Year 3 - Diseases > Cardio 2 > Flashcards

Cardio 2 Flashcards

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1
Q

Define heart block

A
  • Atrioventricular (AV) block is a cardiac electrical disorder defined as impaired (delayed or absent) conduction from the atria to the ventricles.
  • The severity of the conduction abnormality is described in degrees: first-degree; second-degree, type I (Wenckebach or Mobitz I) or type II (Mobitz II); and third-degree (complete) AV block.
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2
Q

Describe epidemiology of heart block

A
  • More prevalent in African American patients
  • More common over age 50
  • 3rd degree incidence is 0.04%
  • More common in men
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3
Q

Describe aetiology of heart block

A
  • Fibrosis and calcification of the conduction system
  • CAD (including patients with a chronic disease and/or an acute coronary syndrome, right coronary artery)
  • Medication such as AV-nodal blocking agents (i.e., beta-blockers, calcium-channel blockers, digitalis, adenosine), anti-arrhythmic medications such as sodium-channel blockers, and some class III agents (i.e., sotalol and amiodarone).
  • High vagal tone; cardiomyopathy (e.g., hypertrophic, sarcoid, amyloid, haemochromatosis); calcification from adjacent valvular calcification; post catheter ablation for arrhythmias
  • Post-surgical causes (i.e., valve repair or replacement myectomy, septal ethanol ablation); blunt cardiac injury;[10]and some indigenous medicines.
  • Severe electrolyte disturbance, acidosis, or hypoxaemia may result in AV block as well as neuromuscular disorders (myotonic dystrophy, Kearns-Sayre syndrome, Erb dystrophy, peroneal muscular atrophy), myocarditis, infective endocarditis, and Lyme disease.
  • AV block may be congenital as well
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4
Q

List risk factors for heart block

A
  • Age-related degenerative changes in the conduction system
  • Increased vagal tone
  • AV-nodal blocking agents
  • Chronic stable CAD
  • Acute coronary syndrome
  • CHF
  • Hypertension
  • Cardiomyopathy
  • Left ventricular hypertrophy
  • Recent cardiac surgery
  • Acid-base or electrolyte disturbance
  • Neuromuscular disorders
  • Sarcoidosis
  • Myocarditis
  • Infective endocarditis
  • Hypoxemia
  • Blunt cardiac injury
  • Some indigenous medicines
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5
Q

List symptoms of heart block

A

Mobitz 2 and 3rd degree only

  • Fatigue
  • Dyspnoea
  • Chest pain, palpitations, and nausea or vomiting
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6
Q

List signs of heart block

A
  • Hypertension
  • Cannon A waves (3rd degree heart block, irregular large wave of the JVP)
  • Hypoxaemia
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7
Q

Describe diagnosis of heart block

A
  • ECG
  • First degree increased PR interval
  • Mobitz 1 increasing PR interval then dropping a QRS complex
  • Mobitz 2 PR the same with randomly dropped QRS
  • Third degree P and QRS dissociated
  • Troponin may be elevated, measure potassium, calcium, pH
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8
Q

Describe treatment of heart block

A

First degree or Mobitz 1

  • Monitor for development
  • Discontinue AV-nodal blocking medications including beta-blockers, non-dihydropyridine calcium-channel blockers, and digitalis.
  • Pacemaker if symptoms continue

Mobitz II or third degree

  • Discontinue AV blocking drugs
  • Give atropine
  • Pacemaker insertion with or without ICD
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9
Q

List complications of heart block

A

Pacemaker insertion 2-3% risk of

  • Bleeding, infection, vascular trauma, pneumothorax, cardiac tamponade, lead dislodgement, and pocket haematoma development.
  • The risk of MI, stroke, and death is <1%.
  • Long-term complications include pulse generator or lead malfunction and infection, requiring replacement or extraction
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10
Q

Describe prognosis of heart block

A
  • First-degree AV block 2-fold increase in the probability of atrial fibrillation, a 3-fold increase in the probability of pacemaker implantation, and an increase in all-cause mortality.
  • In symptomatic patients with irreversible AV block, symptoms are likely to persist or potentially worsen.
  • Patients with irreversible advanced AV block (type II second-degree or third-degree) are at high risk for progression to third-degree AV block or ventricular asystole.
  • Low rate of pacemaker complications
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11
Q

Describe prognosis of ACS and angina

A
  • Stable angina 58% of patients free of symptoms within 1 year following lifestyle modification and medical therapy
  • non-ST ACS patient mortality after 6 months 4.8%
  • At 12 months, rates of adverse cardiovascular events (MI and death) 10%
  • NSTEMI high risk of morbidity and death, sudden death rate 4-6 times higher than general population
  • STEMI in hospital mortality 4-12% and 1 year mortality 10%
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12
Q

List risk factors for myocarditis

A
  • Infection (non-HIV)
  • HIV infection
  • Smallpox vaccination
  • Autoimmune/immune-mediated diseases
  • Peripartum and postnatal periods
  • Drugs and toxins
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13
Q

Describe diagnosis of myocarditis

A
  • 12-lead ECG (ST and T wave abnormalities, commonly ST elevation/depression)
  • CXR (bilateral pulmonary infiltrates)
  • Serum CK (mildly high)
  • Serum CK-MB (mildly high)
  • Serum troponin (I or T - elevated)
  • Serum B-type natriuretic peptide (elevated in ventricular distention)
  • Two-dimensional echocardiogram (global and regional left ventricular motion abnormalities and dilatation)
  • Endomyocardial biopsy (EMB - myocardial cellular infiltrated and or necrosis)
  • Coronary angiography (normal)
  • Cardiac MRI (early enhancement myocarditis)
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14
Q

Define constrictive pericarditis

A
  • A type of chronic pericarditis (lasts more than 3 months)
  • Characterized by thickening and rigidity of the pericardium, resulting in both backward and forward failure. There is a characteristic pericardial knock on auscultation, which is caused by a sudden stop in ventricular diastolic filling.
  • Effusive-constrictive pericarditis (the other type of chronic pericarditis) is characterized by a thickened pericardium with an effusion; this can lead to cardiac tamponade
    .
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15
Q

