A: Finals: Cardiology

• Autonomic and endocrine control
• Sinu-atrial node (right atrium)
• Atrioventricular node
• Bundle of His
• Left/Right bundle (left has 2 branches, ant/post)
• Purkinje fibres

Pressure of blood on the left ventricle after diastole (when passive filling has completed)

The amount of systemic pressure that needs to be exceeded by the ventricles to open the aortic/pulmonary valves

• A relatively unchanging reduction in coronary blood flow
• Insufficient blood flow occurs when heart activity increases
• No thrombotic pathogenesis

• Acute reduction in coronary blood flow
• Typically caused by endothelial rupture in pre-existing stable angina/atheromatous disease
• Symptoms of this angina occur at rest, with rise in troponin due to clotting involvement

• Causative organism in 2 separate cultures
• Positive echo OR new valve regurgitation detected in auscultation

• ECG: Ischaemia, conduction delay or arrhythmia
• Blood cultures: S. Viridans/S. Aureaus
• Echo: Valve function and ejection volume
• CXR: Valve calcification

• S. Pyogenes infection
• 'Molecular mimicry' effect
• Autoimmunity against valves and kidneys
• Both stenosis and regurgitation occur

• 80ms
• 2 small boxes

• Examine QRS in lead I and II
• Normal = Both are mostly positive
• Posterior deviation = I positive and II negative
• Anterior = I is negative, II positive

• Absorbed in GI, enter lymph as chylomicrons
• In liver, converted to cholesterol then either bile, vLDL or LDL
• Transported to tissues, which can return it as HDL (which is then converted to bile)

• LDL enters sub-endothelial space when high blood content
• Macrophages consume and oxidise the LDL
• Cytoplasm enlarges and saturates, making "foam cells"
• Apoptotis occurs, causing LDL release and inflammation

• Inhibit HMG-CoA reductase activity in liver
• Reduced cholesterol production from acetyl CoA
• Liver LDL receptors expressed to remove cholesterol from bloodstream
• Cholesterol processed into bile salts, excreted and 95% absorbed by bowel

• Smoking
• Alcohol consumption
• Blood pressure
• BMI/obesity
• Cholesterol
• Blood glucose

Side effects: Muscle/joint pain or cramps, malaise, GI features

Complications: Serious drug interactions, rhabdomyolysis, acute renal failure

Fibrates: Increase liver FFA uptake and converstion to acetyl-CoA

Ezetimibe: Reduced absorption of lipids in small intestine

Resins: Same as ezetimibe

- Build up of exacerbating factors, especially increased systemic resistance

- Intrinsic changes, e.g. ventricular hypertrophy and frank-starling mechanism, allow compensation

- Injury to heart, acute or chronic increase in preload or afterload cause decompensation and dilation of ventricles

- Loss of systolic output, as sufficient ventricular pressure in systole not able to be maintained

• Loss of systolic output causes compensation, relying on frank-starling mechanism
• Systemic modulation via ANS (carotid sinus receptors - medulla - SA node/peripheral constriction)
• ADH secretion from carotid/atrial baroreceptor activation
• RAS system causes vasoconstriction and retention of Na/H20 by aldosterone (juxtaglomerular cells)

• HEART FAILED
• Hypertension
• Environment
• Anaemia
• Rheumatic
• Thyroid
• Failed medication
• Arrhythmia
• Infection/infarction
• Lung disease
• Endocrine
• Diet

• Symptoms:
• - Dypnoea
• - PND
• - Orthopnoea
• - Cough
• - Exercise intolerance

• Signs:
• - Crackles
• - Bilateral effusion
• - Pitting oedema
• - Increased JVP
• - Displaced apex

• ECG: Axis deviation, evidence of ischaemia/MI (st segment or q wave changes)
• CXR: Cardiomegaly, effusion, oedema, kerley b-lines [<1cm lines in lung peripheriesl], cuffing
• Echo: Dilated ventricle/hypertrophy with poor ejection fraction

