CVS Flashcards
1
Q
Give some red flag symptoms for chest pain
A
- SOB
- Not relieved by rest
- Not relieved by GTN spray
- Weight loss
- New dyspepsia
2
Q
What is acute coronary syndrome?
A
A sudden reduction in blood flow to the heart.
It encompasses a variety of diagnoses and can be subcategorised into:
- ST-elevation ACS (STEMI)
- Non ST elevation ACS (NSTEMI)
- Unstable angina
3
Q
What is the cause of ACS?
A
ACS is caused by a mismatch between myocardial oxygen demand and myocardial oxygen delivery
In some cases, myocardial supply and demand mismatch may be caused by conditions that only indirectly affect the coronary arteries (e.g. severe anaemia, hypotension, tachycardia, aortic stenosis, PE) → address underlying cause
4
Q
Give some risk factors for ACS
A
- These include any factors which increase the risk of coronary artery atherosclerosis
- Modifiable:
- Obesity
- Smoking
- Longstanding hypertension
- Hyperlipidaemia
- Non-modifiable:
- Male sex
- Older age
- Diabetes
- Renal insufficiency
- Previous history of ACS/ischaemic heart disease
- FH of ACS/ischaemic heart disease
5
Q
Give some differentials for ACS
A
- VTE
- MSK
- Respiratory; pneumothorax, pneumonia
- GI symptoms; heartburn
- Anxiety
6
Q
Give some pathologies that can cause myocardial damage in the absence of coronary artery pathology and thus present with a raised serum troponin and ECG changes
A
- Myocarditis
- Pericarditis
- PE
- Aortic dissection
- Acute heart failure
- Arrhythmias
- Sepsis
- Cardiotoxic agents
7
Q
Give the red flag symptom of ACS
A
Chest pain
8
Q
What investigations would be required in ACS
A
Bedside:
- 12-lead ECG
- Blood glucose
Labs:
- Troponin
- FBC
- U&Es
- Glucose
Imaging:
- Coronary angiography
- Echocardiogram
- CXR
9
Q
What is troponin?
A
a structural protein solely found in cardiac myocytes
10
Q
What does the presence of troponin in the blood indicate?
A
myocardial necrosis
11
Q
What troponin levels are indicative of myocardial damage?
A
Troponin 3x standard deviations from normal range
12
Q
Why is an FBC useful in the context of ACS?
A
Low Hb → underlying anaemia can exacerbate ACS (increase risk of negative outcomes) or be indicative of an occult bleed
13
Q
Why is it vital to check kidney function in ACS?
A
Cardiac troponin levels are challenging to interpret among patients with CKD → raised troponin levels and non-coronary artery related myocardial damage can be seen in CKD patients
CKD is also a risk factor for coronary artery disease
14
Q
Why is it essential to check blood glucose in ACS?
A
Hyperglycemia is a frequent condition in patients ACS → caused by an inflammatory and adrenergic response to ischaemic stress, when catecholamines are released and glycogenolysis induced.
Hyperglycaemia can lead to poorer outcomes
15
Q
Why should a CXR be conducted in ACS?
A
rule out other potential causes of chest pain e.g. pneumothorax, pneumonia
16
Q
Aetiology of a STEMI?
A
Mismatch almost always caused by total occlusion of a coronary artery from atherosclerotic plaque rupture and subsequent thrombus formation
17
Q
What are the diagnostic features for unstable angina?
A
Cardiac chest pain + abnormal/normal ECG + normal troponin
18
Q
What are the diagnostic features for NSTEMI?
A
Cardiac chest pain + abnormal/normal ECG (but not ST elevation) + raised troponin
19
Q
What are the diagnostic features for STEMI?
A
Cardiac chest pain + persistent ST elevation/new LBBB
20
Q
ACS may atypically present with no pain. Who is this more common in?
A
Elderly, diabetics
21
Q
Give some atypical presentations of ACS
A
- Epigastric pain
- No pain (more common in elderly and patients with diabetes)
- Acute breathlessness
- Palpitations
- Acute confusion
- Diabetic hyperglycaemic crisis
22
Q
Location of ST elevation → leads II, III and aVF
a) what area of myocardium?
b) which coronary artery?
