CVS Flashcards

Question

Complications of angina

Answer 1

Stroke MI Unstable angina sudden cardiac death anxiety depression

Answer 2

chest pain....... Non -cardiac : : ACS ........... STEMI (ST elevation) : : Unstable angina/NSTEMI (ecg shows no st elevation) : : if normal troponin levels, then = unstable angina if raised troponin levels then NSTEMI

Answer 3

Antiplatelet - 300mg aspirin Anti-thrombin - fondaparinux

Answer 4

offer 300 mg of aspirin assess eligibility for reperfusion therapy: if yes offer PCI or fibrinolysis if no proceed with medical management, offer ticagrelor with aspirin

Answer 5

ACEi Clopidogrel B-blocker statin rivaroxaban

Answer 6

cardiac rehab and secondary prevention

Answer 7

Coronary artery spasm Common in patients with underlying heart disease but can occur in healthy people as well

Answer 8

- Not fully clear but is thought to be linked with low nitric oxide (secondary to reduced acetylcholine release), increased adrenergic activities, vasoconstrictor mediators (thromboxane, serotonin etc) - Acetylcholine normally results in the release of nitric oxide and also act directly as a vasodilator at rest - Thromboxane/serotonin are involved in platelet activation/recruitment. There is more of these mediators in prinzmetal - Increased adrenergic activities can cause an increase in heart rate and peripheral vasoconstriction

Answer 9

- Heart disease - Stress - Drugs such as cocaine, sympathomimetics such as epinephrine - Alcohol - Smoking

Answer 10

- Rest chest pain common at midnight/morning and lasting between 5-30 minutes - Headache - Patient may have a history of coronary heart disease - - Deranged vital signs such as tachycardia, tachypnoea, high BP - There might not be any focal cardiac examination finding unless patient has underlying heart disease - Raynaud phenomenon if severe

Answer 11

**Bloods** - Most important blood test is Troponin to rule out ACS. - FBC, renal function, electrolytes, fasting blood glucose and lipid levels **X-ray/Imaging** - CXR to rule out alternative causes **ECG** - STAT ECG might show transient STE. 24 hour ECG tape can be used if symptoms have resolved **Special Tests** - Coronary angiography is the investigation of choice. Other options include stress echocardiography

Answer 12

- Lifestyle management - Manage co-existing disease - GTN/Calcium channel blockers are mainstay of medical treatment (avoid beta blockers as may aggravate symptoms) - Revascularization - coronary artery stenting

Answer 13

- Arrhythmias - MI

Answer 14

congenital narrowing of the aorta

Answer 15

- Men > Women - Turner’s syndrome - Aortic valve is bicuspid in 80% of cases - Patent ductus arteriosus - Ventricular septal defect - Mitral stenosis/regurgitation - Circle of Willis aneurysms

Answer 16

asymptomatic headaches and nose bleed to due to HTN Claudication and cold legs HTN in upper limbs Week delayed pulse in legs radio femoral delay

Answer 17

CXR ECG LVH aortagraphy CT/MRI

Answer 18

- Narrowing of the aortic valve - Progressive disease

Answer 19

- Calcification of the valve is most common cause. - Congenital, history of rheumatic heart disease

Answer 20

- Can be asymptomatic for many years - Shortness of breath with exertion, angina, syncope - Systolic murmur, mid-to-late peaking with a crescendo-decrescendo pattern, radiates to carotids - Can cause left ventricular hypertrophy, heart failure. Can lead to sudden cardiac death. Damaged valve prone to endocarditis

Answer 21

avoid heavy exertion, surgical intervention

Answer 22

- Diastolic leakage of blood from the aorta into the left ventricle - Acute :caused by endocarditis or aortic dissection - Chronic: asymptomatic for years until symptoms of heart failure develop

Answer 23

Caused by disease of the aortic valve (bicuspid aortic valve, rheumatic fever, infective endocarditis, collagen vascular disease, degenerative aortic valve disease) or aortic root

Answer 24

Acute presents with sudden onset pulmonary oedema and hypotension/cardiogenic shock. May also present as myocardial ischaemia or aortic root dissection

Answer 25

Chronic: initial symptoms can include palpitations and uncomfortable awareness of pounding heart when lying on left side

Answer 26

- Acute severe AR – urgent surgical intervention - Chronic severe AR – goals of treatment to prevent death, diminish symptoms, to prevent development of hear failure and avoid aortic root complications - Valve replacement

Answer 27

Aneurysm is a bulge in the aorta it can be abdominal (common) or thoracic dissection is a tear Aortic dissection can either be Type A (Ascending aorta) or Type 2 (Descending aorta)

Answer 28

- Arteries are made up of three layers from proximal to distal namely tunica intima, tunica media and tunica adventitia - Aortic aneurysm occurs when there is an irreversible degradation of the elastic lamellae (outermost part of the tunica intima) and associated smooth muscle loss - Aortic dissection occurs when there is a damage to the tunica intima and blood pulls inside the tunica media

Answer 29

- Advanced age - Hypertension - Marfan syndrome - Smoking - Trauma

Answer 30

- Sudden ripping/tearing chest pain radiating to the back - Shortness of breath - Abdominal/back pain - Asymmetric pulse - Abdominal pain/distension - Unequal blood pressure in both arms - Abdominal bruit - Flank haemorrhage

Answer 31

**Bloods** - FBC (Anaemia-although not immediately) - Cross match - LFT/RFT (to look for end organ ischaemic damage) **Orifice Test** - PR test when indicated **X-ray/Imaging** - CXR (can initially show widened mediastinum if thoracic aneurysm/dissection) - CT-aortogram (widely used) or MRI angiography for confirmation **ECG** - Might show ischaemic changes like STE/STD depending where the dissection occurs **Special Tests** - If aneurysm/dissection in the context of trauma, A FAST scan can be done

Answer 32

- Lifestyle/risk factor management (stop smoking etc) - Statin/Aspirin when indicated - Further Medical management depends on the size of the aneurysm (Refer to secondary care) - If between 3-4.4cm (Annual ultrasound), If 4.5-5.4 (3 monthly ultrasound), if >5.5cm (Immediate referral for surgery and 3 monthly ultrasound) - There is a one off screening program for over 65s in england which can rule out aneurysm for life if negative

Answer 33

- Cardiac tamponade - Cardiogenic shock

Answer 34

Arrhythmias are abnormalities of the heart rate or rhythm caused by disorders of impulse generation or conduction.

Answer 35

A supraventricular tachyarrhythmia with uncoordinated atrial electrical activation and consequently ineffective atrial contraction.

Answer 36

- Irregularly irregular R-R intervals(when atrioventricular conduction is not impaired) - Absence of distinct repeating P waves - Irregular atrial activations.

Answer 37

**Paroxysmal AF** – episodes lasting longer than 30 seconds but less than 7 days (often less than 48 hours), that are self-terminating and recurrent **Persistent AF** – episodes lasting longer than 7 days (spontaneous termination of the arrhythmia is unlikely to occur after this time) or less than seven days but requiring pharmacological or electrical cardioversion **Permanent AF** – AF that fails to terminate using cardioversion, AF that is terminated but relapses within 24 hours, or longstanding AF (usually longer than 1 year) in which cardioversion has not been indicated or attempted

Answer 38

Flutter wave (instead of P waves) organize atrial depolarisations of a rate around 300bpm producing a saw-tooth pattern in typical counterclockwise flutter. Narrow QRS complex

Answer 39

Irregular R-R interval

Answer 40

Middle aged - older adults Europe and North America Comorbidities

Answer 41

age comorbidities - HTN, diabetes, HF, CHD ,CKD Obesity Obstructive sleep apnoea

Answer 42

ischemic degeneration mitral stenosis metabolic

Answer 43

Left atrial arrhythmia often in the form of rapidly firing ectopic foci located inside one or more pulmonary veins, and an abnormal atrial tissue substrate capable of maintaining the arrhythmia.

