Cardiovascular clinical Flashcards
(335 cards)
1
Q
What is transient loss of consciousness defined as?
A
A state of real or apparent loss of consciousness with loss of awareness,characterised by amnesia for the period of unconsciousness,loss of motor control,loss of responsiveness, and a short duration.
2
Q
What are the causes of TLOC?
A
- Head trauma
- syncope
- Epileptic seizures
- TLOC mimics e.g. psychogenic, pseudo-syncope.
3
Q
Define what syncope is.
A
Transient loss of consciousness due to cerebral hypoperfusion, characterised by rapid onset,short duration, and spontaneous complete recovery.
4
Q
What are the three categories of syncope?
A
- Reflex
- Orthostatic
- Cardiac
5
Q
What is reflex syncope
A
Neural reflexes Causes cardioinhibition through vagal stimulation.
This causes bradycardia and a decrease in CO
Depression of sympathetic activity to blood bessels cause vasodepression.
This causes vasodilation (decrease in SVR, CO, SV and eventually MAP)
This leads to systemic hypotension causing a transient period of cerebral hypoperfusion
results in syncope
6
Q
What are the three subtypes of reflex syncope?
A
- Vasovagal syncope ( most common type for all syncope)
- situational syncope
- Cartoid sinus syncope.
7
Q
How is faint activated in Vasovagal reflex syncope?
A
- Emotional distress
2. orthostatic stress
8
Q
What is vasovagal reflex syncope associated with?
ii. Give examples of this.
A
Typical prodrome.
ii. Pallor
Sweating
Nausea
9
Q
How can Vasovagal reflex syncope be averted?
A
- Adopting the horizontal gravity neutralisation position (lying down)
- crossing legs.
this increases venous return
10
Q
VVS is associated with increased mortality true or false?
A
false
11
Q
How do you treat VVS?
A
- Education
- reassurance
- avoidance triggers
- adequate hydration
12
Q
How does fainting occur from a situational reflex syncope?
A
- cough
- Micturition- action of urinating
- swallowing
i. e a specific trigger.
13
Q
How do you treat SRS?
A
Treat the cause, if possible (e.g. cough)
Advise patient to lie down, if possible (e.g. during a coughing episode)
Avoid dehydration and excessive alcohol
Cardiac permanent pacing may be needed in some cases of situational syncope
14
Q
What are the risk factors of Carotid sinus reflex syncope?
ii. how do you treat CSS?
A
- mechanical manipulation of the neck
- shaving
- tight collar
- Elderly males
- carotid artery atherosclerosis
- Injury to head or neck
- radiation
ii. Cardiac permanent pacing
15
Q
How does Postural (orthostatic) hypotension occur?
A
failure of Baroreceptor responses to gravitational shifts in blood, when moving from horizontal to vertical position
16
Q
What are the risk factors to orthostatic hypotension?
A
Age related Medications Certain diseases Reduced intravascular volume Prolonged bed rest
17
Q
What is a positive result for orthostatic hypotension?
ii. What needs to occur?
A
When there is a drop in:
- systolic pressure by 20 mmHg (with or without symptoms).
- diastolic blood pressure of at least 10 mm Hg (with symptoms)
ii. A positive result is indicated by a drop, within 3 minutes of standing from lying down
18
Q
What are the symptoms of orthostatic hypotension?
A
Symptoms may include those of cerebral hypoperfusion such as: 1. lightheadedness 2. dizziness, 3. blurred vision, 4.faintness 5. falls
19
Q
What the causes for cardiac syncope?
A
- Arrhythmias
- acute myocardial infarction
- structural cardiac disease e.g. aortic stenosis
- PE
- Aortic dissection
all lead to sudden drop in CO
20
Q
What are the main factors which suggest cardiac syncope and not other forms of reflex syncope?
A
- Syncope during excretion or when supine
- structural cardiac abnormality or coronary heart disease is present
- A family history of sudden death at young age
- Sudden onset palpitations immediacy followed by syncope
Findings on ECG suggestive of arrhythmic syncope
21
Q
What are the risk factors of atheroma?
A
- cigarette smoking
- hypertension
- Hyperlipidemia
- diabetes
- Age (elderly)
- gender (males)
- Genetics
22
Q
How does the process of atherosclerosis occur?
A
- Primary endothelial injury
(e. g. smoking, hypertension, hyperlipidemia) - accumulation of lipids and macrophages
- Migration of smooth muscle cells
- increase in size
23
Q
when is atherosclerosis likely to cause a critical disease?
A
It is the only artery supplying an organ or tissue (i.e. There is no collateral circulation)
The artery diameter is small (e.g coronary artery versus common iliac artery)
Overall blood flow is reduced (i.e. cardiac failure)
24
Q
What can atherosclerosis cause?
A
- Stenosis
- Thrombosis
- Aneurysm
- Dissection
- Embolism
25
What are the characteristics of arterial stenosis?
NARROWING OF THE ARTERIAL LUMEN
REDUCED ELASTICITY
REDUCED FLOW IN SYSTOLE
TISSUE ISCHAEMIA
26
What the clinical effects of cardiac ischemia?
REDUCED EXERCISE TOLERANCE
ANGINA
UNSTABLE ANGINA
MYOCARDIAL INFARCTION
CARDIAC FAILURE
27
What are the clinical effect of cardiac fibrosis?
LOSS OF CARDIAC MYOCYTES
REPLACEMENT BY FIBROUS TISSUE
LOSS OF CONTRACTILITY
REDUCED ELASTICITY & FILLING
28
What are the clinical effects of thrombosis?
MYOCARDIAL INFARCTION
CEREBRAL INFARCTION
RENAL INFARCTION
INTESTINAL INFARCTION
29
Clinical examples of lipid related issues?
1. Xanthomata - deposition of yellowish cholesterol-rich material that can appear anywhere in the body in various disease state
2. Xanthelasma - yellow deposits of plaque on upper eye lids
3. Corneal arcus - epositing of phospholipid and cholesterol in the peripheral cornea in patients over the age of 60 which appears as a hazy white, grey, or blue opaque ring
4. milky blood /serum- Turbid, cloudy or milky serum (lipemic serum) may be produced by the presence of fatty substances (lipids) in the blood
5. Coronary heart disease.
30
What lipid related values do we measure?
1. Total cholesterol
2. HDL cholesterol
3. Triglycerides if requested - this is effective by prandial status
4. LDL cholseterol if requested
31
What is the average value of LDL cholesterol in relation to total cholesterol?
LDL is normally 2 mmol ml lower then total cholesterol
32
What should be the value for Total Cholesterol HDL ratio?
If value is lower than 4.5 than good
if higher than 5 than needs to be treated.
33
Describe the types of studies used to treat diseases.
Case-control study: two different groups differing in outcome are identified and compared on their causal attribute
cohort study - Follows a group of people over time
randomised clinical trial- experiment in which trial participants are randomly allocated treatment
systematic review
meta-analysis
Expert opinion.
34
What is the role of statins?
1. Lowers cholesterol
| 2. slows down atherosclerosis process
35
What is the normal BMI range?
18-24 kg/m2
36
What would be the BMI an overweight person.
Range of 25-30 kg/m2
37
What would be the BMI of an obese person?
30 kg/m2 or higher
38
Give examples of statins
```
atorvastatin
fluvastatin
lovastatin
pravastatin
simvastatin
rosuvastatin - more efficient than atorvastatin and simvastatin
```
39
what is familial hypercholesterolemia
ii. what should you look at?
1. As common as type 1 diabetes
It causes LDL cholesterol level to be very high
ii. Ankles and knuckles
40
what is familial hypercholesterolemia
ii. what are the symptoms
1. As common as type 1 diabetes
It causes LDL cholesterol level to be very high
```
ii.
chest pain with activity
xanthomas
xanthelasmas
corneal arcus
```
41
# Define what hypertension is.
ii. What is its clinical blood pressure?
