to assess the structure and function of the heart, using a contrast medium and x-rays of the heart and coronary arteries

Answer 102

The combination of coronary angioplasty with stenting, widening blocked or narrowed coronary arteries

Answer 103

Coronary angiography: diagnosis, treatments and procedures - Post MI: where the heart's blood supply is blocked - Diagnose angina: chest pain is caused by restricted blood supply to the heart - Plan interventional or surgical procedures – such PCI - Diagnose coronary heart disease PCI: may be required to restore the blood supply to the heart in severe cases where medication is ineffective for MI and angina -Coronary angioplasties are also often used as an emergency treatment after a heart attack

Answer 104

Allergic reaction to contrast dye Bleeding under the skin where the catheter was inserted Damage to the artery in the arm or leg where the catheter was inserted Rare: Heart attack, Stroke, Kidney damage and, very rarely, death

Answer 105

A surgical procedure used to treat coronary heart disease by diverting blood around narrowed or clogged parts of coronary arteries to improve blood flow and oxygen supply to the heart

Answer 106

Atherosclerosis causing coronary heart disease | Reduce the risk of MI

Answer 107

Arrhythmias Infection risk Rare: stroke or heart attack

Answer 108

A procedure to convert an abnormal heart rhythm to a normal heart rhythm (most commonly AF)

Answer 109

Arrhythmias

Answer 110

Usually temporary: - Headaches and dizziness from a drop in your blood pressure from anaesthetic - Discomfort in chest where the shock was given - Nausea (from anaesthetic)

Answer 111

Venous stasis Vessel wall injury Blood hypercoagulability

Answer 112

Formation of a thrombus within the deep veins (most commonly of the calf or thigh) which may result in impaired venous blood flow and consequent leg swelling and pain

Answer 113

Oral contraceptive pill Surgery Prolonged immobility Long bone fractures Obesity Pregnancy Dehydration Smoking Polycythaemia Anti-phospholipid syndrome Thrombophilia disorders (e.g. protein C deficiency) Active malignancy

Answer 114

Common, especially in hospitalised patients- yearly incidence of approximately 1 in every 1000 adults Long-term complications of DVT (venous insufficiency, ulceration) affect 0.5% population Incidence increases with age (increased medical co-morbidities, declining mobility, and perhaps age-related changes in coagulation)

Answer 115

Asymptomatic or lower limb swelling or tenderness May present with signs/ symptoms of a pulmonary embolus (sudden onset dyspnoea, chest pain)

Answer 116

Examine for swelling, calf tenderness: Severe leg oedema (usually unilateral) Dilated superficial veins over foot and leg Cyanosis (phlegmasia cerulea dolens) is rare *Respiratory examination for signs of a pulmonary embolus (Sudden onset dyspnoea, cough, haemoptysis and pleuritic chest pain)

Answer 117

*Doppler ultrasound: gold standard -Good sensitivity for femoral veins; less sensitive for calf veins (reduced/absent spontaneous blood flow) Bloods: -D-dimers (fibrinogen degradation products) are sensitive but very non-specific and only useful as a negative predictor in low-risk patients -If indicated (e.g. recurrent episodes), a thrombophilia screen should be sent, prior to starting anticoagulation -FBC (platelet count prior to starting heparin) -U&Es and clotting ECG, CXR and ABG: If there is suggestion that there might be PE

Answer 118

Lower limb trauma or surgery or immobilisation in a plaster cast (+1) Bedridden for >3 days or surgery within the last 4 weeks (+1) Tenderness along deep venous system (+1) Entire limb swollen (+1) Calf >3 cm bigger circumference; 10 cm below tibial tuberosity (+1) Pitting oedema (+1) Dilated collateral superficial veins (non-varicose) (+1) Malignancy (including treatment up to 6 months previously) (+1) Alternative diagnosis more likely than DVT (-2) Clinical probability of DVT: High >3 Moderate 1–2

Answer 119

Anticoagulation: - Patients should be treated with heparin while awaiting therapeutic INR from warfarin anticoagulation - DVTs not extending above the knee treated with anticoagulation for 3 months, while those extending beyond the knee require anticoagulation for 6 months - Recurrent DVTs may require long-term warfarin* - If active anticoagulation is contraindicated and/or high risk of embolisation, placement of an IVC filter, e.g. Greenfield filter, by interventional radiology is indicated to prevent embolus to the lungs Prevention: - Use of graduated compression stockings - Mobilisation if possible (physical activity) - At-risk groups (immobilised hospital patients) should have prophylactic heparin, e.g. low molecular weight heparin if no contraindications

Answer 120

Of the disease: -Pulmonary embolus -Damage to vein valves and chronic venous insufficiency of the lower limb (post-thrombotic syndrome) *Rare: Venous infarction (phlegmasia cerulea dolens) Of the treatment: -Heparin-induced thrombocytopaenia -Bleeding

Answer 121

Depends on extent of DVT: - Below-knee DVTs lower risk of embolus - More proximal DVTs have higher risk of propagation and embolisation, which, if large, may be fatal

Answer 122

An elevation of total cholesterol (TC) and/or low-density lipoprotein cholesterol (LDL-C)

Answer 123

Dyslipidaemia is classified as serum Total cholesterol, LDL-C, triglycerides, apolipoprotein B, or lipoprotein(a) concentrations above the 90th percentile for the general population

Answer 124

Primary causes: due to single or multiple gene mutations, resulting in a disturbance of low-density lipoprotein (LDL) and triglyceride production or clearance - most commonly seen in children and young adults Secondary causes: caused by lifestyle factors or disorders that interfere with blood lipid levels over time such as obesity, chronic renal insufficiency, abdominal obesity, diabetes mellitus and hypothyroidism

Answer 125

Common, particularly in developing countries Strong correlation between body mass index and coronary heart disease Primary causes are common in children and young adults whereas secondary is seen more in adults

Answer 126

Excess body weight PMH Diabetes Mellitus Type 2 or cardiovascular disease Consumption of saturated fats FH of early onset of coronary heart disease or Dyslipidaemia

Answer 127

Xanthelasmas: Yellow plaques that occur most commonly near the inner canthus of the eyelid Tendinous xanthomas: Slowly enlarging subcutaneous nodules (on tendons or ligaments)

Answer 128

Lipid profile: -total cholesterol (TC) >5.18 mmol/L (>200 mg/dL) -LDL-cholesterol >2.59 mmol/L (>100 mg/dL) -triglycerides >1.7 mmol/L (>150 mg/dL) Fasting (12h) triglycerides: ≥2.3 mmol/L (200 mg/dL) Thyroid stimulating hormone: elevated in primary hypothyroidism Lipoprotein (a): values >50 mg/dL or >125 nmol/L are considered high

Answer 129

Combination of lifestyle changes to diet and exercise, medications, and dietary supplements Lifestyle changes: dietary reduction in total and saturated fat, weight loss in overweight patients, aerobic exercise Drug therapy: Statins inhibit 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, a key enzyme in cholesterol synthesis, which leads to up-regulation of LDL receptors and increased LDL clearance

Answer 130

Atherosclerosis: Ischaemic heart disease Peripheral vascular disease Acute coronary syndrome Stroke Erectile dysfunction (endothelial dysfunction)

Answer 131

The rate of adverse outcomes has been significantly reduced with the use of statins Useful in the rid reduction of coronary heart disease

Answer 132

Having a fasting plasma triglyceride level of ≥2.3 mmol/L (≥200 mg/dL)

Answer 133

Eruptive xanthomas: Small yellowish papules, frequently surrounded by an erythematous base, that appear predominantly on the buttocks, elbows, and other pressure-sensitive areas

Answer 134

A complication of necrosis characterised by the decay of body tissues. There are two major categories: - Infectious gangrene (wet gangrene) - Ischaemic gangrene (dry gangrene)

