Cardiac Pathology Flashcards
HOW CAN ISCHAEMIC HEART DISEASE OCCUR?
Reduced blood flow to the heart muscle (clot or atheroma)
Increased distal resistance (LV hypertrophy)
Reduced O2 carrying capacity (anaemia) or availability (hypoxia)
What are some risk factors for IHD?
Modifaible and non-modifiable?
MODIFIABLE
Smoking.
Diabetes
Hypertension.
Hypercholesterolaemia.
Sedentary lifestyle
Non-modifiable
Gender.
Family history.
Personal history.
Age.
What is a QRISK2 score?
Predicts risk of CVD in next ten years.
What does QRISK2 take into account?
BP
Age
Smoking status
Cholesterol
RA
DM
Anti-hypertensives
BMI
Ethnicity
Measures of deprivation
WHAT IS ANGINA?
Presents with chest pain brought on by exertion but rapidly resolves with rest.
What are the different types of angina?
Stable angina
Unstable angina
Decubitus angina (precipitated by lying flat)
Variant (Prinzmetal’s) angina: caused by coronary artery spasm.
What are the causes of angina?
Mostly atheroma
Anaemia
What are the symptoms of angina?
Chest pain/discomfort.
Heavy, central, tight, radiation to arms, jaw, neck.
Precipitated by exertion.
Relieved by rest or GTN within 5 mins
What are the tests for stable angina?
ECG
Usually normal, may show ST depression and T wave inversion.
Bloods
Anaemia
CXR
Check heart size and pulmonary vessels
Angiogram
Gold standard, shows luminal narrowing
What are the management options for angina pectoralis?
Aspirin, Statin, Glyceryl Trinitrate (SL)
BB (atenolol)/CCB (verapamil/diltiazem)
BB + CCB (nifedipine), OR monotherapy + long-acting nitrate/ivabradine/nicorandil/ranolazine
Can use BB + CCB + 3rd Drug whilst waiting for PCI/CABG
PCI
Surgery (CABG)
WHAT IS ACUTE CORONARY SYNDROME PATHOLOGY?
Plaque rupture, thrombosis, and inflammation.
What are the different acute coronary syndomes?
Unstable angina
(NSTEMI) Non-Q wave infarction, ST depression and T wave inversion
(STEMI) Q wave infarction, ST elevation
What are the different ECG changes for ACS?
STEMI
ST elevation and tall T waves, may be a new LBBB in larger MIs (STEMI)
NSTEMI
A retrospective diagnosis, will see ST depression
Ischaemia
ST depression and T wave flattening
WHAT IS UNSTABLE ANGINA?
An acute coronary syndrome (ACS) that is defined by the absence of biochemical evidence of myocardial damage
What is the clinical classification of unstable angina?
Cardiac chest pain at rest.
Cardiac chest pain with crescendo pattern.
New onset angina.
What are the test for unstable angina?
FBC
Anaemia aggravates it
Cardiac enzymes
Excludes infarction
ECG
When in pain shows ST depression
Coronary angiography
What is the treatment for unstable angina?
Anti-platelet agents and Anti-coagulants
Break up any clots and stop new ones from forming.
Nitrates
B-blockers
Calcium antagonists (if B-blocker contraindicated)
CABG and PCI
WHAT IS A MYOCARDINAL INFARCTION?
Plaque rupture leads to a clot forming which then occludes one of the coronary arteries causing myocardial cell death and inflammation.
What are the symptoms of a myocardial infarction?
How long does it need to last to be an MI?
Acute central chest pain radiating to jaw or shoulder
Lasting >20 mins
Nausea
SOB
Palpitations
What are the signs of a myocardial infarction?
Clammy and pale
4th heart sound
Pansystolic murmur
May later develop peripheral oedema
What are the tests for a MI?
ECG: Classically, hyperacute (tall) T waves, ST elevation or new LBBB occur within hours of transmural infarction.
T wave inversion and development of pathological Q waves follow over hours to days.
CXR:
Cardiomegaly, pulmonary oedema, or a widened mediastinum
Blood
FBC, U&E, glucose, lipids.
