1
Q
define pre-load and after-load
A
pre-load = volume in ventricle at end of diastole
after-load = total peripheral resistance
2
Q
what is Frank-Starling’s law?
A
more ventricular distension during diastole = greater volume ejected during systoe
3
Q
How would you calculate the heart rate from an ECG strip?
A
Each strip is 10 seconds long
Count the amount of QRS and then multiply by 6
4
Q
What lead is normally the most positive? What would be the most positive in LBBB and RBBB respectively?
A
Lead II is normally the most positive
LBBB - Lead aVL
RBBB- Lead III
5
Q
State the normal parameters for the PR interval, the QRS interval and the QT interval
A
PR - 120-200ms QRS - <120ms QT - 2 large squares
6
Q
RBBB can be present without heart disease, however name three common causes of LBBB
A
- Anterior MI
- Congestive Heart Failure
- Left Ventricular Hypertrophy
7
Q
Describe the diagnostic features of a STEMI
A
- Cardiac Chest Pain
- ECG changes (persistent ST elevation or new LBBB)
- Raised Troponin I (greater than 100 nanograms)
8
Q
What are the parameters for ECG changes in a STEMI?
A
ST elevation in atleast 2 leads
Elevation greater than 1mm in limb leads and 2mm in chest leads
9
Q
Describe the ECG changes in an NSTEMI
A
may show: ST segment depression T wave inversion Normal
10
Q
When might an STEMI be mistaken for an NSTEMI?
A
If you have ST segment depression in V1-V4, it may be the reciprocal changes of a posterior STEMI
11
Q
Describe the pathophysiology of ACS
A
- Plaque rupture
- Thrombosis to varying degrees
- Inflammation
- Artery occlusion and reduced blood supply to myocardium
12
Q
What layer of the heart do the coronary arteries lie in?
A
Epicardium
13
Q
Describe 5 of the classical presentations of ACS
A
- Central crushing chest pain lasting >20 mins
- Nausea
- Sweating
- Breathlessness
- Palpitations
14
Q
Some ACS can be ‘Silent’, what groups of people can this occur in? How would they present?
A
- Elderly and Diabetics
- Syncope, Epigastric Pain
15
Q
What is the S4 heart sound?
A
Blood striking against a non compliant ventricle
16
Q
What happens to Troponin I in an MI
A
Begin to rise 3-4hrs post MI Remain elevated for up to 2 weeks
17
Q
what level of hs-TnI is highly likely of myocardial necrosis in men and women?
A
34 in men
16 in women
18
Q
When should Troponin I be sampled?
A
One sample on admission If onset of the symptoms was less than 3 hours ago, take another sample one hour after the original
19
Q
Give 4 false positives of Troponin I
A
- Advanced renal failure
- Large PE
- Severe CCF
- Aortic Dissection
- sepsis
- stroke
- cardiomyopathy
- malignancy
20
Q
Give 3 possible features of an MI on a CXR
A
- Cardiomegaly
- Pulmonary Oedema
- Widened Mediastinum
21
Q
In four steps describe the initial medical management of suspected ACS
A
1) Morphine and Antiemetic (Metacloperamide)
2) Oxygen (Sats>94% or <88% if COPD)
3) Nitrates (GTN Spray)
4) Asparin 300mg Loading Dose
22
Q
What are the four requirements for Prasugrel in an MI?
A
- Undergoing PCI
- Less than 75 y/o
- Weight >60kg
- No prior TIA/Stroke
23
Q
non-pharmacological management long term post MI (other than the 5 drugs what else can be done?
A
- Cardiac Rehab
- Cut out smoking
- Diet and Alcohol,
- DVLA advice (able to drive after one week, if a bus/lorry driver can’t for 6 weeks)
- ?Dyspepsia (provide PPI with Asparin)
24
Q
what are the 5 drugs patients must have following an MI?
A
- Aspirin
- ACEi - Ramipril
- B-blocker - Bisoprolol
- Statin - Atrovostatin
- ADP- receptor antagonist - ticagrelor
25
Describe the management of NSTEMI
* Pain relief
* Aspirin 300mg
* LMWH
* Repeat ECG
* Risk assessment of patient with elevated hs-Tnl - grace score
* Ticagrelor if risk \>3%
* Anti-anginals - nitrates
26
What is the Grace Score?