Answer 135

May result from ischaemia, infection, or trauma (or a combination of these processes) Ischaemia may result from either arterial or venous compromise, and may be an acute or chronic process (or a combination of both) *Critically insufficient blood supply is the most common cause of gangrene, and is often associated with diabetes and long-term smoking

Answer 136

Gangrene occurs equally in men and women Type I necrotising fasciitis occurs most commonly in patients with diabetes and patients with peripheral vascular disease- it is the most common form of necrotising fasciitis in the general population

Answer 137

Pain Affected area may become swollen Skin discolouration Low grade fever and chills (infectious gangrene)

Answer 138

Oedema with overlying erythema Skin discolouration: ecchymoses (bleeding underneath the skin), purpura, skin blebs, and haemorrhagic bullae Gas gangrene- crepitus (uncommon) Diminished pedal pulses and ankle-brachial index: Suggests chronic arterial insufficiency

Answer 139

Bloods: -FBC: leukocytosis and anaemia -CRP: elevated -LDH: elevated if haemolytic anaemia and gas gangrene -Metabolic profile: may indicate metabolic acidosis, liver derangement, renal failure Blood cultures: positive for infectious organism Imaging: - Plain X-rays: for gas gangrene- may demonstrate gas in the soft tissues and/or indicate underlying osteomyelitis - CT/MRI of affected site: may reveal abscess formation or evidence of enhancement, oedema, or thickening in the fascia - Doppler ultrasound: may indicate presence and severity of arterial or venous obstruction Others: - Skin biopsy - CT angiography: region of obstruction - CT chest/abdomen: if suspected malignancy

Answer 140

Impairment of the atrioventricular (AV) node impulse conduction, as represented by the interval between P wave and QRS complex

Answer 141

Prolonged conduction through the AV node

Answer 142

The progressive prolongation of AV node conduction culminating in one atrial impulse failing to be conducted through the AV node. The cycle then begins again

Answer 143

Intermittent or regular failure of conduction through AV node Also defined by the number of normal conductions per failed or abnormal one (e.g. 2 : 1 or 3 : 1)

Answer 144

Also known as complete heart block No relationship between atrial and ventricular con- traction Failure of conduction through the AV node leads to a ventricular contraction generated by a focus of depolarization within the ventricle (ventricular escape)

Answer 145

Most common cause: MI or ischaemic heart disease Other causes: -Infection e.g. rheumatic fever, infective endocarditis -Drugs e.g. digoxin ,b-blockers, Ca2+ channel blockers -Metabolic e.g. hyperkalaemia, cholestatic jaundice, hypothermia - Infiltration of conducting system e.g. sarcoidosis, cardiac neoplasms, amyloidosis -Degeneration of the conducting system

Answer 146

The majority of pacemakers implanted annually are for heart block First degree heart block is associated with increased risk of AF

Answer 147

``` First degree: Asymptomatic Wenchebach: Usually asymptomatic Mobitz type II and third-degree block: -May cause Stokes–Adams attacks (syncope caused by ventricular asystole) -Dizziness -Palpitations -Chest pain -Heart failure ```

Answer 148

``` Often normal Complete heart block: -Slow large volume pulse -JVP may show ‘cannon waves’ Mobitz type II and third-degree block: Signs of a reduced cardiac output (e.g. hypotension, heart failure) ```

Answer 149

Prolonged PR interval (>0.2 s)

Answer 150

Progressively prolonged PR interval, culminating in a P wave that is not followed by a QRS The pattern then begins again

Answer 151

Intermittently a P wave is not followed by a QRS There may be a regular pattern of P waves not followed by a QRS (e.g. two P waves per QRS, indicating 2 : 1 block)

Answer 152

No relationship between P waves and QRS complexes If QRS initiated by focus in the bundle of His, the QRS is narrow- the QRS initiated more distally are wide and slow rate (􏰄30 beats/min)

Answer 153

ECG: different findings CXR: may show hilar lymphadenopathy, cardiac enlargement, pulmonary oedema Bloods: -TFTs: hypo or hyperthyroidism -Digoxin level: identify cause -Cardiac enzymes, troponin: may be elevated Echocardiogram: Ventricular dysfunction or hypertrophy, valvular disease, wall-motion abnormalities

Answer 154

No specific treatment is required Patients are at low risk for progression to higher-degree AV block

Answer 155

First line of treatment is to stop all AV-nodal blocking medications: beta-blockers, non-dihydropyridine calcium-channel blockers, and digoxin. While discontinuing these medicines may improve AV conduction, they are not likely to completely reverse a clinically significant AV block If severe: Permanent pacemakers should be considered (recommended in patients with third-degree heart block, advanced Mobitz type II and symptomatic Mobitz type I)

Answer 156

If associated with clinical deterioration, IV Atropine (anti-muscarinic) and consider temporary (external) pacemaker

Answer 157

Asystole- cardiac arrest Heart failure Complications of any pacemaker inserted

Answer 158

Mobitz type II and third-degree block (advanced) usually indicate serious underlying cardiac disease whereas first degree and Mobitz type I have a low risk

Answer 159

Defined as systolic BP >140mmHg and/or diastolic BP >90mmHg measured on three separate occasions

Answer 160

Defined as BP 􏰃200/ 130 mmHg

Answer 161

Primary: Essential or idiopathic hypertension (Commonest, >90% of cases) Secondary: - Renal: Renal artery stenosis, chronic glomerulonephritis, chronic pyelonephritis, polycystic kidney disease, chronic renal failure. - Endocrine: DM, hyperthyroidism, Cushings syndrome, Conns syndrome, hyperparathyroidism, phaeochromocytoma, congenital adrenal hyperplasia, acromegaly - Cardiovascular: Aortic coarctation, increase in intravascular volume. - Drugs: Sympathomimetics, corticosteroids, OCP - Pregnancy: Pre-eclampsia

Answer 162

Very common- 10–20% of adults in the Western world

Answer 163

Often asymptomatic | If secondary, symptoms of the cause

Answer 164

BP: measure on two to three different occasions before diagnosing hypertension and record lowest reading (>140/90mmHg) Longstanding hypertension: retinopathy (retinal vascular changes)

Answer 165

(I) ‘silver wiring’ (II) as above, plus arteriovenous nipping (III) as above, plus flame haemorrhages and cotton wool exudates (IV) as above, plus papilloedema

Answer 166

ECG: May show signs of left ventricular hypertrophy or ischaemia Ambulatory BP monitoring: Excludes ‘white coat’ hypertension, allows monitoring of treatment response Fasting metabolic profile with estimated GFR: -may show renal insufficiency, hyperglycaemia, hypokalaemia, hyperuricaemia, or hypercalcaemia Lipid panel: metabolic syndrome, high LDL/triglycerides Urinalysis: proteinuria (end organ damage from albumin excretion) Bloods: U&Es, glucose, lipids (secondary causes)

Answer 167

Lifestyle modification (conservative): Stop smoking, lose weight, reduce alcohol, reduce dietary salt Medical: *-Thiazide diuretics (e.g. bendrofluamethiazide): Recommended first line, especially in >55 year-olds or black patients -ACE inhibitors (e.g. ramipril) or angiotensin-II antagonist (e.g. losartan): First line in <55 year-olds, diabetic patients, heart failure or left ventricular dysfunction *-Ca2+ channel antagonists (e.g. amlodipine): Recommended first line, especially in >60- year-olds or black patients -b-Blockers (e.g. atenolol): Not preferred initial therapy, but may be considered in younger patients. Avoid combining with thiazide diuretic to reduce patient risk of developing diabetes. May increase risk of heart failure *-a-Blockers (e.g. doxazosin): Fourth-line agent. May be useful for patients with prostatism Severe hypertension (diastolic BP > 140 mmHg): Atenolol or nifedipine

