C1 Online Tutorial: Byker Paul Flashcards
What is CVD?
The term cardiovascular disease is used in clinical practice as an umbrella term that means diseases that involve the heart, the blood vessels caused by a pathological process known as atherosclerosis. CVD is a significant cause of mortality (death) and morbidity (ill health), accounting for almost a third of all deaths in the UK. his is a condition where patches (plaques) of atheroma form within the inside lining of arteries. Atheroma itself is a complex mixture of many constituents that includes white blood cells, lipids (cholesterol and fatty acids), calcium, and fibrous connective tissue. Over months or years, plaques of atheroma can become larger and thicker; this can cause arterial narrowing and restrict blood flow. Sometimes a plaque of atheroma develops a tiny crack (rupture) on the inside surface of the artery. This may trigger a blood clot (thrombosis) to form which may completely or partially block blood flow in the affected artery. Cardiovascular conditions caused by atherosclerosis include:
- Coronary heart disease ( CHD-including angina and myocardial infarction)
- Stroke.
- Transient ischaemic attack (TIA)
- sPeripheral arterial disease.
Socio- economic factors in CVD prevalence
Between 2002 and 2012 deaths due to myocardial infarction (MI) roughly halved. However, CVD remains the most common cause of death in the UK: in 2010 Coronary heart disease (CHD) resulted in the deaths of 17% of men and 12% of women — a total of about 80,000 deaths (compared to about 101,000 in 2005). These are overall figures but socioeconomic factors and geographic location account for large differences in risk and outcomes for different populations. CVD is strongly associated to low income and social deprivation, with a North-South divide.(Prevalence rates for CVD 4.6% in North East, 2.2% London -BHF Coronary Heart Disease statistics 2012)
What is meant by a patient’s social context?
Human social environments encompass the immediate physical surroundings, social relationships, and cultural settings within which defined groups of people function and interact.
Define the term infarction and explain how infarction of cardiac muscle can lead to sudden death?
Infarction is tissue death (necrosis) due to inadequate blood supply to the affected area. It may be caused by artery blockages, rupture, mechanical compression or vasoconstriction. The resulting lesion is referred to as an infarct.
When an area of cardiac muscle is infarcted the normal electrical activity of the heart can be disrupted. The dead and dying tissue is inexcitable, but around these areas usually lies a penumbra of hypoxic tissue that is excitable and re-entry ventricular arrhythmia may occur - one of these, Ventricular fibrillation results in the ventricles beating in a disorganised manner and the heart is unable to function as a pump. If Ventricular fibrillation is not treated, inadequate cardiac output will result in collapse and death.
Define the term ischaemia and how does ischaemia of cardiac muscle lead to the symptoms described above?
Ischaemia is a restriction in blood supply to tissues, causing a shortage of oxygen and glucose needed for cellular metabolism. It develops when coronary blood flow becomes inadequate to meet myocardial oxygen demand. This causes myocardial cells to switch from aerobic to anaerobic metabolism, with a progressive impairment of metabolic, mechanical, and electrical functions.
Angina pectoris is the most common clinical manifestation of myocardial ischemia. It is caused by chemical and mechanical stimulation of sensory afferent nerve endings in the coronary vessels and myocardium.
Symptomatology reported by patients with angina commonly includes the following: Retrosternal chest discomfort (pressure, heaviness, squeezing, burning, or choking sensation) as opposed to frank pain Pain localized primarily in the epigastrium, back, neck, jaw, or shoulders. It often radiates into the left arm. Pain precipitated by exertion, eating, exposure to cold, or emotional stress, lasting for about 1-5 minutes and relieved by rest or nitroglycerin ( GTN) Pain intensity that does not change with respiration, cough, or change in position
Having listened to Paul’s story and acknowledged Paul’s thoughts about what was going on, he went on the explore the history further. He particularly asked about the nature of the pain, how often it was happening, what situations brought it on and whether it settled quickly with rest. He asked about other symptoms like palpitations, breathlessness, and ankle swelling. He checked his BMI and examined his cardiovascular system including his blood pressure.The GP thought he could hear a soft ejection systolic murmur, loudest in the right second intercostal space, which radiated to the carotids.
He decided that Paul had stable angina and went on to arrange an ECG and some blood tests (FBC, U/Es, fasting blood sugar and serum lipid profile) and explained to Paul that he would need to refer him to the Rapid Access Chest Pain Clinic (RACPC) for assessment of both the chest pains and the murmur.
Why did the doctor ask about those particular symptoms?
A range of factors would feed into the GPs decision to explore the cardiovascular history in detail, particularly to focus on the typical symptoms of ischameic heart disease and rule out other potential causes.