Used on ACS patients to estimate their inpatient and 3 year mortality
27
Describe the complications of an MI
* DARTH VADER
* Dresler syndrome - pericarditis post MI
* Arrhythmias
* Rupture of heart
* Tamponnade
* HF
* Valve complications
* Aneurysm of ventricle
* Death
* Emboli
* Recurrence
28
Name four STEMI mimics on ECG
* Early repolarisation in young & fit
* Pericarditis (saddle shaped)
* Brugada Syndrome (Sodium Channelopathy)
* Takotsubo Cardiomyopathy (temporary and brought on by stress - broken heart syndrome)
29
what is significant about an ECG showing ST depression in leads V1-V4 and what should be done?
may be a true STEMI in posterior aspect of heart so should be treated as a STEMI and should have posterior leads done - V7-9 as well as Right ventricular lead
30
what is ST elevation in RV4 highly sensitive for?
right ventricular infarction
31
What is stable angina?
Chest discomfort provoked by effort/emotion and relieved by rest
32
Describe four potential symptoms of Stable Angina
* Chest Pain
* Throat tightness
* Arm Heaviness
* Exertional Breathlessness
33
What features would make Angina unlikely?
Continuous/Very prolonged pain
Unrelated to activity level
Associated with other symptoms such as dizziness/dysphagia
34
Describe two methods of functional imaging
Stress Echo
Cardiac MRI
35
Describe pharmacological managements of Stable Angina
* Immediate - GTN spray
* Prevent symptoms - B-blocker, CCB, nitrates
* Secondary prevention - AAAA
* Aspirin, ACEi, Atorvostation, Atenelol (Bblocker)
36
When would you prescribe Ivabradine?
As an alternative to a Beta Blocker, for example if the patient is Hypotensive
37
When would you prescribe Ranolazine in Stable Angina?
* If intolerant to all the other drugs
* Commenced by consultants
* eGFR\>30 (reduces sodium and hence calcium - relaxes muscle)
38
Other than Stable/Unstable, describe two other types of Angina
* Decubitus Angina - precipitated by lying flat
* Vasospastic Angina - spasm of coronary artery
39
How would you educate a patient in how to use GTN spray in Stable Angina?
* Repeat dose after 5 minutes if required If still persisting after 5 minutes of the second dose, call an ambulance
* SE: Headache, Hypotension
40
Describe the classes of HTN in terms of clinic readings
* Class 1 - 140/90
* Class 2 - 160/100
* Severe - 180/110
41
Describe the classes of HTN in terms of home readings
* Class 1 - 135/85
* Class 2 - 150/95
42
what is essential hypertension?
* accounts for 95% of hypertension
* aka primary hypertension
* hypertension has developed on its own and does not have a secondary cause
43
Give 4 broad causes of Secondary HTN
* Renal (Renal Artery Stenosis, PCKD)
* Pregnancy
* Drugs (Steroids, COCP, Cocaine)
* Endocrine (Cushings, Conns)
* Obesity
* (ROPED)
44
what are some complications of hypertension?
* Ischaemic heart disease
* Cerebrovascular accident (i.e. stroke or haemorrhage)
* Hypertensive retinopathy
* Hypertensive nephropathy
* Heart failure
45
at what blood pressure should a patient be offered ambulatory monitoring?
\>140/90
46
when should treatment be initiated for hypertension?
treat stage 1 if \<80 and
* evidence of end organ damage
* cvd
* enal impairement
* DM
* 10-year risk \>20%
treat all stage 2
47
What is Malignant Hypertension?
* Rapid rise in blood pressure to over 200/130, leading to vascular and organ damage
* Can causes bilateral retinal haemorrhages, headache, visual disturbances
48
How does Hypertension present?
Generally asymptomatic - may have headache
If sweating/palpitations - Phaeochromocytoma
If muscle tetany/weakness - Hyperaldosteronism
49
Describe 5 investigations (apart from BP) necessary for HTN
1. Full range of bloods (inc cholesterol)
2. Urinalysis (A:Cr, Protienuria, Haematuria)
3. ECG
4. Fundoscopy
5. Cardiac Echo
50
You should aim to reduce blood pressure slowly in Hypertensive patients. What is the BP goal in treated patients?
