1
Q
How is hypertension diagnosed?
A
24 hour ABPM
2
Q
What are the values for stage 1 HTN?
A
Clinic reading: 140/90 – 159/99
ABPM: 135/85 – 149/94
3
Q
Stage 2 HTN values
A
Clinic reading: 160/100 -180/120
ABPM: (>150/95)
4
Q
Stage 3 HTN values
A
Clinic reading: >180/120
5
Q
What are the next steps if clinic reading is >140/90 mmg?
A
Offer ABPM or HBPM then:
- if > 135/85 mmg - Diagnose stage 1 HTN + treat if:
- < 80 years
- target organ damage
- established cardiovascular disease
- renal disease
- diabetes
- a 10-year cardiovascular risk equivalent to 10% or greater - if > 150/95 mmHg - Stage 2 HTN + treat all ages
6
Q
What are the next steps if BP is >180/120?
A
admit for specialist assessment if:
signs of retinal haemorrhage or papilloedema (accelerated hypertension)
- life-threatening symptoms such as: new-onset confusion, chest pain, signs of heart failure, or acute kidney injury
If none of the above:
- Arrange urgent investigations for end-organ damage
7
Q
What do you do if pt < 40 years old had HTN?
A
Exclude secondary causes
8
Q
1st line management for HTN
A
Patients < 55 or T2DM:
ACEi or ARB
Patient > 55 or Black:
CCB
9
Q
2nd line for HTN
A
If already on ACEi or ARB
- Add CCB or thiazide like diuretic
If already on CCB:
ACEi or ARB or thiazide like diuretic
10
Q
3rd line for HTN
A
ACEi or ARB + CCB + thiazide-like diuretic
11
Q
4th line for HTN
A
Resistant HTN:
K+ < 4.5 = add low-dose spironolactone
K+ > 4.5 = add alpa or beta blocker
12
Q
BP target for < and > 80 years old
A
< 80 year = 135/85
> 80 year = 145/85
13
Q
What is isolated systolic HTN?
A
Systolic blood pressure rises, but your diastolic blood pressure stays normal - 160 mmHg or more.
14
Q
1st line for isolated systolic HTN
A
thiazides
15
Q
Secondary causes of HTN
A
Renal diseases:
- glomerulonephritis
- pyelonephritis
- Renal artery stenosis
Endocrine:
- phaechromocytoma
- Cushing’s syndrome
Drugs:
- steroid
- COCP
Other:
- pregnancy
16
Q
What is malignant HTN?
A
EMERGENCY
>180/120 w/ signs of retinal haemorrhage, papilledema – target organ damage
17
Q
Orthostatic/postural hypotension
A
a drop in BP (usually >20/10 mm Hg) within three minutes of standing
18
Q
Treatment for Orthostatic/postural hypotension
A
- fludrocortisone (increases blood volume)
- Midodrine (causes vasocontriction)
19
Q
How is end organ damage assessed?
A
Fundoscopy: check for retinopathy
Urine dipstick: renal disease as a cause or consequence of HTN
ECG: left ventricular hypertrophy or ischaemic heart disease
20
Q
What might you see in an ECG in someone who has postural hypotension?
A
prolonged QT, bundle branch block
21
Q
Sx with severe HTN
A
- headaches
- visual disturbances
- seizures
22
Q
What tests do patients typically have following a diagnosis of hypertension?
A
- U&Es
- HbA1c
- Lipids
- ECG
- Urine dipstick
23
Q
Treatment algorithm for HTN
A
1) <55yo/T2DM : ACEi/ARB
>=55yo or AfroCarribean : CCB
2) ACEi/ARB + CCB
3) ACEi/ARB + CCB + Thiazide-like diuretic
4) K+ <= 4.5 : low-dose spironolactone
K+ >4.5 : alpha/beta blocker
24
Q
When is an ARB preferred over an ACEi?
A
patients of black African or African–Caribbean origin taking a CCB, if they require a second agent consider an ARB in preference to an ACEi
25
Which symptoms are life threatening in severe HTN?
- new-onset confusion - chest pain
- signs of heart failure
- AKI
26
Which algorithm can be used to estimate the risk of developing cardiovascular risk of the next 10 years and what is considered as high risk?
QRISK
>= 20% is considered high risk
27
Lifestyle advice for managing Hypertension?
- low salt diet
- reduced caffeine intake
- smoking cessation
- less alcohol
- weight loss and exercise
28
Signs of hypovolaemic shock
- Tachycardia/tachypnoea
- Reduced CRT
- Cold peripheries
- Hypotension
- End organ dysfunction:
- -> Oliguria/anuria
- -> Confusion
- -> irritability
- -> Chest pain/ SOB
29
Management of hypovolaemic shock
1. Look for treat and cause
2. High flow oxygen
3. Control haemorrhage if present – maintain adequate perfusion of vital organs
4. Blood should be given
5. IV fluid resuscitation – crystalloid: normal saline or
Hartmann’s solution.