Answer 168

``` Heart failure Coronary artery disease and MI Cerebrovascular accident Peripheral vascular disease Thomboembolism Retinopathy Renal failure Uncommon: -Hypertensive encephalopathy -Posterior reversible encephalopathy syndrome (PRES) -Malignant hypertension ```

Answer 169

*Good, if BP controlled Uncontrolled hypertension linked with increased mortality (6x􏰇 stroke risk and 3􏰇x cardiac death risk) Treatment reduces incidence of renal damage, stroke and heart failure

Answer 170

A machine that is placed under the skin to monitor heart rate. If it detects an arrhythmia it can deliver one or more of: - Pacing: a series of low-voltage electrical impulses (paced beats) at a fast rate to try and correct the heart rhythm - Cardioversion: one or more SMALL electric shocks to try and restore the heart to a normal rhythm - Defibrillation: one or more LARGE electric shocks to try and restore the heart to a normal rhythm

Answer 171

Arrhythmias Other cardiac conditions such as cardiomyopathy or Heart Block Cardiac failure

Answer 172

Infection at the implant site Allergic reaction to the medications used during the procedure Swelling, bleeding or bruising where ICD was implanted Damage to the vein Bleeding around heart (pericardium), which can be life-threatening Blood leaking through the heart valve where the ICD lead is placed Pneumothorax

Answer 173

Infection involving the endocardial surface of the heart, including the valvular structures, the chordae tendineae, sites of septal defects, or the mural endocardium

Answer 174

The endocardium can be colonized by virtually any organism, but the most common are: 1. Streptococci (40%): Mainly a-haemolytic 2. Staphylococci(35%):Staphylococcusaureus 3. Enterococci (20%) Historical sources of bacteraemia should be considered, such as indwelling vascular catheters, recent dental work, and intravenous drug use RF: prosthetic heart valves, congenial heart disease, valvular disease, IV drug use

Answer 175

Incidence 16–22 per million per year, around 50% are over 60 years old Incidence increases with age

Answer 176

``` Fever with sweats/chills/rigors (may be relapsing and remitting) Malaise Fatigue Weight loss Headache Arthralgia Myalgia Dyspnoea Confusion (particularly in elderly) Skin lesions ```

Answer 177

Pyrexia, tachycardia, signs of anaemia Clubbing (if long-standing) New regurgitant murmur or muffled heart sounds: Frequency: Mitral > aortic > tricuspid > pulmonary Splenomegaly Vasculitic lesions: -Petechiae particularly on retinae (Roths spots) -Pharyngeal and conjunctival mucosa -Janeway lesions (painless palmar macules, which blanch on pressure) -Oslers nodes (tender nodules on finger/toe pads) -Splinter haemorrhages (nail-bed haemorrhages)

Answer 178

Bloods: -FBC (leukocytosis, normocytic anaemia) -Raised ESR and CRP -U&Es: mildly elevated urea -Rheumatoid factors: may be positive (minor criteria for diagnosis) -Complement levels: decreased Blood culture: At least three sets 1h apart: bacteraemia or fungaemia ECG: progression of the infection may lead to conduction system disease Imaging: Echocardiography: Should be performed in all cases of suspected IE, detection of vegetations and valve abscess, diagnosis of prosthetic valve endocarditis and assessment of embolic risk CT/CXR: valvular abnormalities and vegetations, septic pul- monary emboli: focal lung infiltrates

Answer 179

Major criteria: Positive blood culture in two separate sample -Positive echocardiogram (vegetation, abscess, prosthetic valve dehiscence, new valve regurgitation) Minor criteria: - High-grade pyrexia (temperature >38􏰂C) - Risk factors (abnormal valves, IV drug use, dental surgery) - Positive blood culture, but not major criteria - Positive echocardiogram, but not major criteria - Vascular signs

Answer 180

ABC approach 1. Broad-spectrum antimicrobial therapy is required empirically on clinical suspicion: -Benzylpenicillin + gentamicin (empirical treatment) 2. Streptococci: Continue as above (alternatives – ceftriaxone, vancomycin) 3. Staphylococci: Flucloxacillin/vancomycin + gentamicin (for prosthetic valves: vancomycin + gentamicin + rifampin) Enterococci: Ampicillin + gentamicin Surgery: If poor response or deterioration, urgent valve replacement is indicated. *Antibiotic prophylaxis for patients with a PMH of infective endocarditis undergoing high risk procedures

Answer 181

``` Valve incompetence Intracardiac fistulae or abscesses Aneurysm formation Heart failure Renal failure Glomerulonephritis Arterial emboli from the vegetations (brain, kidneys, lungs, spleen) ```

Answer 182

Fatal if untreated | Even when treated, 15–30% mortality (mortality is greater in older patients)

Answer 183

Characterized by reduced blood supply (ischaemia) to the heart muscle resulting in chest pain known as angina pectoris. Can present as: - Stable angina - Acute coronary syndrome (ACS)

Answer 184

Unstable angina (no cardiac injury) Non-ST-elevation myocardial infarction (NSTEMI) ST-elevation MI (STEMI, transmural infarction) *MI refers to cardiac muscle necrosis resulting from ischaemia

Answer 185

Occurs when myocardial oxygen demand exceeds oxygen supply The most common cause is atherosclerosis Other causes of coronary artery narrowing are: RARE -Spasm (e.g. from cocaine) -Arteritis -Emboli

Answer 186

Caused by sudden occlusion of a coronary artery due to rupture of an atheromatous plaque and thrombus formation

Answer 187

1. Endothelial injury 2. Migration of monocytes into subendothelial space and differentiation into macrophages 3. Macrophages accumulate LDL lipids in the subendothelium and become foam cells 4. They release growth factors, which stimulate smooth muscle proliferation, production of collagen and proteoglycans 5. This leads to the formation of an atheromatous plaque

Answer 188

``` Male Diabetes mellitus FH of MI Hypertension Hyperlipidaemia Smoking PMH MI ```

Answer 189

Common, prevalence is >2% More common in males Annual incidence of MI in the United Kingdom is 􏰄5 in 1000

Answer 190

Chest pain or discomfort of acute onset Central heavy tight ‘gripping’ pain that radiates to arms (usually left), neck, jaw or epigastrium Occurring at rest, increased severity and frequency of previously stable angina Associations: -Breathlessness -Sweating -Nausea and vomiting *Can be silent in elderly or in patients with diabetes*

Answer 191

Chest pain bought on by exertion and relieved by rest

Answer 192

May have no clinical signs Pale, sweating, restless, low-grade pyrexia Check both radial pulses for aortic dissection Arrhythmias, disturbances of BP New heart murmurs (e.g. pansystolic murmur of mitral regurgitation from papillary muscle rupture or ventricular septal defect) Signs of complications, i.e. acute heart failure, cardiogenic shock (hypotension, cold peripheries, oliguria)

Answer 193

Bloods: FBC, U&Es, CRP, glucose, lipid profile, cardiac enzymes: -CK-MB and troponin-T or I1 (sensitive marker of cardiac injury, increase after 12 h), amylase (pancreatitis may mimic MI), TFTs. AST and LDH increase after 24 and 48 h, respectively; occasionally used only to make retrospective diagnosis ECG: Unstable angina or NSTEMI: -May show ST depression, T-wave inversion (Q waves in these patients may indicate old MIs) -ST-elevation (Q-wave) MI: -Hyperacute T waves, ST elevation (>1 mm in limb leads, >2 mm inchest leads), new-onset LBBB -Later: T inversion (hours) and Q waves (days) CXR: To look for signs of heart failure. Exercise ECG testing (treadmill test)2: To determine prognosis and management (for patients with troponin-negative ACS, or stable angina with an intermediate or high pretest probability of coronary heart disease) Radionuclide myocardial perfusion imaging (rMPI): Can be performed under stress (exercise or pharmacological) or at rest *Stress testing would show low uptake in ischaemic myocardium Rest testing can be used in patient with ACS, no previous MI but non-diagnostic troponin and ECGs Echocardiogram: - Measure LVEF (early measurements may be misleading because of myocardial stunning) - Exercise (or dobutamine stress) echocardiography may detect inducible wall motion abnormalities Pharmacologic stress testing: - For patients who cannot exercise or if the exercise test is inconclusive. Pharmacological agents such as dipyridamole, adenosine or dobutamine can be used to induce a tachycardia - Various imaging modalities (e.g. rMPI, echocardi- ography) can be used to detect ischaemic myocardium. *Dipyridamole and adenosine are contraindicated in AV block and reactive airway disease Cardiac catheterization/angiography: In ACS with positive troponin or if high risk on stress testing