* Normal \<140/90
* Diabetic \<130/80
51
non-pharmacological treatments for hypertension
wieght reduction
minimise salt intake
minimise alcohol
aerobic exercise
smoking cessation
52
Describe the four step (up) management of Hypertension
53
Describe the 3 classes of CCBs, an example of each and their actions
* Dihydropyridine - acts on peripheral vasculature (eg Amlodipine, Nifedipine)
* Phenylalkamine - acts on cardiac vasculature (eg Verapamil)
* Benzothiazepine - acts on cardiac and peripheral vasculature (eg Diltiazem)
54
Describe the difference between a Hypertensive Emergency and a Hypertensive Urgency
**Emergency** - High BP with critical illness (AKI,MI, Encephalopathy)
**Urgency** - High BP without critical illness at the moment, often accompanied by retinal damage
55
Describe the management of a Hypertensive EMERGENCY
Reduce diastolic to 110mmHg in 3-12hrs
Use IV Sodium Nitroprusside/Labetolol/GTN/Esmolol (acts in 30s)
56
Describe the management of a Hypertensive URGENCY
* Reduce diastolic to 100mmHg in 48-72hrs
* Usually use Nifedipine AND Amlodipine for 3 days and then continue Amlodipine alone
* some patients have ACEi and calcium antagonist
57
how does phaeochromocytoma present? (triad)
* episodic headache
* sweating
* tachycardia
(most wont have all 3)
58
how is a diagnosis of phaeochromocytoma made?
* measuments of urinary and plasma fractionated metanephrines and catecholamines
* 24 hour urine collection
* CT or MRI scan of abdomen and pelvis to detect adrenal tumours
* MIBG scan can detect tumours not detected by CT or MRI
59
how is a phaeochromocytoma managed?
* all patients should undergo resection
* hyptension control in meantime is combined alpha and beta adrenergic blockade
* phenoxybenzamine most commonly used
* **BETA NEVER INITIATED BEFORE ALPHA**
60
61
Heart Failure is when cardiac output fails to meet the body's requirements. Using the mnemonic HEART MAy DIE, give some causes.
* Hypertension
* Embolism
* Anaemia
* Rheumatic fever
* Thyrotoxicosis
* MI
* Arrhythmia
* Diet
* Infection
* Endocarditis
62
what are the 2 categories of heart failure?
**diastolic** = (filling) ventricular volume/capacity for blood is reduced, too stiff or ventricular walls thick **(HRpEF)**
**systolic** - (contractility) cant pump with enough force, walls thin/fibrosed, chamber enlarged, abnormal or uncoordinated myocardial contraction **(HFrEF)**
63
Describe the features of SYSTOLIC Heart Failure
Inability of the heart to contract, EF\<40% Caused by IHD/MI/Cardiomyopathies
64
Describe the features of DIASTOLIC Heart Failure
* Inability of the heart to relax, EF\>50% (HFpEF)
* Caused by Ventricular Hypertrophy/Tamponade
65
Right Ventricular Failure is caused by LVF or Chronic Lung Disease, give 3 features
1. Peripheral Oedema
2. Ascites
3. Facial Engorgement
66
State 3 causes of ACUTE Heart Failure
1. Infections
2. Anaphylaxis
3. PE
67
Heart Failure can be Low Output or High Output, give some causes of High Output and what is it?
* IE High but not high enough Pregnancy, Hyperthyroidism, Anaemia
* heart has enlarged and becomes fragile
68
Describe the use of BNP
* BNP can be used to rule out Heart Failure if it is less than 100ng/l
* Not diagnostic as BNP can be raised by anything that causes chamber stress (AF etc)
69
Using the A-E mnemonic describe the 5 features of a CXR of Heart Failure
* **A** - Alveolar Oedema (Bat Wings)
* **B** - Kerley B Lines (Interstitial Oedema)
* **C** - Cardiomegaly
* **D** - Dilated Veins
* **E** - Effusions
70
Other than bloods and CXR, what is the gold standard for testing cardiac function?