6. Central venous pressure (CVP) line – more sensitive to the balance between loss & replacement than pulse or BP.
7. Prevent over-replacement - prevents tissues ischaemia
8. Monitor urine output
30
What can cause cardiogenic shock?
Intrinsic:
- MI
- Arrhythmia
Extrinsic:
- PE
- Pneumothorax
31
Why do symptoms occur in cadiogenic shock?
| What are the symptoms?
Due to hypoperfusion or fluid overload
- Chest pain
- SOB
- Palpitations
- Syncope
- Confusion
- Sweating
- Pale skin
32
What are the signs of cardiogenic shock?
- Tachycardia
- Raised JVP
- Cold peripheries
- Hypotension
- Peripheral oedema
- Weak pulse
33
What is a complication of arterial occlusion?
Gangrene
34
What are varicose veins?
Dilated, tortuous, superficial veins that occur due to incompetent venous valves.
35
Sx of varicose veins
- aching, throbbing
- itching
Complications:
1. a variety of skin changes may be seen:
- varicose eczema (also known as venous stasis)
- haemosiderin deposition → hyperpigmentation
- lipodermatosclerosis → hard/tight skin
- atrophie blanche → hypopigmentation
2. bleeding
3. superficial thrombophlebitis
4. venous ulceration
5. deep vein thrombosis
36
Ix for varicose veins
Diagnosis is mainly clinical
37
Management of varicose veins
```
1. If veins are not bleeding:
Conservation advice:
- Weight loss if overweight or obese
- Elevation of legs
- Avoid prolonged sitting or standing
- Compression stockings
```
2. Referral to vascular service if:
- Pt is symptomatic, veins bleeding
- skin changes secondary to chronic venous insufficiency (e.g. pigmentation and eczema)
- Hard painful veins (Superficial vein thrombosis)
- Venous leg ulcer (break in skin below the knee )which hasn’t healed within two weeks- 2WW referral!
- A healed venous leg ulcer
3. Possible tx:
- Surgery: Ligation and stripping
- Endothermal ablation
- Foam sclerotherapy
38
What is acute rheumatic fever?
Inflammation in the heart, joints, skin or CNS.
| - can develop after strep throat
39
How does rheumatic fever develop?
Following an immunological reaction to recent (2-6 weeks ago) streptococcus pyogenes infection (strep throat/scarlet fever)
40
What is the diagnostic criteria for rheumatic fever?
Jones:
Evidence of recent streptococcal infection accompanied by:
--> 2 major criteria
--> 1 major with 2 minor criteria
41
What is the evidence of recent streptococcal infection in rheumatic fever?
1. raised or rising streptococci antibodies,
2. positive throat swab
3. positive rapid group A streptococcal antigen test
42
What is the major criteria in rheumatic fever?
1. erythema marginatum
2. Sydenham's chorea: this is often a late feature
3. polyarthritis
4. carditis and valvulitis (eg, pancarditis)
5. subcutaneous nodules
43
What is the minor criteria in rheumatic fever?
1. raised ESR or CRP
2. pyrexia
3. arthralgia (not if arthritis a major criteria)
4. prolonged PR interval
44
What is the management of acute rheumatic fever?
1. antibiotics: oral penicillin V (10 day course)
2. anti-inflammatories: NSAIDs = 1st line (e.g. aspirin or naproxen) till CRP normalised
3. Treatment of any complications e.g. heart failure
45
Define phlebitis and thrombophlebitis
Phlebitis means inflammation of a vein. Thrombophlebitis refers to a blood clot causing the inflammation.
46
Patients with clinical signs of superficial thrombophlebitis affecting the proximal long saphenous vein should have which investigation?
Ultrasound scan to exclude concurrent DVT
47
Management of superficial thrombophlebitis
Oral NSAIDs more effective than topical NSAID
Compression stockings - measure before ABPI
48
What are the types of arterial occlusion?
Acute limb ischaemia: sudden onset of leg pain pr sudden deterioration in claudication- loss of pulse & pallor
Chronic acute limb ischaemia: progressive development of a cramp-like pain in the calf, thigh or buttock – relieved by resting, unexplained leg pain or non-healing wounds., distal pro proximal extremity., absent foot pulses.