A
area → inferior
coronary artery → right coronary artery
23
Q
Location of ST elevation → V1-V2
a) what area of myocardium?
b) which coronary artery?
A
area → septum
artery → proximal left anterior descending artery (LAD)
24
Q
Location of ST elevation → V3-4
a) what area of myocardium?
b) which coronary artery?
A
area → anterior
artery → LAD
25
Location of ST elevation →V5-6
a) what area of myocardium?
b) which coronary artery?
area → lateral/apex
artery → distal LAD, left circumflex artery (LCx), right coronary artery (RCA)
26
Location of ST elevation → leads I, aVL
a) what area of myocardium?
b) which coronary artery?
area → lateral
artery → left circumflex artery
27
Serum troponin levels typically rise how long after MI begins?
3 hours
28
What do **low levels** of troponin indicate? Differentials?
No myocardial death
Patient not having MI but may be having **unstable angina**
29
What do **mildly** **raised levels** of troponin indicate? Differentials?
* This is an equivocal result and may be due to other **non-MI related factors**
* These patients need a 6-12 hour repeat test:
* If repeat troponin is raised → having an MI
* If repeat troponin is stable or falling → unlikely to be having an MI
30
What do **definitely** **raised levels** of troponin indicate? Differentials?
MI confirmed
31
Give some non-ACS causes of a raised troponin
* Pericarditis
* Myocarditis
* Arrhythmias
* Defibrillation
* Acute heart failure
* Pulmonary embolus
* Type A aortic dissection
* Chronic kidney disease
* Prolonged strenuous exercise
* Sepsis
32
Acute management steps of a STEMI?
1. **Oxygen** (aim for sats \>90%)
2. **Aspirin** 300mg (protocols often also call for 2nd antiplatelet e.g. clopidogrel 300mg or ticagrelor 180mg)
3. Sublingual **GTN spray**
4. IV **morphine**/**diamorphine**
5. Primary percutaneous coronary intervention (PPCI) if possible
33
Purpose of GTN spray in STEMI?
Symptom relief
34
Purpose of IV morphine/diamorphine in STEMI?
* Symptom relief
* Also causes **vasodilation** reducing preload on heart
35
Who is eligible for PPCI?
Those who present within **12 hours of onset of pain**
36
Acute management of NSTEMI (and unstable angina)?
1. **Oxygen**
2. **Aspirin** 300mg and fondaparinux
3. Sublingual **GTN** spray
4. IV **morphine**/**diamorphine**
5. Start **antithrombin** therapy e.g. LMWH or fondaparinux if they are for an immediate angiogram
37
What is fondaparinux?
**A synthetic anticoagulant**
Similar to low molecular weight heparins, it is an indirect inhibitor of factor Xa, but it does not inhibit thrombin at all.
38
In all post MI patients, what 5 drugs should they be offered?
1. **Aspirin** 75mg OM + **2nd antiplatelet**
2. **Beta** **blockers** (bisoprolol)
3. **ACEi** (ramipril)
4. High dose **statin** (e.g. atorvastatin 80mg ON)
39
Why should all post-MI patients have an echocardiogram?
to assess systolic function and any evidence of heart failure should be treated
40
Aetiology of a STEMI?
**Complete occlusion of a coronary artery** from atherosclerotic plaque rupture and subsequent thrombus formation
41
Aetiology of an NSTEMI?
Severe but incomplete stenosis/occlusion of a coronary artery:
a) **Partial coronary artery occlusion** from a rupture plaque (most common)
b) P**artial occlusion from a stable plaque**
c) Coronary artery vasospasm (Prinzmetal’s angina)
d) Coronary arteritis
42
What is Dressler's syndrome?
A post-infarction **pericarditis** that tends to occur 2-6 weeks following an MI
43
What is the presumed pathophysiology behind Dressler's syndrome?
Thought to be autoimmune reaction against antigenic proteins formed as the myocardium recovers
44
Presentation of Dressler's syndrome?
Fever, pleuritic chest pain, pericardial effusion, & raised ESR
45
Management of Dressler's syndrome?
high dose aspirin
46
What is the most common cause of death following an MI?
Ventricular fibrillation
47
How can an MI lead to cardiogenic shock?