A disorder in which the level of sustained arterial pressure is higher than expected for the age,sex,and race of the individual.
ii. 140/90 mm Hg or higher
42
How can you classify hypertension?
In regards to cause - primary/essential (unknown cause) and secondary (known)
In regards to consequence - benign and malignant( acute severe).
white-coat hypertension - elevated clinical pressure but normal ABPM( <135/85)
43
What occurs in malignant hypertension?
ii. what can it cause?
Severe hypertension
Bilateral retinal haemorrhages and exudates
papilloedema (may not be present)
ii. AKI
heart failure
encephalopathy
44
What are the characterstics of primary hypertension?
```
No obvious cause
Genetic factors (twin studies)
Salt intake -25% salt sensitive
Protein intake
Renin - Angiotensin system
Sympathetic activity (as BP = TPR x CO)
```
45
What underlying diseases could be the cause for secondary hypertension?
Renal disease (any renal disease) - reduced renal blood flow causes excess renin release and salt and water overload
Endocrine disease
Aortic disease
Renal artery stenosis
Drug therapy (cortizol steroids have an increase in BP)
46
What can benign hypetenson cause?
Serious life threatening morbidity.
eventually leading to :
Left ventricular hypertrophy Congestive cardiac failure Increases atheroma Increases aneurysm rupture - aortic dissection, Berry aneurysms
Renal disease
47
What can left ventricular hypertrophy cause?
```
INCREASED LV LOAD
POOR PERFUSION
INTERSTITIAL FIBROSIS
MICRO-INFARCTS
DIASTOLIC DYSFUNCTION
```
sudden cardiac death!
48
The greater the diastolic pressure in benign hypertension the greater the risk of ?
Strokes and Myocardial infarction
Every 10mmHg of diastolic pressure above 85 doubles risk of MI
Every 8mmHg of diastolic pressure above 85 doubles risk of stroke
49
What is the diastolic pressure of malignant hypertension?
>130-140 mm Hg
50
What are the symptoms of malignant hypertension?
Causes cerebral oedema - seen as papilloedema (swelling of optic disc)
Acute renal failure
Acute heart failure
Headache and cerebral haemorrhage
Blood vessels show fibrinoid necrosis and endarteritis proliferans of their walls
51
What is pregancy associated hypertension known as?
ii. what are its symptoms?
iii. What are its causes?
Pre- eclampsia
ii. Increased maternal and fetal morbidity and mortality
Hypertension secondary to silent renal or systemic disease
52
Describe what Stage 1 hypertension is.
When clinical BP is higher or 140/90 mmHg
| and at home BP is 135/85 mmHg
53
Describe what stage 2 hypertension is
Clinical blood pressure is 160/100 mmHg or higher
When resting BP is 150/95 mmHg or higher.
54
Describe what severe hypertension is.
when clinical Blood pressure 180/110 mmHg or higher.
55
Describe the effect of hypertension on elastic arteries.
ii. What does this have on the peripheral vascular resistance?
Internal lamina thickening, smooth muscle,hypertrophy and fibrosis.
Therefore lumen narrows and decreases endothelial function causing a decrease in compliance.
ii. Increases it thereby again increasing blood pressure
56
Describe the effect of hypertension on smaller arteries.
Hyaline sclerosis occurs narrowing the lumen.
57
Atherosclerosis is accelerated under hypertension true or false?
true
58
What are the risk factors which lead to an increase in atheroma?
Hypercholesterolaemia
diabetes
smoking
impaired glucose tolerance
59
What happens with decreased vascular compliance which is secondary to atherosclerosis?
Makes systolic Blood pressure become disproportionately greater than diastolic.
60
Give examples of cerebal complications caused by hypertension.
Transient ischemic attack
Cerebal infarction
Intracerebal haemorrhage- caused by extravasation (leakage of fluid from its vessel) of blood from micro aneurysms along walls of small intracerebral arterioles.
subarachnoid haemorrhage - due to degeneration of internal elastic membrane at apex of bifurcation which itself is caused
by haemodynamic stress.
Dementia
61
Carotid artery bifurcation is particularly vulnerable to atherosclerosis true or false?
true
62
What is the carotid bifurcation?
Where the common carotid artery terminates and where the external and internal carotid artery form.
63
What aortic related issues does hypertension cause?
aortic aneurysm - a sac like dilation of weakened aortic wall
aortic dissection- where blood enters the wall of aorta through a small tear in the tunica intima. Creates a large amount of stress causing two layers which compromises blood flow.
64
where is the main effect of hypertension on the kidneys?
Renal arteries and glomeruli.
65
How do you diagnose Hypertension?
Confirm diagnosis: ABPM or home BP monitoring and also clinic BP. ABPM preferred over HOME BPM
just go straight to management if clinical BPM >180/110
Look for end organ damage:
1. Urine analysis -Proteinuria and microalbumuria.
2. ECG or ECHO for LVH
3. Fundoscopy
Pregnancy - dip stick
Bloods: FBC , U&E, glucose and cholesterol
66
What are the causes for peripheral arterial occlusive disease?
1. Atherosclerotic or inflammatory process causing stenosis.
| 2. Thrombus formation.
67
What is accelerated (malignant) hypertension?
ii. what ethnic group is it most common in?
Refers to accelerated microvascular damage. small arteries and arterioles show fibrinoid necrosis.
ii. afrocaribbean
68
What are the risk factors of hypertension?
Race - Afrocaribbean more likely
Gender - greater in men
Age- if you old uh oh
Enviroment
Obesity
Diabetes
Too much salt in diet
Stress
Abnormalities in nervous,circulatory and renal systems
69
What are the risk factors of CVD?
Age
positive family history
Smoking
diabetes
Male
Afrocaribbean
Hypercholesterolaemia
obesity
70
What are the signs and symptoms of Hypertension?
Mainly asymptomatic - except for malignant hypertentsion
Signs:
renal damage
Radiofemoral delay
weak femoral pulses
renal bruits
cushings syndrome
End-organ damage: LVH , retinopathy and proteinuria
for malignant hypertension:
headaches and visual disturbances
71
Why when taking blood pressure should the arm be elevated to heart level?
If arm is below then there is an overestimate of systolic and diastolic values
while vice versa if arm is raised.
72
If the fourth kortikoff sound is heard what might this suggest?
Left ventricular stress- caused by hypertension
73
what Might carotid bruits suggest?
Indicator of secondary hypertension and organ damage.
74
What does hypertension cause in the eyes?
hypertensive retinopathy - retinal vascular damage. If untreated has high mortality rate.
75
What are the three types of hypertensive retinopathy?
Mild- Generalised arteriolar narrowing and silver wall wiring (arteriolar wall opacity)
Moderate- retinal haemorrhage (dots,blots or flamed shaped)
accerlerated- visual loss
76
What are the gradings for hypertensive retinopathy?
Grade 1- arteriolar narrowing
Grade 2- Increased generalised narrowing
Grade 3- haemorrhages
Grade 4- papilledema
77
What are the two types retinal vein thrombosis?
central vein occlusion
branch vein occlusion
78
No salt added diet leads to blood pressure dropping below 2-4 mm Hg true or false?
true
79
How do you manage hypertension
Treat underlying causes: stop smoking and drinking. Reduce salt intake
Drugs:
A: ACE inhibitor (lisinopril) or ARB (candesartan) if ACE not tolerated
C: calcium channel blocker e.g. nifedipine
D: Thiazide diuretic
Step 1: ACE/ARB if <55year or give C or D if >55/black
Step 2 A+ C or A+D
Step 3 A+C +D
All start at stage 2 or above only stage 1 if:
```
Diabetes.
Renal disease.
End organ damage.
Established cardiovascular disease.
10 year cardiovascular risk > 20%.
```
beta blockers: usually not first line for hypertension but considered in young people who:
Intolerant to ACE/ARB
pregnant
or there is an increase in sympathetic drive (sweating)
80
Give examples of causes of secondary hypertension.
