CV P2

Question 1

Acute coronary syndrome

Answer 1

STEMI, NSTEMI, unstable angina

patho - thrombus

Question 2

STEMI

Answer 2

complete occlusion of major coronary artery, full thickness damage to heart muscle, troponin release

Question 3

NSTEMI

Answer 3

complete occlusion of minor artery or partial occlusion of major artery, partial thickness damage, troponin release

Question 4

Unstable angina

Answer 4

angina of increasing frequency/severity, partial occlusion but no damage to heart, occurs on minimal exertion/at rest, no troponin

Question 5

ACS RFs

Answer 5

ABCDEF

age, BP, cholesterol, diabetes, exercise, fags, fat, family

Question 6

ACS Px

Answer 6

Silent MI - no chest pain - elderly, diabetic

signs
distress, anxiety
pallor
pulse low/high
BP high/low
4th heart sound
signs of HF - raised JVP, 3rd heart sound, basal crepitations
pansystolic murmur maybe

symptoms
central chest pain
N+V, fatigue
sweaty
SOB
palpitations

Question 7

ACS DDx

Answer 7

CV - acute pericarditis, myocarditis, aortic stenosis, aortic dissection, PE, cardiomyopathy

Resp - pneumonia, pneumothorax

GI - oesophageal spasm, GORD, acute gastritis, cholecystitis, acute pancreatitis

MSK - chest pain, broken ribs,

Question 8

ACS Ix

Answer 8

ECG
STEMI - ST elevation, pathological Q waves, tall T waves, new LBBB
NSTEMI - ST depression, T wave inversion, maybe normal ECG
Unstable angina - normal ECG usually

Troponin - I/T - raised in MI

CXR
ECHO
Bloods - FBC, U+E, glucose, lipids,

Question 9

ACS Mx

Answer 9

MONA
Morphine
Oxygen
Nitrates - GTN spray
Aspirin
\+ P2Y12 inhibitor - clopidogrel, ticagrelor

BBs - atenolol
ACEi - ramipril
Statin - atorvastatin

Thrombolysis if indicated
PCI/CABG if indicated

Modify risk factors - stop smoking, lose weight, healthy diet, control diabetes

Question 10

AAA

Answer 10

aneurysm - permanent dilatation of artery >50% normal

True - dilatation involves all layers of arterial wall

False - pseudoaneurysm, blood leaks through wall but contained by adventitia or perivascular tissue

degradation of elastic lamellae - leukocyte infiltrate - proteolysis and smooth muscle cell loss

Question 11

AAA RFs

Answer 11

atherosclerotic damage, FHx, smoking, male, older, HTN, COPD, trauma, hyperlipidaemia

Question 12

AAA Px

Answer 12

unruptured
asymptomatic
pain in abdo, back, loin, groin
pulsatile abdo swelling

ruptured
abdo pain
more pronounced pulsatile abdo swelling
collapse, shock, hypotension, tachycardia
anaemia, death

Question 13

AAA DDx

Answer 13

GI bleed, ischaemic bowel, MSK pain, perforated GI ulcer, pyelonephritis, appendicitis

Question 14

AAA Ix

Answer 14

Abdo USS

CT/MRI angiography

Question 15

AAA Mx

Answer 15

Monitor small aneurysms
Modify RFs - BP, statins, smoking, diet

Surgery - open/endovascular

Ruptured - ABCDE, surgery, permissive hypotension

Question 16

AAA Cx

Answer 16

tear in posterolateral aneurysm wall - retroperitoneal bleed - blood fills space, seals bleed for a while

Anterior wall bleed - severe, rapid

Question 17

Thoracic aortic aneurysm

Answer 17

in aorta in thorax

Question 18

TAA patho

Answer 18

strong genetic link
connective tissue disorders - Marfan’s, Ehlers-Danlos syndrome
Aortic dissection in some cases

Question 19

TAA Px

Answer 19

asymptomatic

signs
aortic regurgitation
fever if infective cause
collapse, shock, sudden death
cardiac tamponade

symptoms
due to compression of local structures - hoarseness, cough SOB
haemoptysis

Question 20

TAA Ix

Answer 20

CT/MRI
USS
ECHO
Aortography - xray + contrast

Question 21

TAA Mx

Answer 21

Regular monitoring
Modify RFs - BP, cholesterol

Surgery

Question 22

Aortic dissection

Answer 22

disruption of medial layer of wall, results in separation of aortic wall layers, false lumen formation

tear in intimal lining of aorta, blood enters aortic wall, separates intima from adventitia

causes - degenerative, atherosclerotic, inflammatory, trauma

Question 23

Aortic dissection Px

Answer 23

Mimics MI
Distal extension - maybe AKI, acute lower limb ischaemia, visceral ischaemia
Peripheral pulses maybe absent

signs
HTN
maybe radio-radial delay (both radial pulses not in sync)
Shock
aortic regurgitation, coronary ischaemia, cardiac tamponade

symptoms
severe, central chest pain, tearing, may radiate to back, down arms

Question 24

Aortic dissection Ix

Answer 24

CXR - widened mediastinum

CT, ECHO, MRI

ECG

Question 25

Aortic dissection Mx

Answer 25

Control BP - metoprolol (BB), GTN (vasodilator) Morphine Surgery, replace, or insert stent

Question 26

AF

Answer 26

supraventricular tachycardia chaotic, irregular atrial rhythm AVN respond intermittently -> irregular ventricular rate No coordinated mechanical contraction of atria risk of stroke from thromboembolism also reduction in CO -> HF Causes idiopathic, HTN, HF, cardiac surgery, damage to atria...

