1
Q
What is atrial fibrillation?
A
Irregular atrial rhythms of 300-600 bpm
2
Q
What is the aetiology of atrial fibrillation?
A
- idiopathic
- any condition that causes raised atrial pressure, increased atrial muscle mass, atrial fibrosis or inflammation of the atria
- hypertension
- heart failure
- coronary artery disease
- valvular heart disease
- cardiac surgery
- cardiomyopathy
- rheumatic heart disease
acute excess alcohol intoxication
3
Q
What is the pathophysiology of atrial fibrillation?
A
- continuous rapid activation of the atria prevents proper emptying into the ventricles
- this causes a drop of cardiac output by 10-20%
4
Q
What are the risk factors of atrial fibrillation?
A
- > 60y
- diabetes
- hypertension
- coronary artery disease
- prior MI
- structural heart disease
5
Q
What is the clinical presentation of atrial fibrillation?
A
- very variable
- may be asymptomatic
- palpitations
- dyspnoea and/or chest pain
- fatigue
- apical pulse rate greater than radial pulse rate
6
Q
What are the differential diagnoses of atrial fibrillation?
A
- atrial flutter
- supra ventricular tachyarrythmias
7
Q
How is atrial fibrillation diagnosed?
A
ECG: absent P waves, irregular and rapid QRS complex
8
Q
How is atrial fibrillation managed?
A
Acute management:
- provoking cause should be treated
- cardioversion (sovversione to sinus rhythm by a direct-current shock) and LMWH
- ventricular rate control with CCB, BB, digoxin, amiodarone
Long term and stable patient management:
- rate control → AV node slowing agents and oral anticoagulation
- rhythm control for younger, symptomatic, physically active patients
- cardioversion
- anticoagulants
9
Q
What is an atrial flutter?
A
Organised atrial rhythms with an atrial rate of 250-350bpm
10
Q
What is the aetiology of an atrial flutter?
A
- 30% idiopathic
- coronary heart disease
- obesity
- hypertension
- heart failure
- COPD
- pericarditis
- acute excess alcohol intoxication
11
Q
What is the main risk factor for an atrial flutter?
A
Atrial fibrillation
12
Q
What is the clinical presentation of an atrial flutter?
A
- palpitations
- breathlessness
- dizziness
- syncope
- fatigue
13
Q
What are the differential diagnoses of an atrial flutter?
A
- atrial fibrillation
- supra ventricular tachycardias
14
Q
How is an atrial flutter diagnosed?
A
ECG: sawtooth-like atrial flutter between QRS complexes
15
Q
How is an atrial flutter managed?
A
- electrical cardioversion after anticoagulant e.g. LMWH
- catheter ablation (thin tube inserted into a coronary vessel to stop abnormal conduction)
- IV amiodarone to restore sinus rhythm
- bisoprolol to suppress further arrhythmias
16
Q
What is the aetiology of 1st degree AV block?
A
- hypokalaemia
- myocarditis
- inferior MI
- AV node blocking drugs e.g. BB or CCB
17
Q
What is the pathophysiology of 1st degree AV block?
A
- prolongation of the PR interval to >0.22s
- delay between atrial depolarisation and conduction to the ventricles
18
Q
What are the symptoms of 1st degree AV block?
A
Asymptomatic
19
Q
How is 1st degree AV block managed?
A
No treatment as asymptomatic
20
Q
What is the aetiology of Mobitz I 2nd degree AV block?
A
- AV node-blocking drugs
- inferior MI
21
Q
What is the pathophysiology of Mobitz I 2nd degree AV block?
A
Conduction becomes progressively slower until there is no conduction for a beat
22
Q
What is the clinical presentation of Mobitz I 2nd degree AV block?
A
- light-headedness
- dizziness
- syncope
23
Q
How is Mobitz I 2nd degree AV block diagnosed?
A
ECG: progressive PR prolongation until a beat is ‘dropped’
24
Q
How is Mobitz I 2nd degree AV block managed?
A
No intervention unless poorly tolerated
25
What is the aetiology of Mobitz II 2nd degree AV block?
- anterior MI
- mitral valve surgery
- SLE
- Lyme disease
- rheumatic disease
26
What is the pathophysiology of Mobitz II 2nd degree AV block?
Failure of conduction through the His-Purkyne fibres
27
What is the clinical presentation of Mobitz II 2nd degree AV block?
- SOB
- postural hypotension
- chest pain
28
How is Mobitz II 2nd degree heart AV diagnosed?
