Cardiac conditions Flashcards
Heart failure risk factors
HIGH VIS
Hypertension
Infection/immune
Genetic
Heart attack
Volume overload - renal failure, nephrotic syndrome, liver failure
Infiltration- sarcoidosis
Structural- valvular heart disease
Diabetes
Smokers
Heart failure symptoms
Dyspnoea
Paroxysmal nocturnal dyspnoea
Poor exercise tolerance
Fatigue
Orthopnea
Wheeze
Cold peripheries
Weight loss
Syncope
Heart failure signs
Raised JVP
Ankle swelling- peripheral oedema
Wheeze
Gallop rhythm on auscultation
Displaced apex beat (due to LV dilatation)
Murmurs associated w/ valvular heart disease
Tachycardia
Heart failure investigations
Clinical Exam
N terminal pro B type natriuretic peptide. BNP.
ECG- broad QRS is main sign for hypertrophy
Echocardiogram- provides info relating to ejection fraction of LV
Cardiac MRI
CXR: ABCDE: Alveolar oedema, kerley B lines, Cardiomegaly, Dilated upper lobe vessels, Effusions
Heart failure management principles
RAMPS:
Refer to cardiology
Advise them about condition
Medical treatment
Procedural or surgical interventions
Specialist heart failure MDT treatment
Heart failure medical management (HFrEF)
ABAL
ACE inhibitor- ramipril
Betablockers- Bisoprolol
Aldosterone receptor antagonist - spironolactone
Loop diuretics- furosemide
Can give digoxin, vasodilators, SGLT2 inhibitors
Heart failure further management (not medical)
Implantable cardiac defibrillators
CRT- pacemaker device
Heart transplant
Heart failure types
HF with preserved LV function (EF>50%), or HF w/ LV systolic dysfunction (EF <40%)
Heart failure w/ preserved LV function (ejection fraction >50%) treatment
treat underlying cause
lifestyle changes
diuretics for symptom control
Acute heart failure signs and symptoms
rapid onset dyspnoea
cough w/ frothy white/pink sputum
swelling in legs, ankles and feet
rapid/irregular heartbeat
tachypnoea
low O2 sats
raised JVP
bilateral basal crackles
displaced apex beat
S3- heart sound
acute heart failure diagnosis
Use a single measurement of BNP or NtpBNP to rule out HF diagnosis:
BNP less than 100 ng/litre
NTpBNP less than 300 ng/litre
W/ raised BNP lvls, perform transthoracic Doppler 2D echocardiography
acute heart failure management
Stop IV fluids
Sit pt upright
High flow oxygen if decreased SpO2
IV access and monitor ICG
Investigations
Furosemide 40-80mg IV slowly
If systolic BP >=100 mmHg, start a nitrate infusion
If pt is worsening give further dose of furosemide
Consider CPAP if resp failure or reduced consciousness or physical exhuastion, helps keep alveoli open
Other potential measures:
Diamorphine
GTN spray
Monitor fluid balance
If systolic BP =< 100 mmHg treat as cardiogenic shock and refer to ICU
AF categories
Paroxysmal- episodes last
>30 s but <7 days and are self terminating but recurrent
Persistent: episodes last less than or more than 7 days but require cardioversion
Permanent: episodes fail to termiante w/ cardioversion OR a termianted episode that relapses within 24 hrs OR long standing AF (usually >1 year) in which cardioversion has not been indicated or attempted
AF causes
Hypertension
Obesity
Alcohol
HF
Atrial/ventricular dilation or hypertrophy
inflammatory condition
Diabetes
PE
electrolyte imbalance
acute infection
AF risk factors
Male
Caucasian
Age
Alcohol
Cigarette smoking
Obesity
AF symptoms
Dyspnoea
Chest discomfort
Palpitations
light headedness
reduced ETT (exercise tolerance test)
Syncope
AF signs
raised JVP
added heart sounds on auscultation (gallop rhythm)
crackles on chest auscultation
ankle swelling
AF investigations
12 lead ECG- irregularly irregular rhythm, absent p waves, chaotic baseline
AF management
Rhythm control for pts w/ new onset AF, reversible cause- electrical cardioversion, pharmacological cardioversion by flecainide or amiodarone, beta blocekrs eg bisoprolol are first line for long term rhythm control
Rate control for pts w/ AF onset >48 hours. Tend to be in elderly or comorbidities. Rate control should be offered first line if AF is NOT acute
Beta blocker or rate limiting CCB (eg diltiazem)
If one drug doesn’t work, do combo therapy w/ any 2 of the following : BCD
Beta blocker- common contraindication is asthma
CCB- verapamil, diltiazem
Digoxin if person does little physical exercise
Paroxysmal AF= pill in pocket- flecainide PRN.
