Block 31 Week 3 Flashcards

Question

palpitations - malignant arrythmia ?

Answer 1

* VT and VF * mostly occur in failing hearts * often presentation is death or aborted death

Answer 2

* 10% of over 65s will have this * as multiple foci and chaotic atrial rate, it's random as to when the signal passes to the ventricles so there's an irregular ventricular rate

Answer 3

* no P wave * irregular rhythm * narrow QRS complexes (less than 120ms) * rate (complexes in rhythm strip x6 for irreg rhythm)

Answer 4

* tachy-induced cardiomyopathy * perisistent fast AF undiagnosed can lead to reduced cardiac function anf heart failure

Answer 5

* loss of atrial contraction leads to loss of 30% of ejection of blood into left ventricle prior to ventricular systole * can be v significant in those with already impaired ventricular function or diastolic/ filling failure

Answer 6

* loss of co-ordinated activity means blood remains static in the atria * blood clots settle out espec in left atrial appendage * blood clots from LA can pass into LV and occlude cranial arteries resulting in ischaemic stroke

Answer 7

* Paroxysmal * perisistent * permanent

Answer 8

* intermittent episodes (go back into sinus rhythm in between) * terminate spont w/o medical intervention * pAF

Answer 9

* ep can be terminated but requires medical intervention

Answer 10

* medical intervention doesn't re-establish sinus R or does not hold it in sinus rhythm for long

Answer 11

- CHAS2DS2-VASc score * assesses patient w AF's risk of stroke

Answer 12

* Score of 1 (unless if the 1 is due to the patient being female) = consider AC * 2+ offer oral AC

Answer 13

cause haemorrhagic stroke

Answer 14

* patients already established on warfarin may choose to remain on it * still used as first line in patients w metal heart valve replacement

Answer 15

* Used as bridging therapy - easy to start and stop e.g. for surgery * used in patients with severe renal failure who are unable to take DOAC or warfarin

Answer 16

* Edoxaban * apixaban * rivaroxiban * dabigatran

Answer 17

* all largely excreted renally * imp to check creatinine clearance - CI if creatinine clearance less than 15

Answer 18

* 1st line: BBs e.g. bisporolol, metoporolol (can drop BP though) * rate limiting CCB: Diltiazem * Digoxin (check renal function)

Answer 19

beta blockers

Answer 20

* consider if symptoms continue despite rate control * pharmacological cardioversion: amiodrane & flecanide

Answer 21

* electrical cardioversion in those w life-threatening haemodynamic instability acutely * also done electively for those w persistent AF

Answer 22

- Left atrial ablation - left atrial appendage occlusion

Answer 23

* if drug tx failed or unsuitable * pulm veins often the source of abn electrical impulses in AF - these can be isolated where scar tissue is formed near PV to stop abn electrical impulses transferring * uses catheter

Answer 24

* either surgically or percutaneously * useful for those w AF with a high bleeding risk

Answer 25

* multiple foci, chaotic contraction * self perpertuating loop (re-enterant circuit) often around RA * saw-toothed pattern on ECG

Answer 26

usually 150bpm every time for flutter w 2:1 block

Answer 27

* calc CHADS2VASC score for stroke risk * and HAS-BLED score for AC * rhythm, rate control and check LV function - echo

Answer 28

* pacemaker sends electrical impulses to the heart to keep it beating regularly and not too slowly * used for: tachycardia, bradycardia, heart block, cardiac arrest

Answer 29

* Sends large electrical shock to the heart which reboots it getting it to pump again * ICDs are often used as a preventative treatment for people thought to be at risk of cardiac arrest at some point in the future. * If the ICD senses the heart is beating at a potentially dangerous abnormal rate, it'll deliver an electrical shock to the heart.

