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Flashcards in CORE CONDITIONS Deck (52):
1

ATRIAL FIBRILLATION: Description

Irregular and disordered contraction of the atria. This leads to blood stasis and a drop in CO because the ventricles aren't primed with blood

2

ATRIAL FIBRILLATION: Aetiology/Risk Factors

Usually occurs in the elderly with no known cause.
Ischaemic heart disease & MI
Hypertension
Hyperthyroidism
Caffeine and alcohol
Hypokalaemia and hypomagnesaemia

3

ATRIAL FIBRILLATION: Presentation (Signs & Sx)

Commonly ASx
Chest pain, palpitations, dyspnoea, faintness/dizziness
IRREGULARLY IRREGULAR PULSE, first heart sound is of variable intensity

4

ATRIAL FIBRILLATION: Investigations and Diagnosis

ECG will show absent P waves or an 'atrial flutter - sawtooth pattern'
Bloods: U&E to rule out ionic causes, TFTs
Consider echocardiogram to look for enlargement or mitral valve disease

5

ATRIAL FIBRILLATION: Management

Rate Control: Beta-blocker or rate-limiting Ca blocker, add digoxin if not successful
Anti-Coagulation: Warfarin or NOACs (NOACs not suitable in valve patients). Use heparin in acute patients
Consider rhythm controllers: amiodarone

6

ACUTE CARDIAC SYNDROME (ACS) & MI: Description

ACS or MI describes an unstable angina or MI with a common pathology progression of plaque-->rupture-->thrombus-->ischaemia

7

ACS & MI: epidemiology and aetiology & RFx

5/1000 p.a. will have am STEMI
Aetiology is through atherosclerosis --> thrombus pattern of ischaemia
Non-modifiable RF: Age, male, FH (MI of relative <55y)
Modifiable RF: smoking, hypertension, DM, hyperlipidaemia

8

ACS & MI: Presentation (Signs and Sx)

Acute, central, 'crushing' chest pain that can radiate to arm (most often left) an up into neck and jaw that lasts >20min.
Nauseous, sweating, vomiting, dizziness, dyspnoea
Can be ASx in the elderly and diabetic
Pulse high or low, High BP, 4th heart sound

9

ACS & MI: Differentials

Angina pericarditis, myocarditis, aortic dissection, PE, reflux

10

ACS & MI: Investigations and Diagnosis

BIOMARKERS
- Troponin (most sensitive and specific): peaks 24hr after event and return to baseline after 5-14 days
- Creatinine Kinase: Of the three types CK-MB is most found in heart and so will be elevated after ACS. Peak after 24hr and back to normal after 48-72hr
- Myoglobin: levels rise from 1-4h after pain onset: not specific.

ECG: Tall T-waves, ST elevation or depression or new LBBB occurring
Bloods: FBC, U&E, glucose and lipids

11

ACS & MI: Management

A-Ps: Aspirin 300mg initially followed by 75mg
A-Cs: LMWH or fondaparinux
GTN
Beta-blockers: consider if tachycardia or hypertensive
ACEi: ramipril, lisonopril

12

ANGINA PECTORIS: Description

Stable angina is pain in the chest upon exertion. Partial occlusion of the vessels due to atherosclerosis means that increasing needs of the myocardium during exercise cannot be met with blood flow leading to anaerobic respiration.

13

ANGINA: Epidemiology

Affects approximately 2-4% of the population.

14

ANGINA: Aetiology and RFx

All cardiac RF and RF for atheromatous plaque formation
Precipitating Factors include Anaemia, diabetes, hyperlipidaemia, thyrotoxicosis

15

ANGINA: Presentation (Signs & Sx)

Depends on the type:
- STABLE: central tight chest pain upon extortion, relived by rest
- UNSTABLE: Angina of unpredictable timing and crescendoing pattern (High risk MI)
- VARIANT: caused by vasopspams and is again unpredictable
PAIN +/- dyspnoea, nausea, faintness, sweatiness

16

ANGINA: Differentials

Myocarditis, Gastritis or reflex, Anxiety, Hiatal hernia, Valvular disease

17

ANGINA: Investigations and Diagnosis

ECG will usually be normal but might show ST depression

18

ANGINA: Management

Modify RFx (first line)
- Statin if TotalCholesterol >4mmol/L
- Aspirin (75mg-100mg)
- Beta-blockers
- Nitrates for symptomatic relief
- Calcium channel blockers: amlodipine