Intermittent claudication
49
Features of intermittent claudication
1. Intermittent claudication: aching or burning in the leg muscles following walking
2. patients can typically walk for a predictable distance before the symptoms start
3. usually relieved within minutes of stopping
4. not present at rest
50
Ix for intermittent claudication
1. check the femoral, popliteal, posterior tibialis and dorsalis pedis pulses
2. check ankle brachial pressure index (ABPI)
3. 1st line = duplex ultrasound
4. magnetic resonance angiography (MRA) should be performed prior to any intervention
51
ABPI for intermittent claudication
0.6-0.9
52
Features of acute limb-threatening ischaemia
6 P's:
- pale
- pulseless
- painful
- paralysed
- paraesthetic
- 'perishing with cold'
53
1st line Ix for acute limb-threatening ischaemia
- handheld arterial Doppler examination
| - Then ABPI
54
Management of acute limb-threatening ischaemia
Initial management:
1. ABC approach
2. analgesia: IV opioids are often used
3. IV unfractionated heparin is usually given to prevent thrombus propagation, particularly if the patient is not suitable for immediate surgery
4. vascular review
Definitive management:
1. intra-arterial thrombolysis
2. surgical embolectomy
3. angioplasty
4. bypass surgery
5. amputation: for patients with irreversible ischaemia
55
Sx for Critical limb ischaemia
Features should include 1 or more of:
- rest pain in foot for more than 2 weeks
- ulceration
- gangrene
Patients often report hanging their legs out of bed at night to ease the pain.
56
ABPI indicative of Critical limb ischaemia
< 0.5 is suggestive of critical limb ischaemia.
57
Management of Critical limb ischaemia
endovascular revascularization:
1. percutaenous transluminal angioplasty +/- stent placement
2. endovascular techniques are typically used for short segment stenosis (e.g. < 10 cm), aortic iliac disease and high-risk patients
surgical revascularization:
1. surgical bypass with an autologous vein or prosthetic material
2. endarterectomy
3. open surgical techniques are typically used for long segment lesions (> 10 cm), multifocal lesions, lesions of the common femoral artery and purely infrapopliteal disease
Amputation
58
Sx of peripheral vascular disease
may be sx free
- sx of intermittent claudication (cramping with exercise, relieved by rest)
- ulcers
- hair loss
- skin changes (thinning, brittle, shiny)
59
Which investigations may be used in suspected PVD?
- Doppler US
- Angiogram
- Ankle-brachial index
60
Treatment options for PVD
- antiplatelets
- vascular surgery to reroute the blood flow if blocked
- angioplasty
61
Complications of PVD
- stroke
- restricted mobility
- reduced wound healing
- amputation
62
Which valvular disease is associated with rheumatic fever?
mitral stenosis
63
investigations for arterial occlusion
ABPI <0.5 is critical (refer to vascular MDT)
ABPI 0.6-0.9 is intermittent claudication (exercise management, angio or bypass)
Ultrasound of blood flow in peripheries
64
How to treat cardiogenic shock?
- ACS protocol: MONA
- Norepinephrine: improve heart function
- antiplatelets as preventative measures
65
Management of arterial occlusion
Clopidogrel
| Embelectomy or bypass if severe
66
What is venous thrombosis?
Formation of a thrombus (blood clot) in a deep vein which partially or completely obstructs blood flow.
67
Types of DVT
Provoked DVT: associated with transient risk factor – significant immobility, surgery, trauma, pregnancy, the pill, HRT.
Unprovoked DVT: occurs in the absence of a transient factor.
68
Sx of DVT
- Unilateral localised pain – throbbing, pain when walking , bearing weight
- Calf swelling
- Tenderness
- Skin change – oedema, redness & warmth
- Vein distension
69
Ix for DVT
Measure leg circumference
| Proximal leg vein USSS scan
70
What score is used to manage DVT?
| What is the criteria?
Well's score:
DVT likely: 2 points or more
DVT unlikely: 1 point or less
Criteria:
1. Active cancer (treatment ongoing, within 6 months, or palliative)
2. Paralysis, paresis or recent plaster immobilisation of the lower extremities
3. Recently bedridden for 3 days or more or major surgery within 12 weeks requiring general or regional anaesthesia
4. Localised tenderness along the distribution of the deep venous system
5. Entire leg swollen
6. Calf swelling at least 3 cm larger than asymptomatic side
7. Pitting oedema confined to the symptomatic leg
8. Collateral superficial veins (non-varicose)
9. Previously documented DVT
10. An alternative diagnosis is at least as likely as DVT (-2)
71
What are the next steps if DVT is likely using Well's score (> 2)?
1. Offer proximal leg vein ultrasound scan within 4 hours if possible.
2. If not possible, offer – D-Dimer test, interim therapeutic anticoagulation , USS scan within 24 hours.
72
What are the next steps if DVT is unlikely using Well's score (< 2)?
1. Offer a D-dimer test with results available within 4 hours.
2. If not available: offer interim therapeutic anticoagulation .
3. If D-dimer is positive – offer proximal leg vein USS, offer interim therapeutic anticoagulation
4. If D-dimer is negative: stop anticoagulation.
73
What is the interim anticoagulation?