Question 27

AF Px

Answer 27

signs irregularly irregular pulse 1st heard sound variable intensity LVF signs ``` symptoms asymptomatic chest pain palpitaitons SOB, fatigue, syncope, TIA ```

Question 28

AF DDx

Answer 28

AFl, atrial extrasystoles, SVTs, VT, WPW syndrome

Question 29

AF Ix

Answer 29

ECG absent P waves, rapid irregular QRS, absence of isoelectric baseline, variable ventricular rate 24hr ambulatory ECG for paroxysmal Bloods - TFTs, FBC, renal function, electrolytes, LFTS, coag screen, cardiac enzymes CXR - may show cardiac structural causes, eg mitral disease, HF ECHO CT/MRI brain if suggestion of stroke

Question 30

AF Mx

Answer 30

Treat cause if due to precipitating event Cardioconversion - DC shock, give LMWH (enoxaparin) as risk of thromboembolism with procedure Anti-arrhythmic drug - amiodarone, flecainide Verapamil, bisoprolol, digoxin - rhythm control Anticoagulation - warfarin, aspirin, DOAC CHA2DS2-VASc score to calculate stroke risk

Question 31

Afl

Answer 31

organised abnormal atrial rhythm caused by re-entry circuit in RA Causes idiopathic, CHD, HTN, HF, COPD, pericarditis, alcohol intoxication, structural abnormalities...