Hyperaldosteronism
Renovascular disease e.g. (atheromatous renal artery stenosis and fibro-muscular hyperplasia)
Paranchymal renal disease
Coarctation of the aorta
Phaechromocytoma
Cushing's syndrome
Drugs
81
What are the presenting features of secondary hypertension?
Onset if younger then 35 and especially if younger than 20
Sudden loss of good blood pressure control.
Resistance to adequate drug treatment.
systolic BP greater than 200 mm Hg and diastolic greater than 120 mm Hg
82
What is ALT?
alanine transaminase. It is an enzyme found mostly in the liver. When liver cells are damaged, they release ALT into the bloodstream.
83
Why is swimming good?
Doesn't cause osteoarthritis.
84
What is a fundoscopy?
An exam that uses a magnifying lens and a light to check the fundus of the eye (back of the inside of the eye, including the retina and optic nerve).
85
What would be shown on an ECG with LVH?
Large QRS wave.
86
Does diuretic drugs increase uric acid?
yes so don't use it with gout.
87
Describe the diastolic pressures pattern.
Rises till age of 50 and then falls.
88
Describe the systolic pressure pattern.
ii. What does this do to pulse pressure?
Keeps increasing.
ii. Increases causing syncope more likely to occur. As drugs will treat how systole pressure but will lower already low diastolic BP in elderly.
89
How do you calculate CV risk ?
Use Assign score.
90
What does an abdominal bruit suggest?
Renal failure.
91
What is a bruit?
A sound heard over an artery or vascular channel, reflecting turbulence of flow. Most commonly, a bruit is caused by abnormal narrowing of an artery.
92
Fasting glucose level ?
00 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes. If it's 126 mg/dL (7 mmol/L) or higher on two separate tests, the the patient has diabetes.
93
Fasting glucose test is used for what?
To detect for diabetes see patients normal blood sugar level
94
What does ankle swelling suggest?
1. Right sidedHeart failure
2. Nephrotic syndrome
3. Calcium channel blockers (drugs)
4. Hypothyroidism
95
What enzyme do statins inhibit?
Hmg Coa reductase
96
What must you say to a patient when prescribing ace inhibitor and ARBs?
1. Never take them if they have diarrhoea and vomiting as it causes acute renal failure.
2. They're renal function needs to monitored at least annually. 7-10 days after if stop using them
3. Be aware of dry cough
97
What is normal eGFR value?
60 or more.
98
What do Aceinhibitors end in?
ii. Beta blockers
iii. ARBs
(rule of thumb not all of them)
i. -pril
ii. -lol
iii. -artan
99
What is papillodema?
Is inflammation of the optic disc
100
What is hypertensive retinopathy associated with?
Generalised or local narrowing of retinal arterioles.
101
What might acute or severe hypertension cause?
Retinal arterioles may leak or become occluded. This causes:
1. extravascular oedema
2. Intra- retinal haemorrhages
3. Nerve fibre layer infarcts
4. retinal microaneurysms
102
What is papilloedema associated with?
flame haemorrhages
venous congestion
vascular exudates
103
Give examples of drugs which cause hypertension.
Alcohol
Caffeine
Nasal sprays and remedies
NSAIDS
Erythropoietin.
Corticosteroids
104
How would you test for chronic kidney diesease?
Estimate Glomerulus filtrate rate.
105
How would you test for cushings syndrome?
24 hour free cortisol and creatinine.
106
How would you test for coarctation of aorta?
BP in both arms plus one leg ; echo
107
How would you carry out urinalysis?
ii Can you give examples of how to make sure the procedure is carried out properly?
dipstick test.
ii. Must be analysed within an hour
keep reagent strips in original container don't refrigerate
108
What would a positive result of protein and blood in urine dipstick test suggest?
ii. what is the proteinuria value which is deemed to significant?
iii. What happens if glycosuria is present?
Renal disease or target organ damage.
ii. 150mg/24 hours.
iii. suggests diabetes.
109
What is hypokalemia?
ii. what does it suggest?
Mean low serum potassium - levels less than 3.5 mmol/L
ii. highly suggestive of primary aldosteronism. Even if patient is on diuretic
110
What is hyperuricaemia?
ii. what does it suggest?
Is an usually high level of uric acid in the blood due to reduced excretion or increased cell turnover.
ii. risk of gout in those who use diuretics.
111
What happens if urea and creatine levels are increased?
Suggest underlying renal damage or disease.
112
What is microalbuminuria?
abnormal urinary excretion of albumin between 30-300mg/24 hour and is found in 8-15% of patients with hypertension.
113
What does anaemia suggest?
Renal impairment can be associated with anaemia which can be caused by hypertension. Or that the hypertension is secondary.
114
What does a raised mean corpuscular volume suggest
covert high alcohol intake, a major cause of secondary hypertension.
115
Describe what happens to people with ischaemic heart disease?
Stable accumulation of flow restriction
angina
unstable clinical syndromes
heart attack
NSTEMI
STEMI
116
What is common symptom of IHD?
ii what is the normal clinical diagnosis?
Chest pain
ii. Angina
117
What is common symptom of IHD?
ii what is the normal clinical diagnosis?
Chest pain
ii. Angina
118
What different diagnosis can you get on the GI tract which seems like chest pain but isn't?
Reflux, burning, acid, waterbrash, provoked by food
Peptic ulcer pain. Epigastric, boring, point of finger gesture, relief by antacids / food
Oesophageal spasm
Biliary colic
119
What differential diagnosis can you get with MSK which seems like chest pain but isn't?
Injury, location, tender, prolonged, exac. by moving area,
| Nerve root pain, character, prolonged
120
What are the differential diagnosis of pericarditis which appears like chest pain?
Central, posture related
121
What is pleuritic pain described as?
Focal, exacerbated by breathing, sharp, catching
122
Give examples of emergency differential diagnosis for chest pain
Myocardial infarction
Severe, associated autonomic upset, angor animi
Ongoing pain, despite >10mg Morphine
Pulmonary embolus
Breathlessness, dull (maybe pleuritic)
Dissection of aorta
Tearing, excruciating, severe then eases
123
What is angor animi?
Angor animi is a symptom defined as a patient's perception that they are in fact dying.
124
What are the pros of perfusion imaging?
Non invasive
Pharmacological stress in less mobile patients
More precision than ETT
Risk stratification
125
What are the cons of perfusion imaging?
Radiation
| False positives and negatives
126
What are the pros and cons of CT angiography?
Non-invasive
Anatomical data and risk stratification
cons
Radiation
Less precise than angiography, particularly when calcium present
Cost
127
What are the pros and cons of an angiography?
```
Pros
“Gold standard”
Anatomical and risk stratification
Follow-on angioplasty
Cons
Risk 1:1000 death, stroke
Radiation
Contrast: renal dysfunction, rash, nausea
```
128
What are the complications of a Coronary artery bypass surgery (CABG)?
```
Death 1-2%
Stroke 2-3%
MI 3%
Atrial fibrillation
Infection
Cognitive impairment
Sternal malunion
Renal failure
Failure to recover
```
129
What are the complications of Percutaneous coronary interventions?
```
Death 0.8%
Stroke 0.6%
MI 1-2%
Renal failure
Bleeding
Vascular complications
Stent thrombosis
Stent restenosis
Emergency CABG may be required.
```
130
What is the PCI technique?
```
Vascular access
Anti-platelet drugs, anticoagulation
Catheter to ostium of coronary
Guidewire down vessel
Balloons threaded over wire
Stent(s) implanted
Balloon, catheter, wires removed
```
131
What symptoms/factors should be presented in a patient in order for a angiography to be used?
```
Suitability for revascularisation
Multi-vessel disease, diffuse or focal
Left main disease
Diabetes
Co-morbidities
```
132
What is the ideal choice of preference if someone is having a STEMI?
PCI
133
What is a STEMI?
ST elevated myocardial infarction
134
What do people complain of if they have intermitten claudication?