Answer 194

Minimize cardiac risk factors: -Control BP, hyperlipidaemia and diabetes. Provide advice onsmoking, exercise, weight loss and low-fat diet. *All patients should receive aspirin (75 mg/ day) unless contraindicated Immediate symptom relief: -GTN as a spray or sublingually. Long-term treatment: b-Blockers, e.g. atenolol, unless contraindicated (contraindications include acute heart failure, cardiogenic shock, bradycardia, heart block, asthma), calcium channel blockers (e.g. verapamil, diltiazem), nitrates (e.g. isosorbide dinitrate). Dual therapy may be indicated if monotherapy is ineffective Percutaneous coronary intervention (PCI): For localized areas of stenosis, in patients with angina not controlled despite maximal tolerable medical therapy Re-stenosis rate is 􏰄25% at 6 months Coronary artery bypass graft (CABG): For more severe cases (three-vessel disease). The rates of MI and overall survival are generally similar between PCI and CABG

Answer 195

Admit to coronary care unit (CCU), oxygen, IV access, monitor vital signs and serial ECG - Analgesia: GTN (initially sublingual, IV infusion if persistent chest pain), morphine sulphate/ diamorphine, antiemetic (metoclopramide). - Aspirin (loading): 300 mg chewed. Maintenance: 75 mg, indefinite. - Clopidogrel (loading-anti-platelet): 300 mg. Maintenance: 75 mg for at least 1 year if troponin positive or high risk - Low-molecular-weight heparin (e.g. enoxaparin or dalteparin). - b-Blocker (e.g. metoprolol) if not contraindicated. - Glucose–insulin infusion if blood glucose >11 mmol/L. - Consider glycoprotein (GP) IIb/IIIa inhibitors, e.g. tirofiban in patients: . undergoing PCI; or . at high risk for further cardiac events (troponin positive, TIMI risk score 􏰃4, continuingischaemia or other high-risk features) *If little improvement, consider urgent angiography 􏰁with revascularization

Answer 196

Admit to CCU, oxygen, IV access, monitor vital signs and serial ECG. - Analgesia: GTN - Aspirin (loading): 300 mg chewed. - Clopidogrel (loading): 600 mg if patient going to primary PCI, 300 mg if undergoing thrombolysis and 􏰅75 years of age, 75 mg if undergoing thrombolysis and >75 years of age. Maintenance: 75 mg, for at least 1 year - b-Blocker (e.g. metoprolol) - If undergoing primary PCI: IV heparin (plus GP IIb/IIIa inhibitor) or bivalirudin (an antithrombin). If undergoing thrombolysis with recombinant tissue plasminogen activator (rtPA): IV heparin. - Glucose–insulin infusion if blood glucose >11 mmol/L -Primary PCI -Thrombolysis: Using fibrinolytics such as streptokinase or rtPA (alteplase, reteplase,tenecteplase) if within 12h of chest pain with ECG changes (ST elevation, new-onset LBBB or posterior infarction) and not contraindicated. Rescue PCI: If continued pain or ST elevation after thrombolysis (<50% decrease of the initial ST-segment elevation on a follow-up ECG 60–90 min after fibrinolytic therapy)

Answer 197

Secondary Prevention: -Antiplatelet agents (aspirin and clopidogrel) -ACE inhibitors, b-blockers and statins -Control other risk factors (smoking, diabetes, hypertension) Advice: Not to drive for 1 month following MI Education by cardiac rehabilitation team: -lifestyle changes (e.g. exercise, stop smoking, changing diet) CABG for patients with left main stem or three-vessel disease

Answer 198

``` At risk of MI and other vascular diseases (e.g. stroke, peripheral vascular disease) Cardiac injury can lead secondarily to heart failure and arrhythmias Early complications of MI (24–72 h): -Death -Cardiogenic shock -Heart failure -Ventricular arrhythmias -Heart block -Pericarditis -Myocardial rupture -Thromboembolism Late complications of MI: -Ventricular wall (or septum) rupture -Valvular regurgitation -Ventricular aneurysms -Tamponade -Dresslers syndrome (pericarditis) -Thromboembolism ```

Answer 199

ACS: TIMI score (range 0–7) can be used for risk stratification (high scores are associated with high risk of cardiac events within 30 days), consists of: (1) >65 years; (2) known coronary artery disease; (3) aspirin in last 7 days; (4) severe angina (>2 episodes in 24 h); (5) ST deviation >1 mm; (6) elevated troponin levels; (7) >3 coronary artery disease risk factors (hypertension, hyperlipidaemia, family history, diabetes, smoking) Killip classification of acute MI: Class I: no evidence of heart failure. Class II: mild to moderate heart failure (S3, crepitations

Answer 200

The retrograde flow of blood from LV to left atrium during systole

Answer 201

Mitral valve damage or dysfunction: - Rheumatic heart disease (most common) - Infective endocarditis - Mitral valve prolapse (prolapse of mitral valve leaflets into the left atrium during systole) - Papillary muscle rupture or dysfunction (secondary to ischaemic heart disease or cardiomyopathy) - Chordal rupture and floppy mitral valve associated with connective tissue diseases (e.g. Marfan's syndrome, SLE) *Functional mitral regurgitation may be secondary to left ventricular dilation

Answer 202

Affects 􏰄5% of adults | Mitral valve prolapse is more common in young females

Answer 203

Acute MR: May present with symptoms of left ventricular failure (dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea and fatigue) Chronic MR: May be asymptomatic or present with exertional dyspnoea, palpitations if in AF and fatigue (decreased exercise tolerance) Mitral valve prolapse: Asymptomatic or atypical chest pain or palpitations

Answer 204

Pulse may be normal or irregularly irregular (AF) Apex beat may be laterally displaced and thrusting (left ventricular dilation) *Pansystolic murmur, loudest at apex, radiating to axilla (palpable as a thrill) S1 is soft; S3 may be heard (rapid ventricular filling in early diastole) *Signs of left ventricular failure in acute mitral regurgitation (pulsus alternans (strong and weak beats), gallop rhythm)

Answer 205

*Transthoracic echo: visualises presence and severity of MR; other structural and flow abnormalities ECG: Normal or may show AF or broad bifid p wave (p mitrale) indicating delayed activation of left atrium due to left atrial enlargement CXR: -Acute mitral regurgitation may produce signs of left ventricular failure -Chronic mitral regurgitation shows left atrial enlargement, cardiomegaly (caused by left ventricular dilation) or mitral valve calcification in rheumatic cases Echocardiography: Every 6–12 months for moderate–severe MR to assess the LV ejection fraction and end-systolic dimension

Answer 206

The mitral valve narrowing causing obstruction to blood flow from the left atrium to the ventricle

Answer 207

``` Most common cause is rheumatic heart disease (90%)- untreated streptococcal pharyngitis infection Rarer causes are: -Congenital mitral stenosis -SLE, rheumatoid arthritis, amyloidosis -Endocarditis -Atrial myxoma (rare cardiac tumour) ```

Answer 208

Incidence is declining because of declining incidence of rheumatic fever Women are 3x more likely than men

Answer 209

May be asymptomatic Presents with fatigue, shortness of breath on exertion or lying down (orthopnoea). Palpitations (related to AF) RARE CAUSES: -Cough -Haemoptysis -Hoarseness caused by compression of the left laryngeal nerve by an enlarged left atrium