Describe aetiology of constrictive pericarditis

A
  • Idiopathic
  • Infectious (most commonly viral e.g., coxsackie B virus), bacterial e.g., Staphylococcus spp., Streptococcus spp., or M. tuberculosis, fungal or toxoplasmosis)
  • Myocardial infarction (Postinfarction fibrinous pericarditis within 1–3 days as an immediate reaction or dressler syndrome within weeks to months following an acute myocardial infarction)
  • Postoperative (postpericardiotomy syndrome): blunt or sharp trauma to the pericardium
  • Uremia (e.g., due to acute or chronic renal failure)
  • Radiation
  • Neoplasm (e.g., Hodgkin lymphoma)
  • Autoimmune connective tissue diseases (e.g., rheumatoid arthritis, systemic lupus, scleroderma)
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16
Q

List risks for constrictive pericarditis

A
  • Low if idiopathic or viral pericarditis
  • Intermediate risk for autoimmune and neoplastic aetiologies
  • High risk for bacterial aetiologies, especially with TB and purulent pericarditis
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17
Q

Describe epidemiology of constrictive pericarditis

A
  • 9% of patients with acute pericarditis
  • 0.76 cases per 1,000 person-years after acute idiopathic/viral pericarditis
  • 31.7 cases per 1,000 person-years for acute tuberculous pericarditis
  • 52.7 cases per 1,000 person-years for purulent pericarditis
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18
Q

List symptoms and signs of constrictive pericarditis

A

Symptoms of fluid overload (i.e., backward failure)

  • Jugular vein distention
  • Kussmaul sign
  • Hepatic vein congestion: hepatomegaly, painful liver capsule distention, hepatojugular reflux
  • Peripheral edema; or anasarca, ascites with abdominal discomfort

Symptoms of reduced cardiac output (i.e., forward failure)

  • Fatigue, dyspnea on exertion
  • Tachycardia
  • Pericardial knock: sudden cessation of ventricular filling during early diastole that is heard best at the left sternal border
  • Pulsus paradoxus: ↓ blood pressure amplitude by at least 10 mm Hg during deep inspiration
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19
Q

List investigations for constrictive pericarditis and their findings

A
  • Echocardiography (increased pericardial thickness)
  • CT and cardiac MRI (pericardial thickening > 2 mm, calcifications, normal cardiac silhouette)
  • Chest x-ray (heart size normal or slightly increased, pericardial calcifications, clear lung fields)
  • Cardiac catheterization if noninvasive methods have failed to provide a definitive diagnosi (similar pressures in the left and right atria and right ventricle at the end of diastole (e.g., “equalization of pressures”), normal pulmonary artery systolic pressure < 40 mm Hg, mean right arterial pressure > 15 mm Hg)
  • Square root sign - dip-and-plateau waveform, a sudden dip in the right and left ventricular pressure in early diastole followed by a plateau during the last stage of diastole
  • ECG (no conclusive findings: generalized flat/inverted T waves, low QRS voltage, possible AF)
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20
Q

List signs on examination associated with intermittent claudication

A
  • Wet gangrene
  • Shiny hairless skin
  • Ulcers
  • Non-palpable pulses
  • Buergers angle (pale limb under 20 degrees with flushing when the limb is lowered due to overcompensation)
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21
Q

Describe investigations of peripheral vascular disease

A
  • Doppler ultrasound
  • Ankle brachial index (systolic pressure of leg divided by systolic blood pressure of the arm - less than 0.41 is grounds for immediate surgical consultation)
  • HbA1c, lipid screen, u&es, digital subtraction angiogram, cardio exam and lower limb exam
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22
Q

List signs on examination associated with limb ischaemia

A
  • Paralysis
  • Pallor
  • Perrishingly cold
  • Pain
  • Pulseless
  • Paraesthesia
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23
Q

Describe aetiology of limb ischaemia

A

Chronic
- Atherosclerosis (intermittent claudication)

Acute

  • Embolus (eg. mural thrombus, AF, TB, IV drug users, malignant)
  • Thrombotic (Vircows triad - ruptured plaque with clot on it)
  • Aneurysm (eg. marfans)
  • Iatrogenic (eg. air embolis)
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24
Q