DVLA- can drive cars if controlled for > 4 weeks
Smoking cessation
Counsel on stroke risk, support groups
Infective endocarditis risk factors
previous IE
Rheumatic fever
recent prosthetic valve surgery
IV drug use
IE causes
commonest cause- streptococcus viridans
staph aureus
MRSA (methicillin resistant staph aureus)
IE symptoms
Fever
New murmur
high temperature
chills
headache
myalgia
arthralgia
IE signs
Petechial rash
Splinter haemorrhages
Osler nodes
Janeway lesions
Roth spots
digital clubbing
new murmur
signs of IV drug use
any sternotomy or thoracotomy scars suggesting previous cardiac surgery
IE diagnosis
Transthoracic echo is first line imaging modality
Modifeid Duke criteria- requires either 2 major, 1 major 3 minor, 5 minor.
Majors:
Blood culture positive for IE
Positive echo for IE
Minors:
predisposition, IV drug abuse, fever, vascular phenomena, immunlogic phenomena, microbiological evidence
IE treatment
ABx in line w/ trust policy
Surgery if:
Heart failure- urgent surgical valvular replacement
valvular obstruction
persistent bactaraemia
myocardial abscess
Regerral to endocarditis MDT
Aortic stenosis causes
senile calcification
bicuspid aortic valve
rheumatic heart disease
aortic stenosis symptoms
symptomatic fluid overload (dyspnoea/orthopnea/peripheral oedema)
Chest pain
Dizziness
faints
aortic stenosis signs
slow rising pulse w/ narrow pulse pressure. slow rising pulse usually noticeable at carotids.
LV heave
Heaving and undispalced apex beat
Harsh ejection systolic murmur heard at left sternal edge: loudest leaning forward on end expiration. Murmur may radiate to both carotids and is often ehard widely across the chest. Crescendo-decrescdendo. Decreased following Valsalva manouevre
aortic stenosis investigations
ECG- LV hypertrophy (deep S waves in V1 and V2, tall R waves in V5 and V6)
Echocardiohram- diagnostic
aortic stenosis treatment
if asymptomatic observe
diuretics to improve symptoms
surgical aortic valve replacement or transcatheter aortic valve insertion
aortic stenosis treatment
if asymptomatic observe
diuretics to improve symptoms
surgical aortic valve replacement or transcatheter aortic valve insertion
aortic regurgitation causes
Rheumatic fever
IE
connective tissue diseases
biscuspid aortic valve
aortic dissection
aortic regurgitation features
early diastolic murmur- intensity increased by the handgrip manouevre. Heard at lower left sternal edge, sat forward breath held in expiration.
Collapsing pulse
Wide pulse pressure
Quincke’s sign (nailbed pulsation)
De Musset’s sign (head bobbing)
aortic regurgitation management
surgery indications include:
Symptomatic patients w/ severe AR
Asymptomatic patients w/ severe AR who have LV systolic dysfunction
ACS symptoms
Acute sudden crushing pain radiating to jaw, neck or left arm
Exertional pain worsened by stress and exertion
Dyspnoea
N&V
Palpitations
Sweatiness and clamminess
Symptoms should continue at rest for over 15 mins
ECG change in STEMI
ST segment elevation >1mm in adjacent limb leads (I, II, III, aVF, aVL)
ST segment elevation >2mm in adjacent chest leads (V1-V6)
New LBBB w/ chest pain or suspicion of MI
ECG changes in NSTEMI
ST segment depression in a region
Deep T wave inversion/flattening present in more than 2 continuous leads that have dominant R waves
ECG changes in usntable angina
Abnormal/normal ECG, normal consistent troponin. Ie no biochemical evidence of ischaemia
STEMI management
PCI always- blocked arteries are opened up using a balloon following which a stent may be deployed to prevent the artery occluding again in the future. This is done via a catheter inserted into either the radial or femoral artery.
Consider thrombolysis if > 2hrs, using agents like alteplase/streptokinase if PCI is unavailable
Aspirin and second antiplatelet before PCI tho
NSTEMI management
BATMAN
Beta blockers
Aspirin
Ticagrelor/clopidogren
Morphine IV
Antithrombotic eg fondaparinux (LMWH alternative)
Nitrates- GTN sublingual or buccal
Assess need of PCI/thrombolysis using the GRACE score, use CRUSADE score for assesment of risk of bleeding during PCI while being on anti platelet therapies
Long term ACS management
Stop smoking
reduce alcohol
cardiac rehabilitation
6 A’s:
Aspirin 75mg OD
another antiplatelet eg clopidogrel or ticagrelor 12 months
Atorvastatin 80mg OD
ACE inhibitor eg ramipril 10mg OD
Atenolol or other B blocker
Aldosterone antagonist
If PCI is not preferred, or extensive left main stem disease- offer CABG
Complications after MI or unstable angina attack
keep in hospital for a couple days.