Answer 30

alcohol and amphetamines

Answer 31

failure of the heart to meet the circulatory demands of the body

Answer 32

* 10% of over 75s * HF can mildly elevate troponin levels

Answer 33

* Systolic: heart failure with reduced EF * Diastolic: HF with preserved ejection fraction * Left vs right ventricular failure * acute vs chronic

Answer 34

* Cardiomyopathies * congenital HD * ischaemic HD * arrythmuias * hypertension * hyperthyroidism * anemia * chemotherapy * alcohol * drugs

Answer 35

* passive filling * atrial contraction * start of ventricular contraction * closure of mitral and triscupid valves * as pressure increases the aortic and pulmonary valves are forced open * blood forced into aorta from lV and into pulmonary arteries by RV * ventricles relax causing bloodflow back down aorta which closes the aortic valve

Answer 36

* Myocardial ischaemia - not enough oxygen and nutrients to do its function * hypertension - increased peripheral resistance which is too much demand on the heart * cardiac abnormality - valvular disease, cardiomyopathy

Answer 37

* Most common cause of HF in the devloped world * eventually the heart muscle thins and becomes impaired -> ischaemic cardiomyopaThy

Answer 38

- Hypertension - obesity - tachycardia

Answer 39

* longstanding hypertension * cardiac remodelling (concentric LVH) due to longstanding pressure overload

Answer 40

* puts the heart under extra strain which can exacerbate or cause HF

Answer 41

* Most commonly AF * atrial flutter * AVNRT

Answer 42

Cardiomyopathies

Answer 43

- dilated - hypertrophic - restrictive

Answer 44

* usually massive and global hypokinesis * usually very dilated on echo

Answer 45

* cocaine - especially in younger patients * long standing multi vessel coronary disease - ischaemic HD * idiopathic

Answer 46

* genetic disorder * develops obstruction of outflow tract from LV = hypertrophic obstructive cardiomyopathy

Answer 47

* rigid, stiff thickened myocardium usually as a result of infiltration of material or fibrosis

Answer 48

* amyloid * sarcoid * scleroderma * hypereosinophilic syndromes

Answer 49

- heart rate x stroke volume - Usually abt 5L

Answer 50

stroke volume/ total volume

Answer 51

* problem with the ability of the left ventricle to fill with blood * preserved ejection fraction * cardiac output significantly reduced

Answer 52

* processes such as LV hypertrophy can result in less left ventricular cavity space therefore less blood volume in the left ventricle * less blood volume to be pumped out

Answer 53

* failure to pump as much blood out as is coming in * blood backs up into heart * back up of volume into the pulmonary circulation * capillary hydrostatic pressure increases so fluid moves into surrounding space around alveoli

Answer 54

* increased hydrostatic pressure from LV failure * fluid between alveoli and capillary meaning gas exchange is impaired due to this barrier - pulmonary oedema

Answer 55

* SOB * coughing * cardiac wheeze * marked orthopnea * pink/ white frothy sputum

Answer 56

bibasal crepitations

Answer 57

- inadequate LV filling * Mitral stenosis: less flow from LA to LV * LVH: smaller cavity for filling to occur

Answer 58

* aortic stenosis - tight aortic valve that the LV has to pump against * hypertension - pumping against high pressure system

Answer 59

* aortic regurgitation * mitral regurgitation

Answer 60

* ischaemia * cardiomyopathy * -> muscle can't contract properly

Answer 61

* pulmonary diseases cause increased pressure in the pulmonary artery - pulmonary hypertension * RV pumps against higher resistance will impair and eventualy fail * volume and pressure backs up from right heart into venous circulation

Answer 62

* raised JVP - raised pressure in RA * pressure can go into portal veins -> ascites and liver cirrhosis (enlarged cirrhosis) * pitting oedema (increased cap hydrostatic pressure) * tiredness/ SOB * skeletal muscle wasting

Answer 63

* raised JVP * pitting oedma * ascites and * * hepatomegaly

Answer 64

* pitting oedema usually in legs/ feet * lying flat - sacral oedema

Answer 65

* Pulmonary hypertension * PE * lung disease * left sided failure * atrial septal defect