Describe vircows triad

A
  • Hypercoagulability (blood clotting due to liver failure, polycythaemoa vera)
  • Stasis (long haul flights, recent surgery)
  • Endothelial trauma (bruising, crush injury, plaque rupture)
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25
Describe arterial ulcers
- Located distally, over bony prominences - Severe pain, particularly at night - Irregular edge, dry necrotic base, poor granulation tissue, round or punched out with sharp demarcation - Trophic changes of chronic ischaemia associated with it
26
Describe venous ulcers
- Lower third of leg (gaiter area between malleolus and lower calf) - Mild pain, relieved by elevation - Shallow, irregular shape, granulating base, flat or steep elevation markings, fibrinous material at ulcer bed
27
List associated signs alongside venous ulcers
- Lipodermatofibrosis/ lipodermatosclerosis - Pigmentation - Oedema - Atrophie blanche - Telangiectasia - Normal cap refill time
28
List associated signs alongside arterial ulcers
- Trophic changes of chronic ischaemia - Pale - Hair loss - Atrophic skin - Cool feet - Absence of pulses - Prolongued cap refill - ABI less than 0.5 - Dependent rubor
29
Describe neurotrophic ulcers
- Under calluses or pressure points - Punched out, deep sinus variable depth, seep sinus, may involve bone, tendon, fascia, joint capsule - Neuropathy may be associated/ underlying osteomyelitis
30
List investigations for aortic stenosis
- Transthoracic echocardiogram (including Doppler - elevated aortic pressure gradient; measurement of valve area and left ventricular ejection function - diagnostic modality of choice) - ECG (left ventricular hypertrophy and absent Q waves, atrioventricular block, hemiblock, or bundle branch block) - Cardiac MRI - Cardiac catheterisation - ECG exercise stress testing - Dobutamine stress echo
31
Define aortic sclerosis
Narrowing of the aorta which causes a murmur but has no functional impairment. Does not radiate to the carotids
32
Define mitral stenosis
A narrowing of the mitral valve orifice, usually caused by rheumatic valvulitis producing fusion of the valve commissures and thickening of the valve leaflets.
33
Describe aetiology of mitral stenosis
- Rheumatic fever - congenital - Mucopolysaccharidosis - endocardial fibroelastosis - Malignant carcinoid - Prosthetic valve
34
List risk factors for mitral stenosis
- Streptococcal infection - Female sex - Ergot medications - Serotogenic medications - Amyloidosis - Bronchial carcinoid syndrome
35
Describe epidemiology of mitral stenosis
- Mainly in developing countries as primarily caused by rheumatic fever - Highest prevelence in Oceania, South Asia and sub-Saharan Africa - Rheumatic heart disease more common in females - No longer a notifiable disease in US
36
List symptoms of mitral stenosis
- Start at diameter below 2cm - Pulmonary hypertension causes dyspnoea, haemoptysis chronic bronchitis-like picture - Pressure on local structures by enlarged left atrium causes haemoptysis, dysphagia and bronchial obstruction - Paroxysmal nocturnal dyspnoea - Fatigue, palpatations, chest pain, emboli
37
List signs of mitral stenosis
- Malar flush due to decreased cardiac output - Weak pulse - AF - Tapping, non-displaced apex beat - Loud S1, then opening snap with mid diastolic rumble. Closer to S2/ longer rumble = worse disease. Louder on laying on side and expiration (pre-systolic accentuation) - Graham steel murmur may be heard (pulmonary hypertension, high pitched decreascendo diastolic murmur on left sternal border)
38
List investigations for mitral stenosis
- ECG (AF, left atrial enlargement, right ventricular hypertrophy, bifid p waves 'p-mitrale'/ no p waves) - CXR (double right heart border indicating enarged left atrium, prominent pulmonary artery, kerley B lines, mitral valve calcification) - Trans-thoracic echocardiography (hockey stick shaped mitral deformity - diagnostic. Stenosis significant if valve orifice <1cm2/m2 body surface area) - Trans-oesophageal echocardiography (possible left atrial thrombus) - Cardiac catheterisation (high left atrial pressure, low left ventricular pressure and low CO, Indicated if signs of other valve disease, pulmonary hypertension/ calcified mitral valve, angina) - Dynamic exercise testing (pressures increase with exercise)
39
Describe diagnosis of ventricular septal defect
- Chest radiograph - ECG - Echo - Coronary angiogram - Swan ganz pulmonary artery catheter
40
Describe treatment of ventricular septal defect
- Analgesia - Urgent transfer - Intra-aortic balloon pump - Ionotrophic support
41
Describe signs of ventricular septal defect
- Pan systolic murmur left sternal edge with heaves and thrills - Raised JVP - Cardiac failure
42
Compare pericardial effusion with cardiac tamponade
- Both involve fluid in the pericardial space - Cardiac tamponade is a pericardial effusion which raises intrapericardial pressure, reducing ventricular filling and dropping cardiac output. Can lead to cardiac arrest - For both treat the cause, urgent fluid drainage and send for analysis
43
Describe management of stable and unstable angina
- Stop smoking, increase exercise, stop alcohol, weight loss, diet modifications - Aspirin 75mg if not contraindicated - Statin - GTN spray/sublingual (SE headache) - ACEi - B blocker - CABG or angioplasty if necessary
44
Compare aetiology of STEMI and NSTEMI
- NSTEMI subendocardial ischaemia | - STEMI transmural ischaemia
45
Define aortic dissection
- Intimal layer of wall of the aorta separating resulting in a blood filled lumen - Type A ascending aorta - Type B descending aorta
46
List signs and symptoms of aortic dissection
- Acute onset, severe, tearing chest pain radiating from the back. Intense from the onset. - Hypertension, dyspnoea - Asymmetric upper and lower extremity blood pressure and pulses (absent pulse in one arm) - New onset of aortic regurg - Paraplegia, paraesthesia - Limb pain, abdo pain - Left sided decreased breath sounds/dullness
47
List risk factors for aortic dissection
- Hypertension - Atherosclerotic aneurysmal disease - Marfan syndrome - Ehlers-Danlos syndrome - Bicuspid aortic valve - Annulo-aortic ectasia - Coarctation - Smoking - Family history of aortic aneurysm or dissection - Older age - Giant cell arteritis - Overlap connective-tissue disorders - Vasculitis (takayasus/giant cell) - Surgical/catheter manipulation - Cocaine/amfetamine use - Heavy lifting - Infection (syphollis) - Pregnancy
48
Describe epidemiology of aortic dissection
- 0.5-2.95 cases per 100000 annually - US 0.2-0.8 per 100000 cases annually, 2000 new cases each year - Highest rate in italy, 4.04 per 100000 per year - Men predominantly affected, especially over 50 years
49