Cardiac enzymes
Troponin
Creatine kinase
Myoglobin
What is the initial management for a MI?
Morphine
Oxygen
Nitrates
Aspirin (or Clopidogrel if aspirin is contraindicted)
What is the management after a MI?
For ST evelation and non ST elevation?
ST elevation MI
If within 2 hours and ST elevation on ECG then PCI is preferred option.
Beta blocker IV.
ACE inhibitor
Clopidogrel.
Non ST elevation MI
Beta blocker IV.
Antithrombotic; fondaparinux.
High risk; angiography, clopidogrel and aspirin
Low risk; clopidogrel.
What are the complications of MI?
Cardiac arrest; cardiogenic shock; LVF.
Unstable angina
Bradycardias or heart block.
Tachyarrhythmias
Pericarditis
DVT & PE
Systemic embolism
Cardiac tamponade
Mitral regurgitation
Ventricular septal defec
What is Dressler’s syndrome?
Recurrent pericarditis
pleural effusions
fever
anaemia and ESR increase
1–3 wks post-MI
WHAT IS PERIPHERAL VASCULAR DISEASE?
https://www.youtube.com/watch?v=rTbIazck7rk&t=229s
Blood vessels outside of your heart and brain to narrow, block, or spasm.
What is the classification of PVD called?
What do the numbers mean?
Fontaine
1 Asymptomatic
2 Intermittent claudication
3 Ischaemic rest pain
4 Ulceration/gangrene (critical ischaemia)
What are the symptoms of PVD?
Cramping pain in calves, thighs and buttocks relieved by rest
Also known as claudication
What are the signs of PVD?
Absent pulses
Punched out ulcers
Postural colour change (Buerger’s Test)
What are the tests for PVD?
ABPI
Normal is 1-1.2; PAD is 0.5-0.9 gangene<0.5
Colour Duplex USS
Quick and non-invasive, can show vessels and blood flow within them
MR/CT angiography
Identify stenosesand quality of vessels.
Blood tests
Raised CK-MM, shows muscle damage
What are the management options for PVD?
Risk factor modification
Quit smoking, treat HTN, lower cholesterol, improve DM control, lower fat diet.
Medications
Anti-platelet, clopidogrel is recommended as 1st line.
Exercise programmes
Reduce claudication by improving blood flow.
PTA or surgery if severely stenosed
What is critical limb ischaemia due to?
May be due to a thrombosis (in ‘vasculopaths’), emboli, graft occlusion or trauma
What are the 6 P’s of peripheral limb ischaemia?
Pain
Pallor
Pulselessness
Paresthesis
Paralysis
Perishing cold
What are the options for critical limb ischaemia?
If not revascularized then lose limb
WHAT IS SHOCK?
Circulatory failure resulting in inadequate organ perfusion
What is shock defined as?
Low BP
Evidence of tissue hypoperfusion.
What does a patient in shock look like?
Skin is pale, cold, sweaty and vasoconstricted
Pulse is weak and rapid
Pulse pressure reduced, MAP may be maintained
Urine output reduced
Confusion, weakness, collapse, coma
What is the main cause of injury from shock?
Prolonged hypotension can lead to life threatening organ failure
What are the different types of shock?
Hypovolaemic shock
Cardiogenic shock
Distributive shock
Septic shock
Analphylactic shock
Neurogenic shock
WHAT IS HYPOVALEMIC SHOCK?
Low circulating blood volume
What can cause hypovalemic shock?
Loss of blood
Acute GI bleeding
Trauma
Ruptured AA
Loss of fluid
Dehydration
Burns
How do you treat hypovalaemic shock?
Identify and treat underlying cause.
Raise the legs.
Give fluids
WHAT IS CARDIOGENIC SHOCK?
When can it occur?
Cardiogenic shock is a state of inadequate tissue perfusion primarily due to cardiac dysfunction.
May occur suddenly or after progressively worsening heart failure
What are some causes of cardiogenic shock?