Answer 66

* LV impaired contraction and ejection fraction * volume and pressure builds up on left side * increased pressure in pulmonary veins/ capillaries * increased hydrostatic pressure causes fluid leak around alveoli * impairs gas exchange and hypoxia * increased pressure in pulmonary veins increases pressure within PAs * right heart now pumping against increased pressure causing it to fail * volume and pressure builds up in the right heart and backs up into venous system causing increased hydrostatic pressure and peripheral oedema

Answer 67

congestive HF

Answer 68

* largely synonymous w left sided failure * sudden failure to maintain cardiac output * insufficient time for compensation * clinical picture dominated by pulmonary oedema

Answer 69

* Largely synoymous of comb of R and L sided failure * gradual decline in function allowing for compensation

Answer 70

* chronic LV failure leads to pulmonary congestion -> pulmonary hypertension -> right ventricular failure

Answer 71

* decreased CO -> reduced BF to kidneys * kidneys attempt to restore circulating volume by retaining sodium and water

Answer 72

* Acute heart failure may present suddenly with cardiogenic shock or subacutely with decompensation of chronic heart failure.

Answer 73

* due to progressive cardiac dysfunction from structural and or functional cardiac abns * characterised by progressive symptoms with episodes of acute deterioration

Answer 74

* Pulmonary hypertension * Pulmonary/Tricuspid valve disease * Pericardial disease

Answer 75

* cardiac output can't meet the demands of the body * results in increased systemic vascular resistance in order to maintain mean arterial pressure * patients have a weak pulse, cool peripheries and low BP

Answer 76

* normal cardiac function but there's an increased demand * problem is with reduced systemic vascular resistance often due to diffuse arteriole vasodilation or shunting - transfer of blood from arteries to veins bypassing capillary beds that increase venous flow and overloads the heart

Answer 77

* generally due to states of increased metabolic demand (e.g. hyperthyroidism), * reduced vascular resistance (e.g. thiamine deficiency, sepsis) * or significant shunting (e.g. large arteriovenosu fistula).

Answer 78

- anaemia - sepsis - thyrotoxicosis - liver failure

Answer 79

* increases EDV compensating for the reduced EF -> maintaing cardiac output * In severe disease, large increases result in pulmonary oedema, ascites and peripheral oedema.

Answer 80

* increasing HR - sinus tachycardia * RAAS * sympathetic activation via baroreceptors

Answer 81

Physical activity

Answer 82

* Raised JVP * Displaced apex * Crackles * Ankle swelling * Heart sounds S3/S4 * Pulsus alternans * Hepatomegaly * Ascites

Answer 83

* Measuring BNP = >2000 * ECG * Echo to confirm

Answer 84

* Released by cardiomyocytes in response to excessive stretching * used to assess likelihood of HF

Answer 85

diabetes, sepsis, old age, hypoxaemia (PE and COPD), kidney disease, and liver cirrhosis.

Answer 86

* in patients with elevated BNP * looks at the ejection fraction

Answer 87

New York Heart Association

Answer 88

* FBC - exclude anaemia, infective cause. * U&Es - exclude renal failure as a cause of oedema. * LFT - exclude liver failure as a cause of oedema. * Cholesterol and HbA1c - cardiovascular risk stratification. * TFT - exclude thyroid disease. * BNP

Answer 89

- Echo - CXR - cardiac MRI

Answer 90

* Evidence of previous MI * Left ventricular strain / hypertrophy * Conduction abnormalities / AF

Answer 91

* Cardiomegaly (Cardiothoracic ratio > 50% on PA film) * Alveolar shadowing oedema * Kerley B lines (fluid in septae of secondary lobules) * Pleural effusion * Upper lobe diversion

Answer 92

* May be used to determine the aetiology of heart failure (e.g. ischaemic versus non-ischaemic in dilated cardiomyopathy)

Answer 93

furosemide

Answer 94

- ACEi like ramipril and BBs like bisoprolol - both used first line - ARB if intolerance to ACEi - third - MRA like eplerenone added if symptoms continue - if symptoms persist cardiac resynchronisation therapy or digoxin

Answer 95

severe asthma, COPD, pulmonary oedema or bradycardia

Answer 96

hyperkalaemia, hyponatraemia, acute kidney injury.