Describe aetiology of aortic dissection
- Intimal tear extending into the media of the aortic wall - Cystic medial degeneration predisposes to intimal disruption and is characterised by elastin, collagen and smooth muscle breakdown in the lamina media - Inherited conditions (eg. marfans and ehlers danlos) - Aterosclerosis
50
List types of aortic dissection
- Type A ascending aorta (always needs surgery) | - Type B descending aorta
51
Describe diagnosis of aortic dissection
- ECG (look for MI) - CXR showing widened mediastinum, possible pericardial effusion - Cardiac enzymes usually negative - BP in both arms, then transthoracic/oesophageal ultrasound - CT angiography (include abdo and pelvis to see extent - shows intimal flap) GOLD STANDARD - MRI - Renal function tests (elevated creatinine and urea in reduced renal perfusion) - LFTs (asparate transaminase and alanine transaminase raised in reduced hepatic perfusion) - Lactate - FBC - Group and save (prepare for surgery)
52
Describe ECG changes in hypokalaemia
- U wave, elongated PR interval, t wave flattening and inversion and ST depression caused by hypokalaemia. - Untreated hypokalaemia causes toursades de points, a form of ventricular tachycardia
53
Define aortic regurgitation
- The diastolic leakage of blood from the aorta into the left ventricle. - It occurs due to inadequate coaptation of valve leaflets resulting from either intrinsic valve disease or dilation of the aortic root.
54
Describe epidemiology of aortic regurgitation
- Not as common as aortic stenosis and mitral regurgitation - 13% prevalence in men and 8.5% in women trace or mild. - Prevalence increases with age
55
Describe aetiology of aortic regurgitation
- Developing countries rheumatic heart disease is the most common cause Acute: - Infective endocarditis - Ascending aortic dissection - Chest trauma Chronic - Congenital - Connective tissue disorders (eg. marfans, Ehlers Danlos) - Rheumatic fever - Takayasu arteritis - Rheumatoid arteritis - SLE - Appetitie suppressents - Arthritides - Hypertension
56
List risks for aortic regurgitation
- Bicuspid aortic valve - Rheumatic fever - Endocarditis - Marfan's syndrome and related connective tissue disease - Aortitis - Systemic hypertension - Older age
57
List symptoms of aortic regurg
- Exertional dyspnoea - Orthopnoea - Paroxysmal nocturnal dyspnoea - Palpitations, angina, syncope
58
List signs of aortic regurg
- Collapsing (water hammer) pulse - Wide pulse pressure - Displaced, hyperdynamic apex beat - High pitched early diastolic murmur louder on expiration when sitting up in tricuspid region - Corrigons sign (caorid pulsation) - De mussets sign (head nodding with each heartbeat) - Quinckes signs (carotid pulsations in nail bed) - Duroziezs sign (in the groin a finger compressing the femoral artery gives a diastolic murmur) - Traubes sign (pistol shot sound over femoral arteries) - Austin flint murmur (severe AR)
59
Describe investigations for aortic regurg
- ECG showing left ventricular hypertrophy - CXR showing cardiomegaly, dilated ascending aorta, pulmonary oedema - Echo is diagnostic - Cardiac catheterisation to assess severity of the lesion, anatomy of the aortic root, left ventricular function, coronary artery disease and other valve disease
60
Define mitral regurgitation
Backflow through the mitral valve during systole
61
Describe aetiology/risks of mitral regurg
- Functional (LV dilation) - Annular calcification (elderly) - Rheumatic fever - Infective endocarditis - Mitral valve prolapse - Ruptured chordae tendinae - Papillary muscle dysfunction/rupture post MI - Connective tissue disorders (eg. Ehlers Danlos and Marfans) - Cardiomyopathy - Congenital - Anorectic/dopaminergic drugs
62
List symptoms of mitral regurg
- Dyspnoea - Fatigue - Palpitations - Symptoms of causitive factor
63
List investigations for mitral regurg
- ECG showing AF, echo - P-mitrale pn ECG if sinus rhythm - LVH - CXR (large LA and LV, mitral valve calcification, pulmonary oedema)
64
Define tricupsid regurgitation
Backflow of blood through the tricuspid valve in systole
65
Describe epidemiology of tricuspid regurg
- COmmon incidental finding on imaging - 50-60% mild asymptomatic adults - 15% moderate - In developed countries most commonly ischaemic or degenerative mitral regurg. - Developing rheumatic fever
66
Describe aetiology/risks of tricuspid regurg
- Functional eg. RV dilation eg. due to hypertension induced by LV falure or PE - Rheumatic fever - Infective endocarditis - Cardinoid syndrome - Congenital (ASD, AV canal, ebstein) - Drugs (ergot) - RA, marfans, tricuspid valve prolapse
67
List symptoms of tricuspid regurg
- Fatigue - Hepatic pain on exertion due to congestion - Ascites - Oedema - Symptoms of causative condition
68
List signs of tricspid regurg
- Giant v wave and prominent y descent on JVP - RV heave - Pansystolic murmur heard best at lower left sternal border, on inspiration - Pulsatile hepatomegaly - Jaundice - Ascites
69
Describe investigations for tricuspid regurg
- Echocardiogram (assess left and right heart ejection fraction) - ECG (atrial flutter/fib) - LFT - Serum urea and creatinine - FBC - CXR (cardiomegaly, pleural or pericardial effusion)
70
Compare osler nodes and janeway lesions
- Osler nodes are caused by immune complex deposition. Painful in the fingers and toes - Janeway lesions are non-tender palmar or plantar nodules due to emboli
71
List risk factors for atrial fibrillation
- Age over 70 - Thyrotoxicosis - Rheumatic heart disease - Alcoholism - Left ventricular dysfunction Also: IHD, post op, hypokalaemia, pneumonia, caffine
72
Define ventricular fibrillation
An arrythmia causing the ventricles to quiver and cause uncoordinated muscle contraction
73
Describe aetiology/risks for ventricular fibrillation
- MI - Increased catecholamines - Electrolyte imbalances (torsades de pointes) - Hypoxia - Acid-base disturbance - Hyper/hypothermia - Congenital conditions (QT syndrome, Brugada)
74
List signs and symptoms of ventricular fibrillation
- Chest pain - Dizzy - SOB - Unconscious
75
List investigations for ventricular fibrillation
- Time dependent - ECG showing no recognisible P, QRS or T waves - Blood test
76
Describe management of ventricular fibrillation
- CPR/ defibrillation - IV adrenalline 1mg every 3-5 mins - IV amiodarone 300 mg after 3 shocks - IV amiodarone 150mg after 5 shocks - Treat hypoxia, hypothermia, hypovolaemia, electrolyte abnormalities, tension pneumothorax, tamponade, thromboembolism
77
Describe prognosis of ventricular fibrillation
- Prognosis poor without intervention in 4-6 minutes - Early defib increases prognosis - If occuring 48 hours after acute MI high rate of recurrence
78