DARTH VADER
Death
Arrhythmia
Rupture of free wall/papillary muscles
Tamponade
HF
VSD
Aneurysm or another MI
Dressler’s syndrome/pericarditis
Embolism or oedema
Rupture of papillary muscles or Free Wall
Pericarditis also
Stable angina features
Constricting chest pain that radiates to neck/shoulders/jaw/arms precipitated by physical exertion, relieved by rest / GTM in about 5 mins
stable angina investigations
Bloods, ECG, CXR, troponins
CT coroanry angiography- site and degree of stenosis within coronary arteries can then be identified
Need invasive coroanry angiography if CAD is v likely
stable angina medical management
immediate- GTN 2-5,2-5, 2 + 999
2 puffs under tongue, wait 5 mins.
Baseline symptomatic relief- beta blocker and /or CCB. If CCB used as a monotherapy then use a rate limiting one like verapamil or diltiazen. BETA BLOCKERS SHOULD NOT BE PRESCRIBED W/VERAPAMIL- risk of complete heart block.
secondary prevention of CVD- aspirin, ACEi, atorvastatin, already on ebta blocker
stable angina surgical intervention
PCI w/ coronary angioplasty-put catheter into brachial or femoral artery, feeding that up to the coronary arteries under xray and injceting contrast so the coronary arteries and any areas of stenosis are highlighted on xray
CABG- involves opening the chest along the sternum causing a midline sternotomy scar, taking a graft vein from the leg (usually the great saphenous vein) and sewing it on to the affected coronary artery to bypass the stenosis
Aortic dissection risk factors
Hypertension
pregnancy
trauma
cocaine
known AA
bicuspic aortic valve
Connective tissue disorders, eg Marfan’s
Male
Age
Atherosclerotic disease
Aortic dissection symptoms
sudden, tearing chest pain radiating to the back
dyspnoea
abdo pain
can be asymptomatic
aortic dissection signs
unequal arm pulses and BP
weak or absent carotid, brachial or femoral pulse
acute limb iscahemia
Horner’s syndrome in type A dissections (ascending aorta)- Ptosis, Miosis, Anhidrosis
Hypotension
New early diastolic murmur- aortic regurgitation murmur
can present w/ features of dissection complications eg distended neck veins, signs of heart failure etc
aortic dissection investigations
ECG
CXR- widened mediastinum
CT angiogram of chest, abdo, pelvis- can see double lumen, entry tear, evidence of aortic dilatation
MRI angiogram for futher details
Classification is Stanford: Type A- involvement of proximal aorta
Type B- involvement of distal aorta
Aortic dissection type A management
open surgery to prevent aortic rupture into the pericardium.
Aortic root surgery- removal of ascending aorta w/ or w/o the aortic arch and replacement w/ a synthetic graft
aortic dissection type B maangement
Usually conservatively
Usually bed rest and beta blockers- IV beta blockage, pain management w/ IV morphine
Pericarditis risk factors
age
male
steroid treatments
Pericarditis causes
idiopathic
secondary to bacteria, viruses, fungi, drugs etc.
Often follows a viral illness
pericarditis symptoms
central chest pain worse on inspiration or lying flat and relief by sitting forward
pain can be constant or intermittent sharp pain
Unlike iscahemic pain it’s often relieved by sitting forwads and aggravated by thoracic movement, coughing and breathing
Fever
Tachycardia
Pericardial friction rub- typically loudest at left lower sternal border
Pericarditis investigations
Raised WBC/CRP/ESR
ECG- widespread saddle ST elevation, followed later by T wave inversion
Echocardiogram can be used to diagnose a pericardial effusion
Pericarditis management
NSAID w/ PPI for 1-2 weeks
Add colchicine 500mcg onde daily or twice daily for 3 months to reduce recurrent risk
Recurrent/chronic pericarditis- novel treatment options are immunosuppressants
Constrictive pericarditis - final stage of inflammation involving the pericardium definitive treatment is usually surgical pericardiectomy (resection of the pericardium)
Pericardial effusion symptoms
chest pain
dyspnoea
orthopnea
pericardial effusion signs
quiet heart sounds
pulsus paradoxus (abnormally large drop in BP during inspiration)
Hypotension
Raised JVP
Classical features of cardiac tamponade- Beck’s triad- Hypotension, raised JVP, muffled heart sounds
pericardial effusion management
treatment of underlying cause
drainage of effusion where requried- needle pericardiocentesis, surgical drainage