If a large part of the **ventricular myocardium is damaged** in the infarction, the **ejection fraction** of the heart may decrease to the point that the patient develops cardiogenic shock
Other causes of cardiogenic shock include ‘mechanical’ complications e.g. left ventricular free wall rupture
48
How can MI lead to congestive heart failure?
Consequence of impairment of heart muscle function 2ary to ischaemia
49
Pharmacological management of congestive heart failure 2ary to MI?
* Loop diuretics (furosemide) to decrease fluid overload
* ACEi & beta-blockers have been shown to improve long term prognosis
50
Heart (AV) block is more common following what type of MI (i.e. what area)? Why?
**Inferior** MI → as the RCA supplies the SA node
51
Dressler's syndrome vs post-MI pericarditis?
Pericarditis → typically within first 48 hours
Dresslers → within 2-6 weeks
52
Features of pericarditis?
* Pain worse on lying flat
* Pericardial tub may be heard
* Pericardial effusion may be seen on echo
53
How can an MI lead to a LV aneurysm?
Aneurysm can occur following an **anterior** MI where the myocardium can be susceptible to wall stress, leading to aneurysm formation
54
What are the potential complications of a LV aneurysm?
Thrombus may form within aneurysm – increasing risk of stroke, acute limb ischaemia, mesenteric ischaemia
55
Treatment of LV aneurysm?
Anticoagulation
56
How can an MI lead to LV free wall rupture? What are the complications of this?
**Necrosis of the free walls** of either ventricle can lead to _rupture_, allowing blood into the **pericardial** space.
Leads to **rapid tamponade** and often cardiac arrest/death within seconds
57
How can an MI lead to acute mitral regurgitation?
May be due to ischaemia or rupture of **_papillary muscle_**
58
What type of murmur is heard in acute mitral regurgitation?
Pansystolic murmur heart best at apex (rolling patient to their left with stethoscope over mitral area in CVS exam)
59
What 3 features define stable angina?
1. Brought on by physical activity
2. Alleviated by rest or GTN spray within minutes
3. Constriction like pain in chest/neck/arm/jaw
60
Bedside tests for stable angina?
* CVS exam – heart sounds, signs of heart failure, BMI
* 12-lead ECG → this will be normal
* Pregnancy test
* Glucose
61
Lab tests for stable angina?
* FBC → exclude anaemia (can exacerbate angina), infection
* TFTs → exclude hyperthyroidism (can exacerbate angina)
* LFTs (prior to statins)
* Lipid profile
* HbA1c
62
What is the gold standard imaging for angina? Why?
CT coronary angiography
## Footnote
This gives a detailed view of the coronary arteries, highlighting any narrowing
63
What is the **pharmacological 1st line** management for stable angina?
Aspirin
Statin
Beta blocker (or rate limiting CCB)
Sublingual GTN spray
64
What side effects of GTN spray should patients be warned about?
headaches, flushing, dizziness
65
How should GTN spray be used?
* Initial dose when symptoms come on
* 2nd dose after 5 minutes if still symptomatic
* Call ambulance if pain not subsided after 2 doses → may indicate ACS
66
2 surgical management options for angina?
1. Percutaneous coronary intervention (PCI)
2. Coronary artery bypass graft (CABG)
67
Define unstable angina
An ACS that is defined by the absence of biochemical evidence of myocardial damage:
* Prolonged (\>20 minutes) angina at rest
* New onset of severe angina
* Angina that is increasing infrequency, longer in duration, or lower in threshold
* Angina that occurs after a recent episode of MI
68
What is atrial fibrillation?
: A cardiac arrhythmia characterised by disorganised electrical activity within the atria resulting in **ineffective atrial contraction** and **irregular ventricular contraction** (due to delay at the AV node so that only some of the atrial impulses are conducted to the ventricles).
69
What is the most common sustained cardiac arrhythmia?
AF
70
What is fast AF?
When the ventricular rate is \>100bpm
71
Define paroxysmal AF
episodes last \>30 seconds but \<7 days; are self-terminating and recurrent
72
What type of arrhythmia is AF?
supraventricular cardiac arrhythmia
73
Where does AF often originate from?
the **left atrial myocytes** which extend as sleeves around the pulmonary veins
74
How does AF affect ventricular contraction?
**Irregular ventricular contraction -** depends on speed of AVN conduction
75
Why can AF predispose to systemic embolic complications?