Answer 97

* Ivabradine * Valsartan/ Sacubitiril * Digoxin * Dapagliflozin: SGLT2 blocker on PCT

Answer 98

- Implantable cardiac defib - cardiac rescyncronisation therapy - PCI - cardiac transplant

Answer 99

important for primary and secondary prevention of sudden cardiac death (specific indications).

Answer 100

biventricular pacing, which is indicated in certain patients with HFrEF (i.e. ≤ 35%) & prolonged QRS (i.e. ≥ 130 ms). Usually receive combined device with defibrillator.

Answer 101

patients with ischaemic heart disease may be offered revascularisation therapy

Answer 102

* limited evidence for ACEi, ARBs, BBs * loop diuretic like furosemide may be given for fluid overload

Answer 103

* IV diuretic * Closely monitor the person's renal function, weight and urine output during diuretic therapy. * Start or restart beta‑blocker treatment during hospital admission in people with acute heart failure due to left ventricular systolic dysfunction, once their condition has been stabilised

Answer 104

* consultant cardiologist * specialist HF nurse * HCP with expertise in prescribing w HF

Answer 105

* diagnose HF * give information on HF * manage HF * optimise Tx and start new meds that need specialist supervision * manage HF that is not responding to Tx

Answer 106

avoid verapamil, diltiazem and short-acting dihydropyridine agents in people who have heart failure with reduced ejection fraction.

Answer 107

* a clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status * a review of medication, including need for changes and possible side effects * an assessment of renal function.

Answer 108

* drugs such as NSAIDs, verapamil, diltiazem * infections * alcohol abuse * PE * thyroid dysfunction

Answer 109

* AF * arrythmias * bradycardia * MI

Answer 110

* depression * distress * anxiety * stress * hyperaware of physical changes * focusing excessively on the medical details

Answer 111

* co-ordinate care for the patient promotoing MDT approach * assisting patient with self management * accessible to patients and ehtir families - rapid response * support and counselling * easy access to a profressional who knows the patient and can provide consistent care

Answer 112

* severe HF (NYHA class 4) * HF that doesn't respond to tx * HF from valvular disease * LVEF of <35% * women w HFrEF who are plannig a pregnancy

Answer 113

* pro-BNP of >2000 - urgery referral and transthoracic echo within 2 weeks * bnp between 400-2000 for echo within 6 weeks

Answer 114

* caused by inflammation of the parial pleura * 'sharp, knife like, catches my breath, worse when i breathe, too painful to breathe * pleural rub - walking in snow, creaking of a sailing ship

Answer 115

* Pneumonia * Pulmonary embolus * Pneumothorax * Malignancy e.g. mesothelioma

Answer 116

* Musculoskeletal e.g. costochondritis, fractured ribs * Intercostal neuritis e.g. herpes zoster infection (shingles)

Answer 117

- PE * Deep S wave in lead 1 * Q wave in lead 3 * inverted T wave in lead 3

Answer 118

* Oxygen to be given if the patient is hypoxic * Analgesia pain relief from the pleurisy

Answer 119

if a patient is at risk of developing a PE they should be given a low dose (prophylactic) of subcutaneous heparin if they are going to be immobile for a prolonged period of time e.g post operatively

Answer 120

* Aspiration of air via cannula/ 50ml syringe and 3 way tap inserted in midclavicular line in second intercostal space * Chest drain inserted in 5th intercostal space in the anterior axillary line if aspiration is unsuccessful

Answer 121

* Surgery sometimes if there is a persistent air leak and the lung does not reinflate then a surgical procedure may need to be performed.