Patients with intermittent claudication complain of exertional discomfort, most commonly in the calf, which is relieved by rest.
135
what is Spironolactone used for?
Essential hypertension (high blood pressure with an unknown cause)
Hypokalemia (potassium deficiency)
Edema (fluid retention)
Severe heart failure
136
What is a DVT?
Deep Venous Thrombosis. Formation of thrombi within the lumen of the vessels that make up the deep venous system
137
What is a pulmonary embolism?
Pulmonary Embolism. A thrombus (clot) that has embolised (travelled) and lodged in the pulmonary circulation
138
What does Distal vein thrombosis refer to?
refers to DVT of the calves
139
What does does proximal vein thrombosis refer to?
Refers to DVT of the popliteal or the femoral vein. They are closer to the heart then distal ones.
140
DVT can be asymptomatic true or false?
true.
141
What are the three factors which allow for formation of a DVT?
1. Circulatory stasis ( example: Left ventricular dysfunction, immobility or paralysis, varicose veins, venous obstruction)
2. Hypercoagulate state (caused by :malignancy, pregnancy, inflammatory bowel disease, sepsis)
3. Endothelial injury (caused by : venous injury, venous valvular disease, trauma, indwelling catheter).
142
What are the the risk factors of VTE?
i. Exposing risk factors
ii. predisposing risk factors?
```
i. Surgery
Trauma
Acute medical illness
Acute heart failure*
Acute respiratory failure
Central venous catheterisation
Cancer
inflammatory diseases
```
```
ii.
Surgery
Trauma
Acute medical illness
Acute heart failure*
Acute respiratory failure
Central venous catheterisation
```
```
cancer (both types of risk factors)
inflammatory diseases (both types of risk factors)
```
143
What are the symptoms of DVT?
Painful and swollen limb with redness and heat. Tenderness along vein. Sub acute development
144
What are the symptoms of PE?
Sudden SOB with Pleuritic Pain +/- Collapse +/- Haemoptysis. Hypoxia and tachycardia on Obs. BP may be low.
145
How do you test for VTE?
D- Dimer test- 1 Fibrin D-dimer is produced whenever fibrin (a protein that is the chief component of a blood clot), is being actively degraded somewhere within the vascular system
146
What would you do if patient has high risk of DVT or PE?
Scan.
147
What would you do if low risk probability of DVT or ?
D-dimer test.
148
What are the causes of post thrombotic syndrome?
DVT-induced damage to valves in the deep veins and valvular reflux leading to venous hypertension. Typically occurs after 5 years of idiopathic DVT?
149
What are the symptoms Post thrombotic syndrome?
```
Pain
Oedema
Hyperpigmentation
Eczema
Varicose collateral veins
Venous ulceration
```
150
How would you manage DVT?
Oral Anticoagulation
There is a small subset of patients where Thrombolysis can be considered but this is only in highly specialist centres
151
How would you manage PE?
PE – High Risk = Thrombolysis then oral anticoagulation
Intermediate or Low Risk = Oral Anticoagulation
Again highly specialist centres may consider some Intermediate Risk patients for Thrombolysis.
152
What is the definition of stroke?
Acute onset of focal neurological symptoms and signs due to disruption of blood supply
153
What are the two main types of strokes?
1. Ischaemic (80-85%)
| 2. Hemorrhagic (15-20%)
154
What are the causes for hemorrhagic stroke?
Raised blood pressure
Weakened blood vessel wall due to
- structural abnormalities like aneurysm,
arteriovenous malformation(AVM)
- inflammation of vessel wall(vasculitis)
155
What are the causes of ischaemic stroke?
Thrombotic- clot blocking artery at the site of occlusion
Embolic- clot blocking artery has travelled to artery it occludes from somewhere more proximal in the arteries or the heart
Hypoperfusion- due to reduced flow of blood due to stenosed artery rather than occlusion of artery
156
Give examples of non modifiable risk factors?
```
Age
Family history of stroke
Gender
Race
Previous stroke
```
157
Give examples of modifiable risk factors?
Hypertension - 10 mm Hg reduction in SBP reduces risk of Stroke by 20%
Hyperlipidaemia
Smoking- doubles risk of ischaemic stroke.
Prior history of TIA especially if recent and recurrent
Atrial fibrillation
Diabetes
Congestive heart failure
Alcohol excess
Obesity
Physical inactivity
158
What Diet could be used to treat hypertension?
DASH diet- stands for Diet approaches to stop hypertension.
159
How do you differentiate between haemorrhagic and ischaemic stroke?
Brain imaging. e.g CT Brain or MRI
160
How does cardioembolism occur
ii. Where is it normally found
iii. what is the main cause?
embolism from a clot formed in the heart
ii. (usually left atrium)
iii. atrial fibrillation
161
How does atheroembolism occur?
embolism from a thrombus forming on a atherosclerotic plaque- platelet rich clots
162
What test would you carry out to differentiate between the two types of embolitic strokes?
Atheroembolism- carotid scanning, CT/MR angiography of aortic arch
Cardioembolism- Echocardiogram
163
How can you treat an ischaemic stroke?
Thrombolysis- upto 4.5 hrs from onset of symptoms
Thrombectomy- upto 6 hrs from symptom onset, usually after having started thrombolysis
BOTH HEAVILY TIME DEPENDENT AS BRAIN TISSUE DIES RAPIDLY.
164
How would you carry out medical management with a stroke caused by atheroembolic or thrombus?
Antiplatelets(Aspirin 75 mg +Dipyridamole MR 200 mg twice daily/Clopidogrel 75 mg daily)
Statins to treat high lipids
Diabetes management
165
How would you carry out medical management with a stroke caused by atrial fibrillation?
Anticoagulate as soon as possible if less than 48 hours
e.g. Warfarin (Vitamin K antagonist) or NOACS however NOAC only used with non valvular AF
Cardiovert as well
166
Using hypertensives is a good way to manage stroke prevention true or false?
True.
167
Give examples of surgical management.
Haematoma evacuation
Relief of raised intracranial pressure Obstructive hydrocephalus Large total MCA infarctions
Carotid endarterectomy
168
What is a TIA?
Known as transient ischaemic attacks, which have Temporary neurological symptoms due to occlusion of artery stopping flow of blood.
169
Why are they temporary?
because arteries are capable of dissolving small clots.
170
What are the symptoms of chronic venous disease?
very variable though 40% present with varicose veins.
1. bleeding
2. thrombophletis
3. chronic venous insufficiency
4. ulcerations
171
What investigations can be used for chronic venous disease?
Duplex scan
State of the deep veins (occlusions or incompetence)
Saphenofemoral or saphenopopliteal incompetence?
172
Give examples of complications to interventions of chronic venous disease?
```
Thrombophlebitis
Skin staining
Local ulceration
Wound infection (~10%)
Nerve damage
‘Recurrence’
```
173
What is an oedema?
Accumulation of fluid in interstitial space
174
What are the causes of oedema?
1. Raised capillary pressure - caused by :
arteriolar dilatation
Left ventricular failure - pulmonary oedema
Right ventricular failure - peripheral oedema (ankle, sacral)
Prolonged standing - swollen ankles
2. Reduced plasma osmotic pressure
Normal [plasma protein]p = 65-80 g/l
Oedema if < ~ 30 g/l
malnutrition
protein malabsorption
excessive renal excretion of protein
hepatic failure
3. Lymphatic insufficiency
Lymph node damage
Filariasis - elephantiasis
4.Changes in capillary permeability
inflammation
histamine increases leakage of protein
175
What would clinical investigations show for pulmonary oedema?
i. Auscultations
ii. Chest X ray
i. Clinically there may be crepitations in auscultation of lung bases
ii. Chest X-ray shows haziness in perihilar region
176
Symptoms of pitting oedema?
swelling in Ankles
swelling in Sacrum
177
What is heart failure?