Describe complications of ventricular fibrillation
- CNS ischaemic injury - Myocardial injury - Post defib arrythmias - Aspiration pneumonia - Injuries from CPR - Death
79
Describe epidemiology of ventricular fibrillation
- Most common arrythmia in cardiac arrest patients | - Increases age 45-75
80
Define wolf parkinson white syndrome
An arrhythmia that occurs due to the presence of an accessory pathway from the atria to the ipsilateral ventricle causing pre-excitation
81
Describe aetiology of WPW
Congenital - Ebstein’s anomaly (septal and posterior tricuspid leaflets are displaced towards the apex) - Heart defect (VSD, transposition of great vessels, hypertrophic cardiomyopathy) - Mitral valve prolapse - Coarctation of the aorta - Marfan’s syndrome
82
List signs and symptoms of WPW
- Palpitations - Dizzy - Chest pain - SOB
83
Describe investigations for wolf parkinson white
- ECG (slurred upstroke of the QRS (delta wave) with short PR) - Echo if suspect structural disease
84
Describe epidemiology of WPW
- 1-3 people per 1000 population - More common in males - Most common in young, previously healthy people. Prevalence decreases with age
85
Define varicose veins
Varicose veins are subcutaneous, permanently dilated veins 3 mm or more in diameter when measured in a standing position; however, they may not be visible.
86
Describe epidemiology of varicose veins
- Increases in prevalence with age, 41% in 60 year olds - Genetic risk - Higher prevalence in more developed regions. 10-15% in men and 20-25% in women
87
Describe aetiology/risks of varicose veins
- Previous episode of DVT - Female sex - Prolongued standing - Increasing numbers of births - Obesity - Genetic links - Venous valve incompetence, leading to pooling of blood and distention of veins - May be caused by obstruction (DVT, fetus, pelvic tumour), AV malformations, overactive muscle pumps
88
List signs and symptoms of varicose veins
- Dilated torturous veins - Fatigue with prolongued standing - Cramps, heaviness - Restless legs - Corona phlebactica - Itching - Ankle swelling - Venous ulceration, oedema, eczema, lipodermatosclerosis - Tap test (tap on varicose vein and feel a thrill over saphenofemoral junction). Auscultate for bruits
89
List investigations for varicose veins
Duplux ultrasound, valve closure time of over 0.5 seconds indicative of reflux
90
Describe management of varicose veins
- Specialist referal if bleeding, pain, ulceration, severe impact on quality of life or thrombophlebitis - Treat underlying cause - Education (avoid standing lots, elevate legs, stockings, lose weight, regular walks) - Endovascular treatment (radiofrequency ablation, endovenous laser ablation, injection sclerotherapy) - Surgery (eg. saphenofemoral ligation, post op elevation and compression)
91
List possible complications of varicose veins
- Chronic venous insufficiency - Haemorrhage - Venous ulceration - Lipodermatosclerosis - Haemosiderin deposition
92
Describe prognosis of varicose veins
Resolution of symptoms occurs in over 95% of patients
93
Define venous ulcer
- Abnormal break in the epithelial surface, caused by venous insufficiency
94
Describe epidemiology of venous ulcers
- 70% of leg ulcers | - More common with advancing age, 1-3 per 1000 in general population to 20 per 1000 in 80 plus age group
95
List risk factors for venous ulceration
- Pre-existing varicose veins - DVT - Phlebitis - Previous fracture, trauma or surgery - Family history - Increasing age - Prolongued stanging - Obesity - Smoking - Pregnancy
96
List symptoms of venous ulceration
- Pain relieved by elevation - Leg heaviness - Aching - Swelling - Skin dryness - Tightness - Itching - Irritation - Muscle cramps - Venous claducation
97
List signs of venous ulceration
- Ulcer in lower third of leg (gaiter area), between malleolus and lower calf - Shallow, irregular shape, granulating base, slat of steep elevation markers and fibrinous materal at ulcer bed - May also see lipodermatofsclerosis (like an upside down wine bottle), pigmentation (hemosiderin deposition), oedema, atrophie blanche, telangiectasia, normal cap refil, stasis eczema
98
Describe investigations of venous ulceration
- Venous duplex ultrasound showing reflux (less than 500 milliseconds superficial veins, 1000 milliseconds for deep veins) - ABPI to rule out arterial - May swab and biopsy
99
Describe management of venous ulcers
- Graduated compression (reverse venous insufficiency, multilayer dressing) - Debridement and cleaning (release trapped pus) - Dressing (hydrocolloidal) - Antibiotics (if suspician of infection) - Pentoxifylline (chronic if it fails to respond after 4 weeks, given for 6 months) - Topical steroids for surrounding dermatitis - Aspirin - Venous surgery - Skin grafting if extensive
100
Describe prognosis of venous ulcers
Prognosis is improved if the patient is mobile and has no significant comorbidities
101
List complications of venous ulcers
- Recurrent - Malignant change - Osteomyelitis/sepsis - Cellulitis/infection
102
Define arterial ulcer
A break in the epithelium of the skin caused by arterial insufficiency
103
Describe epidemiology of arterial ulcers
- Second most common ulcer in the leg - 10% of all leg ulcers - Both sexes equally affected
104
Describe aetiology of arterial ulcer
- Arterial or arteriolar obstruction leading to ischaemia of skin and subcutaneous tissues - Acute imparment may be trauma/thrombosis, chronic impairment atherosclerosis - Peripheral vascular disease due to atherosclerosis is the most common cause of arterial ulceration (commonly men over 45 and women over 55)
105
List risk factors for arterial ulcers
- Old age - CV risks (smoking, alcohol, obesity, diabetes, HTN, high cholesterol) - Vasculitis - Sickle cell disease - Thalassemia
106
List symptoms and signs of arterial ulcers
- Severe pain, particularly at night which eases when depressing the leg, and intermittent claudication - Distal ulcer on the dorsum of foot or toes, over bony prominences - Irregular edge, poor granulation tissue, dry necrotic base, round or punched out with sharp demarcation - Trophic changes of chronic ischaemia (pale, hair loss, atrophic skin, cool feet, absent pulses, prolongued cap refill, ABI <0.5 rubor - Buergers test where there is pain lifting the legs, pallor, and when legs hung over the side skin initially blue, then red due to reactive hyperaemia
107
List investigations for arterial ulcers
- ABI <0.5 severe - Buergers test - Duplex ultrasound, CT angiography, MRA
108
Define pulmonary hypertension
- Chronically elevated mean pulmonary arterial pressure (mPAP) at rest ≥ 20 mmHg (normal: 10–14 mmHg) or > 30 mmHg with exercise due to chronic pulmonary and/or cardiac disease or unknown reasons - Plus elevated pulmonary vascular resistance of ≥ 3 Wood units for patients with pre-capillary pulmonary hypertension (e.g., pulmonary arterial hypertension)