1st line: apixaban or rivaroxaban (DOAC) continued if diagnosis is confirmed
2nd line: LMWH for 5 days followed by dabigatran or edoxaban or LMWH with a vitamin K antagonist for 5 days.
74
If patient has renal impairment and DVT, what medication is given?
LMWH, unfractionated heparin or LMWH followed by a VKA
75
Ix for DVT in pregnancy
Compression duplex ultrasound
76
Length of anticoagulation in DVT
3 months for all pt then:
1. provoked: stop after 3 months
2. unprovoked: continue till 6 months
77
What is an aortic aneurysm?
It is an abnormal bulge that occurs in the wall of the major blood vessel – aorta.
78
What is aortic dissection?
Occurs when a tear develops in the inner layer of the aorta.
79
Sx of aortic aneurysm
Usually asymptomatic
80
When do you screen for AAA?
single abdominal ultrasound for males aged 65.
81
Management of AAA
1) < 3 cm= No further action
2) 3 - 4.4 cm = Small aneurysm, Rescan every 12 months
3) 4.5 - 5.4 cm = Medium aneurysm, Rescan every 3 months
4) >= 5.5cm = Large aneurysm, Refer within 2 weeks to vascular surgery for probable intervention
82
What is the surgery for AAA > 5.5cm?
Treat with elective endovascular repair (EVAR) or open repair if unsuitable.
83
Sx of ruptured AAA
1. severe, central abdominal pain radiating to the back
2. pulsatile, expansile mass in the abdomen
3. patients may be shocked (hypotension, tachycardic) or may have collapsed
84
Management of ruptured AAA
Surgical repair
85
Features of aortic dissection
1. chest/back pain
- severe and 'sharp', 'tearing' in nature
- pain is typically maximal at onset
- chest pain is more common in type A dissection
- upper back pain is more common in type B dissection.
2. pulse deficit
weak or absent carotid, brachial, or femoral pulse
variation (>20 mmHg) in systolic blood pressure between the arms
3. aortic regurgitation
4. hypertension
5. some pt may have ST-elevation in inferior leads
86
Types of aortic dissection
```
Type A (ascending aorta)
Type B (descending aorta)
```
87
Ix for aortic dissection
1. Chest x-ray
- widened mediastinum
2. CT angiography of the chest, abdomen and pelvis = investigation of choice
- suitable for stable patients and for planning surgery
- a false lumen is a key finding in diagnosing aortic dissection
3. Transoesophageal echocardiography (TOE) = more suitable for unstable patients who are too risky to take to CT scanner
88
Management of aortic dissection
Type A:
surgical management, but BP should be controlled to a target systolic of 100-120 mmHg whilst awaiting intervention
Type B:
conservative management
bed rest
reduce blood pressure IV labetalol to prevent progression
89
What is giant cell arteritis?
It is a type of chronic vasculitis characterized by granulomatous inflammation in the walls of medium and large arteries.
90
What condition is commonly associated with giant cell arteritis?
Polymyalgia rheumatica
91
Sx of giant cell arteritis
1. Headache – new onset, localised, unilateral, temporal, temporal abnormality – (tenderness, thickening or nodularity)
2. Systemic features – fever, fatigues, anorexia, weight loss, depression
3. Polymyalgia rheumatics – bilateral upper arm stiffness, ache & tenderness, pelvic girdle pain)
4. Scalp tenderness
5. Intermittent jaw claudication
6. Visual disturbance
92
Ix for giant cell arteritis
Diagnostic = temperol artery biospy
Other: elevated ESR
93
Management of giant cell arteritis
1. Refer using the local GCA pathway for specialist evaluation (rheumatologist) – same working day
2. Immediately treat with oral prednisolone : visual symptoms (60-100 mg), no visual symptoms (40-60mg)
94
What is bundle branch block?
Condition in which there is a delay or blockage along the pathway that electrical impulses travel to make your heart beat.
The delay or blockage can occur on the pathway that send impulses either to the left or right ride of the ventricles of the heart.
95
Sx for BBB
usually asymptomatic
96
ECG findings for BBB
ECG: QRS complex widened >0.12 secs
1. RBBB: QRS complex changed- M shape V1 & W shape in V6 (MarroW)
3. LBBB: W shape in V1 & M shape in V6 (WiliaM)
97
Causes of RBBB and LBBB
Right - PE
| Left - MI
98
Management of BBB
Not treated but the patient’s symptoms or underlying heart conditions are:
1. Medication to reduce HTN or symptoms of HF.
2. May need pacemaker.
3. BBB with low heart-pumping function – may need cardiac resynchronisation therapy (biventricular pacing)
99
What is premature beat?
Premature Atrial/Ventricle Contractions (PA/VCs) – extra heartbeats that begin in the atria or ventricles.
The extra beats disrupt the regular heart rhythm – patient describe fluttering or skipped beat in their chest.
