DESCRIBETHE HALLMARK CARACTHERISTICS OF TH EFOLLOWING:
CHRONIC HEART FAILURE:
Hallmark symptoms:
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progressive dyspnoea or paroxysmal sleep apnoea
decreased cardiac output (CO) = fatigue/listlessness/poor effort tolerance and cold
peripheries
poor renal perfusion leads to OLIGURIA = (decreased urine output) and URAEMIA =
(increased toxins in urine)
marked weight loss, as a result of the following:
1 anorexia and decreased absorption due to GIT congestion (gastrointestinal toxins),
2 poor tissue perfusion due to low cardiac output,
3 skeletal muscle atrophy due to immobility
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inefficient pumping of heart leads to blood starting to back up, results in increased
pressure in blood vessels, increase in vessel pressure forces fluid into tissue = PITTING
OEDEMA
L. sided heart failure: fluid collects in lungs leading to PULMONARY CONGESTION
DYSPNOEA,
FATIGUE,
DECREASE IN GAS EXCHANGE, due to fluid build up in alveoli,
CYANOSIS
TACHYCARDIA
R. sided heart failure: PERIPHERAL AND ABDOMINAL OEDEMA
Fluid collects in feet and lower limbs = PITTING OEDEMA
Late – stage disease = ASCITES (fluid collecting in the abdomenFATIGUE
WEIGHT GAIN
COR PULMONALE = abnormal enlargement of Rz. Side of hear, due to disease of
pulmonary tissue or blood vessels
Key testing:
IMAGING:
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= ECG/ECHOCARDIOGRAM CHEST X-RAY
BLOOD TEST:
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brain natriuretic peptide - (produced by cardiac myocytes in response to ventricular
stretch, similar action to ANP
serum urea & electrolytes = checking for reduced kidney function
Treatment:
LIFESTYLE MANAGEMENT:
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Patient education, dietary modifications, decrease in alcohol use and smoking,
increase in exercise
PHARMACOLOGICAL MANAGEMENT:
st
 1 line: DIURETICS –FRUSEMIDE, SPIRONOLACTONE
nd
 2 line: ACE INHIBITORS – RAMIPRIL, PERINDOPRIL, ANGINOTENSIN II receptor
blockers – LOSARTAN, CANDESATRAN
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 3 line: VASODILATORS, VENODILATORS NITRATES - reduced preload, ARTETIAL
DILATORS – reduced afterload
th
 4 line: ANTI-ARRYTHMIC DRUGS e.g. AMIODARONE, DIGOXIN – reduce BP, increase
contractility
SURGICAL MANAGEMENT:
 transplantation etc.
ATRIAL FIBRILLATION:
Hallmark symptoms:
 palpitation, angina, fatigue, pre – syncope, oedema, weakness, dyspnoea
decreased cardiac output signs may precipitate or aggravate heart failure
 poor effort tolerance
 3 CLASSIFICATIONS:
Paroxysmal = intermittent, self – terminating, episodic
Persistent = prolonged episode
Permanent = disease progression will result in permanent presence
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TACHYCARDIC ARRYTHMIAS: increased automaticity – increased rate of cardiac action
potential generation
re-entry –retrograde depolarisation of cardiac tissue, causing premature
depolarisation –ECTOPIC PAIN
results in: PALPITATIONS, DIZZINESS, DYSPNOEA, CHEST DISCOMFORT
BRADYCHARDIC ARRYTHMIAS: decreased automaticity – decreased rate of cardiac
action potential generation
blocked/slow conduction rate
results in: SYMPTOMS OF LOW CARDIAC OUTPUT, FATIGUE, PRE – SYNCOPE etc.
Key testing:
IMAGING:
 ECG, ECHOCARDIOGRAPHY
PHYSICAL EXAMINATION:
 PULSE = irregularly irregular
 AUSCULTATION: = possible murmur at persistent stage
Treatment:
PHARMACEUTICAL INTERVENTION: - aim is rate and rhythmic control
 ANTI-ARRYTHMICS – AMIODARONE
 BETA BLOCKERS
 CA++CHANNEL BLOCKERS
 ANTIPLATELETS – ASPIRIN
 ?ANTICOAGULANTS
SURGICAL INTERVENTION
 Catheter ablation
 pacemaker
 implantable cardioverter defibrillator (ICD)
HYPERTHROPHIC OBSTRUCTIVE CARDDIOMYOPATHY:
Hallmark symptoms:
 it is a genetic cardiovascular disease -L. ventricle hypertrophy
 ventricle stiffness leads to decrease in filling capacity – resulting in heart failure
 all symptoms are aggravated by exertion
 dyspnoea
 light headedness -? due to positional changes, or Valsalva’s type manouvres
 pre/syncope – “greying out”, relieved by laying down
 arrythmias, palpitations, angina
Key testing:
PHYSICAL EXAMINATION:
 double apical impulse palpable at apex of heart
 percussion = cardiomegaly
 auscultation = murmur
IMAGING:
 echocardiogram – diagnoses it!
