Disease Flashcards
(164 cards)
1
Q
What is cardiogenic shock?
A
inadequate systemic perfusion as a result of cardiac dysfunction
2
Q
What are some of the main differential diagnoses of chest pain?
A
- GI tract
- MSK
- pericarditis
- pleuritic pain
3
Q
What are the main heart emergencies?
A
- MI
- PE
- dissection of aorta
4
Q
What are the pros of exercise testing?
A
- cheap
- reproducible
- risk stratification
5
Q
What are the cons of exercise testing?
A
- poor diagnostic accuracy
- submaximal tests
6
Q
What are the pros of perfusion imaging?
A
- non-invasive
- pharmacological stress in less mobile patients
- more precise than exercise tests
- risk stratification
7
Q
What are the cons of perfusion imaging?
A
- radiation
- false positives and negatives
8
Q
What are the pros of CT angiography?
A
- non-invasive
- anatomical data and risk stratification
9
Q
What are the cons of CT angiography?
A
- radiation
- less precise than angiography, particularly when calcium is present
- cost
10
Q
What are the pros of angiography?
A
- anatomical and risk stratification
- follow-on angioplasty
11
Q
What are the cons of angiography?
A
- risk of stroke
- radiation
- contrast: renal dysfunction, rash and nausea
12
Q
What is the PCI technique?
A
vascular access anticoagulation catheter to osmium of coronary guide wire down vessel balloons threaded over wire stents implanted
13
Q
What is the suitabilities for revascularisation?
A
- multi-vessel disease
- left main disease
- diabetes
- co-morbidities
14
Q
What happens when infection gets into the compartments of the feet?
A
the infection gets trapped so there is a buildup of pus which builds pressure so there is cell death and necrosis
15
Q
What are the systemic and local effects of diabetic foot sepsis?
A
systemic- pyrexia tachycardia tachypnoea confusion
local- swelling tenderness ulcer erythema necrosis crepitus no pedal pulses
16
Q
What is the management of diabetic foot sepsis?
A
- emergency
- debridement
- removal of al infected tissue
17
Q
What is stroke?
A
Acute onset of focal neurological symptoms and signs due to disruption of blood supply
18
Q
What are the two types of stroke?
A
Haemorrhagic- bleeding occurs inside or around the brain tissue (raised blood pressure and weakened blood vessel walls due to inflammation or structural abnormalities)
Ischaemic- clot blocks blood flow to an area of the brain
19
Q
What are the types of ischaemic stroke?
A
Thrombotic (clot blocking artery at the site of occlusion)
Embolic (clot blocking artery has moved and is blocking another area)
Hypoperfusion (reduced blood flow due to stenosed artery)
20
Q
What is Virchow’s triad?
A
circulatory stasis, endothelial injury and hypercoagulable state
21
Q
What are the risk factors for stroke?
A
non-modifiable= age, family history, gender, race or previous stroke modifiable= hypertension, hyperlipidaemia, smoking, AF, diabetes, exercise and alcohol
22
Q
What is treatment of ischaemic stroke?
A
thrombolysis (dissolve clot) or thrombectomy (remove with stent)
23
Q
How to tell is a stroke is caused by an atheroembolism or cardioembolism?
A
For atheroembolism carotid scanning or CT of aortic arch
For cardioembolism ECG , echo
24
Q
How to test to see if stroke is haemorrhagic?
A
hypertension, look for aneurysm or other rare disease
25
How to treat stroke due to thrombus?
antiplatelet, statins, diabetes treatment, hypertension treatment and lifestyle
26
What are TIAs?
temporary neurological symptoms due to occlusion of artery stopping blood flow
27
What does clopidogrel bind to?
ADP on platelet to stop it causing activation of cascade
28
What does aspirin bind to?
stops thomboxane A2 being produced
29
What are the risks of thrombolysis?
haemorrhage, hypersensitivity and failure to re-perfuse
30
What is the treatment for STEMI?
```
analgesia (diamorphine)
anti-emetic (IV)
aspirin
GTN (if BP us over 90mmHg)
oxygen (if hypoxic)
primary angioplasty
thrombolysis (if angioplasty not available in 120 minutes)
```
31
What are the main complications of STEMI?
death
arrhythmic complications- ventricular fibrillation
structural complications- cardiac rupture, ventricular septal defect and mitral valve regurgitation, left ventricular aneurysm formation, mural thrombus, inflammation and acute pericarditis
functional complications- acute ventricular failure, chronic cardiac failure and cardiogenic shock
32
What other conditions can have elevated troponin?