Answer 44

Breathlessness Palpitations Syncope/dizziness Chest discomfort Reduced exercise tolerance

Answer 45

Patient Hx ECG recording Ambulatory ECG monitoring External loop recorders Implantable Loop Recorders (ILR) Signal average ECG Structural heart imaging – Chest x-ray/Echo/MRI Electrophysiology study ‘Personal smart-tech’ Blood count, electrolyte levels, drug levels, thyroid study

Answer 46

The diagnosis of AF requires rhythm documentation with an electrocardiogram (ECG) tracing showing AF. By convention, an episode lasting at least 30 seconds is diagnostic for clinical AF. if pulse is irregular then 12 lead ECG , Ambulatory ECG monitoring

Answer 47

Urgent referral -If the onset of atrial fibrillation (AF) was within the last 48 hours urgently and haemodynamic instability/loss of consciousness/severe dizziness or syncope/ongoing chest pain/increasing breathlessness. Comorbidities and lifestyle -assess for signs and symptoms and do test to confirm or rule out underlying causes of AF Rate control -beta blocker -rate limiting calcium channel blocker -digoxin Stroke risk Asses CHA2DS2VASC and HAS-BLED score anticoagulant option- DOACS Rhythm control -Pharmacological - anti arrhythmic drugs - Intervention- PVI ablatio, pharmacological cardioversion and DCCV

Answer 48

Emergency – 999 Urgent – transfer ASAP to A&E monitored by a defibrillator and all monitoring/IV line if possible.

Answer 49

stroke TIA HF

Answer 50

occlusion of arteries * Most commonly affected arteries include those in the heart, brain, kidneys & lower limbs.

Answer 51

- A thrombus is a local formation of clot while an emboli is a clot that has broken off to lodge in another area of the body - Embolism/thrombosis occurs due to risk factors like lipidemia, cigarettes etc. These risk factors damage the vascular endothelium and consequently lead to arterial occlusion manifesting as ischaemia.

Answer 52

- Smoking - Lipidemia - Sedentary lifestyle - Recent surgery - Hypertension - Obesity - Atrial fibrillation - Hypercoagulability states e.g thrombocytosis

Answer 53

- Pain - Numbness/Tingling - Muscle spasm/weakness - Change in colour - Skin coldness - Checking CRT, pulse, sensation. All of which would be absent or delayed in peripheral vascular disease

Answer 54

**Bloods** - Lipids. ESR. HBA1c. Renal/Liver function tests. Creatine kinase, Troponin, FBC **X-ray/Imaging** - CT/MRI angiography. Arterial doppler. Echocardiogram **ECG** - Can show ischaemic picture if heart involved **Special Tests** - Ankle brachial pressure index

Answer 55

- Urgent admission and anticoagulation should be started immediately. - Surgical embolectomy or intra-arterial thrombolysis if occlusion is from embolus - Angioplasty or bypass surgery or thrombolysis - Managing risk factors/comorbidities e.g smoking, lipidemia

Answer 56

- Necrosis/Gangrene - Chronic pain syndrome

Answer 57

Communication between the left and right side of the heart hole in the septum that divides the atrial wall chambers

Answer 58

Asymptomatic in infants and children Subtle SOBOE/palpitations in second decade of life Adults with large defect → fatigue, exercise intolerance, palpitations, syncope, SOB, peripheral oedema, thromboembolic manifestations, and cyanosis

Answer 59

Widely split second heart sound. Soft systolic ejection murmur ECHO

Answer 60

Diuretics for those that develop heart failure. Surgical closure

Answer 61

Atrioventricular (AV) block (often referred to as “heart block”) involves the partial or complete **interruption of impulse transmission** from the **atria** to the **ventricles** **sub-types of AV block** including: - First-degree AV block - Second-degree AV block (type 1) - Second-degree AV block (type 2) - Third-degree (complete) AV block

Answer 62

- Rhythm: regular - P wave: every P wave is present and followed by a QRS complex - PR interval: prolonged >0.2 seconds (5 small squares) - QRS complex: normal morphology and duration (<0.12 seconds)

Answer 63

Second-degree AV block (type 1) is also known as **Mobitz type 1 AV block** or **Wenckebach phenomenon** ECG: - Rhythm: irregular - P wave: every P wave is present, but not all are followed by a QRS complex - PR interval: progressively lengthens before a QRS complex is dropped - QRS complex: normal morphology and duration (<0.12 seconds), but are occasionally dropped

Answer 64

Second-degree AV block (type 2) is also known as **Mobitz type 2 AV block** ECG: - Rhythm: irregular (may be regularly irregular in 3:1 or 4:1 block) - P wave: present but there are more P waves than QRS complexes - PR interval: consistent normal PR interval duration with intermittently dropped QRS complexes - QRS complex: normal (<0.12 seconds) or broad (>0.12 seconds) - The QRS complex will be broad if the conduction failure is located distal to the bundle of His

Answer 65

there is **no electrical communication** between the atria and ventricles due to a **complete failure of conduction** ECG: - Rhythm: variable - P wave: present but not associated with QRS complexes - PR interval: absent (as there is atrioventricular dissociation) - QRS complex: narrow (<0.12 seconds) or broad (>0.12 seconds) depending on the site of the escape rhythm (see introduction)

Answer 66

often in athletes post MI Lyme disease Congenital

Answer 67

- Increased vagal tone: often seen in athletes (non-pathological) - Drugs: beta-blockers, calcium channel blockers, digoxin, amiodarone - Inferior myocardial infarction - Myocarditis - Cardiac surgery (mitral valve repair, Tetralogy of Fallot repair)

Answer 68

- Myocardial infarction - Idiopathic fibrosis of the conducting system (Lenegre’s or Lev’s disease) - Cardiac surgery (especially surgery occurring close to the septum such as mitral valve repair) - Inflammatory conditions (rheumatic fever, myocarditis, Lyme disease) - Autoimmune (SLE, systemic sclerosis) - Infiltrative myocardial disease (amyloidosis, haemochromatosis, sarcoidosis) - Hyperkalaemia - Drugs (e.g. beta-blockers, calcium channel blockers, digoxin, amiodarone) - Thyroid dysfunction

Answer 69

- Congenital: structural heart disease (e.g transposition of the great vessels), autoimmune (e.g maternal SLE) - Idiopathic fibrosis: Lev’s disease (fibrosis of the distal His-Purkinje system in the elderly) and Lenegre’s disease (fibrosis of the proximal His-Purkinje system in younger individuals) - Ischaemic heart disease: myocardial infarction, ischaemic cardiomyopathy - Non-ischaemic heart disease: calcific aortic stenosis, idiopathic dilated cardiomyopathy, infiltrative disease (e.g. sarcoidosis, amyloidosis) - Iatrogenic: post-ablative therapies and pacemaker implantation, post-cardiac surgery - Drug-related: digoxin, beta-blockers, calcium channel blockers, amiodarone - Infections: endocarditis, Lyme disease, Chagas disease - Autoimmune conditions: SLE, rheumatoid arthritis - Thyroid dysfunction