Treatment:
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lifestyle management – total abstinence from strenuous activity avoidance of heavy
lifting
Beta-blockers, Ca++ channel blockers
Implantable cardiac defibrillator if severe
DESCRIBETHE HALLMARK CARACTHERISTICS OF TH EFOLLOWING:
PERIPHERAL ARTERIAL DISEASE STAGE II:
Hallmark symptoms:
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tropic changes (changes to soft tissue in response to nerve or circulatory damage) =
TOENAIL FUNGUS, PALLOR OR SHINY SKIN ON LEGS, COOL OR COLD LOWER LIMBS
possible reduction in sensory testing
possible balance issues – wider gait, turning with one foot on the ground or steppage
gait
patterned pain on exertion, e.g.(walking), gets rapidly alleviated by rest – pain most
commonly in the calf
pain possible but uncommon in buttock , hip, thigh or foot
cycle of exacerbation and alleviation, collateral vascular supply created but disease
continues to progress
Key testing:
OBSERVATION:
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cyanosis, digital clubbing, pallor on elevation, skin & nail dry and brittle, tropic changes
to extremities, muscle wastage, loss of hair on legs, reduced pedal pulses
INVESTIGATION:
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Ancle Brachial Pressure Index – doppler comparison of BP in arm to ankle – if lower in
ankle = PAD likely
Treatment:
HISTORY:
 management is usually challenging, Rx = complicated, patients usually elderly and
sedentary, comorbidities or end stage diseases common
LIFESTYLE MODIFICATIONS:
 management of the risk factors, supervised exercise programme
PHARMACEUTICAL INTERVENTIONS:
 ANTI-HYPERTENSIVES, ANTI-PALTELETS, STATINS, OPIOIDS for pain management
(morpheein in stage III, IV)
MANAGEMENT OF CONCORDANT CONDITIONS:
 Diabetes mellitus, heart failure, etc.
SURGICAL INTERVENTION:
 amputation
ABDOMINAL AORTIC ANEURYSM:
Hallmark symptoms:
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often asymptomatic
diffuse pain in central abdomen, back loin, iliac fossa or groin
possible pulsatile sensation, palpable mass
possible nausea/early satiety/urinary disfunction dependent on area of compression
Key testing:
OBSERVATION:
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Pt history
observe for tropic changes
 observe for pulsatile mass
AUSCULTATION:
 auscultate for abdominal bruit
PALPATION:
 palpate abdominal aorta – dependent on pt size, may not be palpable
 palpate pedal pulses
IMAGING:
 USG for diagnosis
 CT to provide an accurate information on size and extent
Treatment:
MONITOR:
 AAA is monitored until size equal of larger then 5.5 cm- until this time surgical risk
higher then rupture risk
 exception – if AAA becomes symptomatic or distal embolus is occurring
SURGERY:
 aneurismal segment replaced with prosthetic graft
 if the surgery is survived for +30 DAYS = prognosis of normal life expectancy
 RUPTURE = sudden onset pain +/- pulsatile mass and syncope 65% die before
reaching hospital
DEEP VEIN THROMBOSIS:
Hallmark symptoms:
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pain
erythema
swelling
oedema
engorged superficial veins, but may be asymptomatic
Key testing:
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HOMAN’S sign may be positive, but not confirmative of diagnostic - (Homan’s sign: pt
supine, actively extends the knee, clinician raises straight leg 10 degrees and
dorsiflexes foot abruptly while squeezing calf
Beware, risk of pulmonary embolism!
Treatment:
HISTORY:
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patient history
physical examination
IMAGING:
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doppler USG (ultrasound)
BLOOD TEST:
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D –dimer test (substance that is created after Fibrin is broken down) – high levels of
D-dimer suggest recent presence of cloth
PHARMACEUTICAL INTERVENTION:
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ANTI-COAGULANS – to reach the target of 2,5 INR
PHYSICAL INTERVENTION:
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bed rest until fully anti-coagulated
elastic stocking