Cardiac Flashcards
Systolic cardiac failure
Inability of ventricle to contract normally, resulting in decreased CO
EF
Causes of systolic failure
IHD
MI
Cardiomyopathy
Diastolic cardiac failure
Inability of ventricle to relax normally, causing increased filling pressures
EF >50%
NB Systolic and diastolic failure often co-exist
Causes of diastolic failure
Constrictive pericarditis
Tamponade
Restrictive cardiomyopathy
HTN
Symptoms of LHF
Exertional dyspnoea, othopnoea, PND Fatigue Nocturnal cough +/- pink frothy sputum Wheeze (cardiac "asthma") Nocturia Cold peripheries LOW Muscle wasting
Mechanism of nocturia in LHF
At night when patient is supine, fluid which has accumulated as peripheral oedema returns to the heart and increases nocturnal CO
Increased CO perfuses kidneys, kidneys produce more urine
Symptoms of RHF
Peripheral oedema Ascites Nausea Anorexia Facial engorgement Pulsation in neck and face (if TR) Epistaxis
Causes of RHF
LHF
Pulmonary stenosis
Cor pulmonale (lung disease)
Low-output cardiac failure
CO decreased, fails to increase with exertion
Causes of low-output cardiac failure
Pump failure: systolic/diastolic HF, decreased HR (B-blockers, heart block, post MI), negatively inotropic drugs (most anti-arrhythmics)
Excessive preload: MR, fluid overload (more common if simultaneous compromise of cardiac function or elderly)
Chronic excessive afterload: AS, HTN
High-output cardiac failure
Output normal or increased in face of increased needs (rare)
Occurs with normal heart, accelerated if heart disease
Causes of high-output cardiac failure
Anaemia Pregnancy Hyperthyroidism Paget's disease AV malformation Beri beri
Framingham criteria for CCF
At least 2 major or 1 major + 1 minor
Major: PND, creps, APO, S2 gallop, cardiomegaly, neck vein distention, increased CVP, hepatojugular reflex, weight loss >4.5kg in 5 days in response to treatment
Minor: bilateral ankle oedema, nocturnal cough, dyspnoea on ordinary exertion, hepatomegaly, tachycardia, pleural effusion, decrease in VC by 1/3 of max recorded
CCF Ix
FBE UEC ECG, BNP (if normal, unlikely HF; if positive, echo required) CXR: ABCDE Echo: cause, assess for LV dysfunction
“ABCDE” HF CXR findings
Alevolar oedema ("bat wings")
Kerley B lines (interstitial oedema)
Cardiomegaly
Dilated prominent upper lobe vessels
Effusion (pleural)Mx of chronic HF
Lifestyle: smoking cessation, salt restriction, optimise weight, nutrition
Treat cause
Treat exacerbating factors (anaemia, thyroid disease, infection, HTN)
Avoid exacerbating factors (NSAIDs cause fluid retention, verapamil is a negative inotrope)
Drugs for chronic HF
Diuretics: reduce mortality, give loop diuretic (consider K+-sparing diuretic if low K+, predisposition to arrhythmia, taking digoxin, pre-existing K+-losing conditions), monitor UEC
ACEIs: improves survival, substitute ARB if cough
B-blockers: reduce mortality, initiate AFTER diuretics and ACEIs, use with caution
Spironolactone: use in those still symptomatic despite optimal therapy as above
Digoxin: patients with LV systolic dysfunction and who have signs and symptoms despite standard therapy, or in patients with AF, monitor UEC and digoxin levels
Vasodilators: combination of hydralazine and isosorbide dinitrate should be used IF intolerant of ACEIs and ARBs
NYHA
1: heart disease present, no undue dyspnoea from ordinary activity
2: comfortable at rest, dyspnoea on ordinary activity
3: less than ordinary activity causes dyspnoea which is limiting
4: dyspnoea present at rest, all activity causes discomfort
In-patient Mx of chronic HF
Strict bed rest +/- Na+ and fluid restriction (
Ix in acute exacerbation of CCF
CXR ECG FBE UEC Troponin ABG Consider echo