100
Sx for premature beats
```
Palpitations
Fluttering
Pounding or jumping
Skipped beats or missed beats
Increased awareness of heartbeat
```
(Syncope, Chest pain, Fatigue)
101
Ix for premature beats
ECG - extra beats originating outside the sinus rhythm
102
Management of premature beats
Conservative:
Lifestyles changes: eliminating common triggers such as caffeine or tobacco
Medical:
1. Beta-blockers – supress premature contractions
2. Calcium channel blockers
3. Antiarrhythmic drugs e.g. amiodarone or flecainide
Surgical:
1. Radiofrequency catheter ablation
103
What is atrial fibrillation?
It is supraventricular tachyarrhythmia resulting from irregular, disorganised electrical activity & ineffective contraction of the atria.
104
What is atrial flutter?
Usually a fast heart rhythm where the atria contract at a very fast rate compared to ventricles, can cause the atria to beat extremely fast ( upto 300bpm)
105
Types of AF
1. Paroxysmal:
>30 secs but < 7 days
Self-termination
Recurrent
2. Persistent
> 7 days
Requires Pharmacological or electrical cardioversion
3. Permanent
> 1 year
Fails to terminate using cardioversion.
Terminated AF but relapses within 24 hours
106
Sx + signs for AF
Symptoms:
palpitations
dyspnoea
chest pain
Signs:
an irregularly irregular pulse
107
Ix for AF
ECG needed for diagnosis
108
1st line management for AF
Rate control with BB (bisoprolol) or rate-limiting CCB (diltiazem)
109
When is rhythm control 1st line in AF?
Pt with coexistent heart failure
First onset AF
Where there is an obvious reversible cause.
110
When you rhythm control in AF what should be considered in regards to stroke risk?
Only rhythm control if:
Either have had a short duration of symptoms (less than 48 hours)
or
be anticoagulated for a period of time prior to attempting cardioversion.
111
What score do you use when using anticoagulant in AF?
CHA2DS2-VASc:
Congestive heart failure
Hypertension (or treated hypertension)
Age >= 75 years (2)
Age 65-74 years
Diabetes
Prior Stroke, TIA or thromboembolism (2)
Vascular disease (including ischaemic heart disease and peripheral arterial disease)
Sex (female)
1 = Treat in male
2 or more= treat with anticoag
112
Contraindication for BB
Asthma
113
Example of rhythm control drugs for AF
Beta-blockers
Dronedarone: second-line in patients following cardioversion
Amiodarone: particularly if coexisting heart failure
114
Types of rhythm control
Pharmacological cardioversion: Drugs (amiodarone)
Electrical cardioversion: Synchronised DC electrical shocks
115
What is the 1st line anticoagulant in AF?
DOAC = apixaban, dabigatran
| 2nd line = warfarin
116
If pt had AF > 48 hours, what needs to be done before electrical cardioversion?
Anticoagulation should be given for at least 3 weeks prior to cardioversion
117
ECG findings of atrial fibrillation
Will have no P-waves, a chaotic baseline, and an irregular irregular rate
118
ECG findings for atrial flutter
'sawtooth' appearance
119
Management of atrial flutter
1. cardioversion
| 2. radiofrequency ablation
120
What is atrioventricular block?
Impaired electrical conduction between the atria and ventricles.
121
Types of AV block + ECG findings
1st degree heart block
- PR interval > 0.2 seconds
- asymptomatic first-degree
- No treatment
2nd degree heart block
- type 1 (Mobitz I, Wenckebach): progressive prolongation of the PR interval until a dropped beat occurs
- type 2 (Mobitz II): PR interval is constant but the P wave is often not followed by a QRS complex
```
3rd degree (complete) heart block
- no association between the P waves and QRS complexes
```
122
Management of AV block
Asymptomatic: monitor ECG
Symptomatic:
1st line : Stop all AV-nodal blocking medications
2nd line: PPM or cardiac resynchronisation therapy +/- ICD placement
123
What is paroxysmal SVT?
any tachycardia that is not ventricular in origin
124
Sx of paroxysmal SVT
```
No symptoms usually but can have:
Palpitations
Dizziness
Sweating
SOB
Chest pain
```
125
Acute management of SVT
1. vagal manoeuvres:
- Valsalva manoeuvre: e.g. trying to blow into an empty plastic syringe
- carotid sinus massage
2. IV adenosine
- rapid IV bolus of 6mg
- contraindicated in asthmatics - verapamil is a preferable option
3. electrical cardioversion
126
What is VT?
broad-complex tachycardia originating from a ventricular ectopic focus.
127
Types of VT
1. monomorphic VT: most commonly caused by MI
2. polymorphic VT: A subtype of polymorphic VT is torsades de pointes which is precipitated by prolongation of the QT interval.