• Bradyarrhythmias <60bpm
• Tachyarrhythmias >100bpm

Tachyarrhythmias: Regular or irregular

Regular: Narrow or broad QRS

Due to failure of impulse formation or impulse conduction from atria to ventricles (AV block)

• - Sinus bradycardia
• - AV-block escape rhythm
• - Hypothyroidism
• - Infarction
• - Drugs; B-Blockers, CCBs, digitalis

• Protein not detectable in normal people (high specificity)
• Also highly sensitive
• Troponin levels can take 9-12 hours to raise, so should be checked on admission AND 12 hours later

• Aspirin
• Lipid lowering therapy (Statin)
• B-Blockers
• CCBs
• Isosorbide mononitrate (symptomatic)

• II, III and aVF (Bottom left)
• I, aVL
• V3, 4 initially and others if infarction large. Lower leads = anteroseptal, higher means anterolateral

• Hyperacute T wave
• ST segment elevation
• Q waves
• New BBB
• VF/VT

• Heart failure
• Myocardial rupture
• Bundle branch block
• Arrhythmias
• VSD

• Almost always due to rheumatic fever (foreigners or elderly)
• Left atrial pressure/volume increases and hypertrophy occurs to maintain flow through valve
• Pulmonary venous pressure increases, causing pulmonary artery hypertension
• Right ventricle hypertrophy, dilatation and failure
• Stenosed valve means mid-diastolic murmur as ventricle refills

• LOW PITCHED MID-DIASTOLIC MURMUR
• Malar flush
• Weak pulse
• AF
• Increased JVP (RHF)

• Hypertensive or systemic disease causes valve damage
• Compliance of L.A. causes regurgitating blood to increase pressure
• Pulmonary venous pressure rises and oedema occurs
• Ventricular systole pushes blood into atrium causing pan-systolic murmur

• Increased resistance leads to left ventricular hypertrophy and ischaemia
• Exercise intolerance, arrhythmia and angina occur in moderate stenosis
• Increased pressure causes ejection systolic murmur

• Reflux of blood means reduction in cardiac ouput, meaning ventricular hypertrophy occurs
• Diastolic run off causes reduction in diastolic BP and reduced coronary perfusion
• Systolic pressure increases to improve perfusion
• "Hyperdynamic" circulation, i.e. difference in sys/dia greater

• Early diastolic AND ejection systolic
• Collapsing pulse
• Pistol shot femorals
• Capillary pulsation
• Head nodding

• Don't bother with this condition
• Caused by rhematic fever and associated with other valve disease typically
• Features of right heart failure

• Don't bother with this condition
• Can be functional due to right ventricle dilation or rheumatic fever
• "Blowing" pan systolic murmur

• Increase in right ventricle pressure causes hypertrophy and dilation
• Systemic features of heart failure occur; JVP, ascites, oedema
• Ejection systolic murmur

• Occurs due to pulmonary hypertension
• Diastolic murmur

• Fuck My NOPP
• Frusemide
• Morphine
• Nitrates
• Oxygen
• Positive pressure airway ventilation

• Implanted device which takes blood from the ventricle and pumps it into the corresponding great vessel
• Can be extra or intracorporeal
• Complications include TE, bleeding, infection and malfunction

• Any condition resulting in injury or distension of atria
• Fibrillation of atria, which conducts to AV node but is physiologically slowed
• Ventricles beat quickly but inefficienctly
• Loss of CO and blood stasis causes thrombosis

• Rate:
• - Patient age >65
• - Known IHD
• - AF duration >1yr
• - Anti-arrhythmics contraindicated

• Rhythm control:
• - Young symptomatic patients
• - Correctable aetiology

• High risk: Previous TE event, >75 with disease or evidence of impaired LV function Warfarin
• Moderate: >65 or <75 with HBP/DM W/A
• Low: Anyone else Aspirin

• Over 75
• Concurrent antiplatelet therapy
• NSAIDs
• Uncontrolled hypertension
• History of bleeds; e.g peptic ulcer, cerebral

• Electrical alone: When little risk of failure
• Sotalol/amiodarone: 4 weeks, then electrical cardioversion
• Drugs: Rhythm control alone