Presence of chaotic electrical activity → **ineffective** atrial contraction → **blood** **stasis** within atria → increased chance of thrombosis and subsequently embolic complications
76
What are the 2 most common cardiac causes of AF in the UK?
1. Ischaemic heart disease
2. Hypertension
77
What is the most common cardiac cause of AF in developing countries?
Rheumatic heart disease
78
Give the 3 major risk factors for AF
1. HTN
2. Obesity
3. Alcohol
79
Most common complication of AF?
* **Thromboembolic events**:
* Ischaemic stroke
* Mesenteric ischaemia
* Acute limb ischaemia
80
How can AF lead to a risk of bleeding?
Due to anticoagulants
81
Give 2 medications that may cause AF?
Bronchodilators
Thyroxine
82
Symptoms of AF?
* Some patients can be asymptomatic, even when causing tachycardia and so may eb an incidental finding on clinical examination or when doing a 12-lead ECG
* **SOB**
* **Palpitations**
* **Chest discomfort**
* Syncope/**dizziness**: due to bradycardia (particularly in paroxysmal AF)
* Light-headedness
* Reduced exercise tolerance
* Malaise
* Remember – a TIA or stroke can be the presenting complaint!!!
83
Signs of AF?
* Irregularly irregular pulse
* Radial-apical deficit/delay
* Tachycardia
* Co-existing heart failure symptoms
84
12-lead ECG features of AF?
* Absent P-wave with a chaotic baseline
* Fibrillation waves (vest seen in lead II and V1)
* Tachycardia
* Irregularly irregular rhythm – irregular R-R intervals
85
Lab tests in AF?
* FBC – assess for reversible causes e.g. acute infection (raised WCC)
* U&Es – assess for reversible causes e.g. hypokalaemia/hyponatraemia
* LFTs – establish baseline hepatic function before giving anticoagulants
* TFTs – rule out/in hyper/hypothyroidism (raised T4 & low TSH hyperthyroidism)
* CRP – assess for reversible causes e.g. acute infection (raised CRP)
* Clotting screen – before giving anticoagulants
* BP – assess for underlying heart failure (N.B. AF can cause raised BNP without evidence of heart failure)
86
Imaging in AF?
* **Echocardiogram** – US of heart can help identify other heart-related problems e.g valve disease
* **CXR**: Can assess for changes associated with heart failure e.g. cardiomegaly, pleural effusion)
87
Why is a CXR useful in AF?
Can assess for changes associated with heart failure e.g. cardiomegaly, pleural effusion)
88
What are the 3 1st line pharmacological management steps for AF?
1. Rate control
2. Rhythm control
3. Anticoagulants
89
Who should rate control drugs NOT be offered to in the context of AF?
* Whose AF has reversible cause
* Who have heart failure thought to be primarily caused by AF
* New onset AF
90
What 2 classes of drugs can be used to control rate in AF?
1. **Beta** **blockers** e.g. bisoprolol
2. **Rate** **limiting** **CBB** e.g. verapamil, diltiazem (note NOT amiodarone)
91
What are beta blockers contraindicated in?
Asthma
COPD
Hypotension
92
What are CCBs contraindicated in?
Heart failure
93
If neither beta blockers nor CCBs are appropriate for rate control in AF, which drug can be used?
Digoxin
94
What are the 2 methods to control rhythm in AF?
1. Electrical cardioversion
2. Pharmacological cardioversion
95
Give 3 examples of drugs that can be used to control rhythm in AF
1. Flecainide
2. Amiodarone
3. Sotalol
96
What class of drug is Flecainide?
Class I antiarrhythmic
97
What is sotalol?
Beta blocker with additional K channel blocker action
98
Why is long term anticoagulation needed in AF?
the **main complication of AF is embolic stroke.**
99
Give 3 possible anticoagulants to use in the long term management of AF
1. DOACs
2. Warfarin
3. LMWH
100
Which anticoagulant is generally considered the one of choice in AF?
DOACs
101
Half life of DOACs?
12-hour half-lives (patients **not** covered if miss a dose)
102
What does warfarin initially require cove with for the first 5 days?
LLMWH - warfarin is initially **prothrombotic**
103
What is the only oral anticoagulant licensed for **valvular AF**?