Echocardiography
71
What is Cardiac MRI used for in the context of Heart Failure?
* Better at imaging the RV
* Good at assessing scar tissue
72
Give 5 features of Heart Failure
* Cyanosis
* Low BP
* Narrow Pulse Pressure
* Apex Displacement
* RV Heave
73
Describe the New York Classification of Heart Failure
* I - Heart Disease present but no limitations
* II - Comfortable at rest but dyspnoea in normal activities
* III - Less than ordinary activity causes dyspnoea
* IV - Dyspnoea at rest
74
There are many medications that can be given for Heart Failure, but what device could patients have fitted?
Cardiac Resynchronisation Therapy Adds pacing to septal and lateral walls will reduce QRS width Considered if signs of LBBB Can combine with Defib device
75
describe NICE management of HF
* Furosemide
* ACEi
* ARB
* Bblockers
76
physiological effects of betablockers in heart failure
1. reduce HR
2. reduce BP
3. 1+2= reduced myocaridal oxygen demand
4. reduce mobilisation of glycogen
5. negate unwanted effects of catecholamines
77
whan is ivabradine used in heart failure?
* when pt cannot tolerate B blockers
* resting hr higher than 75 despite B blockers
* **has no impact on blood pressure**
78
when are vasodilators hydralazine and isosorbide mononitrate used in heart failure?
* in combination shown to be beneficial
* african or carribean patients
* if pt cannot take ARB or ACEi
* add to ACEi or ARB in resistant CCF
79
what is the benefit of using nitrates in HF
reduce preload, reduce pulmonary oedema, reduce ventricular size
80
when are nitrates used in heart failure?
* IV used in acute HF if underlying ischaemia, hypertension or regurgitant aortic and mitral valve disease
* chronic - relief of orthopnoea and exertional dyspnoea
81
State four causes of Aortic STENOSIS
1. Senile Calcification
2. Congenital (Bicuspid Valves)
3. CKD
4. Rheumatic Fever
82
Describe the triad of Aortic STENOSIS
1. Angina
2. Heart Failure (dyspnoea)
3. Syncope
83
Give four features of the murmur heard in Aortic STENOSIS
* Ejection Systolic
* Aortic Area
* Radiates to carotids
* Crescendo Decrescendo
84
non surgical management of aortic stenosis
* antihypertensives
* treat HF symptoms as with HF
* anti arrythmic drugs as indicated
85
What instances would you consider a valve replacement in Aortic Stenosis
Symptomatic Asymptomatic with abnormal LV function, abnormal exercise test, other cardiac surgeries
86
what procedure would you do for aortic stenosis if they werent fit for surgery?
TAVI - Transcatheter Aortic Valve Insertion - through femoral artery
87
Give two acute and two chronic causes of Aortic REGURGITATION
Acute - Chest Trauma, Infective Endocarditis
Chronic - Congenital, Rheumatic Fever
88
Describe three features of Aortic REGURGITATION
* Exertional Dyspnoea (decreased exercise tolerance) 1st symptom
* Orthopnea
* PND
89
Other than the murmur, describe 3 signs of Aortic REGURGITATION
* Corrigan's Pulse - Collapsing pulse
* De Musset's Sign - Head bobbing with heartbeat
* Quinkes - systolic pulsation on light pressure of the nail bed
90
Describe three features of the murmur of Aortic REGURGITATION
Early Diastolic
Left Sternal Edge Best heard sat forward in expiration
91
Describe two managements of Aortic REGURGITATION
* Afterload reduction (ACEI/ARB)
* Valve replacement
92
State three causes of Mitral STENOSIS
* Rheumatic Fever
* Congenital
* Infective Endocarditis
93
Describe two ways in which Mitral STENOSIS can present
* Pulmonary Hypertension (Dyspnoea, Haemoptysis, Malar Flush)
* LA Compression (Hoarseness, Dysphagia)
94
Describe two features of the murmur of Mitral STENOSIS
Mid Diastolic murmur Best heard on expiration with patient on left
95
Describe four possible managements of Mitral STENOSIS