128
Sx of VT
```
Light-headedness
Palpitation
Chest Pain
Dyspnoea
Syncope
Symptoms of HF
```
129
Management of VT
1. If the Pt has adverse signs (systolic BP < 90 mmHg, chest pain, heart failure) then immediate cardioversion is indicated.
2. No adverse signs : antiarrhythmics,
- if these fail = electrical cardioversion may be needed with synchronised DC shocks
130
Management of torsades de pointes
IV magnesium sulfate
131
Example of antiarrhythmics in VT
1. amiodarone: ideally administered through a central line
(2. lidocaine: use with caution in severe left ventricular impairment
3. procainamide)
132
What drug is contraindicated in VT?
Verapamil
133
What is Ventricular fibrillation?
Disorganised electrical impulses causing the heart to quiver rather than contract
134
What is ventricular flutter?
tachycardic arrhythmia affects the ventricles, considered as transition between VT & VF.
135
Management of ventricular fibrillation
Pulseless ventricular tachycardia or ventricular fibrillation should be treated with immediate defibrillation + CPR
Long term: anti-arhytmic , Beta blockers, ICD,
Surgical:
Angioplasty, CABG, Cardioverter Defibrillator
136
Common causes of endocarditis
Staph aureus
Strep
Risk factors such as bacteraemia/IVDU or invasive procedures
137
Sx for infective endocarditis
```
Fever
chest pain (due to local effect or septic emboli to lungs),
Dizziness, weakness.
Arthralgia
Night sweats
```
138
Signs for infective endocarditis
```
Pyrexia
Tachycardia
Red spots on palms/soles
Janeway lesions
Osler nodes
Murmurs in lung fields and heart
```
139
Diagnostic criteria for infective endocarditis
```
Modified Duke criteria:
pathological criteria positive, or
2 major criteria, or
1 major and 3 minor criteria, or
5 minor criteria
```
140
What is the pathological criteria in Duke's
Positive histology or microbiology of pathological material obtained at autopsy or cardiac surgery
141
What is the major criteria in Duke's?
Positive blood cultures
Evidence of endocardial involvement:
- positive echocardiogram (oscillating structures, abscess formation, new valvular regurgitation or dehiscence of prosthetic valves)
or
-new valvular regurgitation
142
What is the minor criteria in Duke's?
1. predisposing heart condition or intravenous drug use
2. microbiological evidence does not meet major criteria
3. fever > 38ºC
4. vascular phenomena: major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions, petechiae or purpura
5. immunological phenomena: glomerulonephritis, Osler's nodes, Roth spots
143
Management of infective endocarditis
amoxicillin or vancomycin with low dose gentamicin
flucloxacillin if Staph
144
Features of acute pericarditis
1. chest pain: may be pleuritic. Is often relieved by sitting forwards
2. other symptoms include non-productive cough, dyspnoea and flu-like symptoms
3. pericardial rub
4. tachypnoea
5. tachycardia
145
Ix for acute pericarditis
1. ECG changes
- widespread 'saddle-shaped' ST elevation
- PR depression: most specific ECG marker for pericarditis
2. all patients with suspected acute pericarditis = transthoracic echocardiography
146
Management of acute pericarditis
1st line = NSAIDs and colchicine
| acute idiopathic or viral pericarditis
147
which valve is associated with endocarditis
mitral
148
What is cardiac tamponade?
characterized by the accumulation of pericardial fluid under pressure.
149
Classic features of cardiac tamponade
Beck's triad:
hypotension
raised JVP
muffled heart sounds
150
Other features of cardiac tamponade
1. dyspnoea
2. tachycardia
3. an absent Y descent on the JVP - this is due to the limited right ventricular filling
4. pulsus paradoxus - an abnormally large drop in BP during inspiration
151
What ECG findings will you have in cardiac tamponade?
electrical alternans
152
Management of cardiac tamponade
urgent pericardiocentesis
153
Features of pericardial effusion
Can cause cardiac tamponade:
- Classic triad: hypotension, muffled heart sounds, jugular venous distention
- Pulsus paradoxus
- Pericardial friction rub
- Tachycardia
- “swinging heart” – heart moves within the pericardial cavity.
154
Ix for pericardial effusion
CXR (effusion/cardiomegaly)
| Pericardial fluid analysis
155
Management of pericardial effusion
1. Treat underlying cause & signs/symptoms
2. Pharmacological :
Oxygen therapy – to relieve symptoms
IV fluids – to improve ventricular filliing (dehydration & hypovolaemia)
3. Surgical :
Pericardiocentesis
156
What is heart failure?
Heart failure is clinical syndrome in which the ability of the heart to maintain the circulation of blood is impaired as a result of structural or functional impairment of ventricular filling or ejection fraction.