Answer 70

asymptomatic

Answer 71

often asympto but can develop bradycardia and syncope, irregular pulse

Answer 72

Palpitations, Pre-syncope, Syncope, regular irregular pulse

Answer 73

- Palpitations - Pre-syncope/syncope - Confusion - Shortness of breath (due to heart failure) - Chest pain - Sudden cardiac death

Answer 74

Stop any AV blocking drugs if symptomatic then pacemaker from second t2 onwards place on cardiac monitor as a result of risk of complete AV block third degree: cardiac monitor, t**ranscutaneous pacing/temporary pacing wire** or **isoprenaline infusion, pacemaker**

Answer 75

First deg→ afib Second deg T1 → haemodynamically compromised second T2- complete AV block third→ sudden cardiac death

Answer 76

A bundle branch block is a condition in which there is a delay or blockage along the pathway that electrical impulses travel to make a heartbeat. The delay or blockage can occur on the pathway that sends electrical impulses either to the left or the right side of the bottom chambers (ventricles) of your heart. Bifascicular → involves both right bundle branch block as well as blockade of one of the fascicles of the left bundle branch. Trifasicular → is present when 3rd degree heart block exists along bifasicular block

Answer 77

A bundle branch block is a condition in which there is a delay or blockage along the pathway that electrical impulses travel to make a heartbeat. The delay or blockage can occur on the pathway that sends electrical impulses either to the left or the right side of the bottom chambers (ventricles) of your heart. Bifascicular → involves both right bundle branch block as well as blockade of one of the fascicles of the left bundle branch. Trifasicular → is present when 3rd degree heart block exists along bifasicular block

Answer 78

Dilated Cardiomyopathy (the main cause of LBBB) Left ventricular hypertrophic cardiomyopathy (LBBB) HTN MI myocarditis

Answer 79

RBBB Thin tall young people MI myocarditis

Answer 80

asymptomatic underlying cause symptoms like MI with chest pain or SOB

Answer 81

- MarRoW - QRS > 120 ms (3 small squares) - RSR’ pattern in V1-V3 - Wide, slurred S wave in lateral leads – I, aVL, V5-V6

Answer 82

- WiLliaM - QRS duration > 120ms (3 small squares) - Dominant S wave in V1 - Broad, monophasic R wave in lateral leads – I, aVL, V5-V6 - Absence of Q waves in lateral leads - Prolonged R wave > 60ms in leads V5-V6

Answer 83

Patient based treat any underlying cause if hx of syncope due to it then pacemaker

Answer 84

- Complete heart block - Ventricular tachycardia - Ventricular fibrillation

Answer 85

Accumulation of blood, fluid, pus, clots, or gas in pericardial space Results in reduced ventricular filling and reducing cardiac output and subsequent haemodynamic compromise Often: pericardial effusion cardiac tamponade - Iatrogenic (cardiac surgery/intervention), trauma, malignancy, idiopathic effusion, viral, radiation, uraemia

Answer 86

**Dyspnoea, tachycardia and tachypnoea cold and clammy extremities** Distended neck veins, hypotension tachycardia, tachypnoea and hepatomegaly

Answer 87

**Medical emergency!** emergency. Managed in ITU. Pericardiocentesis is definitive treatment

Answer 88

Myocardial disorder Heart muscle is structurally and functionally abnormal Without CAD, HTN, Valvular or congenital heart diseases. Degree of dysfunction ranges from lifelong symptomless forms to major health problems, such as progressive heart failure, arrhythmia, thromboembolism and sudden cardiac death.

Answer 89

- Dilated cardiomyopathy - Hypertrophic cardiomyopathy - Restrictive cardiomyopathy - Arrhythmogenic right ventricular cardiomyopathy (ARVC)

Answer 90

Primary: Idiopathic. No specific cause. Secondary: chronic kidney disease, cirrhosis, obesity, sarcoidosis, amyloidosis, SLE, diabetes, thyroid disease, thiamine deficiency, etc

Answer 91

- Symptomatic management - Mainly directed towards treatment of heart failure and prevention of VTE and sudden death - Implantable cardioverter defibrillators in high risk patients to prevent sudden death - Surgical myectomy/ alcohol septal ablation - Heart transplant

Answer 92

- Narrowing of the coronary arteries which leads to heart problem - Narrowing can occur as a result of blood clot or atherosclerosis - complete blockage leads to heart muscles dying leading to MI - Coronary flow occurs during diastole

Answer 93

- smoking - unhealthy diet (hyperlipidaemia) - age - common in men but increases for women after menopause - hypertension - diabetes - obesity - exercise - ethnicity

Answer 94

atherosclerosis

Answer 95

angina cold sweats dizziness neck pain shortness of breath

Answer 96

ECG Echocardiogram stress test

Answer 97

Immediate management - ABCDE atorvastatin Warfarin beta blocker ACEi ARB

Answer 98

Morphine Oxygen Nitrates Aspirin 300mg Reperfusion PCI Clopidogrel/Ticagrelor Heparin or LMWH

Answer 99

angina MI HF Stroke anxiety reduced qualy

Answer 100

A clot develops at a site of damage to a vessel wall (e.g. an atherosclerotic plaque, or perhaps a site of trauma). This can impair venous drainage of the leg.

Answer 101

- Stasis/immobility – e.g. hospital bed, long flight - Dehydration - Oestrogen ([pregnancy](https://almostadoctor.co.uk/encyclopedia/normal-physiology-of-pregnancy), and to a lesser extent, the [COC](https://almostadoctor.co.uk/encyclopedia/pills-and-similar-preparations) pill) - Genetic clotting defect (e.g. lack of protein C) - Obesity ([atherosclerosis](https://almostadoctor.co.uk/encyclopedia/atherosclerosis-and-coronary-heart-disease-chd)) - Age (old) - **[Varicose veins](https://almostadoctor.co.uk/encyclopedia/varicose-veins)** - Surgery - Previous DVT/embolism - Trauma - Infection - Malignancy **Virchow’s triad** of risk factors: - Stasis - Hypercoagulability - Vessel wall injury

Answer 102

- Red, swollen leg (particularly calf) - Tenderness - **Pitting oedema** - Fever

Answer 103

WELLS score - Venography - D-dimer - negative test rules out dvt - Leg measurement

Answer 104

- Score >3 – Treat as DVT –and also perform a compression USS to confirm - Score 1-2 – Treat as DVT – and perform compression USS to confirm - Score 0 –do a D-dimer test. If negative, then unlikely to be DVT. If positive, Treat as DVT, and perform compression USS.

Answer 105

LMWH Warfarin Thrombolysis

Answer 106

inflammation of the inner layer of the heart known as the endocardium

Answer 107

ACUTE - Present as a rapidly progressive disease with high fevers, rigors, and sepsis - Usually, staphylococcus aureus - Mostly happens in healthy hearts SUBACUTE - Delayed and presents as non-specific symptoms such as weight loss, fatigue, low-grade fever dyspnoea over several weeks to months - **Usually, streptococcus viridans** - Mostly occurs in pre-existing heart disease

Answer 108

- bacteria in other parts - gum disease - STI - Damaged heart valves

Answer 109

Murmurs join aches fever SOB Osler nodes

Answer 110

blood test CT MRI X-ray ECG

Answer 111

ADMIT Antibiotics

Answer 112

septic emboli stroke seizures

Answer 113

a type of chronic vasculitis characterized by granulomatous inflammation in the walls of medium and large arteries

Answer 114

- It usually affects people over 50 years of age. - European background - Females

Answer 115

Fever Fatigue anorexia Weight loss Depression scalp tenderness jaw claudication visual disturbance

Answer 116

refer temporal artery biopsy ESR CRP FBC LFT

Answer 117

ability of the heart to maintain the circulation of blood is impaired as a result of structural or functional impairment of ventricular filling or ejection.