Question 32

Afl Px

Answer 32

``` palpitations SOB Chest pain dizziness, syncope fatigue, HF, rapid pulse ```

Question 33

Afl Ix

Answer 33

ECG 'sawtooth' appearance narrow complex tachycardia regular QRS ECHO CXR, TFTs, FBC, ESR, renal, LFTs...

Question 34

Afl Mx

Answer 34

Electrical cardioconversion Catheter ablation - try to block re-entrant wave Amiodarone, bisoprolol Anticoagulants

Question 35

Heart block

Answer 35

AV block - block in AVN or bundles of His Bundle branch block - block in lower conduction system

Question 36

First-degree AV block

Answer 36

PR prolongation >0.22s every atrial dep followed by conduction to ventricles but with delay Causes - hypokalaemia, myocarditis, inferior MI, AVN blocking drugs (BBs, CCBs, digoxin) Asymptomatic, no tx

Question 37

Second-degree AV block

Answer 37

Mobitz T1 progressive lengthening of PR interval, then beat dropped and QRS missing Causes - AVN blocking drugs, inferior MI Light-headedness, dizziness, syncope May need pacing Mobitz T2 PR interval constant, but occasional atrial dep without ventricular dep (eg 2:1) Causes - anterior MI, mitral valve surgery, SLE, lyme disease, rheumatic fever SOB , postural hypotension, chest pain Pacemaker insertion

Question 38

Third-degree heart block

Answer 38

complete absence of AV conduction, P waves independent to QRS, AV dissociation Causes - structural, MI, HTN, endocarditis, lyme Tx depends on cause - pacemaker, atropine

Question 39

RBBB

Answer 39

no dep down right branch, action of RV delayed, as dep has to spread across septum from LV Causes - PE, IHD, septal defect Wide physiological splitting of second heart sound ECG - QRS >120ms, MARROW - first letter M, so lead 1 has complex resembling an M (R wave) and last letter is W, so lead 6 has complex resembling W (slurred S wave)

Question 40

LBBB

Answer 40

Impulse has to spread from RV to LV Causes - IHD, aortic valve disease Reverse splitting of second heart sound ECG - QRS >120ms, WILLIAM - first letter W, so lead 1 has complex resembling W (slurred S wave), 6th letter is M, lead 6 has complex resembling M (R wave)

Question 41

Sinus tachycardia

Answer 41

>100bpm originates from SAN - normal P then QRS on ECG Causes - anaemia, anxiety, exercise, pain, HT, PE Tx cause, BB if necessary

Question 42

AV nodal re-entrant tachycardia (AVNRT)

Answer 42

Two pathways in AV node - slow/fast - one acts as antegrade limb, the other retrograde Px - rapid, regular palpitations, abrupt onset, chest pain, SOB Neck pulsations - jugular venous pulsations due to atrial contractions against closed AV valves polyuria - release of ANP in response to increased atrial pressures ECG dx - sometimes BBB seen, P waves not seen or are immediately before/after QRS due to simultaneous atrial and ventricular activation

Question 43

AV re-entrant tachycardia (AVRT)

Answer 43

accessory pathway connecting atria and ventricles, impulses can travel down/up this pathway WPW accessory pathway - bundle of Kent, no slowing of conduction between atria and ventricles (as AVN does) -> pre-excitation ECG - short PR, wide QRS, begins with delta wave Tachyarrhythmia only with premature beat from SAN, then signal travels as normal, then up accessory pathway - re-entry circuit -> tachyarrhythmia Px - palpitations, dizziness, SOB, syncope

Question 44

AVRT and AVNRT Tx

Answer 44

Emergency cardioconversion if haemodynamically unstable Stable - breath holding, carotid massage, valsalva IV adenosine Surgery - catheter ablation of accessory pathway

Question 45

Ventricular tachycardias

Answer 45

VF - very funny VT - very tidy

Question 46

Ventricular ectopic

Answer 46

premature ventricular contraction patient complains of extra beats, missed beats, heavy beats, may feel uncomfortable, faint/dizzy, pulse irregular ECG - QRS widened Reassure, BB if symptomatic

Question 47

Prolonged QT syndrome

Answer 47

QT prolonged Causes - congenital, hypokalaemia, hypocalcaemia, drugs (amiodarone, TCAs), bradycardia, acute MI, diabetes Px - syncope, palpitations ECG Tx cause, if acquired - IV isoprenaline

Question 48

Cardiomyopathy

Answer 48

disease of the myocardium, affects mechanical/electrical function of heart, all carry arrhythmic risk generally inherited genetic conditions, some acquired types RFs - FHx, HTN, obesity, diabetes, previous MI

Question 49

Hypertrophic cardiomyopathy

Answer 49

ventricular hypertrophy - thickening of muscle non-compliant ventricles impair diastolic filling - reduced SV and CO thick, powerful heart -> disarray of cardiac myocytes - conduction affected ``` Px signs - cardiac arrhythmia - ejection systolic murmur - jerky carotid pulse symptoms - chest pain/angina - SOB - dizziness, palpitation, syncope ``` DDx other causes of LVH - obesity, athletic training, amyloidosis ``` Ix ECG - LVH with progressive T wave inversion, deep Q waves ECHO CXR Genetic analysis ``` Mx Amiodarone - anti-arrhythmic CCB - verapamil BB - atenolol

Question 50

Dilated cardiomyopathy

Answer 50

dilated LV which contracts poorly Caused by - ischaemia, alcohol, thyroid disorder, genetic, cytoskeletal gene mutations ``` Px signs - arrhythmias - increased JVP - HF signs - since heart can't contract symptoms - SOB, fatigue ``` Ix CXR ECG - tachycardia, arrhythmia, non-specific T wave changes ECHO - dilated ventricles Mx Tx HF and AF Diuretics, ACEi, digoxin, BBs, nitrates

Question 51

Restrictive cardiomyopathy

Answer 51