```
CCF
hypertension
renal failure
sepsis
PE
stroke
pericarditis
post-arrhythmia
```
33
What is a type 2 MI?
due to imbalance of oxygen supply from coronary spasm etc, anything that increases myocardial oxygen demand or reduces myocardial blood flow
34
What does interstitial fluid act as?
the go-between blood and body cells
35
How much of the body water is extra-cellular?
1/3rd
36
What do the terminal arterioles do?
regulate regional blood flow to the capillary bed
37
Why is blood flow through the capillary bed slow?
to allow for adequate exchange
38
What do pre-capillary sphincters do and what is an example of where they are found?
regulate blood flow eg in mesentery
39
What is trans-capillary fluid flow passively driven by?
pressure gradients across capillary wall
40
What is net filtration pressure proportional to?
forced favouring filtration minus forces opposing filtration
41
What is the filtration coefficient representative of?
how permeable the capillaries are to fluid
42
What are the forces favouring filtration?
capillary hydrostatic pressure and interstitial fluid osmotic pressure
43
What are the forces opposing filtration?
capillary osmotic pressure and interstitial fluid hydrostatic pressure
44
What do Starling forces favour?
filtration at the arteriolar end and reabsorption and the venular end
45
What forces change from arteriole to venule end?
osmotic doesn't change
| hydrostatic pressure decreases
46
What is oedema?
is an accumulation of fluid in the interstitial space
47
What is different about the lung circulation?
pulmonary resistance is much lower so hydrostatic pressure is lower in the lungs but osmotic pressure is normal
48
What happens to diffusion and gas exchange in pulmonary oedema?
increased diffusion distance
| compromised gas exchange
49
What is pulmonary oedema?
pulmonary oedema is accumulation of fluid in the interstitial and intra-alveolar lung spaces
50
What is clinically seen in pulmonary oedema?
SOB seen and crepitations in lung bases, haziness in perihilar region of CXR
51
What are the factors causing oedema?
- Raised capillary pressure: arteriolar dilation, raised venous pressure (LVF so pulmonary oedema as fluid can’t come back from the lungs and RVF so peripheral oedema)
- Reduced plasma osmotic pressure: malnutrition, protein malabsorption, excessive renal excretion of protein and hepatic failure
- Lymphatic insufficiency: lymph node damage and filariasis
- Changes in capillary permeability: inflammation and histamine increases leakage of protein
52
What does heart failure do to the Frank-Starling curve?
shifts to the right so the curve appears to have dropped in height
53
What type of MI causes bradycardia?
inferior
54
What are the complications of MI?
- arrhythmias
- ventricular septal perforation
- mitral regurgitation
- ventricular free wall rupture
- systemic embolism
- ventricular aneurysm
- pericarditis
- cardiogenic shock
55
How do you treat a polymorphic VT?
DCCV, Cath lab, electrolyte correction, amiodarone (w/glucose not saline), beta-blocker
56
When should you not give nitrates?
hypotension and if headaches are too bad (1 in 10)
57
What is cardiac arrest?
effective cessation of the heart so there is no circulation and no oxygen delivered
58
What are the four parts of the chain of survival?
- early recognition and call for help
- early CPR
- early defibrillation
- post resuscitation care
59
How to treat excess or reduced afterload?
vasodilators for excess afterload
vasoconstrictors for reduced
afterload
60
How do you assess oxygen delivery factors in an ABC scenario?
- SaO2: clinical, pulse oximetry and ABG
| - [Hb]: clinical, part of FBC and bedside
61
What can the airway be obstructed by?
- CNS depression so tongue
- Blocked lumen
- Swelling
- Muscle
62
What are some primary causes of circulatory problems?
- acute coronary syndromes
- dysrhythmias
- hypertensive heart disease
- valve disease
- drugs
63
What are some secondary causes of circulatory problems?
- asphyxia
- hypoxaemia
- blood loss
- hypothermia
- septic shock
64
What things do you test in D of ABCDE?
AVPU
GCS
Pupils
Glucose
65
What are the features of VF?
- shockable
- bizarre irregular waveform
- random frequency and amplitude
66
What are the features of VT?
- shockable if pulseless
- monomorphic has broad complex rhythm, rapid rate and constant QRS morphology
- polymorphic is torsades de pointes
67
How often do you defibrillate between rounds of CPR?
every 2 minutes
68
How often do you administer adrenaline in CPR?
after 3rd shock then after every alternate shock
69
What are the features of asystole?