Warfarin
104
What is valvular AF
AFib is considered valvular **when it's seen in people who have a heart valve disorder or a prosthetic heart valve**.
Nonvalvular AFib generally refers to AFib caused by other things, such as high blood pressure or stress.
105
Options for permanent treatment of AF?
**Atrial ablation or pacemaker insertion**
106
How does anaemia affect ACS?
Anaemia further potentiates this imbalance between myocardial oxygen supply and demand by both
a) r**educing oxygen‐carrying capacity**
b) simultaneously **increasing myocardial oxygen consumption** via increased cardiac output
107
Define essential hypertension
HTN where no **identifiable** cause is found
108
What is the most common type of hypertension?
Essential (90%)
109
How common is hypertension?
Around ⅓ adults in UK
110
Which ethnicities are at higher risk of HTN?
Black African and Black Caribbean origin are at higher risk
111
What is the single biggest risk factor for CVS disease?
HTN
112
What are some red flag symptoms of **accelerated** or **malignant** HTN?
* Headache
* Visual disturbances
* Seizures
* N&V
* Chest pain
113
What is ambulatory blood pressure monitoring (ABPM)?
BP during normal activities of daily life recorded using a 24-hour blood pressure monitor
114
What does home blood pressure monitoring (HBPM) consist of?
recorded by patient 2x a day (morning & evening)
115
What is the 1st line pharmacological management option for patients \<55y who are **not** of Black African or African-Caribbean descent?
ACEi (ramipril)
116
What is the 1st line pharmacological management option for patients with diabetes (regardless of ethnicity)?
ACEi (ramipril)
117
What is the 1st line pharmacological management option for patients patients \>55y (without diabetes) or of Black African or African-Caribbean descent (any age, without diabetes)?
Calcium channel blocker e.g. amlodipine
118
What is offered is an ACEi is not tolerated in HTN?
**Angiotensin II receptor blocker** e.g. losartan
119
PRESCRIBING for HTN:
120
If a CCB is not tolerated in HTN, what can be offered instead?
Thiazide-like diuretic e.g. indapamide
121
Define a DVT
The formation of a blood clot in the deep veins of a limb, most commonly affecting those of the legs or pelvis, which partially or completely obstructs blood flow
122
DVTs can be provoked or unprovoked. What does this mean?
Provoked - presence of risk factors (80%)
Unprovoked - absence of risk factors
123
What is thrombophilia?
**a condition that increases your risk of blood clots**.
124
What is factor V Leiden?
A thrombophilia - mutation in factor V means it is unable to be degraded by protein C
125
What is antiphospholipid syndrome?
An autoimmune condition in which the immune system mistakenly creates antibodies that attack tissues in the body. These antibodies can cause **blood** **clots** to form in arteries and veins.
126
Give some inherited risk factors for DVT
* Family history (1st degree relative with VTE)
* Thrombophilia
* Antiphospholipid syndrome
* Factor V Leiden
127
What is the most serious complication of a DVT?
**PE** – 10% of people with untreated DVT will develop PE
128
Give some signs & symptoms of a PE
Pleuritic chest pain, SOB, tachycardia, syncope, hypotension, heart failure, sudden death
129
What is the most **common** complication following a DVT?
Post-thrombotic syndrome (up to 50% will develop this)
130
What is post-thrombotic syndrome?
chronic pain, swelling, and other symptoms in your leg in the months following a DVT
131
Signs & symptoms of a DVT?
* Unilateral leg pain (throbbing) and swelling
* Pitting oedema
* Tenderness over deep veins of leg
* Heavy ache in affected area
* Pain may be worse when dorsiflexing foot
* Can be asymptomatic
* Skin changes e.g. oedema, redness, warmth
132
What screening test can be used to assess DVT risk?
Well's score
133
What Wells score indicates a d-dimer test?
Above or equal to 2
134
Investigations in DVT?
* Wells score
* D-dimer
* Leg circumference
* Imaging → duplex US
* Obs
* Bloods - FBC, U&Es, d-dimer, LFTs
135
How do you measure leg circumference in a potential DVT?
Measure circumference of leg **10cm below tibial tuberosity** and _compare_ with asymptomatic leg → a difference \>3cm indicates DVT
136
What is the 1st line imaging in a DVT?
Duplex US
137
1st line pharmacological management in DVT?