increased myocardial stiffness - ventricle incompliant - impaired filling/dilatation - is restrictive Causes - amyloidosis, idiopathic, sarcoidosis, endomyocardial fibrosis ``` Px similar to constrictive pericarditis signs - elevated JVP - hepatic enlargement, ascites, oedema - S3, S4 symptoms - SOB, fatigue - embolic symptoms ``` Ix CXR, ECHO, ECG Cardiac catheterisation to diagnose ``` Mx Poor prognosis Cardiac transplantation HF - diuretics, ACEi BBs, CCBs for arrhythmias ```

Question 52

Arrhythmogenic right ventricular cardiomyopathy

Answer 52

progressive fatty and fibrous replacement of ventricular myocardium cause unknown, is genetic Px arrhythmia, RHF, syncope Ix ECG - maybe normal, T wave inversion ECHO Genetic testing Mx BBs - atenolol Amiodarone for symptomatic arrhythmias Cardiac transplant

Question 53

Heart failure

Answer 53

CO is inadequate for body requirements

Question 54

Cor pulmonale

Answer 54

abnormal enlargement of right heart from disease of lungs/pulmonary blood vessels - eg COPD

Question 55

HF patho

Answer 55

Systolic inability of ventricle to contract normally, reduced CO (EF <40%) - IHD, MI, cardiomyopathy Diastolic inability of ventricle to relax and fill normally, SV decreased - hypertrophy, constrictive pericarditis, tamponade, restrictive cardiomyopathy, obesity, aortic stenosis (causes LVH) Left / right sided / CCF Low-output cardiac failure CO reduced and failure to increase with exertion - excessive preload (fluid overload, mitral regurgitation), pump failure, excessive afterload (HTN, aortic stenosis) High-output CO normal but fails to rise to meet demands - anaemia, pregnancy, hyperthyroidism, Paget's Causes IHD, HTN, MI, alcohol excess, cardiomyopathy, valvular ``` Mechanisms of HF increased preload increased afterload salt and water retention myocardial remodelling ```

Question 56

HF Px

Answer 56

SOB, fatigue, ankle swelling ``` signs tachycardia displaced apex beat (LV dilatation) RV heave (pul HTN) added heart sounds - gallop (S3), murmurs, raised JVP hepatomegaly ascites peripheral oedema PO cyanosis pleural effusions ``` ``` symptoms SOB, fatigue cold peripheries PND - paroxysmal nocturnal dyspnoea nocturnal cough (maybe pink frothy sputum) orthopnoea (SOB when lying down) wheeze light-headed/syncope ``` NYHA classification for severity I-IV

Question 57

HF Ix

Answer 57

Bloods - brain natriuretic peptide - secreted in ventricles in response to increased myocardial wall stress - if normal, HF unlikely, and other blood tests ECG - underlying causes - ischaemia, LVH, arrhythmia ECHO ``` CXR - ABCDE Alveolar oedema (bat's wing shadowing) Kerley B lines - septal lines Cardiomegaly - cardiothoracic ratio >50% Dilated prominent upper lobe veins (upper lobe diversion) Pleural Effusions ```

Question 58

HF Mx

Answer 58

lose weight, exercise, stop smoking Diuretics - furosemide, thiazide, spironolactone ACEi - ramipril, enalapril (S/E cough, hypotension, hyperkalaemia, renal dysfunction) ARB BB - bisoprolol Surgery to repair cause, heart transplant

Question 59

HF Cx

Answer 59

renal dysfunction rhythm disturbances DVT, PE...

Question 60

HTN

Answer 60

High BP Stage 1 - 140/90 Stage 2 - 160/100 Stage 3 - 180/110

Question 61

HTN patho

Answer 61

Primary - unknown cause, 95% of cases Secondary - inc renal disease, endocrine causes, aorta coarctation, drugs

Question 62

HTN Px

Answer 62

Asym Retinal haemorrhage, papilloedema, headaches - malignant htn

Question 63

HTN Ix

Answer 63

24hr ABPM Urinalysis, bloods, fundoscopy, ECG, echo

Question 64

HTN Mx

Answer 64

Lifestyle ACEi (under 55yo)/CCB (55+, afro-caribbean) Then the other one Then thiazide Then another diuretic (spironolactone), alpha/beta blockers

Question 65

IE

Answer 65

infection of endocardium fever + new murmur = IE until proven otherwise

Question 66

IE patho

Answer 66

Valves most commonly affected - mitral most commonly affected, tricuspid in IVDU Valves do not have direct blood supply Causes S.aureus, S.viridans, candida... RFs valvular heart disease, valve replacement, congenital heart disease, IVDU, skin breaches

Question 67

IE Px

Answer 67

Fever, rigors, night sweats, malaise, wt loss, anaemia, splenomegaly, clubbing, myalgia, anorexia New murmur or change to murmur Aortic root abscess - long PR, maybe complete AV block ``` Immune complex deposition vasculitis microscopic haematuria glomerulonephritis/AKI splinter haemorrhages Osler's nodes, Janeway lesions, Roth spots ``` Abscesses in organs from emboli

Question 68

IE Ix

Answer 68

Modified Dukes Criteria to dx Blood cultures - 3 sets, different times, different sites Bloods - anaemia, neutrophilia, ESR/CRP raised Urinalysis - for microscopic haematuria CXR ECG ECHO CT - look for emboli

Question 69

IE Mx

Answer 69

ABs Surgery if HF, valvular obstruction...

Question 70

IE Cx

Answer 70

MI, pericarditis, arrhythmias, heart valve insufficiency, CCF, stroke sydromes

Question 71

MI

Answer 71

necrosis of myocardial tissue due to ischaemia NSTEMI/STEMI from thrombus/atherosclerosis

Question 72

MI Px

Answer 72

silent MI - elderly, diabetics ``` signs pale, clammy, sweaty distress, anxiety BP high/low 4th HS Signs of HF - raised JVP, 3rd HS, basal crepitations pansystolic murmur pericardial rub/PO ``` ``` symptoms central chest main, crushing radiation to jaw, neck, left arm N+V SOB palpitations ```

Question 73

MI Ix

Answer 73

ECG STEMI - ST elevation, tall T waves, LBBB, later T wave inversion and pathological Q waves NSTEMI - ST depression, T wave inversion, maybe no change Cardiac enzymes - troponin, myocardial muscle creatine kinase (CK-MB) CXR, ECHO, cardiac catheterisation and angiography

Question 74

MI Mx

Answer 74