157
Sx of HF
SOB – on exertion, rest, orthopnoea, PND, nocturnal cough
Fatigue
Ankle swelling, bloated, abdo swelling
Light-headedness, syncope
158
Signs of HF
```
Signs
Tachycardia (rhythm)
Displaced apex beat
Heart murmurs
3rd or 4th heart sounds
Raised JVP
Enlarged liver
Tachypnoea, basal crepitation, PE
```
159
Signs for left-sided HF
Pulmonary oedema:
1. dyspnoea
2. orthopnoea
3. paroxysmal nocturnal dyspnoea
4. bibasal fine crackles
160
Signs for right-sided HF
1. peripheral oedema
- ankle/sacral oedema
2. raised JVP
3. hepatomegaly
4. weight gain due to fluid retention
5. anorexia ('cardiac cachexia')
161
Ix for HF
1st line = BNP
| Diagnostic = Transthoracic echocardiogram
162
Management of acute HF
1. IV loop diuretics (furosemide)
Possible additional treatments:
1. oxygen
2. Patients with respiratory failure: CPAP
3. Patients with hypotension (e.g. < 85 mmHg)/cardiogenic shock:
- inotropic agents
e. g. dobutamine
- vasopressor agents
e. g. norepinephrine
163
Long term drug treatment for chronic HF
1st line = ACEi & BB (bisoprolol)
2nd line = aldosterone antagonist (spironolactone)
164
What murmur is associated with Aortic stenosis?
ESM
| - radiates to carotid
165
Features of aortic stenosis
narrow pulse pressure
| slow rising pulse
166
Management of valvular disorders
Valve replacement
167
What murmur is associated with Aortic Regurgitation?
early diastolic murmur
168
Features of Aortic Regurgitation
collapsing pulse
wide pulse pressure
Quincke's sign (nailbed pulsation)
De Musset's sign (head bobbing)
169
What murmur is associated with Mitral stenosis?
mid-late diastolic murmur (best heard in expiration)
170
Features of mitral stenosis
loud S1, opening snap
low volume pulse
malar flush
171
What murmur is associated with Mitral regurgitation?
a pansystolic murmur described as “blowing”.
| - heard best at the apex and radiating into the axilla.
172
What murmur is associated with Tricuspid regurgitation?
pan-systolic murmur
173
Features of Tricuspid regurgitation
prominent/giant V waves in JVP
pulsatile hepatomegaly
left parasternal heave
174
Murmur associated with pulmonary stenosis
Ejection systolic louder on inspiration
175
Murmur associated with pulmonary regurgitation
Early diastolic - Graham-steel murmur
176
Murmur associated with mitral valve prolapse
late systolic murmur
177
Features of mitral valve prolapse
1. patients may complain of atypical chest pain or palpitations
2. mid-systolic click (occurs later if patient squatting)
3. late systolic murmur (longer if patient standing)
178
What is dilated cardiomyopathy?
Characterised by ventricular chamber enlargement and contractile dysfunction with normal left ventricular wall thickness
179
Features of dilated cardiomyopathy
1. classic findings of heart failure
2. systolic murmur: stretching of the valves may result in mitral and tricuspid regurgitation
3. S3
4. 'balloon' appearance of the heart on the chest x-ray
180
Diagnosis of dilated cardiomyopathy
Diagnosis of exclusion
181
Management of dilated cardiomyopathy
Treat symptoms
182
What is hypertrophic obstructive cardiomyopathy (HCOM)?
Autosomal dominant disorder of muscle tissue caused by defects in the genes encoding contractile proteins.
183
Features of HCOM
often asymptomatic
- exertional dyspnoea
- angina
- syncope
- sudden death (most commonly due to ventricular arrhythmias),
- jerky pulse, large 'a' waves,
- double apex beat
- ejection systolic murmur
184
Ix for HCOM
Echo
| ECG : LVH, non-specific ST abnormalities
185
Management of HCOM
```
Amiodarone
Beta-blockers or verapamil for symptoms
Cardioverter defibrillator
Dual chamber pacemaker
Endocarditis prophylaxis*
```
186
What is restrictive cardiomyopathy?
Characterised by normal left ventricular cavity size and systolic function but with increased myocardial stiffness.
187
Sx for restrictive cardiomyopathy
HF symptoms
188
Ix for restrictive cardiomyopathy
Diagnostic: right ventricular biopsy for positivity for congo red staining
MRI – distinguish from constrictive pericarditis
189
Management of restrictive cardiomyopathy
Treat symptoms
Implantable cardioverter defibrillator
190
What is atrial septal defect?
congenital heart defect
191
Features of ASD
1. ejection systolic murmur
| 2. fixed splitting of S2
192
Ix for ASD
ECG - RBBB with RAD
| Diagnostic - Echo
193
Sx for ASD
1. Dyspnoea, heart failure or stroke
| 2. Child – SOB, difficulty feeding, poor weight gain, LRTI
194
Management of ASD
1. ASD – small & symptomatic – watching & waiting
2. Referral to cardiologist
3. Surgery – transvenous catheter closure via femoral vein or open-heart surgery
4. Medication – anticoagulant e.g., aspirin, warfarin & NOACs
195
What is VSD?