- non-shockable
- absent QRS
- P waves may persist
- adrenaline as soon as possible then every 3-5 minutes
70
What are the features of PEA?
Pulseless electrical activity
- non-shockable
- ECG with an output
- treat reversible causes
- give adrenaline asap then every 3-5 minutes after
71
What are the two drugs in advanced life support?
- adrenaline 1mg every 3-5 minutes which is an alpha vasoconstrictor and is beta inotropic
- amiodarone 300mg
72
What are the reversible causes of cardiac arrest (4Hs and 4Ts)?
- hypoxia
- hypovolaemia
- hypo-/hyperkalaemia
- hypothermia
- thrombosis
- tension pneumothorax
- tamponade
- toxins
73
What are exertion symptoms characteristic of?
valvular heart disease
74
What will be the signs of right heart failure?
raised JVP (4cm or above is not normal)
pitting oedema
hepatic congestion
75
What is a tapping apex a sign of?
mitral stenosis
76
What does a displaced and diffuse apex beat suggest?
LV dilation so volume overload
77
What does a displaced and heaving apex beat suggest?
LVH and pressure overload
78
What is the sign associated with right ventricular overload?
left parasternal heave
79
What are the main categories for describing murmurs?
- systole or diastole
- type (eg pansystolic)
- where it is loudest
- radiation
- grade (1-6 with 4+5 including addition of a thrill)
- changes with respiration
80
What is the condition associated with a continuous murmur?
patent ductus arteriosus
81
What is an innocent murmur?
soft, position dependent and is often early systolic (if diastolic it is almost always pathological)
82
What are the features of aortic stenosis?
- Degeneration with age
- Congenital (aortic valve is bicuspid)
- Rheumatic §
83
What are the symptoms and signs of aortic stenosis?
SOB, chest pain, dizziness, syncope
low volume pulse, forceful displaced apex, ejection systolic murmur radiating to the carotids, pressure gradient across the valve indicates aortic stenosis
84
What is seen on an ECG with aortic stenosis?
LVH
85
What is the treatment for aortic stenosis?
valve replacement, Trans catheter aortic valve replacement (TAVI is not an open heart procedure) and balloon aortic valvotomy (BAV)
86
What are the choices of prosthetic valves for aortic stenosis?
mechanical lasts longer and need warfarin so younger patients, bio-prosthetic only lasts 10 years and no warfarin so older patients
87
What are the features of mitral regurgitation?
- Leaflets can be affected by prolapse, rheumatic, myxomatous or endocarditis
- Chordae rupture can prolapse
- Papillary muscle rupture
- Annular dilation
88
What are the signs and symptoms of mitral regurgitation?
SOB, peripheral oedema, fatigue
| Displaced apex and pansystolic murmur radiating to axilla
89
What is seen on a CXR for mitral regurgitation?
cardiomegaly
90
What is the treatment for mitral regurgitation?
medication (diuretics and heart failure), surgical (repair prolapse or replace degenerative) and percutaneous
91
What is the main feature of mitral stenosis?
rheumatic
92
What are the main symptoms and signs of mitral stenosis?
SOB, fatigue, palpitations so AF
| Malar flush, tapping apex beat and mid diastolic rumbling localised to apex
93
What is seen on a CXR in mitral stenosis?
cardiomegaly and straight left heart border for enlarged left atrium
94
What is the treatment for mitral stenosis?
medication (diuretics and treat AF), surgery (valve replacement) and balloon valvuloplasty
95
What are the features of aortic regurgitation?
Leaflets so endocarditis, connective tissue disease or rheumatic
Annulus so Marfans or aortic dissection
96
What are the signs and symptoms of aortic regurgitation?
SOB
| Collapsing pulse, wide pulse pressure, displaced apex and early diastolic murmur at left sternal edge
97
What is seen on a CXR for aortic regurgitation?
cardiomegaly
98
What is the treatment for aortic regurgitation?
medications so ACEI and surgery
99
What is congenital heart disease?
an abnormality of the structure of the heart which is present at birth
100
What is the spectrum of severity for congenital heart disease?
Mild- asymptomatic that can resolve or progress
Moderate- requires intervention from a specialist and monitoring from a cardiac centre
Severe- will present very ill and will be an extreme problem if not dealt with
101
How can congenital heart disease present?
