Cardiac causes of SOB Flashcards
What are the main cardiac causes of SOB?
Heart failure
Cardiomyopathy
Constrictive pericarditis
Myocarditis
A 70-year old lady presents with dyspnoea, which has becoming worse over the last months. She also reports cough, productive of pink frothy sputum. On examination her pulse is irregularly irregular, and she has a high respiratory and heart rate. What is the most likely diagnosis?
Clue:
A Acute Coronary Syndrome
B Aortic stenosis
C Congestive Heart Failure
D Right Heart Failure
E Left Heart Failure
Answer: E Left Heart Failure
Chronic heart failure
Definition
Types And Basic concepts
Aetiology- Low output [LHF and RHF], High output
Risk factors
Symptoms- LHF, RHF and scoring
Signs- LHF, RHF
Investigations
Diagnosis [risk score]
Management- chronic, acute
Prognosis
Complications
Chronic heart failure
Definition
Long standing failure of heart to provide adequate circulation for requirements of body
Types and basic concepts
Low output HF CO is low and cannot meet body’s demands
High output HF CO is normal but body’s requirements have increased - less common
Right sided heart failure
Left sided HF
Congestive cardiac failure- both sided
Aetiology
Left HF-low output
Valvular
Aortic stenosis
Aortic regurgitation
Mitral regurgitation
Heart muscle - IHD, Cardiomyopathy, Myocarditis Arrhythmia -AF
Systemic
Drugs- cocaine, beta blocker. chemotherapy, alcohol
Hypertension
Amyloidosis
Right HF- low output
Left HF
Pulmonary- pulmonary hypertension, PE, chronic lung disease
Valvular- Tricuspid regurg, Pulmonary valve disease
High output heart failure [rare]- NAP MEALS
Nutritional deficiency-lack of thiamine
Anaemia
Pregnancy
Malignancy- multiple myeloma
Endocinne- hyperthyroidism
AV malformations
Liver cirhhosis
Sepsis
Risk factors
Increased age
Symptoms
Left heart failure
Generally resp symptoms because blood backs up into lungs
- Exertional dyspnoea
- Orthopnea
- Paroxysmal noctural dyspnoea
- Fatigue
- Nocturnal cough- usually with pink frothy sputum
- Wheeze
Right heart failure
Generally peripheral symptoms [blood backs up into body]
- Swelling [ankles, face, ascites]
- Weight gain [oedema]
- Fatigue
- Reduced exercise tolerance
- Anorexia
- Nausea
- Nocturia
Scoring of symptoms
New York Heart Association
Stage I: no symptoms
Stage II: symptoms on exertion
Stage III: symptoms on minimal exertion
Stage IV: symptoms at rest
Signs
Left HF
S3 gallop S4 if severe
Increased HR, RR
Irregularly irregular heart beat [AF]
Pulsus alternans- strong and weak beats
Displaced apex beat
Murmur [left sided]
LUNGS
fine end inspiratory bibasal crackles
Wheeze [cardiac asthma]
Right HF
Face- face swelling
Neck- raised JVP
Heart- TR murmur,
Increased HR, RR
Abdo- Ascites, hepatomegaly
Other- pitting oedema- ankles and sacrum
Investigations
Bedside- ECG
Bloods- FBC, U and E, LFT, TFT, BNP
Imaging- CXR Signs -ABCDE [see other flashcard] -
If BNP high- Do transthoracic echo with doppler- this is diagnostic gold standard - can indicate cause- MI, valvular disease - calculate ejection fraction
Diagnosis
Heart failure - Framingham criteria - More than two major, or one minor + one major [see other flashcard for criteria]
Management
Chronic:
- Conservative: smoking. diet, exercise etc.
- ARB/ACE inhibitors - first line
- Diuretic
- Beta blockers
- Digoxin [symptom control]
- Other to treat cause: ICD etc.
Types/classification of heart failure
- Acute vs Chronic
- Reduced ejection fraction [systolic] vs preserved ejection fraction [diastolic]
- Low output vs. high output
- Left vs right heart failure
What is cor pulmonale
Enlargement or failure of right ventricle due to increased resistance in pulmonary vascular bed/pressure in lungs
What is the sensitivity/specificity of BNP
Sensitive but not specific
What can a transthoracic echo with doppler show
- cause of HF - ejection fracture
What is seen on CXR with heart failure?
A-lveolar oedema B-Kerley B lines C-ardiomegaly D-ilated upper lobe vessels E- Pleural effusion- transudate
What ejection fraction is HF with reduced ejection fraction?