Congenital hole in the septum (wall) between the two ventricles.
196
Features of VSD
* Poor feeding
* Dyspnoea
* Tachypnoea
* Poor feeding
* Failure to thrive
* Features of HF – tachypnoea, hepatomegaly, tachycardia, pallor
197
Signs of VSD
- Pan-systolic murmur – more prominent on left lower sternal boarder in the 3rd & 4th ICS
- Systolic thrill on palpation
198
Ix for VSD
VSD may be picked up on antenatal scans or when murmur is heard during newborrn baby check
199
Management of VSD
1. Refer to (paediatric) cardiologist – high specialised management
2. Small VSD with no symptoms – watchful waiting
3. Surgery – transvenous catheter closure or open-heart surgery
200
What is Coarctation of Aorta?
congenital narrowing of the descending aorta usually around the ductus arteriosus.
201
Sx for Coarctation of Aorta
1. neonate – weak femoral pulses
2. Tachypnoea and increased work of breathing
3. Poor feeding
4. Grey and floppy baby
5. HTN at a young age (resistant to treatment)
202
Ix for Coarctation of Aorta
ECG, CXR, Echo
203
Management of Coarctation of Aorta
1. In mild cases patients can live symptom free until adulthood without requiring surgical input
2. In severe cases patients will require emergency surgery shortly after birth.
204
What is Patent Ductus Arteriosus?
The ductus arteriosus normally stops functioning within 1-3 days of birth and closes completely within the first 2-3 weeks of life.
When it fails to close, this is called a “patent ductus arteriosus” (PDA).
205
Sx for Patent Ductus Arteriosus
* Shortness of breath
* Difficulty feeding
* Poor weight gain
* Lower respiratory tract infections
206
Examination findings for Patent Ductus Arteriosus
1. continuous crescendo-decrescendo “machinery” murmur that may continue during the second heart sound
2. left subclavicular thrill
3. large volume, bounding, collapsing pulse
4. wide pulse pressure
5. heaving apex beat
207
Diagnosis of Patent Ductus Arteriosus
Echo
208
Management of Patent Ductus Arteriosus
- Typically monitored until 1 year of age using echo
| - After 1 year – trans-catheter or surgical closure (ligation)
209
What is tetralogy of fallot + its features?
TOF is a result of anterior malalignment of the aorticopulmonary septum.
The four characteristic features are:
1. ventricular septal defect (VSD)
2. right ventricular hypertrophy
3. pulmonary stenosis, right ventricular outflow tract obstruction
4. overriding aorta
210
Sx of tetralogy of fallot
1. Cyanosis
2. Clubbing
3. Poor feeding
4. Poor weight gain
5. Ejection systolic murmur heard loudest in the pulmonary area
6. “Tet spells” – cyanotic episode
7. Older children may squat when a tet spell occurs.
- Younger children can be positioned with their knees to their chest.
211
Management of tetralogy of fallot
Surgical repair is often undertaken in two parts
Cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm
212
What are the shockable rhythms?
VF
| pulseless VT
213
In ALS, when can (1mg) adrenaline be administered?
After chest compression have started ( 30:2)
214
What ESM is heard louder on expiration?
1) aortic stenosis
| 2) hypertrophic obstructive cardiomyopathy
215
What ESM is heard louder on inspiration?
1) pulmonary stenosis
| 2) atrial septal defect
216
What ECG abnormality is associated with hypercalcaemia?
Shortened QT interval
217
When a patient in cardiac arrest has organised electrical activity but there is still no pulse and there are no signs of life, what do you do?
1) continuing CPR at a rate of 30:2
| 2) IV adrenaline
218
Which ECG changes would you see in hyperkalaemia?
Tall Tented T waves
219
Side effects of ARB
hyperkalaemia, hypotension, renal failure
220
When are loop diuretics given to HF patients?
in acute HF, presenting symptomatic
221
How can you distinguish which class of meds to give a patient with an arterial or venous blood disorder?
Arterial: antiplatelets (aspirin, clopidogrel)
Venous: anticoagulants
222
Endocarditis which causes HF requires...
emergency valve replacement surgery
223
which ECG finding is seen in cardiac tamponade
electric alternans
224
ECG findings in an NSTEMI
pathological P waves
225
what is Prinzemtal angina
sometimes relieved by medication but not by rest
226
What is the most common complication of Hypertrophic obstructive cardiomyopathy?
Sudden death due to ventricular arrhythmia
227
What is the gold-standard for ST-elevation MI?
PCI
FCM Matrix
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