* AF - Rate control and anticoagulate
* Diuretics
* Balloon Valvuloplasty
* Valve Replacement
96
Describe four causes of Mitral REGURGITATION
* Rheumatic Fever
* Mitral Valve Prolapse (APCKD, Marfans)
* IHD
* Infective Endocarditis
97
Give 5 features of Mitral REGURGITATION
* Dyspnoea
* Fatigue
* Palpitations
* Displaced Apex
* AF
98
State 3 features of the Mitral REGURGITATION murmur
1. Pan Systolic Murmur
2. Heard in Mitral Area
3. Radiates to Axilla
99
What two features indicate Infective Endocarditis unless proven otherwise
* Fever
* New Murmur
100
Give 4 risk factors of Infective Endocarditis
1. Mitral Valve Prolapse
2. Prosthetic Material (not stent)
3. Rheumatic Heart Disease
4. Poor Dental Hygiene + Procedure
101
Signs and Symptoms of infective endocarditis
* **F** fever
* **R** roth spots
* **O** osler nodes
* **M** murmur
* **J** janeway lesions
* **A** anaemia
* **N** nail bed haemorrhages
* **E** emboli
102
State the two most effective diagnostic methods for Infective Endocarditis
Blood Cultures - Atleast 3 from different sites over a few hours TOE
103
Describe the criteria of MAJOR Infective Endcarditis
1. Positive Blood Cultures
2. Endocardial Involvement
3. Positive Echo (vegetation, abscess)
4. new valvular Regurgitation
104
Describe the criteria of MINOR Infective Endcarditis
1. Predisposing valvular or cariac abnormalities
2. IV drug abuser
3. Pyrexia \>38
4. Embolic or vasculitic phenomenon
5. Blood cultures suggestive (organism growth but not meeting major criteria)
6. Suggestive ECHO findings (not meeting major criteria)
105
what criteria have to be met to make a diagnosis of IE?
2 MAJOR
1 MAJOR & 3 MONOR
5 MINOR
106
Antibiotics are given via a central line in Infective Endocarditis. Give the Empirical, Strep, Enterococci and Staph management
* Empirical - Amoxicillin and Gentamicin
* Strep - Benzylpenicillin and Gentamicin
* Enterococci - Amoxicillin and Gentamicin
* Staph - Flucloxacillin and Gentamicin
107
How would you monitor Infective Endocarditis? and why?
Echo Weekly (assess vegetation and look for complications)
ECG Twice Weekly (may indicate aortic root abscess in aortic valve infection)
Bloods Twice Weekly
108
what are some indications for surgery in infective endocarditis?
* moderate to severe cardiac failure
* valve dehiscence
* uncontrolled infection despite appropriate antimicrobial therapy
* relapse after optimal medical therapy
109
Bradycardia can be caused by SA or AV node dysfunction. Give 4 causes of SA node dysfunction
Hypothyroidism Hypothermia Rheumatic Fever Haemachromatosis
110
What is Sick Sinus?
Sinus Node Fibrosis Presents as Tachy Brady
111
What is 1st Degree HB? How would you manage?
PR Interval \>0.2 seconds (5 large squares) No specific treatment, just monitor
112
What is 2:1 HB? How would you manage?
AKA Wenkebach Progressive lengthening of PR followed by drop of QRS Can occur in young fit patients OR after MI No specific treatment, just monitor
113
What is 2:2 HB? How would you manage?
Constant PR interval then QRS suddenly dropped Pacing required as can progress to complete HB
114
Complete HB occurs when there is no relationship between P and QRS. How does the ECG change depending on where the block is?
Occurring at Bundle of His - Narrow Escape Complex Occurring below Bundle of His - Broad Escape Complex
115
Give 3 causes of Complete HB
Digoxin toxicity Inferior STEMI Severe Hyperkalaemia
116
Complete HB requires urgent pacing. What medical management can you give?
Atropine - Muscarinic Antagonist Isoprenaline - Beta Agonist
117
What is a Junctional Rhythm
Abnormal rhythm arising from AV node
118
Give 4 causes of AF
Heart Failure Hypertension PE Hypokalaemia
119
What investigations would you do for AF?