Answer 118

- Heart failure with preserved ejection fraction (HF-PEF) - heart failure with reduced ejection fraction - LVEF less than or equal to 35-40%

Answer 119

**Class I** — no limitation of physical activity. Ordinary physical activity does not cause undue fatigue, breathlessness, or palpitations. **Class II** — slight limitation of physical activity. Comfortable at rest but ordinary physical activity results in undue breathlessness, fatigue, or palpitations. **Class III** — marked limitation of physical activity. Comfortable at rest but less than ordinary physical activity results in undue breathlessness, fatigue, or palpitations. **Class IV** — unable to carry out any physical activity without discomfort. Symptoms at rest can be present. If any physical activity is undertaken discomfort is increased

Answer 120

factors that can increase myocardial work may aggravate existing HF or initiate cardiac damage → decreases CO → neuroendocrine activation → increased peripheral resistance Fluid retention can also decrease CO

Answer 121

CHD AGE Diabetes. High blood pressure. Obesity. Other Conditions Related to Heart Disease. Valvular Heart Disease.

Answer 122

Fatigue increased peripheral venous pressure ascites enlarge liver and spleen distended jugular vein anorexia or GI distress weight gain oedema

Answer 123

Restlessness confusion orthopnoea tachycardia exertional dyspnoea fatigue cyanosis PND Pulmonary congestion

Answer 124

measure NT-proBNP (can also perform ecg, CXR blood test urinalysis peak flow or spirometry at this point) if bnp levels more than 2000 ng/l then refer urgently to be seen within 2 weeks if bnp between 400-2000 then refer urgently to be seen within 6 weeks if bnp below 400 then hf not confirmed and consider other causes

Answer 125

offer diuretics for fluid retention like furosemide if HF with pr EF then manage comorbidities and cardiac rehab if HF with red EF then offer aceI, BB and an MRA like spironolactone

Answer 126

- depression - cardiac arrhythmias - chronic kidney disease - sexual dysfunction - sudden cardiac death

Answer 127

- Age -increased risk with age - sex-More common in male than female - ethnicity - genetic factor - social deprivation - lifestyle - stress and anxiety - Other things that can raise BP Cocaine and other substance of abuse combine oral contraceptive corticosteroids NSAID Liquorice symptathomemtic

Answer 128

14/90 to 159/99

Answer 129

160/100 or higher but lower than 180/120

Answer 130

higher than 180/120

Answer 131

- Renal artery stenosis - Pheochromocytoma - Aortic coarctation - Cushing disease - Conn’s syndrome - Hyperparathyroidism

Answer 132

increase risk of: heart disease stroke chronic kidney disease peripheral artery disease

Answer 133

sys rises but diastolic remains in the normal range diastolic less than 80 but systolic is 130 or higher common in people older than 65

Answer 134

Caused by : - Artery stiffness - An overactive thyroid (hyperthyroidism) - Diabetes - Heart valve disease - Obesity

Answer 135

increase your risk of strokes, heart disease or ckf

Answer 136

HTN caused by a medication sympathomimetics (amphetamine) NSAIDS and COX inhibitor (ibuprofen) Corticosteroids (prednisone) CNS stimulants (caffeine) Oestrogen and Progesterone (contraceptives and ERT) Immunosuppressants (cyclosporine)

Answer 137

- Hypercholesterolemia, an elevation of total cholesterol (TC) and/or low-density lipoprotein (LDL)-cholesterol or non-HDL-cholesterol in the blood(dyslipidaemia). - increase in both cholesterol and triglycerides - primary e.g. genetic - secondary e.g. underactive thyroid

Answer 138

- Family history - Diet- food high in saturated fats - lack of physical activity - obesity

Answer 139

- Plaques of atheroma within inside lining of arteries - Many constituents: white blood cells, lipids (cholesterol and fatty acids), calcium, fibrous connective tissue - Over time gets larger and thicker → arterial narrowing → poor blood flow - Sometimes atheroma develops a tiny crack (rupture) → blood clot

Answer 140

- Hypercholesterolemia does not cause any symptoms but may eventually lead to heart attack, peripheral artery disease, or stroke due to atherosclerosis. - Familial hypercholesterolemia is associated with: - Xanthelasma palpebrarum (yellowish patches underneath the skin around the eyelids) - Arcus senilis (white or gray discoloration of the peripheral cornea) - Xanthomata (deposition of yellowish cholesterol-rich material) of the tendons

Answer 141

Health check programme - Incidental finding on bloods - Symptoms (angina/claudication) - Risk factors - Comorbidities - QRISK

Answer 142

Statins lipid lowering therapies e.g ezetimibe

Answer 143

- atherosclerosis - heart attack - stroke - any cvd

Answer 144

total cholesterol level greater than 7.4mmol/l and or family history of premature CHD

Answer 145

- Cardiac failure is a clinical syndrome where due to ventricular dysfunction, the heart has an impaired ability to cope with the metabolic requirements of the body and can lead to fluid retention, fatigue and breathlessness. This is due to the heart being unable to provide the tissue with adequate perfusion, leading to elevated pulmonary or systemic venous pressure which could lead to organ congestion. - Abnormalities can be with systolic or diastolic function, or both. - In systolic failure there is left ventricle dysfunction, leading to an increased diastolic volume and pressure and decreased ejection fraction (<40%). - In diastolic failure, there is a filling defect of the left ventricle, leading to an increased end-diastolic pressure and normal volume and a normal ejection fraction (>50%). - In right ventricular failure systemic venous pressure increases which can lead to fluid extravasation and congestion in the peripheries leading to oedema in the ankles and feet, and congestion in the abdominal viscera leading to hepatic dysfunction, and malabsorption.

Answer 146

- Hypertension - Advanced age - Female gender - Obesity - Diabetes - Chronic kidney disease - Coronary artery disease

Answer 147

- Fatigue - Shortness of breath at rest - Peripheral oedema (feet and ankles) - Persistent cough or wheeze - Reduced exercise tolerance - Peripheral oedema in feet and ankles – deep visible palpable imprint on digital pressure. - Enlarged liver - on palpation can be detected below right costal margin, may be able to illicit hepatojugular reflux. - Abdominal distention, can have ascites - Visibly raised JVP – large alpha or V waves may be seen, even at rest. - Pulmonary crackles on auscultation - S3 may be heard on auscultation

Answer 148

- Chest X-ray – enlarged cardiac silhouette, pleural effusion, fluid in major fissures, kerley B lines, upper lobe pulmonary venous congestion. ECG – may show previous MI, LVH, LBBB or any arrhythmia, such as AF, may indicate towards of cardiac failure Echocardiogram - to evaluate any structural abnormalities. - Systolic heart failure: dilated left/right ventricle and low EF, left ventricular hypertrophy, abnormal diastolic filling patterns - Diastolic: left ventricular diastolic dysfunction, left ventricle filling defect, normal EF. Cardiac MRI – can be used to further determine aetiology such as amyloidosis, sarcoidosis and myocarditis

Answer 149

**Conservative** - Dietary and lifestyle changing advice. Dietary sodium intake reduction, daily weights, regular exercise. **Medical** - BP control (see management algorithm in hypertension) - ACE inhibitors, beta blockers, ARBs can be used for long term management. - Diuretics, nitrates and digoxin for any symptomatic relief. - Implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy (CRT) devices can be considered in some patients. ICDs should be considered in patients with good expected clinical outcomes with symptomatic SVT or VF. CRTs can be considered in patients with an EF <35%, on ECG widened QRS (>0.15s) and LBBB. A CRT can also have an ICD incorporated. - In some patients (severe cardiorenal syndrome) venovenous filtration can be considered in an intensive care setting. **Surgical** - CABG can be considered in patients who have multivessel coronary artery disease - Valvular replacement can be considered in patients, especially those with primary mitral regurgitation.

