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yr3 > Cardiac causes of SOB > Flashcards

Cardiac causes of SOB Flashcards

1
Q

Risk factors for heart failure

A 
Older men
PMH of Heart disease – MI is strongest risk factor
Diabetes
Family history of heart disease
Dyslipidaemia
Drug abuse
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2
Q

What is heart failure?

A

Failure of heart to maintain CO (=HRxSV) needed for the body’s requirement

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3
Q

Compare acute and chronic HF

A

Acute

  • rapid onset
  • worsening sx and signs of HF
  • urgent tx

Chronic

  • long-term
  • develops and progresses slowly
  • can have periods of acute decompensation
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4
Q

Compare low and high output HF

A

Low output
- CO decrease so fails to match normal body demands thus normally appears on exertion
High output
- CO normal but high body demand thus occurs when heart fails to meet high demands so heart is overworked and strained

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5
Q

Causes of high output HF

A 
NAP+MEALS:
N utritional (thiamine def.)
A naemia
P regnancy
M alignancy (muliple myeloma)
E ndocrine (hyperthyroidism)
A V malformations
L iver cirrhoisis
S epsis
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6
Q

Top ddx of increased JVP

A

1) RHF
2) Triscuspid regurgitation
3) Constrictive pericarditis

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7
Q

Sx of chronic RHF

A 
*Due to fluid accumulation in periphery:
Swelling (ankles, facial enlargement, ascites)
Weight gain (oedema)
Fatigue
Reduced exercise tolerance
Anorexia
Nausea
Nocturia
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8
Q

Sx of chronic LHF

A 
*Due to fluid accumulation in lungs:
Exertional dyspnoea
Orthopnoea (SOB lying down)
Paraoxysmal nocturnal dyspnoea (attack of SOB at night)
Fatigue
Wheeze
Nocturnal cough +/- pink frothy sputum
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9
Q

Signs of chronic RHF

A 
Face swelling
Increased JVP
Ascites +/- hepatomegaly
TR murmur
Increased HR and RR
Pitting oedema in ankles and sacrum
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10
Q

Signs of chronic LHF

A 
Increased HR and RR
Fine end inspiratory crackles at lung bases (pulmonary oedema)
Wheeze
Irregularly irregular heart beat
AS/AR/MR murmur
S3; gallop rhythm
S4; severe HF
Displaced apex beat
Pulsus alternans (alternating strong and weak beats)
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11
Q

Which heart failure can occur as cor pulmonale?

A

Pulmonary HTN => increased pressure in lungs/vascular resistance => enlarged RV => failure of RV => RHF

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12
Q

Causes of RHF

A

LHF
Heart valves: TR, pulmonary valve disease
Lungs: pulmonary HTN, PE, chronic lung disease (CF, pulmonary fibrosis, interstitial lung disease)

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13
Q

Causes of LHF

A

Systemic: HTN, amyloidosis, drugs (cocaine, BBs, alcohol)
Valvular: MR, AR, AS
Heart muscle: AF, IHD, cardiomyopathy, myocarditis

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14
Q

Ix for HF

A

Bedside: ECG
Bloods: FBC, U&Es, LFTs, TFTs, BNP*
Imaging: CXT, TTE w/ doppler*

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15
Q

Which ix is diagnostic for HF?

A

Transthoracic echocardiogram (TTE) with doppler

  • calculates ejection fracture
  • shows the % of blood present in LV when pumped during systole (n=50-70%)
  • can indicate cause, i.e. MI or valvular disease
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16
Q

What can the results from a TTE show?

A

EF<40% => HFrEF

  • systolic HF
  • unable for ventricle to contract normally

EF>50% => HFpEF

  • diastolic HF
  • unable for ventricle to relax normally
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17
Q

Which bloods is most sensitive to HF?

A

Brain natriuretic protein (BNP)

  • if high => TTE next step
  • if low => HF unlikely

Highly sensitive but non-specific as increases whenever there is increased stretch to the heart

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18
Q

What may a CXT show if HF present?

A 
A lveolar oedema
B -lines (Kerley)
C ardiomegaly
D ilated upper lobe vessels
E ffusion (pleural, transudative)
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19
Q

Which criteria is used for HF diagnosis and how?

A

Framingham Criteria
- must have 2+ major signs/sx present of 1 major and 2 minor

MAJOR includes
- acute pulm. oedema, wt loss, neck vein distention, cardiomegaly, increased central venous pressure, bilateral creptitations, PND, S3 gallop
MINOR includes
- bilateral ankle oedema, dyspnoea on ordinary exertion, tachycardia, pleural effusion, nocturnal cough, decrease in vital capacity by 1/3

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20
Q

Management of chronic HF

A

Conservative:
- smoking cessation, exercise, diet (reduce salt)
Medical:
1. ACEi - enalapril (improves survival + slows down progression)
2. BBs - carvedilol, bisoprolol (reduce O2 demand on heart, synergistic effect with ACEi)
3. Diuretics - furosemide, chlorothiazide, spironolactone (use if eveidence of fluid retention, monitor electrolytes)
4. Digoxin - positive inotrope (increase contractility, good for sx relief not overall survival)
5. Other - hydralazine nitrate, cardiac resynchronisation, implantable cardiac defib. (treat cause!)