Answer 122

stop smoking - more likely to reoccur if they continue smoking

Answer 123

* life threatening * air enters the pleural space but can't escape which increases pressure which causes displacement of the mediastinum * this causes cardiac compromise - needs immediate aspiration followed by chest drain

Answer 124

* Sputum should be sent for culture and sensitivity. * Blood culture * Urine can be sent to look for antigens to pneumococcus or legionella * atypical serology can be sent to look for other causes of pneumonia.

Answer 125

Strep pneumonia

Answer 126

* mycoplasma pneumoniae * viruses e.g influenze * legionella * staph a * haemophilus influenza

Answer 127

* gram negative organsims cause 50% * staph a * strep pneumoniae * anaerobes

Answer 128

CURB-65 score Confusion- new mental confusion Urea – urea > 7mmol/l Respiratory Rate >30/min Blood pressure SBP<90mmHg and/or DBP,60mmHg 65 – age > 65 years

Answer 129

2 (score of 2+ consider hospital care)

Answer 130

low risk of pneumonia

Answer 131

* Ab - IV if severe, may be oral if disease mild * oxygen * iV fluids if dehydration/ poor oral intake * analgesia if pleurisy

Answer 132

heparin to prevent DVTs if patient likely to be immobile

Answer 133

- If patient was getting better but spikes temperarures again - dull percussion note - decreased air entry

Answer 134

* less than 25g is a transudate Pleural effusion

Answer 135

* more than 35g/l = exudative * if the pleural LDH is high its more likely to be exudate

Answer 136

- congestive HF - cirrhosis - nephrotic syndrome - PE - pericardial disease

Answer 137

- infections - pneumonia, TB - malignancy - connective tissue disease - abnd disorder - pancreatitis, oesophaeal rupture

Answer 138

* gram stain on samples taken * fluid can be sent in blood culture bottles * pH below 7.2 indicates sig infection which should be drained

Answer 139

* 5 day course of amoxicillin * consider macrolide/ tetracycline in those allergic to penicillin

Answer 140

* 7-10 day course * moderate severity: mcacrolide and amoxillin

Answer 141

* high severity: beta lactam and macrolide

Answer 142

* Chest pain and haemoptysis * dyspnoea

Answer 143

Wells score

Answer 144

* D-dimer levels elevated in the presence of a clot * A negative D-dimer test reliably excludes PE * The specificity of D-dimer for VTE is poor and the positive predictive value (PPV) is low; D-dimer is not useful for confirming PE

Answer 145

Dyspnoea, tachypnoea, hypoxaemia

Answer 146

* Permits assessment of clot load * visualises right ventricular dilatation/ strain * some false negatives (v small peripheral emboli)

Answer 147

* LMWH usually for 5 days * oral anticoagulation for 6 weeks post op

Answer 148

if shocked - SBP <90mmHg

Answer 149

* shock/ hypotension * RV dysfunction * myocardial injury

Answer 150

* Rivaroxaban * Apixaban * Dabigatran * Edoxaban

Answer 151

* can be used in severe renal impairment * AC can be reversed * monitoring of INR required

Answer 152

- normal CXR - or wedge shaped and peripheral consolidation - can get bibasal consolidation

Answer 153

* history of RF for DVT * history lacking infective symptoms * breathlessness, pleurisy

Answer 154

* abrupt onset SOB * pleuritic chest pain * cough * deterioration in those w underlying chronic CR disease * leg pain and swelling * haemoptysis * syncope * dizziness

Answer 155

* tachycardia * low grade fever * hypoxia

Answer 156

* hypotension * elevated JVP * tricuspid regurgitation - pansystolic murmur * split second heart sound - elevated pulmonary pressure leads to delay in pulmonary valve closure.