Consider Percutaneous transluminal coronary angioplasty (PCTA) if angina is severe

19

ESSENTIAL HYPERTENSION: Description

Hypertension is generally regarded to be high blood pressure to the point that requires treatment but this thresholds different for different groups.
ALL over 160/100 mmHg
>140/90mmHG if other RFx
(also trust specific)

20

ESSENTIAL HYPERTENSION: Epidemiology

Affects >50% of the over 60s. Doubles risk of MI and triples risk of CVA

21

ESSENTIAL HYPERTENSION: Aetiology/Risk Factors

All Cardiac RFx, hypertension usually results from the stiffening of arteries and atherosclerotic change

22

ESSENTIAL HYPERTENSION: Presentation (Signs & Sx)

Sx are rare and any Sx mean treatment is necessary.
- Retinal haemorrhages, papilloedema, headaches or visual disturbances (malignant)

23

ESSENTIAL HYPERTENSION: Investigations and diagnosis

ABPM over 24hr is good practise to avoid white coat but high BP on two separate occasions is diagnostic

24

ESSENTIAL HYPERTENSION: Treatment

Initially lifestyle advice
Offer people <55y an ACEi OR low cost ARB if not tolerated (combine with CCB for second line)
Offer people >55y a or people of afro-caribbean descent a CCB

25

DVT: Description

Clot formation in one of the deep veins, usually in the leg causing occlusion and swelling

26

DVT: Epidemiology

25-50% of post-surgical patients. ALL hospital patients should be assessed for risk.

27

DVT: Aetiology & RFx

Caused by poor venous return, occurs when blood pools behind valves in the leg.
Rex: immobility, OCP, long-haul flight, hypercoagulability

28

DVT: Presentation (Signs & Sx)

Around Clot Site: Warmth, Redness, Tenderness, Swelling, Mild Fever, Pitting Oedema

29

DVT: Differentials

Cellulitis, Ruptured Baker's Cyst (**Can co-exist)

30

DVT: Ix & Dx

- D-dimer is sensitive but not specific (raised in infection and pregnancy)
- Check by US

31

DVT: Management

All people who are at risk should be on LMWH, Also consider stopping OCP pre-op, consider compression stockings and starting warfarin in those who have a confirmed DVT

32

CONGESTIVE HEART FAILURE: Description

Heart Failure = The cardiac output is not sufficient. Congestive heart failure describes L and R-sided. Normally L-sided precedes R-sided but this depends on the cause.

33

CONGESTIVE HEART FAILURE: Epidemiology

Affects 1-3% of the general population and around 10% of elderly patients

34

CONGESTIVE HEART FAILURE: AETIOLOGY & RFx

- Ischaemic Heart Disease and post MI
- Hypertensive heart failure
- Cardiomyopathies (presentation in the young)
- Valve diseases
- Lung diseases (Cor pulmonale: these are the causes that usually cause R-sided to precede)

35

CONGESTIVE HEART FAILURE: PRESENTATION SIGNS & Sx

LEFT
- Dyspnoea
- Fatigue
- Oedema
- Orthopnoea
- Paroxysmal Nocturnal Dyspnoea
- Wheeze
- Nocturia
- Weight loss and muscle wasting
CONGESTIVE
- Peripheral oedema (good sign on R-sided)
- Ascites
- Nausea
**A lot of fluid build up suggest R-sided

36

CONGESTIVE HEART FAILURE: Dx

FRAMINGHAM CRITERIA: 2 major 1 major and 2 minor
MAJOR: PND, Lung crackles, S3 Gallop, Cardiomegaly, Weight loss, Neck vein distension, Pulmonary oedema, positive hepatojugular reflex
MINOR: Bilateral ankle oedema, dyspnoea, tachycardia, decrease in VC, nocturnal cough, pleural effusions

37

CONGESTIVE HEART FAILURE: Ix

CXR: ABCDE Criteria
A - Alveolar oedema = Bat's wings around hilar
B - Kerley B lines
C - Cardiomegaly
D - Dilated prominent upper lobe vessels
E - Effusions

BLOODS: FBC and U&Es and BNP (B-natiuretuc peptide) determine cardiac cause of dyspnoea
ECHO: Gold-standard

38

CONGESTIVE HEART FAILURE: Management

Diuretics to clear fluid: Loop-diuretics only, furosemide and bumetanide
Beta-Blockers: atenolol an d propanolol
ACE-is to control BP

39

INFECTIVE ENDOCARDITIS: Description

Infection on the inner lining of the heart (usually the heart valves).