ECG - May wish to use home monitor if intermittent Echo - to look for any underlying structural abnormalities/prepare for cardioversion
120
How would you manage ACUTE AF (\<48hrs ago)? What do you need to consider?
Give Heparin and aim to DC cardiovert Generally cardiovert young patients due to stroke risk (always listen for carotid bruits first)
121
What anticoagulation would you give in Chronic AF? State the two scoring systems used.
DOACs - Rivaroxiban, Apixiban, Dabigatran Warfarin CHADS VASc and HAS BLED
122
Describe the rate control of AF
1 - Beta Blockers 2 - CCB 3 - Amioderone
123
Describe the rhythm control of AF
Flecainide or Amioderone If cardioverting will require atleast 3 weeks of anticoagulation and an echo prior
124
AVRTs are Narrow Complex Tachycardias, describe their pathway
Impulse starts in AV node, travels to ventricles and then back up into atria via accessory pathway (ORTHODROMIC)
125
AVNRTs are Narrow Complex Tachycardias, describe their pathway
Re-entrant loops form within the AV node itself
126
What is diagnostic on an ECG about AVRT/AVNRTs?
No P Waves
127
Describe the managements of AVRT/AVNRT
Aim to transiently block the AVN (also helps differentiate it from AF) 1 - Vagal Manouvres 2 - IV Adenosine (6mg, then 12g, then 12mg with long flush)
128
Describe 3 side effects of Adenosine
Chest Discomfort Transient Hypotension Flushing
129
Describe the 2 types of VT
Monomorphic - Appearance of all beats match eachother, common post MI scarring Polymorphic - Beat to beat variation, includes Torsades de Pointes
130
What is Torsades de Pointes? Give two causes.
A type of long QT syndrome Amioderone, Hypokalaemia
131
Ventricular Tachycardia can be managed medically (lidocaine), but when would you cardiovert?
If haemodynamically compromised
132
What are fusion beats?
Sinus and ventricular beats fuse
133
What are capture beats?
Normal conduction of SVT beats Appears normal
134
What is SVT with Aberrancy?
Aberrancy is a functional BBB with increased HR Won't be able to tell the different between SVT with BBB until back in sinus rhythm
135
What is Antidromic WPW?
AVRT that conducts the opposite way Conducts down through accessory pathway and up through AV node Delta waves form as the impulse passes through accessory pathway Treated the same as NCT
136
What is a Cardiac Tamponade?
Accumulation of blood/fluid/pus/clots/gas resulting in reduced ventricular filling an haemodynamic compromise
137
Give 5 causes of Cardiac Tamponade
Malignancy Trauma Aortic DIssection Infective Drugs (Hydralazine, Isoniazid)
138
Give 5 presentations of Cardiac Tamponade
Dyspnoea Tachycardia Tachypnoea Distended jugular vein Pericardial Friction Rub
139
What is Pulsus Parodoxus?
Exaggeration of a normal decrease in systolic in inspiration in Cardiac Tamponade Helps differentiate between that and Pericardial Effusion
140
Name two investigations you would do for Cardiac Tamponade. What would they show?
Bloods - CK, Troponin, Us and Es CXR - Water Bottle shaped heart
141
Describe three managements of Cardiac Tamponade
Pericardiocentesis Oxygen Leg Elevation - promotes venous return
142
How would an Ostium Secondum ASD present?
Usually asymptomatic until left to right shunt develops Shunt becomes more exaggerated as you age due to decreased LV compliance Onset of Dysponea/HF aged 40-60
143
How would an Ostium Primum ASD present? What are it's associations?
Usually presents in childhood May be asymptomatic or may be fatigued, dyspnoea Associated with Downs Syndrome and AV Valve abnormalities
144
How would ASD present on an ECG and a CXR?
RBBB with LAD (primum) or RAD (secondum) CXR - Atrial Enlargement, Small aortic knuckle
145
Give two complications of ASD
Eisenmenger Syndrome (Reversal of shunt an subsequent cyanosis) Paradoxical Emboli
146
Describe some possible presentations of VSD
May present with Heart Failure in infancy, or may remain asymptomatic until later life Signs of Pulmonary Hypertension Murmur (Harsh pansystolic at left sternal edge with left parasternal heave)
147
VSD present normally on an ECG, how would they present on a CXR?