MI
Arrhythmias
PE
Tension pneumothorax
Cardiac tamponade
Myocarditis
Endocarditis
Aortic dissection
What are the symptoms for cardiogenic shock?
Low BP
High HR
High RR
Confusion
Pallor
Clammy
Pale peripheries
Reduced urine output
What are the investigations for cardiogenic shock?
ECG
Tachycardic
Blood pressure
Low
JVP pressure
RAISED
U&E, troponins/cardiac enzymes,
ABG
CXR
Echocardiogram
What is the management of cardiogenic shock?
What do you need to monitor?
Treat the cause
Oxygen
Diamorphine IV for pain and anxiety
Correct arrhythmias, U&E abnormalities or acid–base disturbance
Monitor CVP, BP, ABG, ECG, urine
WHAT IS SEPSIS?
Sepsis exists when a systemic inflammatory response is associated with an infection
What is septic shock?
Septic shock exists when sepsis is complicated by persistent hypotension unresponsive to fluid resuscitation
What are the risk factors for septic shock?
Age
Diabetes mellituis (DM)
Immunocompromised
Alcoholics
Burns
IVDU
Pregnancy
Catheter
What are the symptoms for septic shock?
Low BP
High HR
Low sats (O2)
High resp rate (RR)
Lactate >2
Unresponsive
What are the investigations for septic shock?
Cultures (2 peripheral blood, plus urine/sputum/CSF)
LACTATE
ABG and BP
What is the treatment for septic shock?
OXYGEN
FLUIDS (check BP and ABG)
IV ANTIBIOTICS
(Tacozin and gentamicin, and vancomycin)
WHAT IS ANAPHYLATIC SHOCK?
Intense allergic reaction.
Massive release of histamine and other vasoactive mediators causing haemodynamic collapse.
What type of hypersensitivity is this reaction?
Type-I IgE-mediated hypersensitivity reaction.
What are some causes of anaphylatic shock?
Drugs, eg penicillin, and contrast media in radiology
Latex
Stings, eggs, fish, peanuts, strawberries, semen (rare)
What are the signs and symptoms of anaphylatic shock?
Itching, sweating, diarrhoea and vomiting, erythema, urticaria, oedema
Wheeze, laryngeal obstruction, cyanosis
Tachycardia, hypotension
What is the management of anaphylatic shock?
Oxygen
Remove the cause
Adrenaline IM
IV fluids
Chlorphenamine (antihistamine) and hydrocortisone (steroid)
If wheeze, treat for asthma
WHAT IS NEUROGENIC SHOCK?
Distributive
Disruption of the autonomic pathways within the spinal cord
What can cause neurogenic shock?
Spinal cord injury
Epidural
Spinal anaesthesia
What are the investigations for neurogenic shock?
Cold and clammy suggests cardiogenic shock or fluid loss.
Warm and well perfused, with bounding pulse points to septic shock.
Any features suggestive of anaphylaxis—history, urticaria, angio-oedema, wheeze?
CVS: usually tachycardic and hypotensive.
JVP or central venous pressure: If raised, cardiogenic shock likely.
Check abdomen: Any signs of trauma, or aneurysm? Any evidence of GI bleed?
What are the treatment options for neurogenic shock?
Dopamine and vasopressin (ADH).
Atropine is administered for slowed heart rate.
What organs are at risk of shock?
Kidneys - Acute tubular necrosis
Lung – Acute Respiratory Distress Syndrome (ARDS) (or “shock lung”)
Heart – myocardial ischaemia and infarction
Brain – confusion, irritability, coma
WHAT IS ARDS?
Acute Respiratory Distress Syndrome
Impaired oxygenation
Bilateral pulmonary infiltrates
No cardiac failure / normal PAOP
What processes are involved with ARDS?
Alveolar capillary membrane injury
Non-cardiogenic pulmonary oedema
Neutrophil influx
Exudative phase
Proliferative phase
Reorganisation of exudates, fibroblast proliferation
Fibrotic phase
Scarring
What are some causes of ARDS?
Extrapulmonary Causes
Pulmonary Causes
What are some extrapulmonary causes of ARDS?