ECG: PR interval is constant and QRS interval is intermittently dropped
29
How is Mobitz II 2nd degree heart AV managed?
Pacemaker inserted due to high risk of sudden complete AV block
30
What is the aetiology of 3rd degree (complete) AV block?
- structural heart disease
- ischaemic heart disease
- hypertension
- endocarditis
- lyme disease
31
What is the pathophysiology of 3rd degree (complete) AV block?
- all atrial activity fails to conduct to the ventricles
| - ventricle contractions are maintained by a spontaneous escape rhythm which originates from below the block
32
What is the clinical presentation of 3rd degree (complete) AV block?
- faintness
- breathlessness
- extreme fatigue, sometimes with confusion
- chest pain
- bradycardia
- palpitations
33
How is 3rd degree (complete) AV block diagnosed?
ECG: presence of complete AV-dissociation (atrial rate > ventricular rate i.e. more P waves than QRS complexes with no relationship between them)
34
What is the management of 3rd degree (complete) AV block?
- depends on aetiology
- only option is permanent pacemaker
- IV amiodarone
35
What is the aetiology of a RBBB?
- PE
- IHD
- atrial/ ventricular defect
36
What is the pathophysiology of a RBBB?
Right bundle of His doesn't conduct, so impulses spread from left to right, causing late activation of the right ventricle
37
What is the clinical presentation of bundle branch blocks?
Usually asymptomatic
38
How is a RBBB diagnosed?
ECG: MarroW (QRS looks like an M in lead V1 and a W in leads V5/6)
39
How are bundle branch blocks managed?
- pacemaker
| - cardiac resynchronisation
40
What is the aetiology of a LBBB?
- IHD
| - aortic valve disease
41
What is the pathophysiology of a LBBB?
***********
42
How is a LBBB diagnosed?
ECG: WilliaM (QRS looks like a W in leads V1/2 and an M is leads V4-6)
43
What is the aetiology of sinus tachycardia?
- anaemia
- anxiety
- exercise
- pain
- heart failure
- pulmonary embolism
44
What is sinus tachycardia?
HR >100bpm
45
What is the clinical presentation of sinus tachycardia?
- abnormally strong or forceful heartbeats
- irregular heartbeats
- difficulty breathing
- dizziness and fainting
- chest pain
- anxiety
- changes in BP
46
How is sinus tachycardia diagnosed?
- ECG: *****
47
How is sinus tachycardia managed?
- treat underlying cause
| - use beta blockers if necessary (e.g. bisoprolol)
48
What is the aetiology of supraventricular tachycardia?
- can be triggered by tiredness, caffeine, alcohol or drugs
| - often no obvious trigger
49
What is the pathophysiology of supraventricular tachycardia?
- arise from the atria or the AV junction
| - **********
50
What is the clinical presentation of supraventricular tachycardia?
- sudden fast heart beat for several minutes to sometimes hours
- sometimes also chest pain, weakness, breathlessness, nausea, fatigue
51
How is supraventricular tachycardia managed?
Acute: stimulate vagus nerve to slow HR (= vagotonic manoeuvres)
Maintenance: BB or verapamil
52
What is ventricular tachycardia?
HR>100bpm with at least 3 irregular beats in a row
53
What is the pathophysiology of ventricular tachycardia?
- rapid ventricular beating so there is inadequate filling of the ventricles
- this results in decreased cardiac output therefore decreased circulation of oxygenated blood
54
What are the symptoms of ventricular tachycardia?
- breathlessness
- chest pain
- palpitations
- lightheadedness/ dizziness
55
How is ventricular tachycardia managed?
- IV amiodarone or IV lidocaine
- Oral amiodarone
- Treat symptoms with a BB
56
What is the pathophysiology of ventricular ectopic tachycardia?
- premature ventricular contraction
| - if the ectopic are frequent then LV dysfunction may develop
57
What are the risk factors of ventricular ectopic tachycardia?
```
Previous MI
(VET is the most common type of post-MI arrhythmia)
```
58
What is the clinical presentation of ventricular ectopic tachycardia?
- usually asymptomatic
- may be uncomfortable (especially if frequent)
- irregular pulse
- can feel faint or dizzy
- may complain of extra beats, missed beats or heavy beats
59
How is ventricular ectopic tachycardia diagnosed?
ECG: wide QRS complex (>0.12s)
60
How is ventricular ectopic tachycardia managed?
- reassure patients
| - BB if symptomatic
61
What is the aetiology of prolonged QT syndrome?
