Cardiac Diseases, Investigations and Treatments Flashcards
Define hypertension.
The blood pressure above which the benefits of treatments outweigh the risks in terms of morbidity and mortality.
Define stage one hypertension.
- BP of 140/90 or higher
- ABPM daytime average of 135/85 or higher
Define stage two hypertension.
- BP of 160/100 or higher
- ABPM daytime average of 150/95 or higher
Define severe hypertension.
- systolic BP of 180 or higher
- diastolic BP of 110 or higher
List the causes of secondary hypertension.
- renal disease
- drug induced (NSAIDs, oral contraceptive, corticosteroids)
- pregnancy
- endocrine
- vascular
- sleep apnoea
What are the risk factors for hypertension?
- smoking
- diabetes mellitus
- renal disease
- male
- hyperlipidaemia
- previous MI or stroke
- left ventricular hypertrophy
- family history - a closer correlation in siblings
Describe the treatment for hypertension in under 55’s (not afro-Caribbean or women of child-bearing age).
- start on ACEinhibitor (Ramipril) or ARB (losartan)
- add a thiazide-type diuretic (indapamide or clortalidone)
- add CCB (amlodipine)
Describe the treatment for hypertension in over 55’s.
- start CCB (amlodipine)
- add thiazide-type diuretic (indapamide)
- add ACEinhibitor (ramipril)
- add a beta blocker
- add one of the less commonly used agents
Describe the treatment for hypertension in Afro-Caribbean’s or women of child-bearing age.
- start CCB (amlodipine)
- then follow the appropriate age pathway ( NO ACEI OR ARB)
Describe the treatment of preeclampsia.
- CCB
- thiazide-type diuretic
- intravenous hydralazine, esmolol and labetalol
Which investigations would you carry out into a hypertensive person?
- ECG
- Echocardiograph
- renal ultrasound
- renal function
- all to access end-organ damage
Define atheroma.
Formation of focal elevated lesions (plaques) in the intima of large and medium-sized arteries.
List the risk factors of atheroma.
- hypercholesterolaemia
- hyperlipidaemia
- smoking
- hypertension
- diabetes mellitus
- male
- elderly
- obesity
What are the preventative and therapeutic approaches for atheroma?
- stop smoking
- control of blood pressure
- weight-loss
- regular exercise
- dietary modifications
What is the spectrum of Acute Coronary Syndrome?
- unstable angina
- non-ST elevation myocardial infarction
- ST elevation myocardial infarction
- sudden cardiac death
How would you treat a patient with a STEMI?
- percutaneous coronary intervention
- if not available within two hours then thrombolysis is indicated
How would you treat a patient with ACS and no evidence of STEMI?
- aspirin
- ticagrelor
- antiplatelet (clopidogrel)
- Low molecular weight heparin
- intravenous nitrate
- beta blockers
- statins
- analgesia
What are the symptoms of cardiomyopathy?
- progressive, slow onset dyspnoea
- fatigue
- orthopnoea
- PND
- Oedema
- Cough
What is a true aneurysm?
- all three tunica layers buldge
What is a false aneurysm?
- the blood is contained by the thin adventitia layer
List the symptoms of an aneurysm.
- often asymptomatic
- dyspnoea
- dysphagia
- sharp chest pain radiating to back
Define an aortic dissection.
A tear in the inner wall of the aorta.
Describe Debakey’s classifications of aortic dissections.
1 - originates in ascending aorta and propagates
2 - originates and is confined to ascending aorta
3 - originates in descending aorta and can move
Describe the Stanford classifications of aortic dissections.
A - involves the ascending aorta
B - excludes the ascending aorta
Define a stroke.
Sudden localised loss of brain function due to ischaemia or haemorrhage, and lasting more than 24hrs.
List the four sub-types of strokes.
Total Anterior Circulation Stroke - 20% (worst mortality rate)
Partial Anterior Circulation Stroke - 35%
Lacunar Stroke - 20%
Posterior Circulation Stroke - 25% (highest recurrence rate)
Define atherothrombosis.
An unpredictable process caused by unstable plaques.
What are the four subtypes of acute coronary syndromes?
- unstable angina
- NSTEMI
- STEMI
- sudden cardiac death
When are ACS symptoms present?
Almost always, including at rest.
in contrast to stable angina which is only on exertion
What changes may be seen in an ECG of a patient with ACS?
- ST-segment depression
- ST-segment elevation
- T-wave inversion
List the immediate treatment for ACS, after ABCDE.
M - morphine (or diamorphine)
O - oxygen
N - Nitroglycerine (GTN)
A - Aspirin 300mg orally
What is the long term treatment for ACS?
- dual anti-platelet therapy (both aspirin and ADP receptor blocker) - Heparin - anti-thrombotic - beta blockers - statins - ACEi
In which circumstances would thrombolysis be the optimal reperfusion strategy for STEMI?
- if door-balloon >90mins
- if (door-balloon) minus (door-needle) >1-2hrs
- if <3hrs since symptoms onset
In which circumstances would primary PCI be the optimal reperfusion strategy for STEMI?
- if door-balloon <90mins
- if >3hrs since symptoms onset
- if cardiogenic shock
- if there is a high bleeding risk
- if a diagnosis is uncertain
What is Virchow’s triad?