Answer 150

- Chronic renal insufficiency - Pleural effusion - Anaemia - Acute decompensation of chronic heart failure - Acute renal insufficiency - Sudden cardiac death

Answer 151

Young children have small, slim chests so heart is near to stethoscope Blood travelling through heart and blood vessel can make a murmur like noise

Answer 152

Common in babies and young children Heart is usually working fine

Answer 153

Sometimes fevers can bring on heart murmurs in children. Get them back in in 1-2 weeks time for review

Answer 154

Obviously if symptomatic or other symptoms discuss with paediatrician / cardiology

Answer 155

Narrowing of the mitral valve

Answer 156

rheumatic fever. Degenerative calcification, congenital mitral stenosis, infective endocarditis, etc.

Answer 157

Progressive breathlessness is main symptom. Shortness of breath on exertion, orthopnoea, paroxysmal nocturnal dyspnoea Palpitations due to AF Malar flush, raised JVP, laterally places apex beat, right ventricular heave, loud first heart-sound with an opening snap in early diastole Mid-late diastolic murmur, best heard with the patient in the left lateral position, with the bell of the stethoscope

Answer 158

CXR: left atrial enlargement and interstitial oedema. Mitral valve calcification ECG- AF, left atrial enlargement and right ventricular hypertrophy ECHO

Answer 159

Diuretics long acting nitrates beta blocker percutaneous mitral commissurotomy Valve replacement

Answer 160

Bulging of one or both of the mitral valve leaflets into the left atrium During ventricular systole

Answer 161

Genetic? Myxomatous Degenenration

Answer 162

Usually incidental finding on clinical examination or ECHO

Answer 163

Low risk vs high risk No treatment/ beta-blockers/surgical repair or replacement

Answer 164

Mitral valve not closing properly, causing abnormal leaking from left ventricle through the mitral valve and back into the left atrium with the left ventricle contracts

Answer 165

Causes: traumatic, mechanical, infectious, degenerative, congenital or metabolic Acute caused by: infective endocarditis, ischaemic papillary muscle dysfunction or rupture

Answer 166

cxr, ECG,ECHO

Answer 167

Should be closed after birth but remains open - No umbilical cord: Increased oxygen levels and decreased prostaglandin from placenta help close PDA - So poor oxygenation (born prematurely) or increased prostaglandins in foetal circulation or increased sensitivity to prostaglandins keep it open - Rubella infection also keeps it open

Answer 168

Small PDA – asymptomatic Large PDA – LRTI, feeding difficulties, poor growth, failure to thrive Tachycardia, tachypnoea, wide pulse pressure, bounding peripheral pulses

Answer 169

Continuous murmur. Described as machinery murmur or Gibsons’ murmur - Accentuated in systole - Best heard in left infraclavicular area

Answer 170

- Diuretics in those with features of HF - Non surgical or surgical closure - In asymptomatic well infants: wait until 1 year of age with regular ECHO to check for spontaneous closure. If still open by 1 year of age  close with surgery

Answer 171

Collection of fluid in pericardial space Many causes. Local vs systemic - Local e.g.: Acute/chronic pericarditis → effusion - Systemic e.g.: kidney failure → rise in urea →uremic pericarditis → effusion

Answer 172

Small to moderate formed over some time: asymptomatic Quick forming → cardiac tamponade → symptoms Chest pain similar to pericarditis, light headedness, palpitations

Answer 173

Large effusions →drained if >1month - Smaller effusions → followed up with regular ECHO clinical examination - Oxygen therapy, treat underlying condition, surgery (pericardiocentesis?)

Answer 174

stand up→ blood shifts from chest to diaphragm → reduces venous return → reduces filling of vernicles → decrease preload → reduced CO This gravity induced drop BP is detected by baroreceptors →triggers baroreflex → vasoconstriction and compensatory tachycardia, also increase total peripheral resistance HOWEVER, postural hypotension occurs when this mechanism to regulate BP are impaired. It can occur due to: - Failure of baroreflexes (autonomic failure) - Volume depletion - End-organ dysfunction

Answer 175

Pregnancy Drugs Age Addison's disease Diabetes Parkinsons disease

Answer 176

Dizziness weakness confusion Blurred vision Nausea Headache syncope

Answer 177

Diagnosis is made by doing a lying and standing blood pressure. The patient lies down for 15 minutes, and the blood pressure is taken. The patient is then asked to stand for 2 minutes, and the blood pressure is taken again. A drop of >20mmHg along with symptoms is postural hypotension.

Answer 178

Management mainly involves avoiding exacerbating factors - Heat - Long periods of immobility - Large meals - Dehydration - Sitting with crossed legs Fludrocortisone Midodrine Pyridostigmine

Answer 179

increases falls decrease ADL

Answer 180

Superficial veins become inflamed and blood clot can occur - **Phlebitis** refers to inflammation of a vein and it can be caused by any insult to the blood vessel wall, impaired venous flow, or coagulation abnormality - **Thrombophlebitis** refers to the formation of a blood clot associated with phlebitis

Answer 181

blood flow stasis damage to the blood vessels walls Hyper-coagulability of bloods IV infusion, Obesity, Pregnancy, smoking, oral contraceptive

Answer 182

thrombophilia disorder hx of thrombophlebitis

Answer 183

- Localized redness & swelling of the vein affected - Pain or burning along the length of the vein - Vein feeling hard and cord-like

Answer 184

doppler ultrasonography biopsy/screening

Answer 185

compression socks keep legs elevated NDAIDS Hirudoid cream Fondaparinux

Answer 186

Suppurative thrombophlebitis ( a serious complication resulting in pus in the the vein, that can lead to the patient becoming septic)

Answer 187

chronic condition due to atherosclerosis of arteries

Answer 188

- High cholesterol, smoking, diabetes can cause arterial narrowing through inflammatory mediators - Narrowing of the arteries cause tissue hypoperfusion/hypoxia to tissues downstream of infarct - Signs/symptoms due to hypoperfusion

Answer 189

- Diabetes - Smoking - Hypertension - Lipidaemia

Answer 190

pain hx of cvd weak/absent pulses bruit

Answer 191

lipids doppler

Answer 192

Lifestyle advice - e.g. smoking cessation, healthy diet, weight loss/exercise Pharmacological treatment of identifiable cause - e.g. Treating hypertension, diabetes, lipidemia Symptomatic treatment with antiplatelets (aspirin, clopidogrel) and vasodilators (cilostazol-only effective in intermittent claudication) Surgical management (revascularisation) only used when lifestyle/pharmacological management has failed Revascularization also recommended for those with critical limb ischaemia (restpain/ABPI <0.3)

Answer 193

amputation

Answer 194

Extra heartbeats that begin in the atria or ventricles. These extra beats disrupt the regular heart rhythm, sometimes causing patients to describe a fluttering or skipped beat in their chest