Presence of risk factors for CVD, his age, sex, family history of heart disease, smoking, BMI ( particularly central obesity), sedentary lifestyle
The typical history of anginal chest pain would need to be confirmed - so GP needed to ask about what brought the pain on, relieved it, what it was like, radiations and associated symptoms
The GP was also assessing the severity and urgency of the problem. If the history had shown that Paul was getting severe, frequent symptoms, particularly pain at rest or minimal exertion, the GP would have considered admission rather than referral.
Why did the doctor refer him and what features in the history would have made the doctor consider a same day referral?
Paul’s history was very suggestive of new onset angina, and examination had also revealed an unexplained heart murmur. Hospital referral was indicated to confirm the diagnosis of angina, arrange prognostic testing and assess why he had a murmur. Aortic stenosis is a possibility and could be contributing to the anginal symptoms and increasing the risk of a poor outcome if left untreated.
See New angina guidelines for more detail
If Paul had any symptoms that suggested unstable angina, rest pain, increasing frequency of pain, then a same day referral would have been necessary.
What communication skills could Dr Baker use at the beginning of the interview to put the patient at ease?
He would have introduced himself, given the patient his full attention by making sure he had finished previous computer task.
Good eye contact, and warm introduction.
He may have mentioned that he hadn’t see Paul for years but that he remembered him.
Allow the patient time to tell his story in his own words without interruption to begin with, using active listening skills ( body language, gestures, verbal cues to encourage continuation)
Briefly explain atherosclerosis? What conditions other than coronary artery heart disease can it lead to?
Atheroma or atherosclerosis is a condition of medium to large arteries. The initial ‘fatty streak within the wall goes on to form atherosclerotic plaques, with a fibrous cap and lipid core which narrow the lumen and are predisposed to rupture and overlying thrombosis ( blood clot formation).
Atheromatous plaques formation involve a complex process involving an interaction between the arterial wall, blood components with inflammation playing a major role.
Other conditions resulting from it are:
Cerebrovascular disease, ( strokes and vascular dementia), TIAs ( Transient Ischaemic attacks)
Peripheral vascular disease
Aortic aneurisms
Visceral ischaemia: Renal artery stenosis and mesenteric angina
List non-modifiable and modifiable risk factors for developing atheroma.
Modifiable Unhealthy blood cholesterol levels High blood pressure Smoking Overweight or obesity Sedentary lifestyle Unhealthy diet Stress Alcohol
Non-Modifiable Insulin resistance, diabetes Older age Family history of early CVD Ethnicity
These are the ECG strips for lead 2 before and after Paul collapsed. What do they show? What are the reasons for the interventions described by Sharon?
The first ECG shows sinus tachycardia ( heart rate > 100/min)
The second shows ventricular fibrillation. Ventricular fibrillation is when chaotic electrical activity in the heart muscle triggered by the infarct or ischamic tissue, results in an absent cardiac output. This causes Paul to collapse, pulseless.
The ambulance men recognise this and start Cardiopulmonary Resuscitation ( CPR) to maintain a peripheral circulation. They then shock Paul’s heart using an External defibrillator which restores it a normal sinus rhythm.
Explain briefly the pathological between an infarct where ST elevation is demonstrated on the ECG (STEMI) and one where it is not (Non- STEMI)?
An inferior myocardial infarction results from a blockage of the Right Coronary Artery ( RCA).
This artery also supplies the AV node
Ischaemia of the AV node due to impaired blood flow via the AV nodal artery. This artery arises from the RCA 80% of the time, hence its involvement in inferior STEMI due to RCA occlusion.
Bezold-Jarisch reflex = increased vagal tone secondary to ischaemia.
Both mechanisms result in heart rate slowing ( bradycardia <60/min) or a type of heart block ( First, second and third degree heart block)
What does the term epidemiology of a condition mean? What is meant by incidence and prevalence of a condition?
Epidemiology: the distribution of the condition and determinants of said condition in populations.
Incidence: a measure of morbidity based on the number of new episodes of a condition arising in a population over a certain period.
Prevalence: a measure of morbidity based on current levels of disease in a population.
What socioeconomic factors are responsible for a variation in the prevalence rates for IHD in the UK and worldwide?
Socioeconomic factors: low socio-economic status, lack of social support, stress at work and in family life, depression, anxiety, hostility, unemployment and educational level.
( For interest -over three quarters of CVD deaths take place in low- and middle-income countries.
Most cardiovascular diseases can be prevented by addressing behavioural risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity and harmful use of alcohol – all of which are more common in lower socio-economic groups)
What restrictions will Paul have as a taxi driver because of his recent heart problems
The DVLA Website states that as he is a vocational driver he must inform them and stop driving for 6 weeks, before being reassessed by his GP. He may then be allowed to start driving again. He may be required to undergo specific tests before being allowed to drive again.
