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what is coarctation of the aorta?
aorta narrows at sight of insertion of ductus arterioles
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what are the signs and symptoms of coarctation of aorta?
- arterial hypertension in the right arm
- normal to low BP in lower extremities
- weak peripheral pulses
- if coarctation before left subclass then synch radial pulses
- radio-femoral delay on the right (not left)
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which syndrome is assoc. with coarctation?
turners
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When is a 4th HS heard?
just before the 1st
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what is the 4th HS caused by?
abnormally forceful atrial contraction against a stiff ventricle caused by hypertrophic cardiomyopathy and systemic HTN
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what % of the EDV volume is ejected in systole?
50-70%
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which valve closes first, aortic or pulm?
aortic
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In AS why would you get angina?
severe LVH in the presence of normal coronary arteries
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why would you get chest pain in mitral stenosis?
- RV ischaemia
- coronary embolisation
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what are the 4 CV conditions assoc. with turners? (XO)
- coarctation of aorta
- aortic dissection
- congenital bicuspid aortic valve
- aortic regurgitation
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if someone with migraine gets central chest pain and palps and no signs of HF, what is the cause?
coronary artery vasospasm
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how is coronary artery vasospasm treated?
- CCB
- nitrates
- only add BB when FIXED coronary artery disease
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which criteria is used to diagnose rheumatic fever?
revised Jones criteria
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how is the diagnosis of rheumatic fever made?
- evidence of recent strep infection and
- 2 major OR
- 1 major + 2 minor criteria
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what are the evidence of strep infection?
- recent strep infection (sore throat)
- history of scarlet fever
- positive throat swab
- increase in ASOT > 200iu/l
- increase in DNAse B titre
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what are the major criteria for jones criteria? remember pneumonic
- CASES
- carditis: tachy, murmur, pericardial rub, CCF, cardiomegaly
- arthritis: flitting polyarthritis
- subcutaneous nodules: extensor surfaces
- erythema marginatum: red raised edge and clear centre on trunk, thigh, arm
- sydenham's chorea: St Vitus dance= invol semi-purposeful movements
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what is the key pathological feature of acute rheumatic fever?
aschoff body: focal inflammatory lesion in heart (small, sterile veg)
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what is the Rx of acute rheumatic fever?
- bed rest
- benzylpenicillin stat then penicillin V
- analgesia for carditis, arthritis
- haloperidol/diazepam for chorea
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what % of acute rheum fever develop chronic?
60%
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what is the secondary prophylaxis for pts with acute rheum fever, what age?
- under 30 (as when over no longer at risk)
- penicillin V
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What is the commonest cause of subacute bacterial endocarditis?
strep viridans
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what is the commonest cause of endocarditis in prosthetic valve or IVDU?
staph aureus
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which valve is most commonly affected by IE?
aortic
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which valve in IVDU is most commonly affected in IE?
tricuspid
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what is the classification of IE?
- native valve
- prosthetic valve: < or > 6 months from insertion
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what are the causes of native valve IE?
- strep viridans (gram +)
- staph aureus
- enterococci
- HACEK bacteria
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what are strep viridans?
- normal flora of oropharynx e.g. strep mutans, sanguis, mitis
- gut flora: strep bovis
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what kind of haemolysis is assoc. with strep viridans?
alpha haemolysis (turns blood agar green hence viridans)
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what are the causes of EARLY prosthetic valve IE?
- staph aureus
- coagulase negative staph eg staph epidermidis
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what are the causes of LATE prosthetic valve IE?
- same as native.
- strep viridans: eg mutilans sanguis, mitis, bovis
- staph aureus
- enterococci
- HACEK bacteria
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what is the difference in presentation between strep viridans and staph aureus?
- strep viridans: more subacute presentation so have peripheral stigmata of IE e.g. splinters, roth spots
- staph aureus: present quickly: hours-days so no peripheral stigmata of IE, flash pulmonary oedema as aortic valve is damaged, or stroke
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what is the treatment of staph aureus IE?
- high dose iv flucloxacillin and gentamicin
- 4-6 weeks
- need to give both as fluclox opens the cell wall (of G+ as thick cell wall) and so gentamicin can get in and inhibit protein synthesis
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how is IE diagnosed?
- modified dukes criteria
- need 2 major or
- 1 major and 3 minor or
- 5 minors
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what are the 3 major criteria for IE?
- positive blood cultures
- endocardial involvement: echo
- new valve regard (murmur)
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what are the minor criteria for IE?
- ivdu
- fever
- ICH
- petechiae
- GN - microscopic haematuria
- oslers
- RhF
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what is the empirical treatment for native valve IE?
amoxicillin and gentamicin iv
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what is the empirical treatment for prosthetic valve IE?
vancomycin and gentamycin iv
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what is the Rx of strep viridans IE in native valve?
- benzylpenicillin and gentamicin
- 2 weeks
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what is the treatment for MRSA and MRSE IE?
- vancomycin and gentamicin
- 4-6 weeks
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what is the treatment of enterococcal endocarditis?
- amoxicillin and gentamicin 4 weeks
- if allergic to pen or resistant to amox then give vancomycin instead of amox
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what is brugada's syndrome?
- abnormal Na channel transport in the heart
- results in SCD often due to VF
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what is the best treatment for brugadas?
ICD
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what are the ECG features of brugadas?
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why do you get haemoptysis in mitral stenosis?
due to pulmonary HTN
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why is AF assoc. with Mitral stenosis?
due to left atrial enlargement
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when you put someone on digoxin, what needs to be monitored regularly?
- renal function
- deranged renal function increases chance of digoxin toxicity
-
what is the MOA of carvedilol? 2, and 2 uses?
- non selective beta blocker
- alpha 1 block
- good for CHF and HTN
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in which murmur do u get a 3rd HS and why?
- mitral regurg
- in diastole blood rushing back into ventricle
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when do you hear a left parasternal heave?
- RV enlargement eg pulmonary stenosis, cor pulmonale, ASD
- also in mitral regurgitation due to left atrial distension in systole
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Loud first heart sound, opening snap and pulmonary hypertension are suggestive of…?
MITRAL STENOSIS
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Give 4 indications for thrombolysis in MI
- STE >2mm in at least 2 chest leads
- STE >1mm in at least 2 limb leads
- new onset LBBB
- posterior MI signs: positive R wave and STD in V123
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what is the time limit for thrombolysis?
12 hours of ECG findings
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what are the CI for thrombolysis?
- coagulopathy
- recent haemorrhage esp. brain
- recent surgery or injury
- pregnancy
- severe HTN
- peptic ulcer disease
- previous hypertensive stroke
- proliferative diabetic retinopathy
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what is pulmonary artery hypertension definition (numbers)
- >25mmHg at rest
- >30mmHg on exercise
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