Answer 210

*May have peripheral or facial cyanosis (malar flush) Pulse: *May be ‘thready’ or irregularly irregular (AF) Palpation: *Apex beat is undisplaced and tapping Parasternal heave (right ventricular hypertrophy and pulmonary hypertension) Auscultation: *Loud first heart sound with opening snap *Mid-diastolic murmur (presystolic accentuation if in sinus rhythm) Evidence of pulmonary oedema on lung auscultation (if decompensated)

Answer 211

ECG: May be normal, broad bifid p wave (p mitrale) caused by left atrial hypertrophy AF or evidence of right ventricular hypertrophy in cases of severe pulmonary hypertension CXR: -Double right heart border indicating enlarged left atrial , cardiac enlargement, pulmonary congestion -prominent pulmonary artery; Kerley B lines (interstitial oedema) -Mitral valve may be calcified in rheumatic cases Transthoracic Echocardiography: To assess functional and structural impairments: hockey stick-shaped mitral deformity Transoesophageal gives better valve visualization (presence of possible left atrial thrombus) Cardiac catheterization: high left atrial pressure, low left ventricular pressure, and low cardiac output

Answer 212

Acute inflammation and necrosis of cardiac muscle (myocardium) in the absence of the predominant acute or chronic ischaemia characteristic of coronary artery disease

Answer 213

Usually unknown (idiopathic) Infection: -Viruses: e.g. Coxsackie B, echovirus, EBV, CMV -Bacterial: e.g. post-streptococcal, tuberculosis, -diphtheria, Lyme disease -Fungal: e.g. candidiasis. -Protozoal: e.g. trypanosomiasis (Chagas disease) Non-infective: -Systemic disorders (e.g. SLE, sarcoidosis, polymyositis) -Hypersensitivity myocarditis (e.g. sulphonamides) Drugs: -Chemotherapy agents (e.g. doxorubicin, streptomycin) Others: Cocaine abuse, heavy metals, radiation

Answer 214

True incidence is unknown, as many cases are not detected at the time of acute illness Coxsackie B virus is a common cause in Europe and the USA but in South America Chagas disease is the common cause *Patients with myocarditis tend to be younger (<50 years) than those presenting with more common cardiac conditions such as acute coronary syndrome

Answer 215

``` Prodromal ‘flu-like’ illness Fever Malaise Fatigue Lethargy Breathlessness (pericardial effusion/myocardial dysfunction) and orthopnoea Palpitations Sharp chest pain (suggesting associated pericarditis) ```

Answer 216

Atrial and ventricular arrhythmias Sinus tachycardia S3 gallop Signs of concurrent pericarditis: -Pericardial friction rub (best heard lower left sternal edge, with patient leaning forward in expiration) -Heart sounds may be faint in the presence of an effusion

Answer 217

12 lead ECG: anyone who resents with chest pain, Non-specific T wave and ST changes, widespread saddle-shaped ST elevation in pericarditis Bloods: - FBC (raised WCC in infective causes) - U&Es, BNP, raised ESR or CRP, cardiac enzymes e.g. creatinine kinase, troponin (may be elevated) - To identify the cause (viral or bacterial serology, antistreptolysin O titre, ANA, serum ACE, TFT) CXR: May be normal or show cardiomegaly with or without pulmonary oedema (frequently reveals bilateral pulmonary infiltrates in the setting of myocarditis-induced CHF) Echocardiography: Assesses systolic/diastolic function, wall motion abnormalities, pericardial effusion: global and regional left ventricular motion abnormalities and dilatation Myocardial biopsy: Rarely required, show histological findings of myocardial cellular infiltrates ± myocardial necrosis

Answer 218

A range of arterial syndromes that are caused by atherosclerotic obstruction of the lower-extremity arteries

Answer 219

The most common cause is atherosclerosis Rarer causes of claudication are aortic coarctation, arterial fibrodysplasia, arterial tumour, arterial dissection, arterial embolism, thrombosis, vasospasm, and trauma

Answer 220

The prevalence of PAD increases with age, beginning after 40 years of age Prevalence is equal in men and women and is often under- recognised and under-treated

Answer 221

Most patients are asymptomatic and diagnosis is based on risk factors Pain in one leg: -Intermittent claudication: ask patients about walking impairment, claudication symptoms, ischaemic rest pain, or presence of non-healing wound/foot ulcer -Pain in the thigh or buttock with walking which is relieved on rest: larger muscle groups Erectile dysfunction: early sign of narrowing of the internal iliac arteries

Answer 222

- Diminished pulse in lower extremities: assessment of pulse in all extremities- palpation of pulses at the brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial artery is essential - Non-healing wound/ulcer - Muscle atrophy - Loss of hair

Answer 223

``` P-pain P-pallor P-paraesthesias P- pulselessness P-perishingly cold P-paralysis ```

Answer 224

Ankle-brachial index: ABI ≤0.90 Toe-brachial index: TBI <0.6 (in patients with an unreliable ABI) Segmental pressure examination: gradient of >20 mmHg between adjacent segments (determine the location and magnitude of stenosis) Duplex ultrasound: Peak systolic velocity ratio >2.0 = stenosis >50% (assess location and degree of stenosis) Continuous wave doppler ultrasound: Provides an accurate location and severity of PAD Exercise ABI: determine the magnitude of walking limitations in symptomatic patients Angiography: invasive but provides superior resolution for stenosis CT/MR angiogram: presence of significant stenosis

Answer 225

Pacemakers are electronic devices that stimulate the heart with electrical impulses to maintain or restore a normal heartbeat

Answer 226

Sinus node dysfunction (SND) and high-grade atrioventricular (AV) block Others: Hypertrophic cardiomyopathy Pacing to detect and terminate tachycardia Cardiac resynchronization therapy in patients with severe systolic heart failure Patients with congenital heart disease

Answer 227

``` Lead complications are the main reason for the re-implantation of the pacemaker Other complications include: -Infections -Hematoma formation -Pericardial effusion or tamponade -Pneumothorax -Coronary sinus dissection -Perforation ```

Answer 228

Occlusion of pulmonary vessels, most commonly by a consequence of thrombus formation within a deep vein of the body, most frequently in the lower extremities

Answer 229

Thrombus (>95% originating from DVT of the lower limbs and rarely from right atrium in patients with AF) Other agents that can embolize to pulmonary vessels include amniotic fluid embolus, air embolus, fat emboli, tumour emboli and mycotic emboli from right-sided endocarditis

Answer 230

``` Surgery Immobility Obesity PMH of DVT OCP Pregnancy Heart failure Malignancy ```

Answer 231

Relatively common, especially in hospitalized patients, they occur in 10–20% of those with a confirmed proximal DVT The incidence and direct mortality from PE increases with age

Answer 232

Depends on the size and site of the pulmonary embolus: - Small: May be asymptomatic. - Moderate: Sudden onset dyspnoea, cough, haemoptysis and pleuritic chest pain. - Large (or proximal): All of the above plus severe central pleuritic chest pain, shock, collapse, acute right heart failure or sudden death.