HF is a complex clinical syndrome resulting from structural or functional impairment of ventricular filling (mainly left) or ejection of blood
178
What are the causes of heart failure?
Coronary Heart Disease (± MI)
Hypertension (~80%)/ Diabetes
Dilated Cardiomyopathy Primary/~30% hereditary, secondary eg EtOH, adriamycin etc)
Valve disease
Tachycardic arrhythmias (poorly controlled AF)
~40% have (predominantly) HEFpEF (Heart failure with Preserved Ejection Fraction)
(typically elderly, hypertensive/diabetic ♀)
179
What are the two types of heart failure?
Diastolic and systolic.
180
What are the symptoms of heart failure?
1. Shortness of breath
2. Difficulty breathing at night when recumbent:
i. Orthopnoea
ii. Paroxysmal nocturnal dyspnoea
3. Reduced exercise tolerance
4. Fatigue
5. Tiredness
6. Ankle swelling
181
What would you find on physical examination in relation to heart failure?
Neck exam
Elevated jugular venous pressure
Auscultation of the lungs
Rales or crackles
Auscultation of the heart 2,3,4
Third or fourth heart sound (S3 or S4) sometimes called a gallop rhythm
Murmur
Oedema in dependent areas2
Sacrum
Feet/ankles/lower legs
182
What can ECG identify for HF?
Arrhythmias (irregular heart rhythms)
Past myocardial infarction (MI)
Left ventricular hypertrophy
183
What can chest X-Ray identify for HF?
Size and shape of the cardiac silhouette
Evidence of fluid accumulation in the lungs
184
How is BNP useful for testing for HF?
If it is elevated and patient has S.O.B then suggests Heart failure is present.
185
What is a BNP?
a protein that is made by your heart and blood vessels. Think of as a cardiac hormone.
186
What is a transthoracic echocardiogram?
ultrasound of the heart obtained by placing the transducer on the chest wall. Images of the heart are obtained and can provide information on chamber size, wall thickness and chamber function.
187
What is an ejection fraction?
EF is the percentage of blood that is pumped out of the heart during each beat
188
What are the ranges for healthy ejection fraction
A normal EF is ≥50%
189
What is heart failure called when EF is normal?
Heart failure in the setting of a normal EF is known as heart failure with preserved ejection fraction (HFpEF)
190
What is heart failure called when EF is reduced?
Heart failure with an EF ≤40% is known as heart failure with reduced ejection fraction (HFrEF)
191
What is the patho-physiological differences between HFrEF and HFpEF
In HFrEF the LV is unable to eject an adequate amount of blood during systole
In HFpEF less blood is able to fill the LV in diastole, due to myocardial stiffness. Thus the LV has less blood to eject during systole
192
What is the difference between STEMI and NSTEMI?
A STEMI or ST-elevation myocardial infarction is caused by a sudden complete (100 percent) blockage of a heart artery (coronary artery). A non-STEMI is usually caused by a severely narrowed artery but the artery is usually not completely blocked.
193
When would you no longer be able to use PCI?
after 2 hours
194
Where is the normal apex beat found?
Normal 5th intercostal space/mid clavicle line.
195
What might a displaced apex beat suggest?
LVH- pressure overload
196
What does a tapping apex suggest?
Mitral stenosis
197
What does a parasternal heave suggest?
Right ventricular overload.
198
What is a cardiac murmur?
Audible turbulence of blood flow
innocent and pathological.
199
Where are the valves found?
A-2nd-3rd right inter space
P- 2nd 3rd left interspace
T- left sternal border
M- apex
200
What does the 1st heart sound mean?
Mitral and tricuspid valve closing
start of systole
201
What does the 2nd heart sound mean?
Aortic and pulmonary valves closing
start of diastole
202
What type of systolic murmurs are there?
Pansystolic
Ejection systolic
203
What type of diastolic murmurs are there?
Early diastolic
Mid diastolic
204
How do you grade murmurs?
Six point scale
```
I. Very quiet
II. Quiet - easy to hear
III. Loud
IV. Loud with a thrill
V. Very loud with a thrill
VI. Loud - audible without a
stethoscope
```
205
What are the differences between left and right sided murmurs?
Right sided louder with inspiration
Left sided louder with expiration.
206
Name 5 conditions which give common murmurs?
innocent murmur
mitral regurgitation
aortic stenosis
aortic regurgitation
Mitral stenosis
207
What is an innocent murmur?
soft sound
position is dependent
Often early systolic sound
208
All diastolic murmurs are pathological true or false?
true
209
What is valve stenosis?
Valves do not open properly
210
What is valve regurgitation
Valves do not close properly
211
coronary angiography is always advised along with valve replacement true or false
true.
212
What is a raised JVP?
Greater than 4cm
213
What do you do with persistent AF and its after 48 hours?
Rate control and anti coagulate
214
What does troponin in the blood suggest?
Myocardial Infarction
215
How do you class rheumatic disease?
JONES class
```
J- joints
O- MyOcarditis
N- Nodules
E- erythema marginatum
S- Sydenham chorea
```
216
How do you examine mitral stenosis?
Use bell of stethoscope and make patient move left.
217
What is angina pectoris?
chest pain which may spread to jaws and arms
it is symptomatic reversible myocardial ischaemia
218
What are the main causes of angina?
1. Atheroma (main)
2. Anaemia
3. coronary artery spasm
4. Tachyarrhythmias
5. Hypertrophic cardiomyopathy
219
What are the signs and symptoms of Angina?
Main three features
1. Constricting discomfort to the chest, jaw,neck,shoulders or arms
2. Symptoms are brought on by exertion
3. symptoms relieved by rest or GTN within 5 mins
Other precipitants which bring on syptoms include:
1. cold weather
2. emotion
3. heavy meals - cardiac work load increases
Other symptoms include:
1. Dyspnoea
2. Nausea
3. sweatiness
4. faintness
220
What are the main types of angina pectoris?
Stable angina - Induced by effort relieved by stress
unstable angina - Angina of increasing frequency or severity occurs on minimal exertion or at rest - associated with very high risk of MI
Decubitus angina - precipitated by lying flat
Variant angina - caused by coronary artery spasm (only one which causes ST elevation)
221
How do you diagnose Angina?
ECG - usually normal (may shows ST depression or flat/inverted T waves)
or show signs of past MI
Blood tests: FBC ,U&E, TFTs , Lipids , HbA1C
can consider echo or CXR
Testing for Ischaemic heart disease can be taken after:
Angiography - use cardiac CT with Contrast or transcatheter angiography
222
How do you manage Angina?
1. address exacerbating factors (e.g. anaemia, tachycardia)
2. Prevention of cardiovascular disease:
Stop smoking
exercise
optimise hypertension
diabetes control
manage hyperlipidaemia
take aspirin
3. Symptom Relief: GTN spray - stable angina pain should go after 5 mins of use
4. First Line prophylaxis :
Beta blockers and or Calcium channel blockers( calcium antagonists)
E.g. Atenolol - beta blocker
amlodipine - this is an example of a dihydropyridine calcium antagonist ( don't mix non dihydropyridine and beta blocker)
5. Second line prophylaxis: only used if BB and CBB are in contraindication
i. Long acting nitrates ( isosorbide mononitrate) - venodilator - lowers BP and gives headaches
ii. Nicorandil - K+ channel activator gives Mouth/GI ulcers
iii. Ivabradine - reduces heart rate only in sinus rhythm
iv. Ranolazine : inhibits late Na+ current. effective against refractory angina
6. Revascularisation (PCI)
223
When do you dial 999 when using GTN relief for angina?
If chest pain has still not gone after 5 mins on the second dosage
224
What is acute coronary syndromes (ACS)?
A collection of diseases sharing the same pathology
These include:
1. Unstable angina
2. STEMI (ST elevated myocardial infarction)
3. NSTEMI (Non ST elevated myocardial infarction)
225
What does Myocardial infarction mean?
Myocardial cell death
causes release of troponin
226
What are the causes of ACS?