109
Define cor pulmonale
- Altered structure of impaired function of the right ventricle caused by pulmonary hypertension resulting from a primary disorder of the respiratory or pulmonary artery system
110
Describe aetiology of pulmonary hypertension
Group 1: pulmonary arterial hypertension - Idiopathic - Hereditary (BMPR2) - Drug induced (amphetamines, cocaine, appetite suppressants) - Associated conditions (connective tissue diseases, congenital heart disease, HIV) Group 2: left heart disease Group 3: chronic lung diseases and or hypoxemia - Obstructive sleep apnea - COPD/emphysema - Interstitial lung disease - High altitude Group 4: chronic thromboembolic occlusion Group 5: Unclear (sickle cell, scleroderma, metabolic syndrome, compression of pulmonary vessels by a tumor)
111
Describe epidemiology of pulmonary hypertension
- PAH rare, 10-52 cases per million - PH more common in severe respiratory and cardiac disease, 18-50% pateints assessed for transplantation and 7-83% of those with diastolic heart failure - 0.5-4% post PE
112
List symptoms of pulmonary hypertension
- Dyspnoea, syncope on exertion - Chest pain - Fatigue - Cyanosis - Clinical features of underlying aetiology - Hoarseness and cough occur rarely
113
List signs of pulmonary hypertension
- Loud and palpable second heart sound - Jugular vein distention - RHF (palpitations, oedema) - Nail clubbing - Parasternal heave
114
List investigations for pulmonary hypertension
- Doppler echocardiography (hypertrophy of right ventricle, dilation of coronary sinus, estimation of pulmonary arterial pressure) - Right heart catheterisation (mPAP >20mmHg at rest, if pre capillary pulmonary vascular resistance over 3 wood units) - Electrocardiography right axis deviation, RBBB, p pulmonale - CXR right heart hypertrophy, vascular changes (increased diameter of pulmonary arteries) - LFTs, TFT, autoimmune screening
115
List the grades of hypertensive retinopathy
- Grade 1 tortuosity of retinal arteries with increased reflectiveness (silver wiring). - Grade 2 grade 1 plus arteriovenous nipping (thickened retinal arteries pass over retinal veins). - Grade 3 additional flamed shaped haemorrhage and cotton wool exudates due to small infarct. - Grade 4 additional papilloedema (blurry margin of optic disc)
116
List side effects of spironolactone
- Hyperkalaemia | - Gynaecomastia
117
List side effects of b blockers
- Bronchospasm - Heart failure - Lethargy
118
List the mid diastolic murmurs
- Mitral stenosis | - Tricuspid stenosis
119
List the pan systolic murmurs
- Tricuspid regurg - Mitral regurg - VSD
120
List mid systolic murmurs
Aortic stenosis
121
List late systolic murmurs
Valve prolapse
122
List early diastolic murmurs
- Aortic regurg | - Pulmonary regurg
123
Describe austin flint murmurs
- Occurs in severe aortic regurg | - Low pitch rumbling and mid-diastolic murmur best heard at the apex
124
Define cardiac arrest
- A sudden state of circulatory failure due to a loss of cardiac systolic function - The result of 4 specific rhythm disturbances - VF, pulseless VT, pulseless electrical activity and asystole
125
Describe epidemiology of cardiac arrest
- 84 per 100000 population per year in Europe out of hospital considered for resus - US 110.8 per 100000 out of hospital arrest
126
Describe aetiology of cardiac arrest
- Ischaemic heart disease (62%) - Unspecified cardiovascular disease (12%) - Cardiomyopathy/dysrhythmias (9%) - 4 arrythmias: VT, VF, PEA, asystole - VT and VF most common, due to ischaemic heart disease, left vent dysfunction, premature ventricular beats - PEA MI, hypovolaemia, PE - Other causes: hypoxia, hyper/hypokalaemia, acidosis, hypothermia, glucose abnormalities, trauma, tamponade, tension pneumothorax
127
List risk factors for cardiac arrest
- Coronary artery disease - Left ventricular dysfunction - HCM - Arrythmogenic right ventricular dysplasia - Long QT syndrome - Acute emergency - Illicit substances - Brugada syndrome - Valvular heart disease - Smoking - ED
128
List signs and symptoms of cardiac arrest
- Patient unresponsive - Absence of normal breathing - Absence of circulation - Cardiac rhythm disturbance
129
List investigations for cardiac arrest
- Continuous cardiac monitoring to identify shockable rhythm (VF or VT) or non-shockable rhythm (asystole or pulseless electrical activity) - FBC (haemorrhage) - Serum electolytes (for potassium abnormalities) - ABG - Cardiac biomarkers (positive) - Echo (tamponade, valve disorders, assess left ventricular function) - ECG once circulation returned - Coronary angiography - CXR
130
Describe management of cardiac arrest
- CPR - Defibrillation if shockable - Adrenaline (IV), anti-arrythmic (amiodarone), magnesium (torsades de pointes) - Post resus care - rewarming, prevent recurrence
131
List complications of cardiac arrest
- Death - Rib fracture - Anoxic brain injury - Ischaemic liver injury - Renal tubular necrosis - Recurrent cardiac arrest
132
Describe prognosis of cardiac arrest
- Poor - early CPR increases survival - Survival <20% out of hospital VF - Survival <10% all patients out of hospital cardiac arrest - 36% in hospital VF/VT survival to discharge
133
Define cardiomyopathy
- Cardiomyopathies are diseases of the muscle tissue of the heart. - Types of cardiomyopathies include dilated, hypertrophic, restrictive, and arrhythmogenic right ventricular cardiomyopathy - Dilated cardiomyopathy (DCM) is the most common type of cardiomyopathy. - Unclassified: arrythmia induced, left ventricular non-compaction
134
Describe aetiology of dilated cardiomyopathy
Dilated - Idiopathic - TTN gene mutation - IHD - Infections (coxsackie B virus, chagas, HIV) - Systemic disorders (sarcoidosis, haemochromatosis, thiamine deficiency) - Peripartum - Toxic substances (cocaine, alcohol, medication) - Valvular disease (aortic stenosis, aortic regurg, mitral regurg)
135
Describe aetiology of hypertrophic cardiomyopathy
- Autosomal dominant | - Mutation of myosin binding protein C and B-Myosin heavy chain
136
Describe aetiology of restrictive cardiomyopathy
- Idiopathic - Systemic disorders (amyloidosis, sarcoidosis, haemochromatosis, systemic sclerosis) - Heart disease (Loffler endocarditis eospinophilic, endocardial fibroelastosis first 2 years of life) - Post radiation fibrosis
137
Describe epidemiology of cardiomyopathy
- Dilated 6/100000 per year, most common cardiomyopathy. 3:1 male to female - Restrictive least common - Arrythmogenic right ventricular cardiomyopathy most common in young adults (mean age 30), 1:1000-2000 prevalence
138