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21
Q

How does acute HF typically present?

A

Hx
- dyspnoea, cough, wheeze, pink frothy sputum, swelling legs, sx of underlying condition
O/E
- pulsus alternans, increased HR + RR, cyanosis, peripheral shutdown, S3 gallop rhythm, fine end inspiratory crackles

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22
Q

Causes of acute HF

A

Decompensation of previous chronic HF
- MI, AF, infection, uncontrolled HTN
ACS

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23
Q

Mx for acute HF

A
  1. Sit patient up
  2. High-flow oxygen, non-rebreathable mask (target 94-98%)
  3. Furosemide 40-80mg IV
  4. GTN if pul. oedema + SBP >90mmHg
  5. Consider CPAP if sats dropping
  6. Treat cardiogenic shock if BP <90mmHg w/ +ve inotropes (dobutamine, digoxin)
24
Q

Potential complications of acute HF

A

Pleural effusion
Renal failure
Acute exacerbation
Death

25
Q

What’s the prognosis for acute HF?

A

50% of pts die within 2 years

Hospital mortality: 2-20%

26
Q

What is cardiomyopathy?

A

Group of diseases where myocardium becomes structurally and functionally abnormal in the absence of coronary artery, valvular and congenital heart diseases

Primary => continued to myocardium
Secondary => part of systemic disease

27
Q

How could cardiomyopathies present?

A

Hx
- sx of HF (SOB on exertion, fainting, dizziness, fatigue), sudden death in FHx
O/E
- inspiratory crackles, murmurs, S3, S4, HF signs (increased JVP, oedema)

28
Q

Possible ix if suspected cardiomyopathy

A 
Bloods, including BNP
CXR
ECG
ECHO
Cardiac catheritisation
Non-invasive stress test
*no single test diagnostic test for all types
29
Q

Compare the four types of cardiomyopathy

A

Dilated
- ventricles enlarge thus weakening so cannot properly contract
Hypertrophic
- heart thickens inwards so may block blood flow out of ventricle
Arrhythmogenic right ventricular
- progressive fatty and fibrous replacement of ventricular myocardium
Restrictive
- ventricles become abnormally rigid and lack flexibility to expand as ventricles fill with blood

30
Q

Restrictive cardiomyopathy summary card

A 
Idiopathic, familial, systemic
Signs:
- increased JVP
- *Kussmaul's sign (paradoxical increased JVP in inspiration due to restricted filling of the ventricles)
- S3
- ascites/ankle oedema/hepatomegaly
- asymptomatic to sx of HF
31
Q

HOCM signs and symptoms card

A 
Athletes with no PMH + syncopal episodes
50% familial (autosomal dominant)
Sx:
- sudden cardiac death (FHx)
- angina, dyspnoea on exertion, palpitations, syncope
Signs:
- *ejection systolic murmur
- *jerky carotic pulse
- S4
- apex beat NOT displaced
- double apex beat
32
Q

HOCM ix findings card

A

ECHO => ventricular hypertrophy

ECG => left axis deviation, Q waves, signs of left ventricular hypertrophy

33
Q

Dilated cardiomyopathy summary card

A

Associated with genes, alcohol, post-viral, autoimmune, haemochromatosis
Signs + sx:
- sx of HF, increased JVP, TR/MR murmur, displaced apex beat
Ix:
- CXR = globular heart
- ECHO = dilated ventricles

34
Q

Arrhythmogenic right ventricular cardiomyopathy summary card

A

Autosomal dominant inherited

Initially asymptomatic then present w/ arrhythmias during exercise

35
Q

Signs of left ventricular hypertrophy in ECG

A

deep S wave in V1/2
tall R wave in V5/6
S in V1 + R in V5/V6 >/=7 large squares

36
Q

Signs and sx of constrictive pericarditis

A

(resembles restrictive cardiomyopathy)
Kussmaul’s sign
RHF sx: fluid congestion, increased JVP, dyspnoea

37
Q

Causes of c pericarditis

A

Idiopathic
Infection (TB, bacterial: Pseudomonas/Staphylococci, viral)
Acute pericarditis
Cardiac surgery + radiation

38
Q

Ix for c pericarditis

A

CXR = pericardial calcification
*ECHO = increased pericardial thickness
Cardiac CT/MRI
*distinguishes from restrictive cardiomyopathy

39
Q

Presentation of myocarditis

A

<50 y.o. associated with acute ischaemic disease

  • flu-like prodrome
  • SOB
  • palpitations
  • chest pain worse when lying down
40
Q