``` Pre-hospital Aspirin 300mg GTN Morphine, O2 Thrombolytic drugs if indicated - reteplase/tenecteplase ``` ``` Hospital Morphine, O2 PCI - balloon angioplasty, stent CABG Thrombolytic drugs - streptokinase, alteplase, if indicated ``` secondary prevention statins aspirin BBs, ACEi, clopidogrel Stop smoking, lose weight, exercise, healthy diet

Question 75

Acute pericarditis

Answer 75

inflammation of the pericardium

Question 76

Acute pericarditis causes

Answer 76

Viral Bacterial Autoimmune Neoplastic - secondary metastatic tumours - lung, breast, lymphoma Trauma, iatrogenic Others - amyloidosis, aortic dissection, pulmonary arterial HTN

Question 77

Acute pericarditis Px

Answer 77

signs pericardial friction rub (crunching snow) tachycardia tachypnoea fever lymphocytosis signs of effusion - pulsus paradoxus, Kussmaul's sign ``` symptoms chest pain - sharp, pleuritic, radiates to arm, worse on inspiration or lying flat SOB Cough, non-productive Hiccups - phrenic involvement viral symptoms ```

Question 78

Acute pericarditis Ix

Answer 78

ECG diffuse ST elevation (all leads) Saddle-shaped ST elevation PR depression Bloods - FBC, ECR, CRP, troponin CXR

Question 79

Acute pericarditis Mx

Answer 79

Tx cause NSAIDs - ibuprofen, also aspirin Colchicine for 3 months Maybe prednisolone Pericardiectomy

Question 80

Pericarditis Cx

Answer 80

Pericardial effusion, tamponade, constrictive pericarditis, chronic pericardial effusion (slow fluid accumulation, rarely causes tamponade)

Question 81

Constrictive pericarditis

Answer 81

rigid pericardium

Question 82

Con. pericarditis patho

Answer 82

Causes - idiopathic, viral, TB, mediastinal irritation, post-surgical restricts ventricular filling

Question 83

Con pericarditis Px

Answer 83

``` signs Kussmaul's sign - rise in JVP, increased neck vein distension during inspiration pulsus paradoxus - systolic BP drops >10mmHg during inspiration diffuse heart sounds, eg apex beat HSM ascites oedema RHF signs atrial dilatation ``` ``` symptoms fatigue hiccups anxiety/confusion hoarseness/cough ```

Question 84

Con pericarditis DDx

Answer 84

Restrictive cardiomyopathy, dilated cardiomyopathy, pericardial effusion

Question 85

Con pericarditis Ix

Answer 85

``` CXR ECG - low voltage QRS ECHO CT/MRI - to distinguish from restrictive cardiomyopathy Cardiac catheterisation ```

Question 86

Con pericarditis Mx

Answer 86

Resection of pericardium

Question 87

Pericardial effusion

Answer 87

accumulation of fluid in the pericardial sac (there is normally 50ml)

Question 88

Cardiac tamponade

Answer 88

pericardial effusion raises intrapericardial pressure, reducing ventricular filling, dropping CO

Question 89

Pericardial effusion causes

Answer 89

``` idiopathic acute pericarditis malignancy TB myocardial rupture aortic dissection (great vessels in pericardium) ```

Question 90

Pericardial effusion Px

Answer 90

``` signs soft, distant heart sounds apex beat obscured raised JVP bronchial breathing at left base ``` symptoms SOB chest pain nausea

Question 91

Tamponade Px

Answer 91

``` high pulse, low BP high JVP Kussmaul's sign Pulsus paradoxus reduced CO ```

Question 92

Pericardial effusion Ix

Answer 92

CXR - large globular heart ECG - low voltage QRS, sinus tachycardia ECHO

Question 93

Tamponade Dx

Answer 93

CXR - large globular heart Beck's triad - falling BP, rising JVP, muffled heart sounds ECG - low voltage QRS ECHO

Question 94

Pericardial effusion Mx

Answer 94

most resolve spontaneously treat cause pericardial fenestration - create window to allow slow fluid release

Question 95

tamponade Mx

Answer 95

pericardiocentesis - drain fluid, risk of cardiac arrest

Question 96

Peripheral arterial disease

Answer 96

narrowing of artery, from atherosclerosis/thrombus, leads to insufficient perfusion of limb and lower limb ischaemia

Question 97

PAD patho

Answer 97

``` 3 main patterns of Px: intermittent claudication cramping/burning/aching pain in calf, thigh, buttock after walking certain distance, relieved by rest pain in calf - femoral disease pain in buttock - iliac disease ``` critical limb ischaemia rest pain, typically nocturnal acute limb-threatening ischaemia sudden decrease in arterial perfusion, limb threatened RFs smoking, diabetes, high cholesterol, HTN, physical inactivity, obesity