Extrapulmonary Causes
Shock of any cause
Head injury
Drug reaction
Sepsis
What are some pulmonary causes of ARDS?
Pulmonary Causes
Pneumonia
Chemical pneumonitis
Smoke inhalation
Near drowning
WHAT DOES CARDIOMYOPATHY REFER TO?
Primary heart muscle disease – often genetic.
Three types.
WHAT IS HYPERTROPHIC CARDIOMYOPATHY?
https://www.youtube.com/watch?v=8RnkKB8xvwA
Heart muscle becomes thick, heavy and hypercontactile.
What is Hypertrophic cardiomyopathy (HCM) caused by?
What inheritance is it?
Sarcomeric protein gene mutations.
Autosomal dominant inheritance.
What is the epidemology of HCM?
Leading cause of death in the young
What is the pathology HCM?
Asymmetric septal hypertrophy
Intervenricular septum more than free wall
Take up more room so less filling
More stiff and less compliant
Stroke volume goes down
Heart failure
LV outflow tract (LVOT) obstruction
What type of heart failure if HCM?
Diastolic heart failure
What does the obstuction of the ventricular outflow tract cause?
Pulling of the mitral valve towards the atrioventricular septum
Venturi effect
What kind of heart sound is heard in HCM? Where is it also seen?
Crescendo-decrescendo murmur
Aortic valve stenosis
What are the symptoms of HCM?
Sudden death.
Fast arrythmias
Palpitations
Dyspnoea
Dizzy spells or syncope
What are the sings of HCM?
Jerky pulse
Double apex beat
Systolic thrill at lower left sternal edge
Harsh ejection systolic murmur
What are the tests for HCM?
Echo
Asymmetrical septal hypertrophy; small LV cavity with hypercontractile posterior wall; midsystolic closure of aortic valve
ECG
LVH; progressive T wave inversion; deep Q waves, AF
What is the treatment for HCM?
Beta-blockers or verapamil for symptoms.
Amiodarone for arrhythmias (AF, VT).
Anticoagulate for paroxysmal AF or systemic emboli.
What drug is contraindicated in HCM?
Digoxin
Increase contraction force, increase obstruction
WHAT IS DILATED CARDIOMYOPATHY (DCM)?
Causes all four chambers of the heart to enlarge
What is Dilated cardiomyopathy (DCM) often caused by?
Alcohol
Increased BP
Haemochromatosis
Viral infection
Autoimmune
What happens in Dilated cardiomyopathy (DCM)?
What type of heart failure is it?
Large space, thin walls
Weak contraction
Less blood pumped out in each beat
Biventicular congestive heart failure
Systolic heart failure
What type of heart sound is heard in DCM?
Holosystolic murmur
S3 sounds also present, blood slamming into wall in diastole
What are the symptoms of DCM?
Fatigue
Dyspnoea
Pulmonary oedema
Right ventricular failure
Emboli
Atrial fibrillation
Ventricular tachycardia
What are the signs of DCM?
Increased pulse
Decreased blood pressure
Increased JVP
Pleural effusion
Oedema
Jaundice, hepatomegaly, ascites
Displaced diffuse apex beat, S3 gallop
Mitral or tricuspid regurgitation
What are the tests for DCM?
Blood:
Plasma BNP is sensitive and specific in diagnosing heart failure.
CXR:
Cardiomegaly, pulmonary oedema.
ECG:
Tachycardia, non-specific T wave changes, poor R wave progression.
Echo:
Globally dilated hypokinetic heart and low ejection fraction. Look for MR, TR, LV mural thrombus.
What is the treatment for DCM?
Digoxin
Diuretics
ACE-i
Anticoagulation
Bi-ventricular pacing
Cardiac transplantation.
WHAT IS RESTRICTIVE CARDIOPATHY?
Heart muscle becomes stiff and less compliant
What diseases commonly cause RCM?
Amyloidosis
Familial amyloid cardiomyopathy
Afro-americans
Senile cardiac amyloidosis
Elderly
What are the causes of RCM?