Answer 233

Depends on the size and site of the pulmonary embolus: - Small: May be asymptomatic - Moderate: Sudden onset dyspnoea, cough, haemoptysis and pleuritic chest pain - Large (or proximal): All of the above plus severe central pleuritic chest pain, shock, collapse, acute right heart failure or sudden death * maybe fever

Answer 234

Low probability: Use D-dimer blood test (cross-linked fibrin degradation products, highly sensitive but poor specificity) High probability: Requires imaging Additional initial investigations: -Bloods: ABG, consider thrombophilia screen. -ECG: May be normal or more commonly show a tachycardia, right axis deviation or RBBB. -CXR: Often normal but to exclude other differential diagnoses 1. Spiral CT pulmonary angiogram: Poor sensitivity for small emboli, but very sensitive for medium to large emboli 2. Ventilation-perfusion (VQ) scan: identifies any areas of ventilation and perfusion mismatch (infarction) 3. Pulmonary angiography: Gold standard, but invasive 4. Doppler USS of the lower limb: To examine for venous thrombosis 5. Echocardiogram: May show right heart strain

Answer 235

``` WELL'S SCORE (>4 high probability, 􏰅3 probability): Clinically suspected DVT 3.0 PE is most likely diagnosis 3.0 Recent surgery (4 weeks) 1.5 Immobilization 1.5 Tachycardia 1.5 History of DVT or PE 1.5 Haemoptysis 1.0 Malignancy 1.0 ```

Answer 236

Primary prevention: - Graduated pressure stockings (TEDs) and heparin prophylaxis in those at risk (e.g. undergoing surgery) - Early mobilization and adequate hydration post-surgery If haemodynamically stable: -O2, anticoagulation with heparin or LMW heparin, changingto oral warfarin therapy (INR 2–3) for a minimum of 3 months. Analgesics for pain If haemodynamically unstable (massive PE): -Resuscitate, give oxygen, IV fluid resuscitation, thrombolysis with tPA can be considered on clinical grounds alone if cardiac arrest is imminent (50 mg bolus of tPA)- Tissue plasminogen activator to break down clots Surgical or radiological: - Embolectomy (when thrombolysis is contraindicated) - IVC filters (Greenfield filter) may be inserted for recurrent pulmonary emboli despite adequate anticoagulation or when anticoagulation is contraindicated

Answer 237

Death Pulmonary infarction Pulmonary hypertension Right heart failure

Answer 238

30% untreated mortality, 8% with treatment (due to recurrent emboli or underlying disease) Patients have increased risk of future thromboembolic disease

Answer 239

A consistently increased pulmonary arterial pressure (>20mmHg) under resting conditions

Answer 240

Primary: Idiopathic Secondary: -Left heart disease (mitral valve disease, left ventricular failure, left atrial myxoma/thrombosis) -Chronic lung disease (COPD) -Recurrent pulmonary emboli -Increased pulmonary blood flow (atrial septal defect, ventricle septal defect, patent ductus arteriosus) -Connective tissue disease (e.g. SLE, systemic sclerosis) -Drugs (e.g. amiodarone- anti-arrhythmic)

Answer 241

Primary pulmonary hypertension is usually seen in young females (rare) Age 20-50 years

Answer 242

``` *Dyspnoea (on exertion) Chest pain Syncope Tiredness Symptoms of the underlying cause (e.g. chronic cough) ```

Answer 243

Raised JVP (Prominent a wave in the JVP waveform) Palpation: Left parasternal heave (right ventricular hypertrophy) Auscultation: *Loud pulmonary component of S2 (S3/S4 may be heard), an early diastolic murmur caused by pulmonary regurgitation *Tricuspid regurgitation (pansystolic murmur) Signs of the underlying condition, or right heart failure in severe cases

Answer 244

CXR: - Cardiomegaly (right ventricular enlargement, right atrial dilation) - Prominent main pulmonary arteries (which taper rapidly) - Signs of the cause (e.g. COPD, calcified mitral valves) ECG: - Right ventricular hypertrophy (right-axis deviation) - Right atrial enlargement (peaked P wave ‘P pulmonale’) Echocardiography: * Pulmonary artery systolic pressure (sPAP) is considered equal to right ventricular systolic pressure (RVSP) in the absence of pulmonic valve stenosis and outflow tract obstruction - To visualize tricuspid regurgitation - Estimated RVSP >35 mmHg - Right ventricular and right atrial dilation - Pericardial effusion Cardiac catheterization: (required to confirm the presence of pulmonary hypertension) - Mean pulmonary arterial pressure >25 mmHg at rest or >30 mmHg with exercise - Assess severity, right heart pressures and response to vasodilators. Lung function tests: To assess for chronic lung disease VQ scan: To assess for pulmonary embolism High resolution CT-thorax: Images pulmonary arteries and to diagnose lung disease Lung biopsy: Assesses structural lung changes

Answer 245

An inflammatory (autoimmune) multisystem disorder, occurring following group A b-haemolytic streptococci (GAS) throat infection

Answer 246

Streptococcal pharyngeal infection is required, and genetic susceptibility may be present for the autoimmune response to be triggered

Answer 247

Peak incidence: between 5-15 years. More common in the Far East, Middle East, eastern Europe and South America The mean incidence is 19/100 000. Despite the decline in incidence over time in the West, the incidence rates remain relatively high in non-Western countries

Answer 248

``` 2–5 weeks after GAS infection- recent sore throat General: Fever Malaise Anorexia Joints: Painful, swollen, reduced movement/function Cardiac: Breathlessness, chest pain, palpitations ```

Answer 249

Duckett Jones criteria: Positive diagnosis if at least two major criteria, or one major plus two minor criteria are present Major criteria: - Arthritis: Migratory or fleeting polyarthritis with swelling, redness and tenderness of large joints - Carditis: New murmur, e.g. Carey Coombs murmur (mid-diastolic murmur due to mitral valvulitis), pericarditis, pericardial effusion or rub, cardiomegaly, cardiac failure, ECG changes - Chorea (Sydenhams): Rapid, involuntary, irregular movements with flowing or dancing quality. May be accompanied by slurred speech. More common in females - Nodules: Small firm painless subcutaneous nodules seen on extensor surfaces, joints and tendons. - Erythema marginatum (20% cases): Transient erythematous rash with raised edges, seen on trunk and proximal limbs. They may form crescent- or ring-shaped patches Minor criteria: - Pyrexia - PMH rheumatic fever - Arthralgia (only if arthritis is not present as major criteria) - Recent streptococcal infection (supported by positive throat cultures or raised antistreptolysin O titre) - Elevated inflammatory markers (ESR, CRP or WCC) - Prolonged PR and QT intervals on ECG (only if carditis not present as major criteria)

Answer 250

Bloods: -FBC (elevated WCC) -Elevated ESR/CRP -Elevated or rising antistreptolysin O titre *Throat swab: Culture for GAS, rapid streptococcal antigen test ECG: -Prolonged PR interval is a minor criterion of acute rheumatic fever -Features of pericarditis -Arrhythmias Echocardiogram: -Pericardial effusion -Myocardial thickening or dysfunction -Valvulardysfunction CXR: may demonstrate cardiomegaly and/or congestive cardiac failure

Answer 251

An abnormally fast heart rhythm arising from improper electrical activity in the upper part of the heart (atria or AVN) There are four main types: 1. Atrial fibrillation 2. Paroxysmal supraventricular tachycardia (PSVT) 3. Atrial flutter 4. Wolff–Parkinson–White syndrome.

Answer 252

It can occur in healthy people, although often there is underlying cardiac pathology Associated conditions include cardiomyopathies, ischaemic heart disease, previous cardiac surgery, and hyperthyroidism Exogenous stimulants can also cause SVT such as amphetamines, cocaine, and acute alcohol intoxication

Answer 253

Atrial fibrillation is the most common arrhythmia in clinical practice, with an estimated prevalence of 0.4% to 1% in the general population and increasing with age

Answer 254

Supraventricular tachycardia may come and go suddenly, and symptoms can last anywhere from a few minutes to a few days. Some people have no symptoms at all ``` Rapid heartbeat (palpitations) Dyspnoea Fatigue Weakness Lightheadedness or dizziness Sweating A pounding sensation in the neck Syncope or near fainting ```

Answer 255

Heart rate ≥100 bpm Rales Oedema

Answer 256

ECG: regular tachycardia that does not vary in rate, P waves may be unusual (or not present) CXR: abnormalities suggestive of cardiac disease e.g. cardiomegaly that would predispose to arrhythmias Bloods: -U&Es: electrolyte imbalance -Toxicology screen: identify cause e.g. amphetamines -Digoxin level -TFTs: hyperthyroidism Echocardiogram: may show underlying cause such as valvular disease or cardiomyopathy

Answer 257

* Adenosine: rapid reversion to sinus rhythm of paroxysmal supraventricular tachycardias: - Initially 6 mg, administer into central or large peripheral vein and give over 2 seconds, cardiac monitoring required - Followed by 12 mg after 1–2 minutes if required, then 12 mg after 1–2 minutes if required, increments should not be given if high level AV block develops at any particular dose Other medications: - beta blockers or calcium channel blockers - override pacing * Re-entry arrhythmias will often require direct current (DC) cardioversion and, possibly, amiodarone

Answer 258

Patients with sustained tachycardia may develop congestive heart failure Rare complication: cardiomyopathy

Answer 259

Prognosis depends on the ability to control the arrhythmia This is further influenced by the patient's age, underlying cause of the arrhythmia, tolerance of adverse effects of the chosen treatment, and co-morbidities

Answer 260

The backflow of blood from the right ventricle to the right atrium during systole

Answer 261

The most clinically significant form is secondary in nature, commonly due to left-sided cardiac pathology in the form of advanced mitral, aortic, and left ventricular myocardial disorders Congenital: Ebstein anomaly (malpositioned tricuspid valve) Functional: -Consequence of right ventricular dilation (e.g. in pulmonary hypertension) -Valve prolapse Rheumatic heart disease: Associated with other valvular disease Infective endocarditis: -Common in IV drug users -Usually staphylococcal Other: -Carcinoid syndrome, trauma, cirrhosis (long-standing), iatrogenic (e.g. radiotherapy to the thorax)

Answer 262

Infective endocarditis probably most common cause

Answer 263