Congenital: Jervell-Lange-Nielsen syndrome, Romano-Ward syndrome
Acquired: hypokalaemia, hypercalcaemia, some drugs (antibiotics, antihistamines, antidepressants, diuretics), bradycardia, acute MI, diabetes
62
What is the clinical presentation of prolonged QT syndrome?
- syncope
| - palpitations
63
How is prolonged QT syndrome diagnosed?
ECG: QT >0.45 or 0.47s
64
How is prolonged QT syndrome managed?
- treat underlying cause
- IV isoprenaline for acquired
- BB to control heartbeat
- pacemaker if severe
65
What is the aetiology of Wolff-Parkinson-White syndrome?
Congenital accessory conduction pathway between atria and ventricles
66
What is the pathophysiology of Wolff-Parkinson-White syndrome?
- type of AV re-entrant tachycardia
| - atrial activation occurs after ventricular activation
67
What is the clinical presentation of Wolff-Parkinson-White syndrome?
- pounding/fluttering heartbeat
- lightheaded or dizzy
- SOB
- chest pain
- feeling anxious
- fainting
68
How is Wolff-Parkinson-White syndrome diagnosed?
ECG: short PR, wide QRS
69
How is Wolff-Parkinson-White syndrome managed?
For mild symptoms or very infrequent: regular check ups but no intervention
First line symptomatic: catheter ablation, anti-arrhythmic drugs
70
What is the aetiology of an abdominal aortic aneurysm?
Atherosclerotic disease
71
What is the pathophysiology of an abdominal aortic aneurysm?
Degradation of collagen and elastin in the media and adventitious as well as smooth muscle cell loss results in tapering of the medial wall
72
What are the risk factors of an abdominal aortic aneurysm?
- cigarette smoking
- family history
- increasing age
- male sex
- COPD
- hyperlipidaemia
- hypertension
73
What is the clinical presentation of an unruptured abdominal aortic aneurysm?
- often asymptotic
- pain in abdomen, back, loin or groin
- pulsation abdominal swelling
74
What is the clinical presentation of a ruptured abdominal aortic aneurysm?
- intermittent/ continuous abdominal pain radiating to back, iliac fossa and groin
- pulsation abdominal swelling
- hypotension
- tachycardia
- collapse
- profound anaemia
- sudden death
75
What are the differential diagnoses of an abdominal aortic aneurysm?
- diverticulitis
- uterine colic
- irritable bowel syndrome
- inflammatory bowel disease
- appendicitis
76
How is an abdominal aortic aneurysm diagnosed?
First line = abdominal ultrasound (aortic dilation of >1.5x expected diameter)
- FBC
- blood cultures
- CT
- MRI
77
How is an abdominal aortic aneurysm managed?
- ruptured/ symptomatic: urgent surgical repair and perioperative antibiotics
- monitored if small
- treat underlying cause
- modify risk factors (smoking cessation, lowering blood lipid, vigorous BP control)
78
What is the aetiology of an aortic dissection?
Intimate tear that extends into the media of the aortic wall
79
What is the pathophysiology of an aortic dissection?
- blood passes through the media, creating a false lumen
| - flow though the false lumen can occlude flow through the aortic branches
80
What are the risk factors of an aortic dissection?
- hypertension
- Marfan’s syndrome
- Ehlers-Danlos syndrome
- bicuspid aortic valve
81
What is the clinical presentation of an aortic dissection?
- acute severe “tearing” chest pain that radiates to the back and down the arms (mimics an MI)
- hypertension
- may develop aortic regurgitation, coronary ischaemia and cardiac tamponade
- distal extension may cause acute kidney failure, cute lower limb ischaemia or visceral ischaemia
82
What are the differential diagnoses of an aortic dissection?
- acute coronary syndrome
- pericarditis
- aortic aneurysm
- musculoskeletal pain
- PE
- mediastinal tumour
83
How is an aortic dissection diagnosed?
- urgent CT or MRI to confirm the diagnoses
- CXR shows widened mediastinum
- ECG shows ST depression
- cardiac enzymes
84
How is an aortic dissection managed?
- opioid analgesia e.g. morphine
- surgery to replace aortic arch
- endovascular stent-graft repair
- vasodilator
- antihypertensives
- long-term follow up with CT or MRI
85
What is the aetiology of peripheral vascular disease?
- common = atherosclerosis
| - rare = arterial embolism, thrombosis, vasospasm
86
What is the pathophysiology of peripheral vascular disease?
Haemodynamic compromise
87
What are the risk factors for peripheral vascular disease?