1. atherosclerotic plaque rupture and thrombosis which occlude the coronary vessels
2. inflammation
227
What are the risk factors of ACS?
Non modfiable
1. Age
2. Male
3. family history of IHD
Modifiable
1. Smoking
2. hypertension
3. Diabetes
4. Hyperlipidaemia
5. obesity
228
What are the signs and symptoms of ACS?
Symptoms
1. Acute chest pain lasting >20 min - radiates to neck and arms
2. Nausea
3. Dyspnoea
4. Palpitations
5. May have silent ACS (no chest pain) - common in diabetics and elderly
Signs:
1. Distress
2. Anxiety
3. Pallor
4. sweatiness
5. changes in BP and pulse
6. 4th heart sound potentially
229
How do you diagnose ACS?
General : Bloods FBC, U&E , glucose , cardiac enzyme( troponin)
STEMI:
TnT (troponin T and I)
ECG:
shows ST segment elevation
new onset Left bundle branch block (LBBB)
Might show T wave inversion or pathological Q waves
NSTEMI:
Tn (troponin T and I ) increase
ECG:
No ST segment elevation
may show ST depression
T wave inversion or even normal
Unstable Angina:
Troponin level does not rise
ECG:
T wave inversion
ST depression or even normal
230
How do you manage STEMI?
MONA + C (clopidogrel)
1. Morphine: 5-10 mg and anti emetic
2. Oxygen if hypoxic
3. Nitrate: GTN spray to manage symptom and patient has BP >90 mmHg
4. Aspirin (unless already given)
5. Clopidogrel/ticagrelor
PCI if :
i. patient presenting within 12 hours of symptom and available in next 90 mins
ii. ECG changes (new LBBB) or ST elevation
iii. No contraindications
otherwise thrombolysis - unless recent aggressive CPR
231
How do you manage Non STEMI and unstable angina?
MONA + C (clopidogrel)
1. Morphine: 5-10 mg and anti emetic
2. Oxygen if hypoxic
3. Nitrate: GTN spray to manage symptom and patient has BP >90 mmHg
4. Aspirin (unless already given)
5. clopidogrel/ ticagrelor
5. Anticoagulation ( fondaprinux) or LMWH
6. Oral beta locker e.g. bisoprolol
7. PCI and angiography should be requested based on severity (GRACE score)
232
How do you manage ACS in the after initial management?
1. Symptom control
2. Modify risk factors
3. Optimise cardio protective medications - Give ACE inhibitor and Beta blocker
Aspirin for at least 12 months to decrease vascular events risk (MI and stroke)
233
which is more specific for cardiac muscle damage- troponin or creatinine kinase?
troponin
| creatinine kinase also peaks in skeletal muscle and brain
234
what leads have ST elevation in an inferior STEMI?
II, III, aVF
235
what leads have ST elevation in an anteroseptal STEMI?
V1-V4
236
what leads have ST elevation in a lateral STEMI?
1, aVL, V5, V6
237
What is the difference between Angina and MI?
1. Duration is longer for MI ( 30 mins vs 10)
2. Onset - Angina comes about on exertion while MI at rest
3. MI usually more severe
4. MI has sweating, nausea and vomiting as usual associated symptoms Angina doesn't
238
Discuss the three different isoforms of troponin.
Troponin C binds Calcium - Identical in heart and skeletal muscle
Troponin I in absence of Ca2+binds to actin, inhibits actin-myosin ATPase induced contraction - cardiac specific isoforms
Troponin T links troponin complex to tropomyosin, facilitates contraction - cardiac specific isoforms
239
What are the complications of MIs?
1. Cardiac arrest
2, Cardiogenic shock
3. LVF
4. Arrhythmias
5. RVF - Low CO and raised JVP
6. Pericarditis - relieved by sitting forward
7. systemic embolism - presents with pulmonary oedema
8. Mitral regurgitation
9. Dressler's syndrome - recurrent pericarditis , pleural effusions , fever and anaemia also raised ESR. May lean forward (autoimmune phenomenon) . Occurs 4-6 weeks after MI
10. cardiac tamponade - presents with low CO, pulsus paradoxus, Kussmaul's sign
240
what are the types of infarct that are related to an MI?
Transmural - affects all of the myocardial wall - cause ST elevation and Q waves
subendocardial - necrosis <50% of the myocardial wall - cause ST depression
241
What is heart failure?
A condition of the inability of the cardiac output to meet the physiological demands of the body.
It is caused by damage to the valves, ventricular muscle or both. This results in back pressure of blood with congestion of organs
242
What are the key classifications of heart failure?
LVF
RVF
Systolic failure - inability of the the ventricle to contract normally
diastolic failure - inability of the ventricle to relax normally
Low output failure - cardiac output is low and fails to rise normally with exertion.
High output heart failure - rare. Output is normal or normal yet the requirement is much higher. Cardiac output fails to meet these needs
243
What are the causes of Left ventricular heart failure?
CVS: coronary artery disease, hypertension, valve disease arrhythmia, cardiomyopathy.
Volume overload: CKD, nephrotic syndrome.
High output states: anaemia, sepsis, liver failure.
244
What are the causes of Right ventricular heart failure?
1. LVF
2. Pulmonary stenosis
3. Lung disease
245
What are the signs and symptoms of LVF?
PULMONARY OEDEMA
1. Dyspnoea
2. Poor exercise tolerance
3. Fatigue
4. orthopnoea
5. Paroxysmal
6. PND
7. nocturnal cough (+/- pink frothy sputum)
8. wheeze
signs:
S3.
Bibasal crepitation’s.
Displaced apex beat.
246
What are the signs and symptoms of RVF?
Peripheral oedema
ascites
nausea
anorexia
facial engorgement
Signs:
Raised JVP,
hepatomegaly,
chest vein dilation,
ascites
247
What is congestive heart failure?
When LVF and RVF occur together and there is a combination of clinical features
248
How do you classify Heart failure?
New york heart association:
1. No limitation of physical activity
2. Slight limitation of physical activity
3. Marked limitation of physical activity
4. Inability to carry out physical activity
Framingham criteria: either 2 or major and 0 minor or 1 major and 2 or more minor
1.Major criteria - PAINS
Paroxysmal nocturnal dyspnoea
Acute pulmonary oedema
Increased heart size and central venos pressure
Neck vein dilation
S3 gallop
2. Minor Criteria - PAIN
Pleural effusion
Ankle oedema
Increased heart reate (>120)
Nocturnal cough
249
How do you diagnose heart failure?
Bloods: FBC, U&E, BNP.
BNP is raised
ECG: LVH, left bundle branch, pathological Q waves, AF.
Echo: should be used if either abnormal. However it is still the gold standard
CXR: ABCDE
Alveolar oedema ( batwings)
Kerley B lines ( septal lines)
Cardiomegaly
Dilated prominent upper lobe veins
Effusion (pleural)
will also have: cuffing and fluid in fissures
250
How do you manage heart failure?
Acute heart failure - emergency treat like emergency pulmonary oedema (ABCDE)
A- sit up and give o2
chronic heart failure - stop smoking and drinking. Eat less salt
Drugs:
Loop diuretics: relieve symptoms e.g. furosemide or bumetanide. Side effects include decrease in k+ and renal impairment
Ace inhibitor: Consider for Left ventricular systolic . Prolongs life by preventing cardiac remodelling (or use ARB)
Beta blocker: carvedilol or bisoprolol - decreases mortality. "start low go slow"
Other drugs
Digoxin: helps symptoms even in sinus rhythm
Hydralazine – isosorbide dinitrate combination. (vasodilator)
Spironolactone – if loops are not providing enough symptom relief or are complicated by hyperkalemia
Sacubitril – Valsartan.
Combination of ARB with Sacubitril, which is a drug the increases the levels of ANP/BNP.
Surgical intervention:
Cardiac resynchronisation
LV assist device
heart transplantation
251
What are the two types of ejection fraction is heart failure asssociated with?