``` Fatigue Dyspnoea Palpitations Headaches Nausea Anorexia Jaundice Lower limb swelling Symptoms due to gut congestion related to reduced cardiac output and associated with right-sided heart failure: -Epigastric pain made worse by exercise -Early satiety -Dyspepsia -Indigestion ```

Answer 264

Pulse: May be irregularly irregular due to AF (may occur with right atrial enlargement) Inspection: -Raised JVP with giant v waves which may oscillate the earlobe -caused by transmission of right ventricular pressure to the great veins Palpation: Parasternal heave Auscultation: -Pansystolic murmur heard best at the lower left sternal edge, louder on inspiration (Carvallo sign) -Loud P2 component of second heart sound Chest: -Pleural effusion Causes of pulmonary hypertension (e.g. emphysema) Abdomen: -Palpable liver (tender, smooth, pulsatile), ascites Legs: Pitting oedema

Answer 265

Bloods: -FBC: anaemia (e.g., anaemia of chronic disease, renal failure), thrombocytopenia (e.g., due to liver failure and cirrhosis) -LFTs: patients with chronic severe TR often develop ascites from advanced liver disease, from chronic congestion or fibrosis (cardiac cirrhosis) -cardiac enzymes -Blood cultures ECG: -Tall P wave (right atrial hypertrophy) if in sinus rhythm -Changes indicative of other cardiac disease (may show atrial flutter/fibrillation; presence of previous MI) CXR: -Right-sided enlargement of cardiac shadow -Pleural or pericardial effusion -Presence of pacemaker Echocardiography: -Extent of regurgitation estimated by colour flow Doppler. -May be able to detect tricuspid valve abnormality (e.g. prolapse), right ventricular dilation -Assessment of left and right heart ejection fraction/dilation Right heart catheterization: Rarely necessary but may be considered to assess pulmonary artery pressure (helps to differentiate between choosing to repair valve or replace it)

Answer 266

They are subcutaneous, permanently dilated veins 3 mm or more in diameter when measured in a standing position; however, they may not be visible

Answer 267

``` Venous valve incompetence is the most common aetiology Predisposing factors include: -Gender -Pregnancy -Occupation (with prolonged standing) -Weight -Ethnicity Causative factors: -Previous episode of deep vein thrombosis -Genetic links (FH) ```

Answer 268

Generally, prevalence rates are higher in industrialised countries and in more developed regions Prevalence increases with age Greater prevalence in women than in men

Answer 269

Visible bulges in legs Leg fatigue or aching with prolonged standing (not present at the beginning fo the day)- improves with elevation Nocturnal leg cramps Restless legs Itching Ankle swelling Overlying skin changes: Lipodermatosclerosis: redness, swelling, and a tapering of the legs above the ankles

Answer 270

Dilated tortuous veins (examine the patient standing) Lipodermatosclerosis (indication of high risk for ulceration and is the result of haemosiderin (venous HTN) causing inflammation and damaging the soft tissues-this leads to scarred and fibrotic tissues) Ulceration

Answer 271

Tourniquet test (Trendelenburg): when patient stands the veins do not fill Duplex ultrasond: -Two sound heard, when the blood flows up the vein when the calf is squeezed and then when released the blood that flows back down the incompetent vein Assesses for reversed flow; -valve closure time >0.5 second is indicative of reflux -valve closure time >1.0 second is indicative of reflux in the deep system *can also be used to exclude DVT

Answer 272

``` Interventional treatment: -Endovenous ablation -Foam sclerotherapy -Phlebectomy- removal of the veins -Open surgery (stripping and ligation) If interventional treatment is unsuitable e.g. pregnant : -Compression stockings ``` If the superficial axial system (the great saphenous vein, the small saphenous vein, or the anterior accessory saphenous vein) is involved: endovenous thermal ablation (radiofrequency or laser ablation) is offered as a first-line option

Answer 273

Chronic venous insufficiency: Increased dilation of venous system leading to axial system reflux Erosion of varices can lead to haemorrhage (low) Venous ulceration Lipodermatosclerosis Haemosiderin deposition: Capillaries become elongated, fibrotic, and leaky

Answer 274

Generally resolution of symptoms occurs in >95% of patient who are treated However, patients need to be counselled that new varicosities will very likely occur with time, as varicose veins are a progressive disease

Answer 275

Long saphenous vein: groin to the medial aspect of the lower leg Short saphenous vein: popliteal fossa along the calf to the lateral malleolus

Answer 276

Oedema Skin changes- Lipodermatosclerosis Venous eczema and ulceration

Answer 277

Neurally mediated reflex syncope (NMRS): A group of related conditions or scenarios in which symptomatic hypotension occurs as a result of neural reflex vasodilation and/or bradycardia Vasovagal syncope: a particular type of NMRS also known as the common faint, and is generally considered to encompass faints triggered by emotional upset, fear, and pain, as well as those occurring in less well-defined circumstances

Answer 278

Syncope has many possible causes commonly grouped in 3 main groups: -Neurally-mediated reflex syncopal syndromes -Orthostatic -Cardiovascular In susceptible people, vasovagal syncope may be triggered by: -Prolonged periods of upright posture -Relative dehydration -Excessively warm, closed-in environments -Extreme emotions

Answer 279

These neurally mediated reflex faints, especially the vasovagal faint, are the most common causes of syncope overall and are particularly prevalent in people without evidence of underlying heart disease or vascular disease

Answer 280

PMH of recurrent faints: (especially beginning in youth) and not associated with structural cardiovascular disease Provocative factors: include painful or emotionally upsetting experiences, excessive dehydration, after vigorous exercise Characteristics of Vasovagal syncope: - Pallor - Diaphoresis: sensation of feeling sweaty and experiencing a coldness and/or clammy sensation - Fatigue after episode Other features: - Diminished hearing or vision - Nausea - Light headedness (occurs in many conditions)

Answer 281

Bradycardia: Slow heart rates are a common finding at the time of vasovagal syncope

Answer 282

12 lead ECG: exclude AV block, bradycardia, asystole, Bundle branch block Bloods: -FBC: exclude syncope caused by anaemia -Blood glucose: exclude syncope caused by hypoglycaemia -Serum B-hCG: exclude syncope caused by pregnancy -Cardiac enzymes: exclude MI -D-dimer: exclude PE -Serum cortisol: exclude syncope caused by adrenal insufficiency -U&Es: dehydration Echo: excludes hypertrophic cardiomyopathy (enquire about FH of sudden death), aortic stenosis, poor ventricular function *Tilt-table test: Used only if there is suspicion of vasovagal syncope (VS) but the medical history is not convincing on its own- reproduction of symptoms/syncope, bradycardia, hypotension