Amyloidosis
Sarcoidosis
Collection of immune cells
Haemochromatosis
Radiation
Endocardial fibroelastosis
Loffler endomyocarditis
Eosinophils in lung tissue and heart tissue
What happens in amyloidosis?
Proteins that have been misfolded and become insoluble
Deposit in tissue in organs making them become less compliant
Familial amyloid cardiomyoopathy
Mutant transthyretin protein misfolded and prone to deposit in heart tissue
Normally transport thyroxine and retionol
Senile cardiac amyloidosis
Normal TTR deposits in heart
What is the pathology of RCM?
Heart muscle stays same size
When blood comes in heart doesn’t stretch
Less blood
Less pumped out
Heart failure
What type of heart failure is RCM?
Diastolic heart failure
What are the signs of RCM?
These are mainly of right heart failure with increase JVP
Kussmaul’s sign (JVP rising paradoxically with inspiration)
Quiet heart sounds
S3
Diastolic pericardial knock, hepatosplenomegaly, ascites, and oedema.
What are the investigations for RCM?
ECG
Low amplitude QRS
What is the treatment for RCM?
Treat underlying cause
Heart transplant
What do all cardiomyopathies carry?
An arrhythmic risk.
WHAT IS INHERITED ARRHYTHMIA (CHANNELOPATHY) CAUSED BY?
Ion channel protein gene mutations.
Which ions are involved with channelopathy?
potassium, sodium or calcium channel.
What do channelopathies include?
Long QT, short QT, Brugada and CPVT.
What do channelopathies normally present with and what do they have that is normal?
Recurrent syncope and have a structurally normal heart.
What is sudden cardiac death in young people normally due to? What disease is it most likely to be?
An inherited condition. Cardiomyopathy or ion channelpathy.
What does sudden arrhythmic death syndrome (SADS) usually refer to?
Normal heart/arrhythmia.
What are common problems to be inherited?
Aortic aneurysm or dissection.
WHAT IS AN ANEURYSM?
https://www.youtube.com/watch?v=pEOqffiwE7k
Abnormal buldge in vessel
What are the risk factors for aneurysms?
Male
Over 60
Hypertension
Smoking
What are the typical causes of an anneurysm
Atheroma
Trauma
Infection
Connective tissue disorders
Inflammations
What is the pathology of an aneurysm?
Weakness in vessel wall
Ballooning outwards of vessel wall due to pressure
Laplace’s law causes positive feedback loop
Gives bigger aneurysm
When is an aneurysm official labelled an aneurysm?
When the diameter exceeds 1.5 times the normal size
What are the common sites for anneurysms
What are the complications?
Common sites Aorta (infrarenal most common), iliac, femoral and popliteal arteries.
Complications Rupture; thrombosis; embolism; fistulae; pressure on other structures.
What are the different types of aneurysms?
True aneurysms
Abnormal dilatations that involve all layers of the arterial wall.
THEN EITHER
Fusiform
OR
saccular (Berry aneurysms)
False aneurysms (pseudoaneurysms)
Blood in the outer layer only (adventitia) which communicates with the lumen (eg after trauma).
What happens when an aneurysm explodes?
Blood spurts out of the hole
Less blood goes downstream
Ischaemia of downstream cells
What are the symptoms and signs of an abdominal aortic aneurysm?
Severe left flank pain
Abdomen
Chest
Lower back
Groin
Pulsating mass with heartbeat
Hypotension
What are the diagnosis options for an aneurysm?
Often incidental finding
Ultrasound
CT
MRI
What are the options for a unruptured anneurysm?
Elective surgery.
Stenting.
WHAT IS AORTIC DISSECTION?
https://www.youtube.com/watch?v=AZElPJtyxck
Tear in tunica intima, causes blood to pool between intima and media
What can cause aortic dissection?
Chronic hypetension
Stress
increase blood volume
Coarctation
Weakened aortic wall
Marfan’s
Ehlers-Danlos syndrome
Decrease blood flow to vasa vasorums
Aneurysms
Where does aortic dissection normally occur?
Within the first 10cm of aorta
What can a aortic dissection cause?