Reduced -:. Reduced cardiac output due to failure of the ventricles to properly contract.
Preserved - Thought to be associated with atrial dysfunction that results in reduced ventricular filling and therefore reduced cardiac output.
252
How do you manage malignant hypertension?
No end organ damage: oral therapy
Signs of CCF or encelphalopathy:
Labetalol or sodium nitroprusside infusion if no LVH
Furosemide + hydralazine if LV failure
want to control the reduction of BP in days not hours
253
What is Mitral regurgitation?
Backflow through the mitral valve during systole
254
What are the causes of Mitral Regurgitation?
1. Left ventricular dilation
2. Annular calcification
3. Rheumatic fever
4. infective endocarditis
5. Mitral valve prolapse
6. ruptured chordae tendinae
7. Papillary muscle rupture
255
What are the signs and symptoms of Mitral regurgitation?
Symptom: Dyspnoea Fatigue Palpitations
signs:
AF
displaced hyperdynamic apex,
Pansystolic murmur at apex spreads to axilla
soft S1
Loud P2
256
How do you diagnose Mitral regurgitation?
ECG: AF and LVH
ECHO
CXR: cardiomegaly
Cardiac catheterisation
257
How do you manage Mitral regurgitation?
1. Symptomatic relief: ACEi / Diuretics.
2. If in AF
Rate control eg digoxin.
Anti coagulation eg Warfarin.
valve replacement
258
What is Mitral stenosis?
Narrowing of the opening of the mitral valve
259
What are the causes of mitral stenosis?
Rheumatic fever
congenital
Mucopolysaccharidoses
Endocardial fibroelatosis
Malignant carcinoid
prosthetic valve
260
What is the normal mitral valve orifice area?
4-6 cm2
261
What are the signs and symptoms of Mitral stenosis?
Symptoms usually begin when the orifice becomes <2cm 2
Dyspnoea
Haemoptysis
Dysphagia
fatigue
palpitations
sign:
Rumbling mid diastolic murmur, best heard on expiration when patient lying on their side
AF due to enlarged LA
malar flush on cheeks
tapping non displaced apex
262
How do you diagnose Mitral stenosis?
ECG: AF, P mitrale
CXR: left atrial enlargement Pulmonary oedema Mitral valve calcification
ECHO: diagnostic
263
How do you manage Mitral stenosis?
SOB: ACEi / diuretics.
AF: rate control and anti-coagulation.
Surgical:
o Balloon valvuloplasty.
o Valve replacement.
264
What are the causes of Aortic stenosis?
Senile calcification (main)
congenital (bicuspid valve, Williams syndrome)
Rheumatic heart disease
265
What are the signs and symptoms of Aortic stenosis?
Classic tirad: Angina, Syncope and heart failure
Dysopnea
dizziness
faints
signs: • Ejection systolic murmur best heard at aortic region that radiates to the carotid.
Crescendo - decrescendo murmur
Bibasal creptiations
Slow rising pulse with narrow pulse pressure
Heaving non displaced apex
LV heave
aortic thrill
266
How do you diagnose aortic stenosis?
ECG: LVH with strain pattern, P- mitrale, LAP poor R wave progression LBBB or complete AV block
CXR: Calcified aortic valve and LVH
Echo
Doppler echo can estimate across valves
267
How do you manage Aortic stenosis?
Generally have a poor prognosis due to progressive heart failure, so surgical intervention favored.
Surgical options:
Valve replacement.
Balloon valvuloplasty.
TAVI: trans aortic valve implantation. ( if surgically unfit)
268
What are the causes of aortic regurgitation?
Acute: Infective endocarditis, ascending aortic, dissection
chronic: Congenital, connective tissue disorders( Marfan's syndrome, Ehlers- Danlos) and rheumatic fever
269
What are the symptoms of Aortic regurgitation?
Exertional dyspnoea
Orthopnoea
PND (paroxysmal night dysopnea)
Palpitations, angina, syncope
signs:
Early diastolic murmur, best heard when patient is sitting forward and expiring.
Displaced apex.
wide volume pulse.
Collapsing pulse.
Head nodding with each heart beat.
Pulsations in capillary nail beds
270
How do you diagnose Aortic regurgitation?
ECG: LVH
CXR: Cardiomegaly : dilated ascending aorta
ECHO: diagnostic
271
How do you manage Aortic regurgitation?
Echo every 6-12 months
Medical: control hypertension – ACEi.
Surgical: valve replacement.
Surgery indicated when LV dilation and heart failure progresses
272
What is infective endocarditis?
Inflammation fo the endocardium and valves due to infection. Usually involves the heart valves with 'vegetation' of the infectious agent
273
What is the pathophysiology of infective endocarditis?
Rare
Heart valves are targeted due to lack of blood supply meaning WCC are unable to reach them
274
What are the risk factors of infective endocarditis?
IV drug users ( especially with tricuspid valve)
Renal failure
immunosupression
Diabetes
prosthetic valves (staph aureus and epidermis main causes)
Valve abnormality
275
What are the causes of Infective endocarditis?
Bacteria:
Strep viridans ( most common)
Staph aureus (second most common)
Strep bovis
Enterococci and coxiella burnetii
staph epidermis
HACEK group (rare)
276
What are the signs and symptoms of Infective endocarditis?
Fever + new murmur - is endocarditis until proven otherwise
Septic signs: Fever, rigor, malaise, anaemia, Weight loss and clubbing
Immune complex deposition: Vasculitis may affect any vessel. Roth spots and splinter haemorrhages and osler nodes
vegetation may embolise causing abscesses in organs
277
How do you classify Infective endocarditis?
Definitive infective endocarditis: 2 major or 1 major and 3 minor or 5 minor
Major Criteria:
2 separate positive blood cultures
single positive blood culture for coxiella burnetii
Minor criteria: FIVE
Fever
IV drug use or predisposing heart condition
and
Immunological phenomena e.g. osler's nodes or roth's spots
Vascular phenomena: mycotic aneurysm
Echocardiograph findings
278
How do you diagnose Endocarditis?
Classification
Bloods cultures: 3 separate cultures from 3 peripheral sites
Blood tests: Anaemia, Neutrophilila, high ESR/CRP
Urinalysis: Microscopic haematuria
CXR: cardiomegaly
1st line imaging: Trans thoracic echo.
2nd line imaging: Trans oeseophageal echo.
TOE done if prosthetic valve, vegetations or non diagnostic images on TTE.
279
How do you manage infective endocarditis?
Native valve indolent (Subacute): Amoxicillin IV 2g 4 hourly + Gentamicin
Native valve severe sepsis (Acute): Flucloxacillin IV 2g 6 hourly (4 hourly if >85kg). DRUG USERS
Prosthetic valve or Suspected MRSA: Vancomycin IV + Gentamicin IV + when therapeutic vancomycin levels reached add Rifampicin PO 600mg bd (Very good replacement VGR)
Viridans - Benzylpenicillin IV + gentamicin IV
280
What is hypertrophic cardiomyopathy (HCM)?
familial condition affecting the heart, characterised by unexplained hypertrophy of the wall of the left ventricle
cavity space to be lost due to obstruction from asymmetric septal hypertrophy
281
Discuss the prevalence of HCM.
Autosomal dominant or Sporadic (mainly)
70% have mutation sarcomeres genes (Beta myosin, alpha tropomyosin and troponin T issues)
282
What are the signs and symptoms of HCM?
Sudden death is common (most common cause for young)- athletes
Angina
dysopnea
Palpitation
Syncope (fainting)
Sign:
double-apex beat
systolic thrill at lower left sternal edge
283
why are arrhythmias (particularly re-entry) common in a heart with hypertrophic cardiomyopathy?
scarring leads to arrhythmias due to increased automacity of surrounding tissue
284
How do you diagnose HCM?
ECG: LVH, Progressive T-wave inversion
Echo: asymmetrical septal hypertrophy;
285
How do you manage HCM?