<40%
What is the pathology behind HF with reduced ejection fraction?
Inability of ventricles to contract normally
What ejection fraction is HF with preserved ejection fraction?
>50%
What is the pathology behind HF with preserved ejection fraction?
Inability of ventricles to dilate/relax/fill normally So even though heart contracts the same, not enough blood fills heart during diastole to have adequate stroke volume
Acute heart failure
Definition
Aetiology
Symptoms
Signs
Management
Complications
Prognosis
Acute heart failure
Definition
Rapid onset/worsening of HF signs and symptoms- requiring urgent evaluation and treatment Aetiology
- Decompensation of chronic heart failure
- due to
MI
infections
uncontolled HTN
thyroid- hypo/hyper
arrhythmias
- Acute coronary sydrome
Symptoms
Dyspnoea
Wheeze
Cough
Pink frothy sputum
Swelling
Symptoms of underlying condition
Signs
Increased HR, RR
Pulsus alternans [alternating strong and weak pulse]
Peripheral shutdown
Cyanosis
S3 gallop
Fine end inspiratory bibasal crackles
Management
Make patient sit up
High flow O2 via non rebreather mask [target is 94-98%]
Diuretic- IV furosemide 40-800mg -
Consider GTN infusion - if pulmonary oedema and SBP above 90
Consider CPAP - if sats dropping
Treat if cardiogenic shock with positive inotropes Complications
Pleural effusion
Renal failure
Acute exacerbation
Death
Prognosis
50% of severe HF patients die within 2 years
AHF - in hospital mortality- 2-20%
A 67-year-old woman presents to her GP complaining of increasing shortness of breath, which becomes worse when trying to sleep. She has a history of hypertension and hyperlipidaemia. On examination, her blood pressure is 148/83 mmHg and heart rate is 126 beats per minute. There is an audible S3 gallop and the jugular venous pressure is elevated 3 cm above normal. Which investigation would be best to confirm the diagnosis?
A ECG
B Brain natriuretic peptide (BNP)
C Endothelin levels
D Echocardiogram
E CXR
D Echocardiogram
A 62 year old man, 3 months after an MI presents with increasing shortness of breath. He is currently on aspirin, atenolol and simvastatin. An echocardiogram shows an ejection fraction of 30% in the left ventricle. What additional medication should he be given?
A Carvedilol
B Furosemide
C Digoxin
D Enalapril
E Morphine
D Enalapril ACEi/ ARB is first line
Cardiomyopathy [Overview]
Definition
Types
Aetiology
Risk Factors
Epidemiology
Symptoms
Signs
Investigations
Cardiomyopathy
Definition
Group of diseases that cause abnormalities in structure and functionality of the myocardium [not related to coronary artery disease, valve disease]
Types
- Dilated cardiomyopathy
- Hypertrophic cardiomyopathy [including hypertrophic obstructive cardiomyopathy]
- Restrictive cardiomyopathy
- Arrhythmogenic right ventricular cardiomyopathy [ARVC]
Also:
- Primary- confined to myocardium
- Secondary- part of a systemic disease
Aetiology
Risk factors
- Family history of sudden cardiac death
Epidemiology
Young
Symptoms
Heart failure
Fainting
Dizziness
Fatigue
SOB on exertion
First presentation often sudden death
Signs
Signs of heart failure
- Increased JVP, crackles, oedema
Murmurs
S3
S4
Investigations
No one investigation is diagnostic for all types
Bloods- FBC, BNP
ECG
ECHO
CXR
Non invasive exercise stress test - to rule out CAD
Cardiac catherisation - rule out CAD + investigate if constrictive pericarditis
Constrictive pericarditis
Definition
Aetiology
Symptoms and Signs
Investigations
Constrictive pericarditis
Definition
Chronic inflammation of pericardium involving thickening and scarring
Aetiology
Infectious [bacteria, viral, TB]
Idiopathic
Acute pericarditis
Cardiac surgery and radiation
Symptoms and signs
Indicative of right heart failure- dyspnea, increased JVP, oedema
Kussmaul’s sign [paradoxical increase in JVP on inspiration because pressure builds in ventricles]
Also pulsus paradoxus [increase in pulse on inspiration]
Investigations
CXR- pericardial calcification
ECHO- pericardial thickening
Cardiac CT/MRI
Myocarditis
Definition
Aetiology
Risk factors
Epidemiology
Presentation
Investigations
Myocarditis
Definition
Inflammation of the myocardium
Aetiology
Infection
Drugs- Cocaine
Metal
Radiation
Epidemiology
<50y
Associated with autoimmune conditions
Presentation
Flu like prodrome
SOB
Palpitations
Pain worse on lying down
Signs of right heart failure
Investigations
- ECG- non specific ST changes and T wave abnormalities
- Blood cardiac biomarkers- CK and troponin
- Endomyocardial biopsy [diagnostic but not routinely done]
A 58 year old man has presents with chest pain and breathlessness, which is worse at night. When questioned, he reports 2 episodes of collapse in the past 3 months. His father died of a heart condition when he was 55, but he cannot recall details of the condition. On examination, he has a jerky carotid pulse. Given the most likely diagnosis, what is it most likely to be found on auscultation of the chest?