- smoking
- diabetes
- hypertension
- elevated C reactive protein
88
What is the clinical presentation of peripheral vascular disease?
- intermittent claudication (pain caused by inadequate blood flow to limbs)
- thigh or buttock pain when walking (relieved at rest)
- leg pain at rest
- gangrene
- erectile dysfunction
89
What are the differential diagnoses of peripheral vascular disease?
- spinal stenosis
- arthritis
- venous claudification
90
How is peripheral vascular disease diagnosed?
- ankle-brachial index (ratio of BP at the ankle to the BP at the upper arm)
- duplex ultrasound
91
What is the management for peripheral vascular disease?
- antiplatelet therapy
- analgesia
- anticoagulation
- surgical revascularisation
92
What is the pathophysiology of critical ischaemia?
- blood supply is barely enough to allow basal metabolism
| - no reserve available for decreased demand
93
What is the clinical presentation of critical ischaemia?
Rest pain (typically nocturnal in the legs)
94
How is critical ischaemia managed?
Hang leg over side of bed at night or walk around to restore blood flow
95
What is the aetiology of pericarditis
- 90% due to viral infection e.g. EBV
- autoimmune disorders
- bacterial infections
96
What is the pathophysiology of pericarditis?
- inflammation of the pericardial tissue
| - pericardium is well-innervated to inflammation causes severe pain
97
What are the risk factors for pericarditis?
- male sex
- age 20-50y
- cardiac surgery
98
What is the clinical presentation of pericarditis?
- chest pain
- fever
- pericardial rub
- myalgia (muscle pain)
99
What are the differential diagnoses of pericarditis?
- myocardial infarction or ischaemia
- PE
- pneumonia
- pneumothorax
100
How is pericarditis diagnosed?
- ECG: ST segment elevation, PR depression
- raised serum troponin
- pericardial fluid/ blood cultures will be positive if infectious cause
- raised ESR, CRP, urea and WCC
- CXR: enlarged cardiac silhouette
101
How is pericarditis managed?
- pericardiocentesis (fluid is aspirated from the pericardium)
- systemic antibiotics
- NSAIDs
- PPI
- exercise restriction
102
What is the aetiology of aortic stenosis?
- calcification of tricuspid valves
| - congenitally bicuspid aortic valve
103
What is the pathophysiology of aortic stenosis?
- valvular endocardium is damaged as a result of abnormal blood flow across the valve
- endocardium injury initiates an inflammatory process
104
What are the risk factors of aortic stenosis?
- age >60y
- congenitally bicuspid aortic valve
- rheumatic heart disease
- CKD
105
What is the clinical presentation of aortic stenosis?
- SOBOE
- angina
- syncope
- ejection systolic murmur
- diminished 2nd heart sound
106
What are the differential diagnoses of aortic stenosis?
- aortic sclerosis
- ischaemic heart disease
- hypertrophic cardiomyopathy
107
How is aortic stenosis diagnosed?
- trans thoracic echocardiogram including Doppler: elevated aortic reassure gradient
- ECG: may have LV hypertrophic and absent Q waves, AV block, hemiblock or bundle branch block
108
How is aortic stenosis managed?
- balloon valvuloplasty
- surgical aortic valve replacement
- long term antibiotic prophylaxis
- long term anticoagulation
109
What is the aetiology of aortic regurgitation?
- diastolic leakage of blood from the aorta into the LV
| - primary disease of aortic valve leaflets
110
What is the pathophysiology of acute aortic regurgitation?
End diastolic pressure in the LV rises
111
What is the pathophysiology of chronic aortic regurgitation?
LV pressure and volume overload
112
What are the risk factors of aortic regurgitation?
- bicuspid aortic valve
- rheumatic fever
- endocarditis
- Marfan’s syndrome
113
What is the clinical presentation of aortic regurgitation?
- diastolic murmur
- SOBOE
- fatigue
- weakness
114
What are the differential diagnoses of aortic regurgitation?
- mitral regurgitation
- mitral stenosis
- aortic stenosis
- pulmonary regurgitation
115
How is aortic regurgitation diagnosed?
- ECG: non-specific ST-T wave changes
- CXR may show cardiomegaly
- echocardiogram
- Doppler scan
116
How is acute aortic regurgitation managed?
- inotropes
- vasodilators
- aortic valve repair/ replacement
117
What is the management of chronic aortic regurgitation?
- no need to intervene until ejection fracture <50%
- aortic valve replacement
- ACEi
- vasodilators
2a mid tier
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