Question 98

PAD Px

Answer 98

``` signs absent pulses cold, white legs atrophic skin punched out ulcers Buerger's angle (angle that leg goes pale when raised off couch) <20 degrees CRT >15s ``` symptoms claudication ischaemic rest pain - relieved by hanging foot out of bed

Question 99

PAD DDx

Answer 99

Lower limb pain - sciatica, spinal stenosis, DVT, entrapment syndromes, muscle/tendon injury OA, neuropathy

Question 100

PAD Ix

Answer 100

Buerger's angle <20 degrees, CRT >15s ESR/CRP - exclude arteritis FBC - exclude anaemia/polycythaemia ECG - look for cardiac ischaemia ABPI - the smaller the ratio of BP in ankle/arm, more severe USS, MRI/CT angiography

Question 101

PAD Mx

Answer 101

Quit smoking, exercise, healthy diet Tx HTN, statins, clopidogrel, vasoactive drugs (naftidrofuryl oxalate) Percutaneous transmural angioplasty, surgical reconstruction, amputation

Question 102

PAD Cx

Answer 102

Qol reduced, infection, poor tissue healing, ulceration, gangrene, amputation

Question 103

Acute limb ischaemia

Answer 103

sudden decrease in arterial perfusion - thrombotic/embolic causes

Question 104

Acute limb ischaemia Px

Answer 104

``` pale pulseless pain paralysed paraesthesia perishingly cold ```

Question 105

Acute limb ischaemia Mx

Answer 105

Surgery/angioplasty Heparin post-op

Question 106

Shock

Answer 106

circulatory failure leads to inadequate organ perfusion can result from inadequate CO, loss of SVR, or both

Question 107

Shock patho

Answer 107

Hypovolaemic - haemorrhagic, burns, DKA, D+V Cardiogenic - heart not pumping properly - MI, heart block, secondary causes of pump failure (PE, tension pneumothorax, tamponade) Distributive - septic shock, anaphylactic, neurogenic (spinal cord transection, interrupts ANS, decreases SNS/increases PNS, decreased PVR) Anaemic shock and cytotoxic shock also Can classify haemorrhagic shock I-IV

Question 108

Shock Px

Answer 108

``` reduced GCS, agitation, confusion pale skin, cold, sweaty, vasoconstricted cool peripheries - cyanosis tachycardia tachypnoea oliguria CRT increased weak rapid pulse pulse pressure reduced (MAP may be maintained) ``` Neurogenic instant hypotension, warm flushed skin, priapism, bradycardia

Question 109

Shock Ix

Answer 109

``` ABCDE General review of signs of shock Tachycardic and hypotensive If JVP raised, cardiogenic shock likely look for trauma ```

Question 110

Shock Mx

Answer 110

Haemorrhagic Stop bleed Permissive hypotension Blood, FFP, crystalloid/fluid boluses Neurogenic Fluids peripheral vasoconstrictors to return tone to normal

Question 111

Cardiogenic shock

Answer 111

inadequate tissue perfusion due to cardiac dysfunction

Question 112

Cardiogenic shock Px

Answer 112

Signs of heart failure - raised JVP, gallop rhythm, basal crackles, PO Signs of shock Symptoms of condition, eg MI

Question 113

Cardiogenic shock Ix

Answer 113

ECG changes ECHO MI troponin levels basically look for cause

Question 114

Cardiogenic shock Mx

Answer 114

ABCDE Supportive Tx cause Surgery, eg if trauma is cause

Question 115

Sepsis

Answer 115

infection and systemic inflammatory response (cytokine release) - dysregulated host response to infection endothelial cell damage, vasodilation, increased capillary permeability, organ failure septic shock - sepsis with lactate >2mmol/L or need vasopressors to maintain MAP >65

Question 116

Sepsis RFs

Answer 116

``` age - old/very young instrumentation/surgery indwelling line, catheter alcohol abuse DM breach of skin immunocompromised high dose steroids, chemo IVDU pregnancy ```

Question 117

Sepsis Px

Answer 117

earlier presentation of infection, rapid deterioration pyrexia, rigors, vasodilation, warm peripheries, bounding pulse, N+V ``` Sepsis screening systolic BP<90 HR >130 sats <91% RR >25 reduced GCS Lactate >2mmol/L ```

Question 118

Sepsis Ix

Answer 118

Assess risk - high/moderate-to-high/low H+E ABG for lactate, observations - HR, BP, RR, sats, temp, ECG, urine dip, urine output Blood cultures, micro samples of sputum/urine, swab wounds CXR/CT/MRI of suspected source

Question 119

Sepsis Mx

Answer 119

``` Sepsis six resus bundle High flow O2 take blood cultures, consider infective source IV ABs IV fluid check Hb, serial lactates hourly urine output measurement ``` surgical involvement, eg wound debridement Manage acute Cx - shock, AKI, DIC, ARDS, arrhythmias

Question 120

Anaphylactic shock

Answer 120

acute life-threatening T1 IgE-mediated hypersensitivity reaction rapid histamine release from mast cells, basophils - cap leakage, mucosal oedema, shock, asphyxia Causes drugs, latex, food, venom