A Ejection systolic murmur
B Pericardial friction rub
C Mid-diastolic murmur
D Coarse crackles
E Pansystolic murmur
A Ejection systolic murmur - Condition is HOCM
A 55-year old man with a heavy history of alcohol abuse presents with breathlessness, which is worse on exertion. He also feels that his heart is racing at times and he complains that his ankles have been swollen. On examination the JVP is increased and the apex beat is displaced. CXR shows a globular heart. Which is the most likely cause of his heart failure?
A Myocarditis
B Hypertrophic Cardiomyopathy
C Dilated Cardiomyopathy
D Tricuspid Regurgitation
E Amyloidosis
C Dilated cardiomyopathy - apex beat displaced
A 45-year-old woman complains of increasing shortness of breath on exertion for the previous 3–4 months. She also reports that her ankles have become more swollen during the same time period. She had apparently recovered from pericarditis about a year earlier. CXR shows pericardial calcification. The presumptive diagnosis is constrictive pericarditis. Which of the following signs would be consistent with this diagnosis?
A Increased JVP on inspiration
B Third heart sound
C Fourth heart sound
D Inspiratory crackles at lung bases
E Loud first and second heart sounds
A Increased JVP on inspiration
Dilated cardiomyopathy
Definition
Aetiology
Risk factors
Symptoms
Signs
Dilated cardiomyopathy
Definition
Ventricles stretch and dilate and can no longer contract efficiently
Aetiology
Alcohol
Post viral
Autoimmune
Haemochromatosis
Genetic
Risk factors
Family history [of sudden cardiac death]
Symptoms
Symptoms of HF [dyspnea, ankle swelling, ascites, fatigue, arrhythmia]
Signs
Raised JVP
S3
TR and MR murmurs [increased pressure in ventricles leads to valve insufficiency]
Displaced apex beat
Investigations
CXR- globular heart
Echo- ventricle dilatation
Hypertrophic cardiomyopathy
Definition
HOCM
Hypertrophic cardiomyopathy
Definition
Myocardium thickens inwards- more muscle
Aetiology
HOCM
Hypertrophic obstructive cardiomyopathy
- when thickened myocardium obstructs blood outflow from ventricle
Risk factors
Family history of sudden death
Athletes
Symptoms
Angina
Dyspnea on exertion
Palpitations
Syncope
Sudden death often first presentation
Signs
Jerky carotid pulse
Double apex beat
Ejection systolic murmur
S4
Apex beat NOT displaced
Investigations
ECG
- Q waves
- Left axis deviation
- Left ventricular hypertrophy [more than 7 small squares difference between tall S wave in V1/2 and tall R wave in V5/6]
Echo- ventricular + asymmetrical septal hypertrophy
Arrythmogenic right ventricular cardiomyopathy
Definition
Aetiology
Presentation
Definition
Fatty and fibrous tissue replacing ventricular myocardium
Aetiology
Autosomal dominant- genetic/inherited
Presentation
Asymptomatic
Or arrhythmia during exercise
Restrictive cardiomyopathy
Definition
Aetiology
Symptoms
Signs
Restrictive cardiomyopathy
Definition
Stiffening of ventricle myocardium, ventricles cannot expand and relax
Aetiology
Familial/genetic
Idiopathic
Systemic- infiltrative-eg. amyloidosis
Symptoms
Asymptomatic or
indicate heart failure
Signs
Raised JVP
Kussmaul’s sign [paradoxical rise in JVP in inspiration due to restricted filling of the ventricles]
S3
Ankle oedema, ascites, hepatomegaly
summary table of cardiomyopathy
ECHO findings