• Before
• - If onset <48 hours then heparin
• - If >48 then 3 weeks of anticoagulation before

• After
• - 4 weeks of anticoagulation unless >48hr onset
• - Further anticoagulation if appropriate

• Standard beta blocker
• Class 1c (flecanide) or sotalol if SHD present
• Amiodarone if SHD present or other drugs fail
• If rhythm control fails, move to rate control or refer for other methods

• Thromboprophylaxis first
• Beta blocker/rate limiting CCB
• Add digoxin if further control required
• Refer to specialist for amiodarone/other if still required

• Rapid but regular atrial depolarisation >300bpm
• Caused by a re-entrant rhythm, i.e. 'loop'
• AV node blocks to a ratio of 2:1 (or 3:1) so pulse is 150bpm

• "Sawtooth" in inferior leads
• Valsalva/massage or adenosine can reduce ventricular beats and reveal P-waves

• Ventricular rate >100bpm
• Monomorphic or polymorphic (life threatening)
• Broad complex

• Hypovolemia
• Hyperkalaemia
• Hypothermia
• Hydrogen ions
• Thromboembolism
• Tension pneumothorax
• Tamponade
• Tablets

• New York Heart Association
• 1: No symptoms or limitation
• 2: Mild
• 3: Marked limitation but comfortable at rest
• 4: Severe limitations even at rest

• Physiological
• Hypothermia
• Hypothyroidism
• Drugs
• Sick sinus syndrome

• 1st degree: PR interval >200ms
• 2nd type 1: Elongating PR interval until QRS drops
• 2nd type 2: PR interval normal but QRS dropped. Can become 3rd
• 3rd degree: No relation between P and QRS (complete). Bradycardia

• Cardiomegaly
• Bat-wing mediastinal opacification
• Bilateral pleural effusions/CPh angle blunting
• Kerley B lines
• Bronchoalveolar cuffing

• Lifestyle: Elevate head at night and secondary prevention
• Symptom management: Domiciliary O2
• Pharmacological: RAAS, IsMN, diuretics, bBs

• Essential (likely atherosclerosis)
• Renal disease (e.g. ADPKD, failure)
• Cushing's
• Phaeo
• Pregnancy

• ACE inhibitors/ARBs (skip step if <55 or black)
• + calcium channel blocker
• + Thiazide
• + increase diuretic, alpha or beta blockers

• Sudden "sharp" pain
• Pain relieved when leaning forward
• Friction rub
• Excessive sweating

• Pallor
• Absent pulses
• Cold
• Low ankle:brachial pressure index

• US doppler to find atherosclerosis
• X-ray angiogram
• CT angiogram

• Exam and doppler US to assess ischaemia
• WHO ladder analgesia
• Surgical referral for revascularisation with angioplasty/stenting
• If revascularisation contra-indicated, amputation required

• Supervised exercise
• Medical: Antiplatelet therapy, thrombolysis
• Surgical: Angioplasty/stenting/bypass/graft when severe
• If above not effective, naftidofuryl oxalate

• MEDICAL EMERGENCY: HIGH INDEX = NO INVESTIGATIONS
• Extreme general abdominal pain
• Hypotension
• Tachycardia
• Flank bruising
• Abdominal mass/rigid

• Male
• Increasing age
• Atherosclerosis
• Connective tissue disorders
• Trauma/surgery

• Men >65
• 10 minute US
• Conservative management if <5.5cm

• Lifestyle: Smoking
• Medication: HTN and dyslipidemia
• Surgical: Endovascular stent

• 1 in 3 fail to survive trip to hospital
• Emergency repair mortality 80%
• Compare with 5% mortality for elective repair

• Conservative: Compression stockings, NSAIDs, dry skin
• Stripping: Removal of saphenous vein
• Ablation: Endovascular laser causes contraction

• Female
• Increasing age
• Pregnancy
• Obesity
• Family history

• 'Punched out' appearance
• Intensely painful
• Distal limb/digits
• Underlying fascia visible