Small VSD - Normal Large VSD - Cardiomegaly, Large pulmonary arteries
148
What is Coarctation of the Aorta? Name two associations
Congenital narrowing of descening aorta usually distal to left subclavian Associated with Bicuspid Valve and Turner's Syndrome
149
Name 5 presentations of Coarctation of the Aorta
Radioradial delay Weak femoral pulse Hypertension Systolic murmur over left scapula Cold feet
150
Name two investigations for Coarctation of the Aorta
CT/MRI Aortogram CXR - Rib notching (blood diverts down intercostal arteries to supply lower body, causing these vessels to dilate and erode ribs)
151
Tetralogy of Fallot is the most common cyanotic heart defect, what is the embryological cause?
Abnormal separation of Truncus Arteriosus into Aorta and Pulmonary Artery
152
What are the four abnormalities in Tetralogy of Fallot
VSD Pulmonary Stenosis RV Hypertrophy Overriding Aorta
153
How might Tetralogy of Fallot present?
May be asymptomatic at birth but gets more cyanotic as PA closes May squat (increases vascular resistance to decrease the degree of shunting) Repaired adult - exertional dyspnoea, palpitations
154
What 3 investigations could you do for suspected Tetralogy of Fallot
ECG - RV hypertrophy with RBBB CXR - classical boot shaped heart Echo
155
What is Dressler's Syndrome?
Late onset Pericarditis post MI Usually 1-6 weeks after initial MI (may be immune mediated)
156
How might Dressler's Syndrome present?
Pain - left shoulder, pleuritic, worse when lying down Malaise Dyspnoea Fever
157
Describe 3 Investigations of Dressler's Syndrome
FBC - Leucocytosis Heart Autoantibodies ECG - ST Elevation
158
Describe the management of Dressler's Syndrome
Asparin - 750-1000mg tds for 2 weeks before tapering Colchicine - Improves response to NSAIDs
159
State two congenital causes of Long QT syndrome
Jervell and Lange Nielson Syndrome - sensorineural deafness Romano Ward
160
Describe the pathophysiology of Rheumatic Fever
Peak incidence between 5-15 y Triggered 2-4wks after Strep Pyogenes infecton
161
Why does Rheumatic Fever cause valvular manifestations?
Antibody to carbohydrate wall of Streptococcus cross reacts with valve tissue (antigenic mimicry)
162
What is the Jones Criteria for Rheumatic Fever?
Requires evidence of Strep Infection (titre, throat culture) +2 major symptoms OR 1 major and 2 minor
163
How do you manage Rheumatic Fever?
Bed rest until CRP has been normal for 2 weeks (this may take up to 3 months) IV Benzylpenicillin Penicillin V Asparin
164
Describe three features of Salicyclate Toxicity
Tinnitus, Hyperventilation, Metabolic Acidosis
165
State three associations of Dilated Cardiomyopathy
Alcohol Hypertension Haemochromatosis
166
How does Dilated Cardiomyopathy present?
Same symptoms as Heart Failure
167
Define Cardiomyopathy
Myocardial disorder where the heart muscle is structurally or functionally abnormal without Coronary Artery Disease, Hypertension, Valvular, or Congenital Heart Defects
168
What is Hypertrophic Cardiomyopathy?
Autosomal Dominant genetic disorder characterised by LV Hypertrophy, impaired diastolic filling, and abnormalities of mitral valve Most common cause of sudden cardiac death in young adults and athletes
169
How does Hypertrophic Cardiomyopathy present?
Varies between asymptomatic to profound exercise limitations, arrhythmias and sudden death Symptoms of mitral regurg
170
What is the most common arrhtyhmia seen in Hypertrophic Cardiomyopathy?
Atrial Fibrillation
171
Describe three possible managements for Hypertrophic Cardiomyopathy
Rhythm Control (Anti Arrhythmics, Catheter Ablation) Anticoagulation (AF risk) ICD (Implantable Cardioverter Defibrillator)
172
What is Restrictive Cardiomyopathy?