List symptoms and signs of hypertrophic cardiomyopathy
- Asymptomatic - Signs of LHF (dyspnoea, syncope, dizziness) - Arrythmias (ejection systolic murmur) - Jerky carotid pulse - S4 gallop - Mitral regurg - Sudden death
139
List symptoms and signd of dilated cardiomyopathy
- Exertional dyspnoea, ankle oedema, ascites, angina pectoris - Mitral or tricuspid regurg - S3 gallop - Left ventricular impulse displacement - JVP raised - Rales - Palpitations - Diffuse oedema
140
Describe investigations for dilated cardiomyopathy
- BNP raised in HF - Troponin and CK-MB to rule out MI - Echo - atrial and/or ventricular dilatation, reduced LVEF, wall motion abnormalities - CXR cardiomegaly, pulmonary oedema - ECG (disorders of condition, arrhythmias, change of cardiac axis, reduced QRS) - Histology (fibrosis without inflammation, more extensive in subendocardium)
141
List signs and symptoms of restrictive cardiomyopathy
- Duspnoea - JVP raised - Peripheral oedema, ascites - Hepatomegaly - Kussmal sign = paradoxical rise in JVP during inspiration - S4 sound
142
Describe diagnosis of restrictive cardiomyopathy
- Echo (diastolic dysfunction - rapid early but reduced diastolic filling, near normal or elevated EF, atrial enlargement) - ECG (low voltage, LBBB) - CXR (pulmonary congestion, underlying disease) Cardiac catheterisation (high atrial pressure, abnormal vnetricular) - Biopsy (fibrosis)
143
List investigations for hypertrophic cardiomyopathy
- Echo showing decreased LV cavity size, normal EF, increased wall thickness, outflow obstruction and reduced diastolic filling - ECG - left ventricular hypertrophy (deep S in V1/2, tall R in V5/6, S in V1+R in V5 or V6 over 7 large squares), left axis deviation, q waves
144
Describe signs and symptoms of arrythmogenic right ventricular cardiomyopathy
- Variable, most asymptomatic - Angina - Dyspnoea - Peripheral oedema - Ascited, hepatic and splenic congestion - Palpitations, syncope, sudden death
145
Describe investigations for arrythmogenic right ventricular cardiomyopathy
- AHA - dysfunction and structural abnormalities of RV, histological characteristics, abnormal repolarisation, conduction abnormalities, arrythmias, family history - ECG epilson wave in right precordial leads, increased QRS duration, ventricular tachycardia, ventricular extrasystoles - Echo (RV enlargement, RV wall motion abnormalities, reduced EF, localised RV aneurysms) - Biopsy fibrofatty replacement - Genetic testing myltiple genetic abnormalities (JUP, DSP.ect)
146
Define gangrene
- A complication of necrosis characterised by the decay of body tissues. - There are two major categories: infectious gangrene (wet gangrene) and ischaemic gangrene (dry gangrene).
147
Describe epidemiology of gangrene
- Type I necrotising fasciitis occurs most commonly in patients with diabetes and patients with peripheral vascular disease. - It is the most common form of necrotising fasciitis in the general population. - Type II necrotising fasciitis has an annual incidence of 5 to 10 cases per 100,000 in the US. - Approximately, half of the cases of streptococcal necrotising fasciitis occur in young and previously healthy people. - Gas gangrene 3000 annual cases US - Atheroembolism 0.3-3.5% incidence.
148
Describe aetiology/risks of gangrene
Infectious - Necrotising fasciitis (strep, staph, enterobacteriaecaea) - Gas (C. perfringes - spore baring) - Surgery/trauma, malnutrition, immunosuppression Ischaemic - Atherosclerosis, diabetes associated microangiopathy. Hypercoagulable states (drug abuse, malignancy, antiphospholipid syndrome) - Inadequate blood supply due to venous obstruction. Phlegmasia cerulea dolens (complete venous obstruction)
149
Describe symptoms and signs of gangrene
- Pain (sudden onset) - Oedema - Skin discolouration (ecchymoses, purpura, blebs, haemorrhagic bullae) - Crepitus (gas gangrene) - Diminished pedal pulses and ABI (ischaemic) - Low grade fever and chills (infectious)
150
List investigations for gangrene
- FBC (leukocytosis, haemoconcentration, anaemia) - Metabolic panel (acidosis, liver derangement, renal failure) - LDH (haemolytic anaemia) - Coagulation - Blood cultures - Serum CRP - X rays (gas in soft tissues (gas gangrene)) - CT, MRI (abscess, enhancement, oedema, thickening of fascia) - Doppler ultrasonography (obstruction) - CT angiogram (artheroemboli) - Surgical exploration, skin biopsy (determine involvement of fascia) - Cryofibrinogens, cryoglobulin, ANA, lupud and anticardolipin for antiphospholipid syndrome
151
Define pressure sore
Pressure ulcers have been defined by the National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panel as localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or of pressure in combination with shear.
152
Describe epidemiology of pressure ulcers
- 4.7-32.1% prevalence in hospitalised patients - 0.58 per 100 person years among elderly patients in UK - Most are on sacrum, coccyx and heels
153
Describe aetiology/risks of pressure sores
- Pressure, shear, friction and moisture - Circulation and tissue perfusion - Most commonly over bony prominances - Risks include increased age, reduced mobility, malnurishment, history of ulcers, neurological impairment, and conditions that prevent normal self positioning
154
List signs and symptoms of pressure sores
- Localised skin changes (non-blanching erythea or discolored skin which may be painful, firm, mushy, boggy, or altered temp) - Shallow open wound or tissue loss on aread under pressure (grade 2) - Full thickness with some slough grade 3 - Full thickness with major tissues involved (bone, tendon or muscle - grade 4) - Localised tenderness and warmth (infection) - Exudate and foul odour (infection)
155
Describe investigations for pressure sores
- Clinical diagnosis - Wound swab - ESR (osteomyelitis), WBC (osteomyelitis), glucose - Deep tissue biopsy (infection) - MRI (bony involvement)
156
Define coronary angiography and PCI
- Coronary angiography is a prodedure where a contrast dye, containing iodine, is is injected. Then a catheter tube is inverted into a blood vessel (arm, groin, thigh) and moved to your cooronary artery. Dye is injected through the catheter to highlight blockages, and X rays are taken of the heart. - PCI is where the catheter is used to pace a stent in blood vessels that have narrowed to open them up. THis uses a baloon to open the vessel, which is then deflated.
157
List indications for coronary angiography and PCI
- Diagnose ischaemic chest pain (abnormal ECG, sudden cardiac arrest, chest pain, abnormal stress test) - Increasing angina - Heart defect you were born with - Valvular defect
158
List complications of coronary angiography and PCI