Answer 195

- Premature beats are abnormal contractions that begin in the ventricles or atria - These extra contractions usually beat sooner than the next expected regular heart beat and they often interrupt the normal order of pumping - Certain triggers, heart diseases, scarring or changes in the body can make cells in the ventricles electrically unstable and electrical impulses to be misrouted

Answer 196

- Caffeine, tobacco, alcohol and illicit drugs - Exercise - if you have certain types of PVCs - Hypertension - Anxiety - Heart disease including CHD, CAD, previous MI, HF or cardiomyopathy

Answer 197

FHx Palpitation fluttering Syncope Fatigue Atypical chest pain

Answer 198

**Bloods** - FBC, TFTs, Electrolytes, calcium, magnesium **ECG** - An ECG will detect extra beats and identify the pattern and source - 24 hour ECG monitoring

Answer 199

**Conservative** - Lifestyle changes: Eliminating common triggers such as caffeine or tobacco **Medical** - Beta blockers - Calcium channel blockers - Antiarrhythmic drugs e.g amiodarone or flecainide **Surgical** - Radiofrequency catheter ablation (radiofrequency energy is used to destroy an area of heart tissue that is causing the irregular contractions)

Answer 200

- Increased risk of Arrhythmias - Cardiomyopathy - Sudden Cardiac death

Answer 201

a type of abnormal heart Rythm

Answer 202

- The cause is not known - Underlying mechanism typically involves an accessory pathway that results in re-entry

Answer 203

- Alcohol intake - Caffeine - Nicotine - Psychological stress - Wolff-Parkinson-White syndrome

Answer 204

Often patients have no symptoms. Otherwise symptoms may include: - Palpitations - Feeling lightheaded - Sweating - SOB - Chest Pain - Episodes start and end suddenly

Answer 205

ECG: Narrow QRS and a fast rhythm typically between 150 and 240 bpm

Answer 206

- If patient has normal BP, 1) Adenosine 2) CCB or BB 3) Synchronized cardioversion 4) Catheter ablation

Answer 207

Pulmonic valve diseases are rare Pulmonary stenosis are usually congenital diseases when they happen. Pulmonary regurgitation commonly occur as a complication of surgical procedures e.g to relieve symptoms of pulmonic stenosis. Can also occur due to pulmonary hypertension or marfans

Answer 208

- Pulmonic valves have three cusps and they regulate blood flow from the right ventricle into the lungs - Pulmonic stenosis causes an obstruction of blood flow to the lungs which lead to right ventricular dilation due to volume overload - Pulmonary regurgitation also cause volume overload during diastole causing right ventricular dilation

Answer 209

- Rheumatic disease - Congenital heart disease

Answer 210

- Sudden death - SOB - Exertional syncope - Parasternal heaves/thrills - Ascites/pedal oedema - In pulmonic stenosis, Systolic murmur can be heard best lying down (can be physiological in healthy individuals). Ejection pulmonic click can also be heard - Loud P2 (Pulmonic component may be heard in pulmonary regurgitation). Diastolic murmur also heard in pulmonary regurgitation

Answer 211

**Bloods** - FBC (Look for anaemia), Us and Es (Look for dilutional electrolyte problems), BNP (Might be raised in heart failure), LFTs (Might be deranged due to liver congestion) **X-ray/Imaging** - CXR might show cardiomegaly. Echocardiogram is useful in seeing valvular function **ECG** - Right ventricular hypertrophy. Right bundle branch block

Answer 212

- Manage cause as appropriate eg antibiotics for rheumatic fever - Resuscitation if acutely unwell. In neonates with pulmonic stenosis, prostaglandin infusion can be used to dilate the ductus arteriosus - Refer all symptomatic cases of pulmonic stenosis/regurgitation to cardiology. Mild Pulmonary regurgitation doesn't require any specific intervention other than for cardiologist to monitor every 1-3 years - If intervention required, patient might undergo valve replacement depending on severity

Answer 213

- Heart failure - Arrhythmia

Answer 214

Hypoperfusion associated with low or declining blood pressure 3 types: - cardiogenic - pump failure - Hypovolemic - loss of intravascular volume - failure of vasoregulation and obtruction to blood flow

Answer 215

cardiogenic: MI, Cardiomyopathy, valve issue and arrythmias Hypovolemic causes: Haemorrhage, burns, heat stress, GI losses Distributive causes: Sepsis, anaphylaxis, poising, Addison's disease Obstructive causes: Pulmonary embolus, cardiac tamponade, tension pneumothorax

Answer 216

cold, unwell, anxious, faint, SOB Oliguria Pale and sweaty Tachypnoea Cold peripheries Tachycardia postural hypotension confusion coma

Answer 217

FBC, U&E, LFT, group and cross-match, coagulation, blood gasses, monitor urine output, CRP, ESR, lactate, blood glucose, pregnancy test?, CXR, ECG

Answer 218

- Remember ABC. Regular OBS - Oxygen. Venous access. Resuscitation with fluid. Blood transfusion? - Vasodilators? Analgesia? Surgery if needed (ectopic pregnancy), vasopressors?

Answer 219

Stroke is a sudden onset of brain dysfunction, caused by **an alteration in cerebrovascular blood supply.** It is characterised by: - Rapid, acute onset – within a few minutes - Focal neurological defect Classification for stroke: - Haemorrhage - Brain ischaemia - TIA

Answer 220

- **Arterial embolism –** from a distant site; e.g. carotids, vertebral or basilar arteries. The embolus will occlude an artery of the brain resulting in infarction. May also come from **heart valves in endocarditis**. - **Haemorrhage –** can be in the cerebrum itself, or also a [subarachnoid haemorrhage](https://almostadoctor.co.uk/encyclopedia/subarachnoid-haemorrhage-sah) may cause a similar effect

Answer 221

HTN Smoking Exercise and diet Afib Diabetes Alcohol Cholesterol sleep apnoea carotid artery stenosis obesity ethnicity age heart disease Family Hx sex-male

Answer 222

- Limb and/or facial weakness - Paraesthesia or numbness - Speech difficulty (aphasia/dysarthria/dysphasia) - Headache

Answer 223

- Non-contrast CT head on admission, can be followed by CT angiogram for vascular causes. - MRI brain with diffusion weighted imaging to provide more accurate imaging about stroke lesion and/or haemorrhage. **Bloods** - FBC – to exclude anaemia or thrombocytopaenia prior to possible initiation of thrombolytic agents. - U&Es – to exclude electrolyte disturbance and renal failure - PT + PTT - coagulopathy - INR - Serum Glucose – to exclude hypoglycaemic cause - Cholesterol HDL/LDL - - Cardiac enzymes – concomitant MI **ECG** - To exclude cardiac arrhythmia or ischaemia, to identify AF/pAF **Special Tests** - ECHO – in subacute stage to investigate cardioembolic cause - Carotid and/or Vertebral Dopplers – in subacute stage to investigate for carotid stenosis

Answer 224

Acute management of Ischaemic stroke: - If patient presents within 4.5 hours of onset of neurological symptoms – r-tPA (alteplase 0.9mg/kg) - Aspirin 300mg OD to be commenced 24 hours post administration of r-tPA - Endovascular intervention (Thrombectomy) – patients must meet the following criteria: - mRS 0 - occlusion of ICA or proximal M1 - Age ≥18 years old - NIHSS ≥6 - ASPECTS ≥6 - Thrombectomy with stent retriever should be undertaken within 6 hours of onset. - Admission to stroke unit for ongoing medical care, treatment of any complications and early initiation of rehabilitation therapy. Encourage VTE prophylaxis and early mobilisation

Answer 225

- Increased risk of further event (Stroke or TIA) - Increased risk of haemorrhagic transformation of infarct - Sepsis - CKD - Death

Answer 226

- Visual loss or double vision - Confusion - Dizziness - Vertigo - Nausea

Answer 227

- Neck or facial pain.