Normal left ventricular cavity size and systolic function, but with increased myocardial stiffness Usually idiopathic or caused by increased deposition (eg Fabry's Disease)
173
How would you manage Restricitve Cardiomyopathy?
Children - Transplant Adults - Heart Failure Management
174
Acute Pericarditis can be primary (idopathic) or secondary. Name four secondary causes.
Infective Autoimmune Drugs (Procainamide, Hydralazine, Isoniazid) Metabolic (Uraemia, Hypothyroidism)
175
Describe the presentation of Acute Pericarditis
Chest pain WORSE on inspiration/lying flat, IMPROVED by sitting forward May hear pericardial rub
176
What would the ECG of Acute Pericarditis?
Saddle shaped ST elevation
177
How would you manage Pericarditis?
NSAIDs/Asparin with PPIs for 1-2wks Colcihicine for 3 months for prevention If non resolving/autoimmune - steroids
178
Apart from dyspnoea/chest pain in Pericardial Effusion, give three other signs/symptoms
Hiccoughs (compression of phrenic nerve) Nausea (compression of diaphragm) Bronchial Breathing at left lung base (Ewarts Sign)
179
What is Constrictive Pericarditis?
Heart is encased in rigid pericardium, normally idiopathic or following TB/Pericarditis
180
How would Constrictive Pericarditis present?
Right heart failure with raised JVP Kussmaul's Sign (JVP rising paradoxically with Inspiration)
181
What would you see on XRAY of Constrictive Pericarditis?
Small heart Pericardial Calcification
182
Using LMNOP mnemonic, how would you manage Acute Heart Failure?
Loop Diuretics Morphine Nitrates Oxygen Position
183
Name a cause of Right Axis Deviation
Pulmonary Embolism
184
Give two points about preparing a patient for an ECG
- The skin must be clean and dry (any recent use of moisturiser will require alcohol wipe) - If excessively hairy and unable to get a good connection (eg by parting the hairs) then the chest must be shaved
185
State the five steps to describing an ECG
1) Rhythm (Regular/Irregular) 2) Conduction Intervals (eg prolonged PR) 3) Cardiac Axis (any deviation) 4) QRS Description 5) ST segment description
186
Which Mobitz type is also called Wenkebach ?
Type 1
187
Describe the septations of the Left Bundle Branch
Divided into anterior and posterior fascicle Anterior fascicle is normally the blocked one
188
How would blockage of the left anterior fascicle present on ECG?
LBBB and Left Axis Deviation
189
How would blockage of the Left Posterior Fascicle present on an ECG?
Right Axis Deviation
190
What is Bifascicular block and how would it present on an ECG?
When there is both RBBB and Left Anterior Fascicle blockage Shows as RBBB and Left Axis Deviation
191
What is Trifascicular Block?
Blockage of both the anterior and posterior left fascicles, and the right bundle branch AKA complete HB
192
Name three places that a supraventricular rhythm can originate
SA node AV node Atrial Muscle
193
How would ventricular pacing appear on an ECG?
A pacing spike prior to each QRS complex
194
How would dual chamber pacing appear on an ECG?
A pacing spike before each P wave and each QRS complex
195
Once a STEMI is confirmed, describe the management options if a PCI centre is quickly accessible.
If the onset of the STEMI was within 12 hours, and a PCI is available within 2 hours. Give loading dose of Prasugrel (60mg) or Clopidogrel (600mg) AND UFH. PCI
196
Once a STEMI is confirmed, describe the management options if a PCI centre is NOT quickly accessible.
Thrombolyse with Alteplase Clopidogrel AND UFH PCI when possible
197
what is the most common sign of phaeochromocytoma?
sustained or paroxysmal hypertension
198
when would cushings syndrome be suspected
* typical pysical appearannce
* hyperglycaemia
* 24 hour urine cortisol excretion will be elevated
* low does dexamethasone suppression test
199
when is primary aldosterone suspected
* low serum potassium and high/normal sodium (potassium is normal in up to 50%)
* consider in pt with hypokalaemia, resistant hypertension, family history of premature hypertension
* aldosterone:renin ratio measured in the morning
* plasma renin activity is low or undetectable in pt with primary aldosterone
Year 3 Medicine
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