- Bleeding - Reaction to contrast - Blood vessel damage - Arrythmias - Infection - Blood clot formation (heart attack or stroke) - Higher risk in older people and those with CKD/diabetes - Restenosis - Cholesterol embolisation
159
Define CABG
Revascularisation technique used to treat patients with significant, symptomatic stenosis of the coronary artery. - Uses a midline sternotomy - The stenosed artery is bypassed using an arterial (internal thoracic, internal mammary, radial) or venous (great saphenous vein) autograft), re-establishing bloodflow to ischaemic areas of the myocardium
160
List indications for CABG
- High grade left main stem coronary artery stenosis - Significant stenosis (>70%) of the proximal left anterior descending artery, with 2 vessel or 3 vessel disease - Symptomatic 2 vessel or 3 vessel disease - Disabling angina despite medical treatment - Poor left ventricular function - Post-infarct angina - NSTEMI - STEMI with inadequate response to all non-surgical therapy - Failed PCI
161
List complications of CABG
- Myocardial dysfunction - Post-pericardiotomy syndrome (autoimmune pericarditis or pleuritis, treated with NSAIDs and drainage) - Postoperative cardiac tamponade with shock - Bypass occlusion - Arrythmias - Postoperative acute mediastinitis (surgical debridement, antibiotics) - Mediastinal haemorrhage (ventilation)
162
Define DC cardioversion
- Direct current cardioversion is a procedure used to convert an abnormal heart rhythm to a normal heart rhythm - Uses defibrillator pads and administers a controllec electrical current while the patient is under general anaesthetic
163
List indications for DC cardioversion
- Treatment of a tachycardia present for less than 24 hours with the aim to revert back to sinus rhythm - Treatment of a tachyarrythmia present for less than 24 hours when pharmacological measures have failed - Treatment of tachyarrythmia where the patient shows signs of decompensation (chest pain, hypotension, or signs of heart failure) - Atrial fibrillation or atrial flutter - Ventricular and sypraventricular tachycardia
164
List complications of DC cardioversion
- Skin soreness - Arrythmia - Stroke - Unsuccessful in 50% - Dislodging bloood clots
165
Define implanted cardiac defibrillator
- An implanted device that prevents sudden cardiac death by delivering electrical impulses to convert heart rhythm back to normal sinus rhythm, and continually monitoring the heart - Subcutaneous is under the skin - It can perform pacing, cardioversion, and defibrillation - Inserted under local anaesthetic, just under the collarbone
166
List indications for an implated cardiac defibrillator
- Previous life threatening abnormal heart rhythm (Cardiac arrest, V fib, V flutter) - Risk of life threatining abnormal heart rhythm (cardiomyopathy, long QT, brugada syndrome) - Heart failure (EF<35%)
167
List complications of implantable cardiac defibrillator
- Bleeding from incision - Damage to blood vessel - Infection - Cardiac tamponade - Collapsed lung - Post surgery: lead complications, movement of the generator causing pain, innapropriate shocks
168
Define permanent pacing
- An electronic device that monitores the heart rhythm and stimulates the heart when indicated (low or absent intrinsic activity) - Single chamber one lead in the right atrium/ventricle - Dual chamber 2 leads one in right ventricle and one in right atrium - Biventricular pacing is a extra lead in the coronary sinus for left ventricular pacing
169
List indications for permanent pacing
- Sinus node dysfunction and high-grade AV block (three or Mibitz II) - Chronic bi-fascicular block - Post acute MI - Hypersensitive carotid sinus syndrome - Post cardiac transplant - Prevent tachycardia, AF - Congenital heart disease - Hypertropic cardiomyopathy - Cardiac resynchronisation in severe systolic HF
170
List complications of permanent pacing
- Haematoma - Lead dislodgement - Infection - Lead perforation - Dysrhythmias - Pneumothorax, pericarditis - Venous thrombosis - Failure to output or capture - Pacemaker syndrome (atrial and ventricular contractions are simultaneous)
171
List signs of longstanding hypertension
- Left ventricular hypertrophy - Heave - S4 atria contracting forcefully to overcome an abnormally stiff or hypertrophic ventricle - Bruits
172
List the 4H and 4T reversible causes of cardiac arrest
- Hypothermia - Hypovolaemia - Hypoxia - Hyper/hypokalaemia - Toxins - Tension pneumothorax - Cardiac tamponade - Thromboembolic
173
List causes and left and right BBB
Left BBB - Hypertension - IHD - MI - Aortic stenosis Right BBB - Congenital heart disease - PE - Fibrosis of conduction system - Cor pulmonale
174
List signs of cardiac tamponade
Becks triad - Muffled heart sounds - Distended neck veins - Hypotension
175
Describe management of prinzmetal angina
- CCB | - Nitrates
176
Describe arrythmogenic cardiomyopathy
- Progressive fatty and fibrous replacement of the ventricular myocardium - Inherited (autosomal dominant
177
Describe takotsubo cardiomyopathy
- Sudden temporary weakening of heart muscle after a significant stressor - ”Broken heart syndrome”
178
List risk factors for cardiac tamponade
- Vasculitis - Trauma - MI
179
List investigations and management for cardiac tamponade
- ECG (electrical alternans) - CXR (globular) - Eco - Management: emergency needle pericardiocentesis
180
Describe ECG changes in right vs left ventricular hypertrophy
- Right has tall R in V1 and deep S in V6, RAD, right ventricular strain (ST depression V1-4) - Left deep S in V1 and tall R in V6 - TO be significant, must be S+R>7 squares
181
COmpare intermittent claudication and critical limb ischaemia
Intermittent claudication - Does not require intervention unless lifestyle impaired - Pain upon movement eased by rest - Pain is a cramping nature Critical limb ischaemia - Pain at rest, requiring opioid analgesia - Over 2 weeks or presense of tissue loss - Pain at night - Gangrene, ulceration - Pain is a burning nature
182
Describe ECG changes in posterior STEMI
- Horizontal ST depression in V1-3 - Prominent R in V2-3. R/S >1 - Positive T in V1-3
183
Describe brugada syndrome
Type 1 - Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave. - This is Brugada Sign Type 2 - >2mm of saddleback shaped ST elevation. Type 3 - Can be the morphology of either type 1 or type 2, but with <2mm of ST segment elevation.
184
List signs of severe aortic stenosis
- Late-peaking murmur - Paradoxically split S2 or inaudible A2 - Small and delayed carotid pulses (pulsus parvus et tardes) - LV heave, - An audible (and occasionally palpable) S4.
185
Describe management of bradycardia
- Where there is no clear reversible cause, use atropine
Year 3 - Diseases
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