Answer 228

- Limb and/or facial weakness (typically affects face, leg and arm) - Speech difficulty - Ataxia - Paraesthesias or numbness (typically affects face, leg and arm).

Answer 229

- Partial or total loss of tone in face and upper and/or lower limbs (usually unilateral) - Expressive and/or receptive dysphasia (or aphasia) - Decreased or loss of sensation in face and upper and/or lower limbs (associated sensory neglect if non-dominant hemisphere stroke) - Gaze paresis (often horizontal and unidirectional). - Gaze deviation (away from the side of lesion, towards the hemiparetic side) this should prompt consideration of seizure but can also occur infarcts in the pons or thalamus. - Horner's syndrome (suggests ipsilateral carotid dissection.)

Answer 230

: - Specific cranial nerve deficits (unilateral tongue weakness, diplopia) - Horner's syndrome (hemilateral triad of miosis, ptosis, and facial anhidrosis) - Loss of visual fields - Dysarthria - Nausea and/or vomiting - Difficulty with gait and fine motor co-ordination - Altered level of consciousness

Answer 231

- Pure motor hemiparesis - Pure sensory hemiparesis - Ataxia - Mixed motor and sensory signs - Dysarthria.

Answer 232

- Headache of gradually increasing intensity - Neck stiffness - Visual changes - Photophobia - Sudden onset of symptoms with progression over time - Aphaisa - Dysarthria - Ataxia - Sensory loss - Altered level of conciousness - NIHSS to calculate severity of stroke

Answer 233

- Lifelong anticoagulation with warfarin in patients with aetiology of AF - Antiplatelet therapy with clopidogrel is indicated in patients who do not have AF. - Carotid endarterectomy should be considered for patients with symptomatic carotid artery stenosis – no evidence for benefit of CEA in patients with near-occlusion. - Treat underlying aeitiology accordingly. - In patients with an embolic stroke of undetermined source and a patent foramen ovale (PFO) and high ROPE score, closure of the PFO may be of benefit for secondary prevention. Acute management of haemorrhagic strokes: - Neurosurgical review for potential need for surgical intervention (craniectomy/craniotomy) - Larger haemorrhages warrant ITU admission for intubation and invasive BP/ICP control - Stable haemorrhages warrant HASU admission to monitor haemorrhage, blood pressure control, DVT prophylaxis and correction of coagulopathy

Answer 234

Common cyanotic congenital heart disease Hole between ventricles → oxygen rich blood mixes with oxygen poor blood Overriding aorta = aorta is deeper in heart overlying the hole = the oxygen poor blood flows into the aorta too Pulmonary artery is narrowed = less blood reaches lungs = right ventricle works harder = hypertrophy

Answer 235

4 main anatomical features: - Large ventricular septal defect - Overriding aorta - Right ventricular outflow obstruction - Right ventricular hypertrophy Baby is blue due to lack of oxygenated blood

Answer 236

Foetal screening and ECHO have led to an increase in prenatal diagnosis Squatting to rest whilst exercising is characteristic of a right-to-left shunt and presents in an older child

Answer 237

Right heart valvular problems Tricuspid stenosis is rare. Tricuspid regurgitation is more common

Answer 238

- The tricuspid valve is in between the right atrium and ventricle - Tricuspid stenosis is commonly caused by rheumatic fever. Other causes include SLE, right atrial myxoma - In tricuspid stenosis the valves become thickened and narrow. This increases pressure in the right atrium causing dilation - Tricuspid regurgitation commonly occurs due to infective endocarditis. This causes an incompetency of the valve causing blood to flow back into the right atrium during ventricular systole - Tricuspid regurgitation may occur with mitral stenosis/regurgitation

Answer 239

- Congenital heart disease - Streptococcal infection

Answer 240

- Fever/history of previous untreated bacterial infection - Fatigue - SOB/exercise intolerance - - Pulmonary oedema/crackles (if biventricular heart failure) - Hepatomegaly - Ankle oedema - Raised JVP - Diastolic murmur in tricuspid stenosis. Pansystolic murmur in regurgitation (Accentuated by pressing the liver, inspiration or raising legs up) - Split S1 or S2 only heard - Ascites - Chest Pain

Answer 241

**Bloods** - FBC-Might show leucocytosis/Anaemia - LFT-Might show deranged LFTs - BNP-Raised in heart failure - Us and Es-might show dilutional electrolyte imbalance **X-ray/Imaging** - Echocardiogram to see valvular pathologies and pressure - CXR-may show right atrial enlargement/cardiomegaly/pleural effusion **ECG** - Tall P waves due to right atrial hypertrophy **Special Tests** - Cardiac catheterisation might be used to determine severity and associated congenital defects

Answer 242

- Manage underlying conditions eg Bacteria infections with antibiotics - Manage arrhythmias - Manage heart failure (see heart failure matrix condition) - Valve replacement in severe cases or if refractory to medical management (MIld cases of tricuspid stenosis/regurgitation does not need surgical input)

Answer 243

- Arrhythmia - Heart failure

Answer 244

One or more holes in the septum Communication between left and right ventricles of the heart

Answer 245

Symptoms depend on size of hole Not obvious at birth Exercise intolerance – impacts feeding  poor weight gain

Answer 246

Splitting of second heart sound, harsh pansystolic murmur ECHO

Answer 247

No treatment/ medical management/ surgical management

Answer 248

dilated and tortuous veins mainly occurring in the superficial venous system of the legs

Answer 249

occurs due to incompetence of the one-way valve → leakage →pooling of blood The weaker thinner walls make it more prone to the effects of high pressure build up leading to distension of the venous walls and tortuosity

Answer 250

increase with age pregnancy long periods of standing FHx common in female Hx DVT

Answer 251

often asymptomatic pain leg fatigue nocturnal leg cramps discoloration

Answer 252

clinically diagnosed doppler used to confirm diagnosis

Answer 253

exercise and weight loss refer to vascular Serivices compression therapy - IMPORTANT to exclude arterial insufficiency **Endothermal ablation** **(first line for surgery)**

Answer 254

bleeding DVT

Answer 255

Blood clot in the deep vein in the leg

Answer 256

DVT in leg, thighs, pelvis or abdomen → impaired venous flow and consequent oedema and pain

Answer 257

- Bedbound - Hospitalisation within 2 months - Major surgery within 3 months - Active Ca - History of trauma - Age - Pregnancy - Factor V Leiden - Obesity - Recent long-distance air travel - Family history

Answer 258

- On history taking note presence of risk factors and social history. - History of DVT or PE - Wells’ score <2 15% probability of DVT - Wells’ score >2 40% probability of DVT - unilateral swelling and difference in circumference more than 3 cm - Pain

Answer 259

- Wells’ Score - >2 = likely DVT - D-Dimer – Consider in patients with a wells’ score of 2 or above. - Elevated d-dimer: >500ng/mL – however d-dimer is non-specific and can be raised in patients who are older, acutely ill, have an underlying hepatic disease, have an infection, or are pregnant. - USS Lower Limbs – whole leg or proximal USS performed to assess the presence of a thrombus by compressibility and venous flow, the presence of a thrombus prevents compression, reduced or absent spontaneous flow, lack of respiratory variation, intraluminal echoes, or colour flow patency abnormalities. - CTPA – in patients with a confirmed DVT a CT pulmonary angiogram can be undertaken to exclude pulmonary emboli if clinically indicated.