DOACs (warfarin if these are contraindicated)
138
Define chronic/congestive heart failure
When the heart is unable to pump sufficiently to maintain blood flow to meet the body’s needs.
139
What are the most common causes of CHF in UK?
1. Coronary artery disease
2. Hypertension
3. Valvular disease (commonly aortic stenosis)
4. Arrhythmias (commonly AF)
140
Which parasitic disease is a common cause of CHF in central/south america?
Chagas disease
141
What is the equation for cardiac output?
Cardiac output (CO) = Heart rate (HR) x Stroke volume (SV)
142
Systolic vs diastolic HF?
Systolic - impaired LV contraction
Diastolic - impaired LV relaxation and filling
143
What is systolic HF also called?
HF with **reduced** ejection fraction
144
What is diastolic HF also called?
HF with **preserved** ejection fraction
145
Causes of **diastolic** HF?
* Hypertrophic obstructive cardiomyopathy
* Restrictive cardiomyopathy
* Cardiac tamponade
* Constrictive pericarditis
146
Causes of **systolic HF?**
* Ischaemic heart disease
* Dilated cardiomyopathy
* Myocarditis
* Infiltration (e.g. in haemochromatosis or sarcoidosis)
147
Does L or R HF cause venous congestion?
Does L or R HF cause pulmonary congestion?
L - pulmonary
R - venous
148
Give some symptoms of pulmonary congestion caused by LHF
* SOB on exertion
* Orthopnoea
* Paroxysmal nocturnal dyspnoea
* Nocturnal cough (+/- pink frothy sputum)
149
What is paroxysmal nocturnal dyspnoea (PND)?
* Suddenly waking at **_night_** with a severe attack of SOB and cough (maybe wheeze)
* Have to sit on side of bed or walk around and gasp for breath – feel they are **suffocating**
* Symptoms improve over several minutes
150
Give some **signs** of pulmonary congestion caused by LHF
* Tachypnoea
* Bibasal fine crackles on lung auscultation
151
HF can also cause **systemic hypoperfusion**. Give some signs of this
* Prolonged CRT
* Cyanosis
* Hypotension
* Low O2 sats
152
Give some symptoms caused by **venous congestion** caused by RHF
* Ankle congestion (peripheral oedema)
* Weight gain
* Abdominal distention & discomfort (ascites)
* Anorexia/nausea
153
Give some signs caused by **venous congestion** caused by RHF
* Raised JVP
* Pitting ankle/sacral oedema
* Tender smooth hepatomegaly
* Ascites
* Transudative pleural effusion (typically bilateral)
154
Transudate is fluid buildup caused by systemic conditions that alter the **pressure** in **blood** **vessels**, causing fluid to leave the vascular system (lower protein)
Exudate is fluid buildup caused by tissue leakage due to **inflammation** or **local cellular damage** (higher protein)
155
Important blood tests in HF?
* **BNP** **test**
* FBC
* U&Es
* LFTs
* TFTs
* Glucose & lipid profile
156
What is BNP?
Brain natriuretic peptide (BNP) is a hormone secreted by cardiac cells in response to increased pressure within the heart i.e. released by ventricles in response to myocardial stretch
157
Why is a FBC important in HF?
Anaemia (high output HF)
Infection
158
Why are TFTs important in HF?
Hyperthyroidism (high output HF)
159
Why are U&Es important in assessing HF?
Renal function
Assess for hyponatraemia
160
What is the most common electrolyte disorder?
Hyponatraemia
161
What causes hyponatraemia in heart failure?
HF increases anti-diuretic hormone (ADH/vasopressin) → reduced excretion of water → dilution of sodium
162
Why are LFTs important in assessing HF?
**Assessing _hepatic_ _congestion_** → Passive hepatic congestion due to increased central venous pressure may cause elevations of liver enzymes (ALP, ALT, AST) and both direct and indirect serum bilirubin.
**Assessing _acute_ _hepatocellular_ _necrosis_** → Impaired perfusion from decreased cardiac output may be associated with acute hepatocellular necrosis with marked elevations in serum aminotransferases (ALT).
163
What imaging can be done in HF?
* Echocardiogram
* CXR
164
What is the purpose of an echocardiogram in HF?