Mx of IHD (angina pectoris)
Modify RFs: smoking cessation, exercise, weight loss, control of HTN and DM
Aspirin
B-blockers: atenolol 50-100mg/24 hrs
Nitrates: GTN spray or sublingual tabs for symptoms, regular oral nitrate (e.g. isosorbide mononitrate) for prophylaxis
Long-acting CCBs: amlodipine 10mg/24 hrs (esp if CI to B-blocker)
K+ channel activator: if still not controlled
Ivabradine: if CI to B-blocker
B-blocker CIs
Asthma COPD LHF Bradycardia Coronary artery spasm
Causes of acute myocarditis
Idiopathic (50%)
Viral (flu, hepatitis, mumps, rubella, Coxsackie, polio, HIV)
Bacterial (Clostridia, diphtheria, TB, meningococcus, mycoplasma, brucellosis, psittacosis)
Spirochaetes (leptospirosis, syphilis, Lyme)
Protozoa (Chagas)
Drugs (penicillin, spironolactone, carbamezapine)
Toxins
Vasculitis
Symptoms and signs of acute myocarditis
Fatigue Dyspnoea Chest pain Fever Palpitations Tachycardia Soft S1 S4 gallop
Mx of acute myocarditis
Supportive
Treat underlying cause
Prognosis of acute myocarditis
May recover or suffer intractable HF
Dilated cardiomyopathy
Dilated, flabby heart of unknown cause
Associations with dilated cardiomyopathy
EtOH HTN Haemochromatosis Viral infection AI Peri- or postpartum Thyrotoxicosis Congenital
Hypertrophic cardiomyopathy
LV outflow tract obstruction from asymmetric septal hypertrophy
Leading cause of SCD in young
Causes of HCM
Inherited (AD)
Sporadic
Mx of HCM
B-blockers or verapamil for symptoms
Amiodarone for arrhythmias
Anticoagulate for paroxysmal AF or systemic emboli
Consider implantable defibrillator
Causes of restrictive cardiomyopathy
Idiopathic Amyloidosis Haemochromatosis Sarcoidosis Scleroderma
Presentation in restrictive cardiomyopathy
Like constrictive pericarditis
Features of RHF predominate
Causes of acute pericarditis
Idiopathic
Viruses: Coxsackie, flu, EBV, mumps, varicella, HIV
Bacteria: pneumonia, rheumatic fever, TB, staphs, streps
Fungi
MI
Drugs: hydralazine, penicillin
Others: RA, uraemia, SLE, myxoedema, trauma, surgery, malignancy, radiotherapy, sarcoidosis
Clinical features of acute pericarditis
Central chest pain worse on inspiration or lying flat
Relief sitting forwards
Pericardial friction rub
Signs of pericardial effusion or tamponade: dyspnoea, raised JVP, tachycardia, hypotension, quiet HS
Mx of acute pericarditis
Analgesia
Treat cause
Consider colchicine before steroids/immunosuppressants if relapse or continuing symptoms (steroids may increase risk of relapse)
Complications of acute pericarditis
May lead to constrictive pericarditis
Causes of cardiac tamponade
Any pericarditis
Aortic dissection
Warfarin
Beck’s triad in cardiac tamponade
Falling BP
Rising JVP
Muffled HS
Mx of cardiac tamponade
Seek expert help
Effusion needs urgent drainage and should then be sent for culture, ZN stain/TB culture and cytology
Mx of acute heart failure
Posture: sit patient upright, consider CPAP
O2: 100% if no pre-existing lung disease
IV access, monitor ECG: treat any arrhythmias
Ix
Morphine 1.25-5mg IV slowly
Frusemide 40-80mg IV slowly (larger doses if in renal failure)
Nitrates: unless SBP less than 90mmHg, if greater than 100mmHg start a nitrate infusion
5 RFs for PE
Malignancy
Surgery (esp pelvic and lower limb; much lower if prophylaxis is used)
Immobility
Combined OCP (also slight risk with HRT)
Previous thromboembolism and inherited thrombophilia
Ix and expected findings for PE
FBE, UEC, coag profile
ECG: commonly normal or sinus tachycardia
CXR: often normal
ABG
Serum D-dimer: high sensitivity but low specificity (if normal it reliably excludes PE)
CTPA or V/Q scan
Mx of PE
O2 if hypoxic
Morphine if patient distressed
If peri-arrest