- antenatal screening
- well baby with clinical signs
- unwell baby with cyanosis, shock or cardiac failure
102
How are newborns tested for congenital heart disease?
clinical examination
femoral pulses
murmurs
pre and post ductal sats
103
What are the differentials of mixing oxygenated and deoxygenate blood causing cyanosis?
- cardiac disease (undistressed)
- respiratory disease (grunting, respiratory stress and CXR changes)
- PPHN (very unwell babies, septic, acidotic with large pre to post ductal differences)
104
What are the differentials of a collapsed baby at time of duct closure?
sepsis
congenital heart disease
metabolic condition
105
How will a collapsed baby present?
- very severe cyanosis, pallor, tachypnoea, distress, rapid deterioration to death
- poor pulses, hepatomegaly, creps, increased work of breathing and acidosis
106
What does a left to right shunt cause in cardiac failure?
increased pulmonary blood flow and increased ventricular load
107
How does cardiac failure present in a baby?
failure to thrive, breathless when feeding, no more weight increase
108
What is the treatment for congenital heart disease?
surgery (repair or palliation), developmental problems in later life (hypoxia and bypass time), further surgery and emotional issues
109
What are the differences between fetal and adult circulation?
- placenta has a role in gas exchange, waste excretion, acid base balance, hormone production, IgG transport, nutrition
- baby has unexpanded fluid-filled lungs
- liver does not have a large role in nutrition or waste management
- gut is not used
110
What is the placenta's role in fetal circulation?
- foetal heart pumps blood to the placenta via the umbilical arteries
- blood from the placenta returns to the foetus via the umbilical vein
111
What does the ductus venous do?
connects the umbilical vein to the inferior vena cava next to the liver and carries the majority of the placental blood
112
What is the foramen ovale?
connection between the RA and LA and is an opening in the mitral septum so allows oxygenated blood into the left atria to go into the aorta
113
What does the ductus arteriosus do?
connects pulmonary bifurcation to the descending aorta
114
How is the patency of the ductus arteriosus maintained?
circulating prostaglandin E2 made by the placenta that relaxes the smooth muscle in the walls
115
What are the main changes that occur at birth?
- lungs open, arterioles have more space to expand so they unfold and the oxygen levels go up so pulmonary vascular resistance drops
- systemic resistance rises as cardiac output to the lungs increases
- foramen ovale closes
- ductus arteriosus closes as it constricts due to oxygen, less blood it flowing and less prostaglandin is holding it open, it then becomes ligament arteriosum
116
How to treat ductus arteriosus that has failed to close?
wait
ibuprofen
surgery
117
When does pulmonary resistance drop to normal levels in a baby?
2-3 months
118
What is PPHN?
Persistent pulmonary hypertension of the newborn is when the resistance to flow in the lungs fails to drop
Pressure in the right heart > left side of the heart so right to left shunt at foramen ovale and ductus arteriosus
119
What is seen clinically in PPHN?
difference between pre and post ductal o2 sats so hands and feet
120
How is PPHN treated?
- lowering PVR so oxygen, ventilation, sedation, thermoregulation, sepsis treatment, acidosis correction and inhaled NO
- increasing systemic vascular resistance so high blood pressure and inotropes
121
What can cause failure to thrive in babies?
- sepsis
- hypoxic ischaemic insult
- meconium aspiration syndrome
- cold stress
- prematurity
122
What ECG feature supports the diagnosis of ischaemic heart disease?
ST depression while exercising
123
What are the main anti-anginal drugs?
```
potassium channel activators eg Nicorandil
nitrates
beta-blockers
calcium channel blockers
ivabradine
```
124
What diseases have raised endothelin?
```
MI
heart failure
ARF
asthma
primary pulmonary hypertension
```
125
What does infective endocarditis increase the risk of?
stroke/ systemic emboli
126
What is bacteraemia?
bacteraemia is bacteria in the bloodstream which is life-threatening and can cause septic shock
127
What is the coagulase test used for in infective endocarditis?
coagulase test distinguishes S.aureus from coagulase-negative staph
128
What are the most common skin organisms?
S. aureus
| S. epidermidis Corynebacterium sp. Propionibacterium acnes
129
What are the risk factors for having an infected implantable cardiac device?
are lack of prophylaxis, number of interventions, fever within 24 hours, heart or renal failure
130
What are the symptoms of ICD infections?
fevers, chills, night sweats, malaise and anorexia
131
What is the criteria used to assist diagnosis of infective endocarditis?