Answer 283

Ulcers that are caused by venous insufficiency. They often appear shallow with irregular borders and a granulating base, characteristically located over the medial malleolus

Answer 284

Impaired venous return This results in venous hypertension causing the “trapping” of white blood cells in capillaries and the formation of a fibrin cuff around the vessel hindering oxygen transportation into the tissue. The white blood cells subsequently become activated, with the release of inflammatory mediators leading to resultant tissue injury, poor healing, and necrosis

Answer 285

``` Increasing age Pre-existing venous incompetence or history of venous thromboembolism (including varicose veins) Pregnancy - increased clotting Obesity or physical inactivity Severe leg injury or trauma ```

Answer 286

Venous leg ulcers are the most common type of leg ulcer; they are prone to infection and can present with associated cellulitis

Answer 287

Associated symptoms of chronic venous disease, such as aching, itching, or a bursting sensation, will be present often before venous leg ulcers appear.

Answer 288

``` Shallow, irregular shape Granulating base Flat or steep elevation margins Fibrinous material at ulcer bed Pain is relieved by elevation Associated findings: -Lipodermatosclerosis -Pigmentation -Oedema -Telangiectasia -Normal capillary refill time and normal pulses ```

Answer 289

Doppler ultrasound: venous insufficiency- DVT, varicose veins ABI: arterial insufficiency Bloods: -FBC: anaemia, high WCC indicates infection -ESR/CRP: inflammation -U&Es: high urea levels may indicate dehydration, which may impair healing -Albumin: low albumin may be associated with protein loss and malnutrition, which may delay healing. -HbA1c: to assess for diabetes mellitus Bacterial swab: only when clinical evidence of infection

Answer 290

Compression therapy: -Ulcer should be cleaned and dressed before Consider prescribing pentoxifylline to aid ulcer healing: -Pentoxifylline is an effective adjunct to compression bandaging for treating venous leg ulcers Assess complications: oedema and eczema and treat if infected *After a venous leg ulcer has healed: lifestyle advice and graduated compression stockings to prevent recurrence

Answer 291

Chronic pain Impaired mobility (often due to pain) Infection, including osteomyelitis and septicaemia Allergic contact dermatitis (caused by allergens in creams and dressings and medications, steroids, antibiotics) Malignant transformation in the ulcer bed (Marjolin's ulcer) Negative impacts on quality of life and daily functioning: time off work, psychological distress, loss of independence, and social isolation

Answer 292

Six-month healing rates have been reported as 45% for those treated in the community (about 80% of people with venous leg ulcers), and 70% for those treated in specialist clinics But: repeat cycles of ulceration, healing, and recurrence are common

Answer 293

Considered the most serious cardiac rhythm disturbance (medical emergency): - Disordered electrical activity causes the ventricles to quiver, or fibrillate, instead of contracting normally - This prohibits the heart from pumping blood, causing collapse and cardiac arrest

Answer 294

Cann have several root causes, including: - Insufficient blood flow to the heart muscle - Damage to the heart muscle (e.g MI) - Cardiomyopathy - Problems with the aorta - Drug toxicity - Sepsis (severe body infection)

Answer 295

Considered the most serious cardiac rhythm | Life threatening

Answer 296

Sudden cardiac arrest (SCA), which requires immediate medical attention Signs of cardiac arrest include: -Loss of responsiveness -No normal breathing

Answer 297

Cardiac monitor e.g. ECG: determine rhythm-classification of the rhythm directs management

Answer 298

Ventricular fibrillation is a SHOCKABLE rhythm: 1. Defibrillate once 2. Resume CPR immediately for 2 min, and then defibrillate 3. Administer adrenaline (1 mg IV) after second defibrillation and again every 3–5 min. 4. If ‘shockable rhythm’ persists after third shock, administer amiodarone 300 mg IV bolus (anti-arrhythmic)

Answer 299

(same as cardiac arrest) | Irreversible hypoxic brain damage, heart failure, death

Answer 300

Resuscitation is less successful in the arrests that occur outside hospital Duration of inadequate effective cardiac output is associated with poor prognosis

Answer 301

An abnormally fast heart rhythm as a result of improper electrical activity in the ventricles- a broad complex tachycardia originating from a ventricular ectopic focus

Answer 302

Caused by a disruption in the normal electrical impulses that control the rate of your heart's pumping action Causes include: - Abnormalities of the heart that result in scarring of heart tissue (sometimes called "structural heart disease"), the most common cause is a prior heart attack - Poor blood flow to the heart muscle due to coronary artery disease - Congenital heart conditions, including long QT syndrome - Imbalance of electrolytes necessary for conducting electrical impulses - Medication side effects - Use of drugs such as cocaine or methamphetamine

Answer 303

Brief episodes of ventricular tachycardia may not cause any symptoms in some people or may cause: - Dizziness - Shortness of breath - Lightheadedness - Palpitations - Chest pain (angina) Sudden cardiac arrest (SCA), which requires immediate medical attention is caused by sustained or more severe episodes of VT: Signs of cardiac arrest include: -Loss of responsiveness -No normal breathing

Answer 304

Cardiac monitor e.g. ECG: determine rhythm-classification of the rhythm directs management

Answer 305

Ventricular fibrillation is a SHOCKABLE rhythm: 1. Defibrillate once 2. Resume CPR immediately for 2 min, and then defibrillate 3. Administer adrenaline (1 mg IV) after second defibrillation and again every 3–5 min. 4. If ‘shockable rhythm’ persists after third shock, administer amiodarone 300 mg IV bolus (anti-arrhythmic)

Answer 306

(same as cardiac arrest) | Irreversible hypoxic brain damage, heart failure, death

Answer 307

Resuscitation is less successful in the arrests that occur outside hospital Duration of inadequate effective cardiac output is associated with poor prognosis

Answer 308

Occurs when one or more strands of myocardial fibres capable of conducting electrical impulses (known as accessory pathways or bypass tracts) connect the atrium to the ipsilateral ventricle across the mitral or tricuspid annulus Conduction from the atrium reaches the adjacent ventricle earlier via the AP, and a part of the ventricle is pre-excited *predisposes supraventricular tachycardias (SVT)

Answer 309

``` Accessory pathway (bundle of Kent) bypasses the atrioventricular node causing ventricular pre-excitation Approximately 90% of APs are rapidly conducting, resulting in circus movement tachycardia involving the atrium and ipsilateral ventricle (AV re-entrant tachycardias) ```

Answer 310

``` Ebstein's anomaly: malformation of the tricuspid valve and right ventricle characterised by adherence of the septal and posterior tricuspid leaflets to the underlying myocardium (strong RF) Hypertrophic cardiomyopathy Mitral valve prolapse Atrial septal defect Ventricular septal defect Transposition of the great vessels Coarctation of the aorta Dextrocardia (heart points toward the right side rather than left) Coronary sinus diverticula Right and left atrial aneurysms Cardiac rhabdomyomas (primary tumour: as seen in patients with tuberous sclerosis) Marfan's syndrome ```

Answer 311

The exact prevalence of ventricular pre-excitation is difficult to estimate because most patients are asymptomatic Slight male predominance (2:1)

Answer 312

``` Palpitations Dizziness Dyspnoea Chest pain Syncope (uncommon) ```

Answer 313

Arrhythmia: - Most common: atrioventricular re-entrant tachycardia (AVRT)- 70-80% - Atrial fibrillation (irregularly irregular) - Atrial flutter

Answer 314

*12-lead ECG: Short PR interval and Delta wave Cardiac electrophysiology: location and physiology of the accessory pathway (AP) Echocardiogram (to detect any associated cardiac anomalies: associated structural heart disease such as hypertrophic cardiomyopathy, Ebstein's anomaly and other congenital heart disease) Treadmill exercise test: intermittent pre-excitation or disappearance of pre-excitation, determine risk of sudden death

Cardiovascular Flashcards

(338 cards)