Causes of myocarditis

A

Inflammation of myocardium

  • drugs (cocaine, penicillin, cephalosporins, digoxin, anti-epileptics)
  • metals
  • radiation
  • infection
41
Q

Ix for myocarditis

A

ECG = non-specfic ST changes, T-wave abnormal
Endomyocardial biopsy = diagnostic, not routinely performed
Cardiac biomarker = CK + troponins (exclude)

42
Q

A 78-year-old woman is admitted with heart failure.
The underlying cause is determined to be aortic
stenosis. Which sign is most likely to be present?
A. Pleural effusion on chest x-ray
B. Raised jugular venous pressure (JVP)
C. Bilateral pedal oedema
D. Bibasal crepitations
E. Atrial fibrillation

A

D. Bibasal crepitations

43
Q

A 60-year-old man presents to his GP with gradually
increasing fatigue and some exertional dyspnoea. Blood pressure is 118/74mmHg and pulse rate is 81/minute. There are no abnormal physical findings and on echocardiography the ejection fraction is 0.47. However, the clinical impression remains one of early heart failure. Which of the following circulating biomarkers would lend support to that conclusion?
A. Atrial natriuretic peptide
B. Brain natriuretic peptide
C. Endothelin
D. Noradrenaline
E. Adrenomedullin

A

B. BNP

44
Q

A 55-year-old male presents with increasing exertional
dyspnoea, fatigue, weight loss and bone pain. Blood results reveal elevated calcium levels and normocytic anaemia. He is treated for heart failure. What is the underlying cause for his heart failure?
A. Hyperthyroidism
B. Malignancy
C. Thiamine deficiency
D. Meningitis
E. Paget’s disease of the bone

A

B. Malignancy

45
Q 
A 74 year old male with a 30 pack year smoking history is admitted to AMU. He has had 2 myocardial infarctions in the last 5 years. On examination he is producing frothy pink sputum, he has bilateral pitting oedema, bibasal crackles and oxygen saturations of 89%. Which of the following is most likely to be identified by
auscultating the chest?
A. Third heart sound
B. Carotid bruit
C. Ejection systolic murmur
D. Pericardial rub
E. Fourth heart sound
A

A. Third heart sound

46
Q 
A 74 year old man presents to AMU with a history of fatigue, breathlessness and has noticed his ankles to be swollen. On examination, he has an oedematous ankles, his JVP is raised and he has finger clubbing. When you ask about work, he says he used to work as a ship builder. He is diagnosed with acute heart failure. What is the most likely cause of his heart failure?
A. Smoking
B. Rheumatic Heart Disease
C. Interstitial Lung Disease
D. Aortic Stenosis
E. Aortic Regurgitation
A

C. Interstitial Lung Disease

47
Q 
A 85 year old woman is seen in Heart Failure clinic for a review of her long term condition. She is currently taking enalapril and bisoprolol. Which other drug can be added to help control her symptoms?
A. Spironolactone
B. Amlodipine
C. Salbutamol
D. Morphine
E. Omeprazole
A

A. Spironolactone

48
Q

Regarding the management of acute heart failure,
which of these statements is not true?
A. The patient should be given a diuretic, such as IV furosemide.
B. High-oxygen is not always recommended
C. Opiate analgesia is always recommended
D. A vasodilator, such as nitrates, can be given
E. An ECG may not show an arrythmia

A

C. Opiate analgesia is always recommended

49
Q 
Which of these x-ray findings is most likely to be seen on a Chest X-ray of a patient with heart failure?
A. Cardiothoracic ratio <50%
B. Blunting of the costophrenic angles
C. Air bronchograms
D. Dilated lower lobe vessels
E. Cannon-ball opacities
A

B. Blunting of the costophrenic angles

50
Q

You are volunteering at a refugee camp in Calais and
you see a 10 year old boy who is acutely breathless, and has fatigue and feels nauseous . His mother tells you he has been having several episodes fevers, elbow pains and difficulty walking for the past 2 years, and has developed a rash. On examination, he has an ejection systolic murmur. He is treated for heart failure. What is the most likely underlying cause of his heart failure?
A. Cor pulmonale
B. Cystic Fibrosis
C. Familial cardiomyopathy
D. Rheumatic Heart Disease
E. Congenital heart disease

A

D. Rheumatic Heart Disease

51
Q

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?

a) Acute Coronary Syndrome
b) Aortic stenosis
c) Congestive Heart Failure
d) Right Heart Failure
e) Left Heart Failure

A

e) Left Heart Failure

52
Q 
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
A

d) Echocardiogram

53
Q

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

A

D. Enalapril

54
Q 
A 58 years 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

A. Ejection systolic murmur

55
Q 
A 55-years 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
A

C. Dilated cardiomyopathy

56
Q

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

A. Increased JVP on inspiration

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