Confirm presence and degree of **ventricular** **dysfunction** which is measured by ejection fraction.
165
How is ventricular dysfunction measured?
By ejection fractino
166
What ejection fraction indicates HF?
\<50%
167
What does a \>40% EF but a raised BNP indicate?
HF with preserved EF
168
What signs can be seen on a CXR in HF (ABCDEF)
A - **A**lveolar oedema
B - Kerley **B** lines (caused by interstitial oedema)
C - **C**ardiomegaly (cardiothoracic ratio \>0.5)
D - upper lobe **D**ivision
E - pleural **E**ffusions
F - **F**luid in the horizontal fissure
169
What is the pharmacological first line management in HF? (ABAL)
A - **A**CEi (ramipril)
B - **B**eta blocker (bisoprolol)
A - **A**ldosterone antagonist when symptoms not controlled with A & B (spironolactone or eplerenone)
L - **L**oop diuretics (e.g. furosemide)
170
What can ramipril be titrated up to in HF?
ramipril titrated as tolerated up to 10mg once daily
171
What can be used in HF if an ACEi is not tolerated?
ARB e.g. candasartan
172
Are ARBs or ACEi contraindicated in valvular heart disease?
ACEi
173
What can bisoprolol be titrated up to in HF?
bisoprolol titrated as tolerated up to 10mg once daily
174
What beta blocker is most often chosen in HF? Why?
Bisoprolol - one of the only **cardio-selective** bet blockers that has been shown to reduce mortality in HF
175
How may spironolactone be useful in the management of HF?
1. Lowers BP
2. May reduce risk of volume overload which reduces risk of HF and CVS disease
176
When giving a HF patient furosemide, what must be monitored carefully?
Kidney function
177
What is high output HF?
Cardiac output is normal but there is an **increase in peripheral metabolic demands** which exceeds those that can be met with maximal cardiac output.
178
Give some cause of output HF? (AAPPTT)
A - Anaemia
A - Arteriovenous malformation
P - Pregnancy
P - Paget's disease
T - Thyrotoxicosis
T - Thiamine deficiency
179
What occurs in LV failure?
LV is unable to adequately move blood through the left side of the heart and out into the body.
180
How does LVF lead to pulmonary oedema?
* This causes a **backlog** of blood that increases the amount of **fluid** stuck in the **left atrium**
* As the vessels in this area are **engorged with blood** due to the increased volume and pressure, they **leak fluid** and are **unable to reabsorb fluid** from the surrounding tissues → _pulmonary oedema_
181
Define pulmonary oedema
Where the lung tissues and alveoli become full of interstitial fluid which interferes with **normal gas exchange**, causing SOB, oxygen desaturation etc**.**
182
Is the fluid seen in pulmonary oedema due to LVF transudative or exudative?
Transudative
183
What type of respiratory failure does LVF cause?
Type 1 (low O2 without an increase in CO2 in blood)
184
Give some triggers for LVF
* Iatrogenic (e.g. aggressive IV fluids in frail elderly patient with impaired LV function)
* Sepsis
* MI
* Arrythmias
185
What causes Kerley B lines?
Fluid in septal lines
186
Initial management for LVF and pulmonary congestion? (Pour SOD)
**P**our away (stop) their IV fluids
**S**it up (takes fluid to bases, leaving upper lungs clear for better gas exchange)
**O**xygen - caution in patients with COPD
**D**iuretics e.g. IV furosemide
187
What are higher levels of BNP associated with?
Poorer prognosis
188
Give some factors that increase BNP levels
* Left ventricular hypertrophy
* Ischaemia
* Tachycardia
* Right ventricular overload
* Hypoxaemia (including PE)
* GFR \<60 ml/min
* Sepsis
* COPD
* Diabetes
* Age \>70 y/o
* Liver cirrhosis
189
Give some factors that decrease BNP levels
* Obesity
* Diuretics
* ACE inhibitors
* Beta-blockers
* Angiotensin II receptor blockers (ARBs)
* Aldosterone antagonists
190
what are some signs to look for in the **hands** during a CVS exam?
* Oslers nodes
* Janeway lesions
* Splinter haemorrhages
* Pallor
* Peripheral cyanosis
* Tar staining
* Clubbing
191
what are some signs to look for in the **eyes** during a CVS exam?