Factors causing thrombosis
- changes in blood constituents - coagulability
- changes in the pattern of blood flow - stasis/turbulence
- changes in blood vessel wall - atheroma
Define dilated cardiomyopathy.
Left ventricle (perhaps more) is enlarged and weakened, and function is impaired. May be a primary problem or arise as an end-result to pathological insult to the myocardium.
Define heart failure.
A clinical syndrome comprising of dyspnoea, fatigue or fluid retention due to cardiac dysfunction.
List the signs of chronic heart failure.
- oedema
- tachycardia
- raised JVP
- chest crepitations
- 3rd heart sounds
- displaced or abnormal apex beat
What are the European soc Cardiology guidelines for diagnosing heart failure?
- Symptoms or signs of HF
- Objective evidence of cardiac dysfunction
- Response to therapy (diuretics)
What pharmacological therapies would be effective to relieve symptoms of heart failure?
improve symptoms - diuretics and digoxin
improve symptoms and survival - ACEi and ARB’s
improve survival - beta blockers
In which condition do 15% of those affected have AV septal defects?
Down Syndrome
List characteristics of Turner’s syndrome.
- affecting only women
- heart defects - coarctation of the aorta
- short stature
- infertility
- absences of periods
List characteristics of Noonan’s syndrome.
- autosomal dominant
- affects males who have all or some of the physical features of Turner’s syndrome, but normal sex chromosomes.
- low testosterone
- reduced sperm count
- short stature
- mild learning difficulties
- neck webbing
- heart defects - pulmonary stenosis
Name and describe the acronym used for 22q11 Deletion Syndrome.
CATCH22 C - Cardiac malformation A - abnormal faces T - thymic hypoplasia C - cleft palate H - hypoparathyroidism 22 - 22q11 Deletion Syndrome
List the characteristics of William’s syndrome.
- deletion of elastin on chromosome seven
- ‘elfin’ appearance
- hypercalcaemia
- short stature
- learning difficulties
- heart defects - aortic stenosis
List the characteristics of foetal alcohol syndrome.
- hearing loss
- visuomotor difficulties
- fine motor difficulties
- low birth weight
- facial abnormalities
Define Marfan’s syndrome.
An autosomal dominant connective tissue disorder caused by a fibrillin 1 gene mutation.
What is used for the clinical diagnosis of Marfan’s syndrome?
Ghent 2010 Criteria
List characteristics of Marfan’s syndrome.
- excessive tallness
- abnormally long and slender fingers and toes
- partial dislocation of eye lenses
- heart defects - aortic dissection/mitral valve prolapse
- pneumothorax
- dural ectasia
List some signs and symptoms of deep vein thrombosis.
- unilateral limb swelling
- calf tenderness
- calor of affected area
- erythema
- ulceration (if severe)
Often asymptomatic
What score is used to assess deep vein thrombosis and pulmonary embolism?
Wells score
List some signs and symptoms of pulmonary embolism.
- pleuritic chest pain
- dyspnoea
- haemoptysis
- tachycardia
- pleural rub
If severe;
- sudden onset severe dyspnoea
- syncope
- cyanosis
- tachycardia
- low BP
- raised JVP
- sudden death
How would you test for a potential blood clot?
D-dimer
How would you treat DVT or PE?
- anticoagulants
heparin or warfarin
How would you treat a massive pulmonary embolism?
- thrombolysis
Define infective endocarditis.
An infection of the endocardium, heart valves, IV septum, chordae tendinae and intra-cardiac devices.
Describe the prognosis and mortality associated with infective endocarditis.
- Poor prognosis
- High mortality
Infective endocarditis is most commonly seen in patients with which morbidities?
- prosthetic heart valves
- mitral valve prolapse
- bicuspid aortic valve
- congenital heart disease
- any immunocompromised patients
List three of the most common bacterial agents causing infective endocarditis, and state which is most common.
- streptococci
- enterococci
- staphylococcus
Most common is Strep. viridans
Describe the Modified Duke Criteria.
The major criteria - identifies organism and provides evidence of infection anywhere within the heart
The minor criteria - focuses on the endocarditis complex of clinical findings
What would be the treatment for infective endocarditis before a causative agent has been identified?
- IV gentamicin and IV amoxicillin
What does SIHD stand for?
Stable Ischemic Heart Disease
What is the most common cause of angina?
Coronary atheroma
Describe the Canadian Classification of angina severity.
I - symptoms only on significant exertion
II - slight limitation of ordinary activity (>1 flight of stairs)
III - marked limitation (1 flight of stairs)
IV - symptoms on any activity (getting washed/dressed)
What does PCI stand for?
Percutaneous Coronary Injection
What does CABG stand for?
Coronary Artery Bypass Graft
List the key symptoms of stroke.
- loss of power
- loss of sensation
- loss of speech
- loss of vision
- loss of coordination
Which key symptom would suggest a haemorrhagic stroke?
- photophobia
What is the importance of localisation when a stroke has occurred?
- confirms diagnosis
- allows better selection of imaging
- gives an indication of the cause
- gives an indication of prognosis
What are the differences between transudates and exudates?
Transudates - low protein/albumin and low specific gravity
Exudates - high protein/albumin and high specific gravity