Question 121

Anaphylactic shock Px

Answer 121

Itching, sweating, D+V, erythema (red skin), urticaria (hives), oedema (larynx, tongue, lips) Wheeze, laryngeal obstruction, cyanosis Tachycardia, hypotension

Question 122

Anaphylactic shock Ix

Answer 122

straight to Mx if suspected Serum mast-cell tryptase to confirm - shows mast cell degranulation

Question 123

Anaphylactic shock Mx

Answer 123

ABCDE high flow O2 IM adrenaline - acts on beta receptors to dilate bronchi (0.5mg) IV fluid Chlorphenamine - H1 antihistamine Hydrocortisone - suppresses prostaglandin and leukotriene mediators Continuing resp deterioration - bronchodilator - salbutamol/ipratropium

Question 124

Stable angina

Answer 124

chest pain from reversible myocardial ischaemia

Question 125

Angina patho

Answer 125

Stable - induced by effort, relieved by rest, 3 features: 1. constricting/heavy discomfort to chest, jaw, neck, shoulders, arms 2. symptoms brought on by exertion 3. symptoms relieved in 5 mins by rest or GTN 3 features = typical angina, 2 = atypical, 1 = non-anginal chest pain Unstable angina crescendo angina, angina of increasing frequency or severity, occurs on minimal exertion/rest Both cases - mismatch between blood supply and metabolic demand Causes - atherosclerosis, valvular disease, aortic stenosis, arrhythmias, anaemia

Question 126

Angina RFs

Answer 126

FHx, smoking, diabetes, metabolic syndrome, HTN, obesity, lack of exercise, cardiac abnormalities

Question 127

Stable angina Px

Answer 127

Provoked by exertion - after meal, cold, windy, exercise, angry/excited signs sweaty distressed ``` symptoms central chest tightness or heaviness pain may radiate SOB nausea, feeling faint ```