Answer 157

* tachypnea * crackles * DVT

Answer 158

* imobility * pregnany * major surgery * cancer * HF * FH * lower limb trauma/ fracture * active cancer

Answer 159

* COCP * HRT

Answer 160

thrombolysis in those that are unstable (shock or ventilator dependent)

Answer 161

* major bleeding * intercranial haemorrhage

Answer 162

PE and DVT

Answer 163

lower order pulmonary vessels. Unilateral or bilateral occlusion

Answer 164

right or left main pulmonary arteries. Unilateral or bilateral occlusion

Answer 165

embolus lodged at the bifurcation of the pulmonary arteries (3-6% of cases).

Answer 166

venous stasis, hypercoaguable state, endothelial injury

Answer 167

* PE likely (score over 4): CTPA * PE unlikely (Score under 4): d-dimer within 4 hrs - if positive arrange CTPA

Answer 168

* Common: tachycardia * right heart strain: RBBB, ST depression and T wave inversion anteriorly (V1-V4) and/or inferiorly (II, III, aVF)

Answer 169

* FBC * D-dimer * ABG * troponin - right heart strain

Answer 170

* CXR * CTPA * lower limb US to confirm presence of DVT * echo: assesment of RV strain in patients w suspected massive PE

Answer 171

* AC for a minimum period of 3 months * LMWH or DOAC, uFH, warfarin * LMWH usually used before confirmation of PE * **DOAC FIRST LINE**

Answer 172

* long term PE can lead to chronic thromboembolic pulmonary hypertension and is associated with RSHF * Factors associated with this complication are inadequate anticoagulation, large or residual thrombi and recurrent disease.

Answer 173

* apixaban or ribaroxaban for confirmed DVT or PE * if neither are suitable offer LMWH for at least 5 days followed by dabigatran or edoxaban * or LMWH with VKA

Answer 174

* PE w haemodynamic instability: offer UFH infusion and consider thrombolytic therapy * consider DOAC for active cancer

Answer 175

* DoH VTE risk assessment tool

Answer 176

- anti-embolism stockings * NOT for: * suspected or proven peripheral arterial disease * peripheral arterial bypass grafting * severe leg oedema * peripheral neuropathy

Answer 177

* apixaban * aspirin * dabigatran etexilate * fondaparinux sodium * low-molecular-weight heparin (LMWH)

Answer 178

LMWH or UFH

Answer 179

* all surgical and trauma patients * pregnant, gave birth or miscarriage or termination of pregnancy in the last 6 weeks * people admitted to critical care * acute psychiatric patients * lower limb immobilisation * fragility fractures

Answer 180

* absent lung markings - Air collects in the pleural space, causing the underlying lung to collapse partially or fully. * visible lung edge - air collects in pleural space causing lung edge to be pushed away and become visible as a line

Answer 181

* pleuritic chest pain * cough * fever * malaise * bronchial breathing

Answer 182

* bronchial breathing * increased vocal resonance, tactile vocal fremitus, and whispering pectoriloquy

Answer 183

- a provoked VTE is due to an obvious precipitating event e.g. immobilisation following major surgery. The implication is that this event was transient and the patient is no longer at increased risk - an unprovoked VTE occurs in the absence of an obvious precipitating event, i.e. there is a possibility that there are unknown factors (e.g. mild thrombophilia) making the patient more at risk from further clots

Answer 184

thrombolysis is now recommended as the first-line treatment for massive PE where there is circulatory failure (e.g. hypotension)

Answer 185

- first line: DOAC - even for cancer - if neither apixaban or rivaroxaban are suitable then either LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin)

Answer 186

- V/Q scan instead of CTPA - if renal impairment is severe (e.g. < 15/min) then LMWH, unfractionated heparin or LMWH followed by a VKA

Block 31 Week 3 Flashcards

(232 cards)