Answer 260

Refer immediately for same day management for a woman who is pregnant or has given birth within past 6 weeks **For people who are *likely* to have DVT:** offer leg vein ultrasound **For people who are un*likely* to have DVT:** D-dimer **If interim therapeutic anticoagulation is required:** offer apixaban or rivaroxaban carry out baseline blood test e.g. FBC eGFR LFT PT and APTT

Answer 261

- Pulmonary Embolism (PE) - Risk of bleeding - Heparin-induced thrombocytopenia (HIT) - Heparin resistance/aPTT confounding - Post-thrombotic syndrome - Osteoporosis (if being treated with unfractionated heparin)

Answer 262

VT is a type of regular and fast heart rate that arises from improper electrical activity in the ventricles of the heart

Answer 263

VT can occur due to - CAD - Aortic stenosis - Cardiomyopathy - Electrolyte problems - Morphology of the VT depends on its cause and the origin of the re-entry electrical circuit in the heart - Monomorphic VT - scarring of the heart muscle from previous MI. This scar cannot conduct electrical activity - Polymorphic VT - abnormalities of ventricular muscle repolarization

Answer 264

- CAD - Structural heart disease - Electrolyte deficiencies e.g hypokalaemia, hypocalcaemia, hypomagnesaemia - Sympathomimetic agents (e.g caffeine or cocaine) may stimulate VT in vulnerable hearts

Answer 265

- Lightheadedness - Palpitations - Chest Pain - Dyspnoea - Syncope - Symptoms of HF - - Signs reflect degree of haemodynamic instability - Basal fine lung crepitations - raised JVP - Hypotension - anxiety - Agitation - lethargy

Answer 266

**Bloods** - electrolytes, including serum calcium, magnesium and phosphate levels. Serum troponin levels **X-ray/Imaging** - CXR if there is a possibility of CHF or other cardiopulmonary pathology as contributing factors **ECG** - showing a rate of greater than 120bpm and at least 3 wide QRS complexes in a row **Special Tests** - Levels of therapeutic drugs - e.g, digoxin

Answer 267

- Address the ABCs of resuscitation and provide BLS and ALS - VF or pulseless VT - unsynchronised defibrillation - VT - synchronised cardioversion - Defibrillation is followed by airway management if required, supplemental oxygen, vascular access

Answer 268

- Ventricular fibrillation - Cardiac Arrest

Answer 269

Fibrillation: disorganised electrical impulses causing the heart to quiver rather than contract Flutter: tachycardic arrhythmia affects the ventricles, considered as transition phase between ventricular tachycardia and ventricular fibrillation

Answer 270

- Ventricular Flutter is an arrhythmia characterised with a typical sinusoidal pattern on an ECG - With a frequency of 250-300 bpm, Ventricular Flutter, due to its repolarisation, results in minimal cardiac output and subsequent ischaemia - This can then lead to flutter becoming fibrillation - Ventricular Fibrillation is a life threatening condition caused by the disorganised excitation replacing organised electrical activity to the ventricles - The most common arrhythmia identified in cardiac arrest - The inability of the ventricles to contract efficiently reducing the cardiac output is what leads to cardiac arrest and eventually death if not treated within the time frame

Answer 271

- Previous ventricular fibrillation - Previous myocardial infarction - Cardiomyopathy - Drug toxicity - Electrocution - Congenital heart diseases - Sepsis

Answer 272

- Nausea - Vomiting - Tachycardia - Shortness of breath - Chest pain - Syncope

Answer 273

**Bloods** - FBC - U&E - LFT - CRP - Troponin - BNP - Toxicology **X-ray/Imaging** - CXR, Echocardiogram, CT, Angiogram **ECG** - Ventricular Fibrillation: unsynchronised rapid irregular electrical activity between 400-500 bpm - Ventricular Flutter: sinusoidal waves without clearly defined QRS and T waves, with a rate of 250-350 bpm **Special Tests** - Other comments: ECG will confirm the diagnosis of ventricular flutter/fibrillation. The rest of the work up is to determine possible cause of these arrhythmias and any damage caused as a result of the arrhythmias

Answer 274

- Beta blockers and surgical treatment are considered after patient is stable **Medical** - Defibrillation, CPR, Beta Blockers **Surgical** - Angioplasty, Coronary Artery Bypass Graft, Implantable Cardioverter Defibrillator

Answer 275

Sudden Cardiac Death

Answer 276

The heart is made up of 4 valves namely aortic, mitral, pulmonic, tricuspid These valves ensure a unidirectional flow of blood normally during systole and diastole

Answer 277

- Valvular heart failure can either be left or right sided depending on which valves are involved - Aortic and mitral valve heart failure are the two types of left sided valvular heart failure - Causes of left valvular heart failure includes idiopathic, SLE, Bicuspid aortic valve, rheumatic heart disease/infective endocarditis (can cause acute/chronic valvular heart failure) - Tricuspid and Pulmonic valve heart failure are the two types of right side heart failure - Pulmonic stenosis can cause valvular heart failure and they are usually congenital related heart failure caused by Tetralogy of fallot, congenital rubella syndrome - Tricuspid valve heart failure can be caused by rheumatic fever and it results in dilation of the right ventricle - Generally speaking, valvular heart failure results in either concentric or eccentric hypertrophy

Answer 278

- Rheumatic fever - IV drug use - Congenital heart disease - Autoimmune conditions

Answer 279

- SOB/reduced exercise intolerance - Orthopnea - Dizziness/LOC - Chest Pain - Lethargy/’blue spells’ in children - Haemoptysis-pressure in the bronchial veins - - Tachycardia/Tachypnea - Raised JVP with hepatojugular reflux - Bilateral pedal oedema - Displaced apex beat - Abdominal distension - Heart murmurs (Can include Pansystolic, Mid systolic, Ejection systolic/Ejection clicks depending on which valves are involved) - Cardiac wheeze/reduced air entry - Framingham criteria is used to diagnose heart failure regardless of the cause. It uses full history, physical examination findings and CXR and it includes major and minor criteria

Answer 280

**Bloods** - FBC-For anaemia - BNP-marker of heart failure, LFT-heart failure can mildly affect liver function, Renal function tests-Deranged electrolytes - Thyroid function test - Blood cultures **X-ray/Imaging** - CXR-Cardiomegaly/interstitial fluid - Echocardiogram - (Urgency depends on BNP levels and history of MI (request echo within 2 weeks and no need for BNP). If no hx of MI and BNP between 100-400 request echocardiogram within 6 weeks and if >400 request echo within 2 weeks). Echocardiogram will then categorise heart failure into either reduced ejection fraction or preserved ejection fraction **ECG** - LVH. Arrhythmias. Bundle branch blocks depending on which valves are involved

Answer 281

- If acute presentation, use ABCDE - Treatment will depend on cause e.g IV antibiotics for rheumatic fever - Refer to cardiology-Symptomatic valvular problems might require TAVI or valvuloplasty depending which valves are involved - Chronic but stable management will involve the stepwise ladder of ACEi and Beta blockers (1st line), ARB/Hydralazine with nitrate/Aldosterone antagonist (2nd Line), Digoxin or cardiac resynchronisation therapy (3rd line) - See matrix condition on Aortic stenosis/Regurgitation, Mitral stenosis/regurgitation, Pulmonic stenosis/insufficiency, Tricuspid stenosis/insufficiency

Answer 282

- Death - Arrhythmias