Question 128

Stable angina Ix

Answer 128

``` ECG - may be normal, ST depression, flat/inverted T waves Treadmill test/exercise ECG Bloods - FBC to exclude anaemia ECHO CXR Coronary angiography ```

Question 129

Stable angina Mx

Answer 129

Modify RFs - stop smoking, exercise, lose weight, atorvastatin Aspirin GTN - dilates systemic veins, reducing venous return to heart, reduces preload, also dilates coronary arteries BBs - atenolol, bisoprolol CCB - verapamil Long acting nitrates Ivabradine - HCN channel blocker, reduces HR Maybe surgery - PCI, CABG

Question 130

Structural heart defects

Answer 130

1% of all live births have some form of cardiac defect ``` Causes of congenital heart disease maternal prenatal rubella infection maternal alcohol misuse single genes - trisomy 21 drugs - thalidomide, amphetamines, lithium diabetes of mother genetic abnormalities ```

Question 131

Atrial septal defect

Answer 131

abnormal connection between atria, often first dx in adulthood Patho LAp > RAp shunt left-to-right, thus NOT blue, acyanotic increased flow into right heart and lungs RV compliant, easily dilates, but can result in: - RVH - Pulmonary HTN - Eisenmenger's - high pressure pulmonary flow, damages pulmonary vasculature, resistance to blood flow through lungs increases, RV pressure increases, shunt direction reverses, patient becomes blue, clubbing Large defect significant flow through right heart - dilatation, SOBOE, increased chest infections Small small increase in flow through right side, no dilatation, no symptoms Px atrial arrhythmias from RA dilatation, pulmonary flow murmur, fixed split second heart sound (delayed closure of pulmonary valve - more blood has to get out) SOBOE Ix CXR ECG ECHO Mx Surgical closure

Question 132

Bicuspid aortic valve

Answer 132

2 cusps instead of 3 commonly causes aortic stenosis, degenerates, becomes regurgitant

Question 133

Ventricular septal defects

Answer 133

abnormal connection between two ventricles Patho LVp > RVp L-R shunt, NOT blue, acyanotic, increased flow through lung Large defects large volumes of blood through heart vessels, pulmonary HTN, Eisenmenger's, then R-L shunt, cyanotic Small defects asymptomatic, IE risk, no intervention needed ``` Px LARGE defects small breathless skinny baby increased RR tachycardia cyanosis murmurs SMALL defects loud systolic murmur thrill (buzzing sensation) well grown, normal HR, normal heart size ``` Ix CXR Mx surgical closure

Question 134

Atrio-ventricular septal defects

Answer 134

hole in centre of heart Instead of two separate AV valves, just one big malformed one, associated with Down's ``` Px COMPLETE defect breathless neonate poor weight gain, feeding torrential pulmonary flow, can result in Eisenmenger, cyanosis PARTIAL defect can present in late adulthood SOB, tachycardia, exercise intolerance ``` Mx Surgical repair

Question 135

Patent ductus arteriosus

Answer 135

persistent communication between proximal left pulmonary artery and descending aorta foetal life - pulmonary vascular resistance high (bronchioles filled with fluid), vessels constricted (lack of O2), right heart pressure exceeds left, flow from RA to LA through foramen ovale, also from pulmonary artery to aorta through ductus arteriosus abnormal L-R shunt (aorta to pulmonary artery), lung circulation overloaded, Eisenmenger's, right sided cardiac failure (RVH in response to increased afterload) ``` Px continuous 'machinery' murmurs bounding pulse Eisenmenger's, clubbed cyanosis, blue toes, but pink and not clubbed fingers SOB ``` Ix CXR ECG - LA abnormality, LVH ECHO Mx Indometacin (prostaglandin inhibitor) - stimulate duct closure Surgical closure

Question 136

Coarctation of the aorta

Answer 136

narrowing of aorta just distal to insertion of ductus arteriosus (distal to origin of left subclavian artery) Patho narrowing just after arch excessive blood flow through carotid and subclavian vessels into systemic vascular shunts to supply rest of body stronger perfusion to upper body rather than lower decreased renal perfusion -> systemic HTN even after surgical correction body grows collateral vessels around narrowing Px Right arm HTN Bruits over scapulae and back from collateral vessels murmur HTN in upper limbs Radial pulse before femoral pulse - discrepant BP headaches and nose bleeds from HTN Ix CXR ECG - LVH CT Mx Balloon dilatation and stenting

Question 137

Tetralogy of fallot

Answer 137

most common form of cyanotic congenital heart disease, consists of: - VSD - pulmonary stenosis - RVH - overriding aorta patho stenosis of RV outflow leads to RVp>LVp blue blood passes from R-L, patients are BLUE, cyanotic ``` Px central cyanosis low birth weight and growth delayed puberty systolic ejection murmur SOBOE ``` Ix CXR - boot-shaped heart Mx Surgery

Question 138

Pulmonary stenosis

Answer 138

narrowing of outflow of RV can be valvar, subvalvar, supravalvar ``` Px RV failure as neonate collapse poor pulmonary blood flow RVH tricuspid regurgitation mild - well tolerated for years ``` Mx Surgery - balloon valvuloplasty - inflates balloon to crush stenosis shunt to bypass blockage

Question 139

Aortic stenosis

Answer 139

narrowing of aortic valve Patho Causes - calcification, bicuspid aortic valve calcified, rheumatic heart disease narrowing obstructs LV emptying, increases afterload, LVH, then relative ischaemia of LV (hypertrophy = higher blood demand) -> angina, arrhythmias, failure increased IE risk Px Classic triad - angina, syncope, heart failure EJECTION SYSTOLIC CRESCENDO-DECRESCENDO MURMUR Prominent S4 from LVH soft/absent S2 slow rising carotid pulse (pulsus tardus), decreased pulse amplitude (pulsus parvus) Ix ECHO ECG - LVH, CXR Mx Surgical aortic valve replacement - TAVI (transcutaneous aortic valve implantation)

Question 140

Mitral regurgitation

Answer 140

Backflow of blood from LV to LA during systole Patho Abnormalities of valve leaflets, chordae tendineae (mitral valve prolapse), papillary muscles Compensatory mechanisms - LA enlargement, LVH (LV puts in same effort to pump less blood, so needs to pump harder to maintain CO), then progressive HF Px PANSYSTOLIC MURMUR soft S1, left-sided murmur so heard loudest on inspiration prominent S3 in congestive HF SOBOE, fatigue, lethargy, palpitations, symptoms of RHF Ix ECG - LA enlargement (broad P wave), maybe AF, LVH CXR ECHO ``` Mx ACEi - act as vasodilator - SM relaxer HR control - BBs, CCB Diuretics for fluid overload Mitral valve replacement ```

Question 141

Aortic regurgitation

Answer 141

Leakage of blood into LV during diastole Causes - rheumatic fever, bicuspid aortic valve, IE LV dilatation, LVH to compensate Px EARLY DIASTOLIC MURMUR apex beat displaced laterally SOBOE, palpitations, angina, syncope Ix CXR ECHO ECG - LVH signs Mx Vasodilator - ACEi Valve replacement

Question 142

Mitral stenosis

Answer 142

obstruction of LV inflow from LA - prevents proper filling during diastole Patho LA dilatation - pulmonary congestion, AF, RHF symptoms from pulmonary venous HTN, haemoptysis from rupture of bronchial vessels from elevated pulmonary pressure Causes - rheumatic fever, IE, calcification ``` Px MID-DIASTOLIC MURMUR loud S1, opening snap malar flush on cheeks - due to low CO low pulse volume peripheral oedema ruddy complexion - mitral facies SOB fatigue, palpitations, chest pain, haemoptysis ``` Ix CXR ECG ECHO Mx BBs, CCBx, diuretics Percutaneous mitral balloon valvotomy mitral valve replacement