40

INFECTIVE ENDOCARDITIS: Epidemiology

Mortality from the disease is between 5-50% dependent on age and other embolic fx

41

INFECTIVE EPIDEMIOLOGY: Aetiology & RFx

Many causes such as poor dentition IV injections, dermatitis and organ transplantation.
RFx include DM and other valvular co-morbidities
MOST COMMON ORGANISM is Streptococcus Viridans or Staphylococcus Aureus or less commonly enterococci

42

INFECTIVE ENDOCARDITIS: Presentation (Signs & Sx)

SX - palpitations, night sweats, fever, nausea, malaise, weight loss,
Signs - anaemia, CLUBBING, new murmur, olser's nodes, janeway lesions, splinter haemorrhages, vasculitis, roth spots, decreased renal function

43

INFECTIVE ENDOCARDITIS: Ix

Gold standard is US to visualise valve vegetations but any new murmur with fever should be suspected IE until proven otherwise. DO blood cultures and CXR (might see cardiomegaly).
BLOODS: Elevated ESR/CRP

44

INFECTIVE ENDOCARDITIS: Dx

DUKE'S CRITERIA (2 Major OR 1 major and 3 minor OR all 5 minor)
MAJOR - +ve 3 sets of blood cultures >12h apart
Typical organism found
Positive echo
New valvular regurg
MINOR - predisposition, Fever >38, vascular/immunological signs, positive cultures that do not meet major criteria

45

INFECTIVE ENDOCARDITIS: Treatment

EMPIRICAL: Amoxicillin or Ceftriaxone +/- Gentamicin (vancomycin if allergic)
TARGETED: Staphs (fluclox) Streps (benzylpenicillin and gentamicin)

46

MITRAL STENOSIS: Causes and Presentation

V RARE MURMUR. Causes include rheumatic fever, congenital causes and prosthetic valves.
WILL HEAR DIASTOLIC MURMUR (listen with bell)
Key signs include Malar flush, dyspnoea and fatigue

47

MITRAL STENOSIS: Ix and Management

ECG and Echo (look for LA enlargement)
May also see pulmonary oedema due to back-log of pressure
MURMUR will be accentuated by leaning over onto left and at end expiration.
MAN. Warfarin, Diuretics for pulmonary oedema, valve placement

48

MITRAL REGURGITATION: Causes and Presentation

More common mitral murmur (MOST COMMON VALVE ABNORMALITY)
CAUSES: LV dilation, calcification, rheumatic fever, Infective endocarditis, papillary muscle or chordae tendinae dysfunction
PRESENTATION: Dyspnoea, fatigue, palpitations, AF, RV heave, PAN-SYSTOLIC MURMUR

49

MITRAL REGURGITATION: Ix and Management

Pan systolic murmur over 5th IC space mid-clav line that is accentuated at end expiration with patient lead on their left - listen with diaphragm.
ECHO confirms, CXR might show big LA and LV, pulmonary oedema
MANAGE: Beta-blockers for AF and rate control, Diuretics to clear oedema and valve replacement

50

AORTIC STENOSIS: Causes and Presentation

Usually in elderly: Calcification, congenital (Bicuspid aortic valve or William's syndrome), Rheumatic disease
S & Sx: Chest pain and exertion dyspnoea and syncope, evidence of heart failure, dizziness. Slow rising pulse with narrow pulse pressure, heaves, LVH, aortic thrill, normal S1
- ACCENTUATED by sitting forwards: radiates to carotid

51

AORTIC STENOSIS: Ix and Management

Ix: ECG will show LVH and poor p-wave progression. Possible heart block
CXR shows LVH and maybe valve if calcified extensively
ECHO: gold standard
MAN: if symptomatic then prognosis is poor

52

POSTURAL HYPOTENSION

Drop in BP of moor than >20/10mmHg.
Common causes are hypovolaemia, overuse of: nitrates, diuretics, anti-hypertensives. Addison's or hypopituitarism
TREATMENT: Lying back down, standing slowly, increasing volume: stopping medications, increasing salt and fluid intake