* Conjunctival pallor
* Corneal arcus
* Xanthelasma
* Kayser-Fleicher rings
192
what are some signs to look for in the **mouth** during a CVS exam?
* Angular stomatitis
* High arched palate
* Central cyanosis
* Dental hygiene
193
What is rheumatic fever a delayed reaction to?
Strep A infection (most commonly Strep. pharyngitis)
194
What is the most common valvular defect following rheumatic heart disease?
Mitral stenosis
195
What type of murmur does mitral stenosis cause?
Mid-diastolic murmur heard over the apex (mitral valve)
196
What heart condition can mitral stenosis lead to?
AF due to increases in left atrial pressure and concomitant atrial dilation
197
What type of murmur does aortic stenosis cause?
Ejection systolic murmur that radiates to the carotid arteries
198
Which valve pathology causes a narrow pulse pressure?
Aortic stenosis
199
Which valve pathology causes a wide pulse pressure?
Aortic regurgitation
200
What happens in aortic dissection?
Tear in tunica intima of wall of aorta, creating a false lumen which fills with large volumes of blood
201
Classic pain felt in aortic dissection?
Tearing chest pain which radiates to back
202
What may be seen on the CXR of someone with aortic dissection
A **widened mediastinum**
203
How does amiodarone affect the P450 system?
Is an **inhibitor**
204
How does amiodarone affect the risk of statin-induced rhabdomyolysis?
Increases risk as amiodarone is an enzyme inhibitor
205
Which artery most likely supplies the AV node?
Right coronary artery
206
What is heart failure with preserved ejection fraction?
This would lead to **abnormal filling of the ventricles** during diastole and **a normal ejection fraction** on the echo **(\>50%**)
207
What is heart failure with preserved ejection fraction typically 2ary to?
Usually caused by **ventricular stiffness** 2ary to **long-standing HTN** or **ventricular hypertrophy**
208
Describe the ECG changes in hyperkalaemia
* Small or absent P waves
* Tall, tented T waves
* Broad bizarre QRS complexes
209
Describe the ECG changes in hypokalaemia
* ST segment depression
* U waves
* Small or absent T waves (occasion ally inversion)
210
What type of murmur is heard in aortic regurgitation? Why?
**Early diastolic**:
* Aortic valve allows blood to flow back into the LV when the heat relaxes
* As a result of the flow back into the ventricle, a murmur can be auscultated in the **aortic area** during diastole
211
Give 3 features seen in aortic regurgitation
1. Wide pulse pressure
2. Early diastolic murmur
3. Collapsing pulse
212
Give 2 causes of aortic regurgitation
Infective endocarditis
Aortic dissection
213
How do nitrates affect intracellular calcium?
Nitrates cause a **decrease** in intracellular calcium.
214
How does NSAIDs affect the anti-hypertensive effects of ACEi?
**NSAIDs _reduce_ the anti-hypertensive effects of ACEi.**
215
What electrolyte abnormality can the combined use of PPIs and thiazide diuretics cause?
severe hyponatraemia
216
Impact of thiazide diuretics and gout?
Thiazide-like diuretics can cause **gout**.
217
What is the most common ECG sign in PE?
* Sinus tachycardia (most common)
* Signs of right heart strain
218
Describe the volume of distribution of warfarin
Warfarin has a **small volume of distribution** as it is **protein bound**.
219
How do antacids affect the absorption of ACEi?
Antacids reduce the absorption of ACEi
220
What is Dressler's syndrome?
A 2ary pericarditis that usually occurs 1-6 weeks post MI
221
Symptoms of Dressler's syndrome?
* It is characterised by pleuritic chest pain, low-grade fever and pericarditis
* Pain can radiate to left shoulder and is worse on lying down
222
Management of Dressler's syndrome?
high-dose aspirin
223
How do NSAIDs affect the efficacy of diuretics?
When NSAIDs are taken with a diuretic the effect of the diuretic is reduced and any heart failure may be exacerbated
224
Why are NSAIDs contraindicated in HF?
NSAIDs can lead to an elevation in blood pressure, especially in patients treated with drugs inhibiting RAAS.
Patients with congestive heart failure are at risk of the disease decompensation while taking NSAIDs.
225
Effect of PPIs on sodium level?
hyponatraemia