Duke's criteria
132
What is infective endocarditis?
an infection of the endothelium of the heart valves and can be acute or subacute
133
What are the risk factors for infective endocarditis?
heart valve abnormalities, prosthetic heart valves, IV drug users
134
What is the pathogenesis of infective endocarditis?
- damages heart valve
- turbulent flow
- platelets deposited
- bacteraemia and organisms settle and form a microbial vegetation
- vegetations are fixable and break off
- these cause abscess or haemorrhage
135
What are the most common organisms for infective endocarditis?
- S.aureus and viridans streptococci are the most common
- can be by enterococcus sp or staph epidermidis
- Q-fever so coxiella burnetii is atypical
- HACEK is a group of organisms that are Gram-negatives
136
What is the presentation of acute infective endocardiits?
overwhelming sepsis and cardiac failure
137
How does subacute infective endocarditis present?
fever, malaise, weight loss, tiredness and breathlessness with clubbing, splinter haemorrhage, splenomegaly, janeway lesions and osler nodes
138
What are the ways in which streptococci can be named?
oxygen requirement, lancefield groups, haemolysis on agar
139
What are the features of viridian's strep?
alpha haemolytic and cause subacute endocarditis
140
What is the treatment for prosthetic valve infections?
vancomycin and gentamicin IV then add in rifampicin PO delayed 3-5 days
141
What is the treatment for native vale infection?
amoxicillin and gentamicin IV
142
What is the treatment for IV drug abusers with valve endocarditis?
flucloxacillin IV
143
How long are antibiotics given for infective endocarditis?
4-6 weeks
144
What is mortality for infective endocarditis?
15-30%
145
What is the presentation of myocarditis?
- more common in young people and sudden death, - - presents with chest pain, fever, SOB and palpitations, with arrhythmia and cardiac failure
- diagnosed with viral PCR
146
What is the presentation of pericarditis?
- often occurs with myocarditis
- chest pain
- supportive treatment for mostly viral causes
147
What is seen on a CXR with heart failure?
Pulmonary oedema/congestion: A-Alveolar oedema
Septal/Kerley B lines: B-B lines
Cardiomegaly: C-Cardiomegaly
Upper zone vessel enlargement: D-Diversion of vessels
Pleural effusion: E-Effusion
148
What are the ECG signs with PE?
Sinus tachycardia (the most common)
Signs of right heart strain (not left)
T wave inversion in the anterior leads
149
What are channelopathies?
mutations in the genes that encode the cardiac ion channels
150
What are the features of channelopathies?
- repolarisation is affected
- abnormalities on the ECG
- normal cardiac structure and function
- atrial and ventricular arrhythmias can arise
151
What does congenital long QT present with?
usually asymptomatic but can present with sudden cardiac death, palpitations and syncope
152
What are the common associated arrhythmias with clQT?
polymorphic VT (Torsades de Pointes with spiral and axis change), lone AF or heart block
153
What are triggers for clQT?
- exercise
- sudden auditory stimuli
- sleep
- QT prolonging states so medication or hypokalemia
154
What is the basic mechanism of clQT?
less K+ out and more Na+ and Ca2+ in
155
What is the treatment for clQT?
beta blockers (nadolol) and avoidance of triggers and QT prolonging drugs
156
What does Brugada present with?
asymptomatic or palpitations and syncope
157
What is seen on an ECG for Brugada?
ST elevation with right bundle branch block in leads V1-V3
158
What is the treatment for Brugada?
Insert an ICD, avoid some drugs and screen family members
159
What are the associated arrhythmias with Brugada?
AF is common and there is a risk of polymorphic VT and VF (triggered by sleep, fever, large meals and alcohol)
160
What is the treatment for HCM?
beta-blocker, if there is outflow tract obstruction then drugs, septal ablation or surgery
161
What is the presentation of arrhythmogenic right ventricular cardiomyopathy?
ventricular arrhythmia, cardiac failure and sudden cardiac death
162
What happens to the heart in ARVC?
fibro-fatty replacement of cardiomyocytes in the right ventricle and sometimes there is left ventricular involvement
163
What heart failure medications are only for symptoms?
vasodilators (nitrates and hydralazine)
loop diuretics
digoxin
164
What heart failure medications are to increase prognosis?
selective beta blockers
ACEIs
angiotensin II antagonist
spironolactone (potassium-sparring diuretic)