Symptomatic control:
Chest pain: B Blockers / Verapamil.
Arrhythmia: Amiodarone / anti coagulation
286
What is Dilated cardiomyopathy (DCM)
A dilated, flabby heart of unknown cause
287
What are the associated factors of DCM?
1. Alcohol
2. congenital (x-linked)
3. Increase BP
4. Haemochromatosis
5. Viral infection
6. Autoimmune
288
What are the signs and symptoms of DCM?
mainly shows signs/ symptoms of RVF and LVF
Fatigue
Dysopnea
Pulmonary oedema
emboli
AF
signs:
Raised pulse and JVP
displaced and diffuse apex
s3 gallop
oedema, jaundice, hepatomegaly ascites
289
How do you diagnose DCM?
Blood: BNP (cardiac failure)
CXR: cardiomegaly, pulmonary oedema
ECG: tachycardia, non specific T-wave changes, Poor R-wave progession
Echo: globally dilated hypokinetic heart
290
How do you manage DCM?
Heart failure – ACEi Diuretics, B blockers etc.
Palpitations: digoxin, anti-coagulation, ICD.
Surgical:
Heart transplant.
291
What is restrictive cardiomyopathy?
the heart becomes stiff but not hypertrophied, which results in the heart resisting normal filling with blood.
292
What are the causes of restrictive cardiomyopathy?
Idiopathic
amyloidosis
sarcoidosis
haemochromatosis
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What are the signs and symptoms of restrictive cardiomyopathy?
SOB.
Peripheral oedema.
Hepatomegaly.
Raised JVP
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What is arrhythmic right ventricular cardiomyopathy?
Is a type of cardiomyopathy in which the myocytes become replaced with fibrous and fatty tissue.
It is an autosomal dominant condition associated with mutations in the ryanodine receptors.
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What are the signs and symptoms of arrhythmic right ventricular cardiomyopathy?
• Primarily presents with ventricular arrhythmias, which can cause:
o Dizziness.
o Palpitations.
o Sudden cardiac death
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How do you manage arrhythmic right ventricular cardiomyopathy
Management is rhythm control with either:
B blockers / amiodarone.
ICD.
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What is myocarditis?
Inflammation of the myocardium often associated with myopericarditis
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What are the causes of myocarditis?
1. Idiopathic
2. Viral: Enteroviruses, EBV, influenza, coxsackie A and B, Hepatitis
3. Bacterial: Staph, strep, clostridia, TB and Mycoplasma
4. Drugs: Trastuzumab
5. immunological: SLE, Sarcoid
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What are the signs and symptoms of myocarditis?
mainly in young adults
ACS- like symptoms
heart failure symptoms
palpitations, Tachycardia soft S1 and S4 gallop
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How do you diagnose Myocarditis?
ECG: ST changes, T-wave inversion,atrial arrthymias
Bloods: Troponin, CRP and ESR may be raised
viral serology: swabs
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How do you manage Myocarditis?
treat underlying cause
supportive management: avoid exercise as this can precipitate arrhythmias
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what is cardiac myxoma?
rare benign cardiac tumour usually sporadic
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What is acute pericarditis?
Inflammation of the pericardium
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What are the causes of acute pericarditis?
1. idiopathic or secondary to:
i. viruses: Coxsackie, EBV,CMV
ii. Bacteria: TB (most common cause worldwide),Lyme disease, Q fever
iii. Drugs
iv. Surgery, trauma
v. Autoimmune: dressler's syndrome
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What are the signs and symptoms of acute pericarditis?
Fever is common - (infection)
Central chest pain- worse lying down or on inspiration. Made better by leaning forward
Pericardial friction rub and pericardial effusion or cardiac tamponade
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How do you diagnose acute pericarditis?
ECG: concave (saddle-seat) ST segment elevation and PR depression
Blood: FBC,ESR,U&E , troponin may be raised
CXR; cardiomegaly - pericardial effusion
ECHO: if pericardial effusion is suspected
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How do you manage Acute pericarditis?
Analgesia.
Treat the underlying cause.
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What is pericardial effusion?
Accumulation of fluid in the pericardial sac
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What are the causes of pericardial effusion
Pericarditis (i.e. same causes)
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What are the signs and symptoms of pericardial effusion?
Dysopnea
Chest pain
raised JVP, bronchial breath at left base (ewart's sign: compressed lower lobe)
muffled heart sound
hiccups - phrenic nerves compressed
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How do you diagnose pericardial effusion?
CXR: Large globular heart
ECG: low voltage QRS complexes
Echo: diagnostic
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How do you manage pericardial effusion?
Treat the cause
Pericardiocentesis: either therapeutic (tamponade) or diagnostic (bacterial)
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What is cardiac tamponade?
Pericardial effusion that raises intrapericardial pressure reducing ventricular filling = lowers cardiac output
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What can cardiac tamponade lead to?
cardiac arrest
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What are the signs and symtpoms of cardiac tamponade?
SOB, fatigue, palpitations, pericarditis.
raised pulse and JVP
Lowered BP
Pulsus paradoxus (large decrease in systolic pressure during inspiration. )
kussmaul's sign (JVP rising with inspiration)
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How do you diagnose Cardiac tamponade?
Beck's triad : falling BP, rising JVP, muffled heart sounds
CXR/ ECG: as per Pericardial effusion
ECHO: diagnostic
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How do you manage cardiac tamponade?
drainage (pericardiocentesis)
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what is coarction of the aorta?
a congenital defect where there is vasoconstriction just below the subclavian artery
319
what is transposition of the great arteries?
a congenital defect where the aorta and pulmonary trunk are switched,
so deoxygenated blood gets taken to systemic circulation and oygenated blood gets taken to the lungs
(2 completely separate circuits)
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What is an atrial septal defect?
Hole connects the atria
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What are the main two defects of an ASD?
Ostium secundum: 80% of cases asymptomatic till adulthood when left to right shunt forms
Ostium primum: associated with AV valve anomaly. Symptomatic in childhood. associated with downs syndrome
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What are the signs and symptoms of ASD?
Chest pain
palpitations
dysopnea
arrythmias
raised JVP
pulmonary systolic murmur
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How do you diagnose ASD?
ECG: RBBB with LAD (primum defect)
| RBBB with RAD (secundum defect)
324
How do you treat ASD?
usually close spontaneously
if not primum defects close in childhood
transcatheter closure more common than surgical
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What is ventricular septal defect (VSD)?
Hole connects the ventricles
326
What are the causes of VSD?
congenital
acquired (post MI)
327
What are the signs and symptoms of VSD?
heart failure in infant or remain asymptomatic
signs:
Harsh pansystolic murmur heard at the left sternal edge
systolic thrill+/- left parasternal heave
328
How do you diagnose VSD?
ECG: normal or LAD (left axis deviation), RVH or LVH
CXR: normal hear size or cardiomegaly
cardiac catheter: step up in o2 saturation in right ventricle
329
How do you treat VSD?
close spontaneously
failed medical therapy or Symptomatic VSD - surgical closure
330
What is Eisenmenger's complex?
occurs in ASD and VSD
initial left to right shunt leads to pulmonary hypertension which increases right heart pressure is greater than left causing a reversal in shunt.
causes cyanosis
331
What is a High LDL/HDL ratio a good indication of?
ii. what can increase HDL?
high risk of cardiovascular disease
ii. fibrate therapy
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when are there micro and macroscopic changes of an acute MI become visible?
12-24 hours
333
what are the three Ps of vasovagal syndrome?
Posture -
Provoking factors - she was in a warm, crowded environment
Prodromal symptoms - she complained of dizziness before the collapse
334
what is dextrocardia?
a congenital defect where the apex and ventricles points to the right side rather than left
335
what are the 4 conditions associated with tetralogy of fallot?
Pulmonary stenosis
right ventricular hypertrophy
ventricular septal defect
overriding aorta