Blood back up into pericardial space causing
Pericardial temponade
Blood goes out intima and comes back into blood vessel through and hole
Blood flows does the aorta inbetween the layers and puts compression on other arteries
Renal artery
Subclavian artery
What are the different types of aortic dissection?
Type A (70%) dissections involve the ascending aorta, irrespective of site of the tear,
Whilst if the ascending aorta is not involved it is called type B (30%)
What are the symptoms of aortic dissection?
Sharp chest pain radiating to back
Weak pulse in downstream artery
Difference in BP between left and right arms
Hypotension
Shock
What are the investigations for aortic dissection?
CXR
Widend aorta
Transoesophageal echo
True lumen and flase aorta
Angiogram
What is the management of aortic dissection?
Surgery
Removal of dissected aorta
Blocks entry of blood into wall of aorta
Wall reconstructed with synthetic graft
Stent
Blood pressure meds
Beta Blockers
WHAT AORTAVASCULAR SYNDROMES ARE THERE?
Marfan, Loeys-Dietz, vascular Ehler Danlos (EDS).
What are ICCs inheritance?
Dominantly with a 50% risk.
HOW MANY LAYERS IS THE PERICARDIUM? WHAT IS THE STRUCTURE?
Two.
Visceral single cell layer adherent to epicardium
Fibrous parietal layer
2mm thick
Acellular collagen and elastin fibres
50ml of serous fluid.
What is contained within the pericardium? What is outside?
Great vessels lie within the pericardium
Two layers are continuous
Left atrium is mainly outside the pericardium
Parietal layer has fibrous attachments to fix the heart in the thorax.
Why is the pericardium important? What is important about the small reserve volume?
Restrains the filling volume of the heart.
If the volume is exceeded the pressure is translated to the cardiac chambers.
WHAT IS CARDIAC TAMPONADE?
Fluid builds up in the pericardium and results in compression of the heart.
What is the cause of cardiac tamponade?
Any pericarditis
Aortic dissection
MI
Trauma
Trans-septal puncture at cardiac catheterization
Cancer
What are the signs of cardiac tamponade?
Pulse increase
BP decerease
Pulsus paradoxus
JVP increase
Kussmaul’s sign
Muffled S1 and S2.
What is Beck’s triad?
Falling BP
Rising JVP
Muffled heart sounds.
What are the investigations for cardiac tamponade?
Beck’s triad
Falling BP; rising JVP; muffled heart sounds.
CXR
Big globular heart (if >250mL fluid).
ECG
Low voltage QRS ± electrical alternans.
Echo is diagnostic
Echo-free zone around the heart ± diastolic collapse of right atrium and right ventricle.
What is the management of cardiac temponade?
The pericardial effusion needs urgent drainage
What does chronic pericardial effusion have that is unique?
Pericardium slowly adapts to the increasing fluid and therefore reduces the effect on diastolic filling of the chambers.
WHAT IS PERICARDIAL EFFUSION?
Accumulation of fluid in the pericardial sac.
What are the causes of pericardial effusion?
Any cause of pericarditis.
What are the symptoms of pericardial effusion?
Dyspnoea
Raised JVP
Bronchial breathing at left base
Look for signs of cardiac tamponade
What are the investigations for pericardial effusion?
CXR
Enlarged, globular heart.
ECG
Low-voltage QRS complexes and alternating QRS morphologies (electrical alternans).
Echo
Shows an echo-free zone surrounding the heart.
What are the management options for pericardial effusion?
Treat the cause.
Pericardiocentesis may be diagnostic (suspected bacterial pericarditis) or therapeutic (cardiac tamponade).
WHAT IS ACUTE PERICARDITIS?
https://www.youtube.com/watch?v=jqClJsqnFFA
Inflammatory pericardial syndrome with or without effusion.
What are most cases of pericarditis?
Idiopathic.
What are the viral (common) causes of acute pericarditis?
Enteroviruses
Coxsackie B viruse
Herpesviruses (EBV, CMV, HHV-6),
What is a syndrome assocaiated with pericarditis?
Dresseler’s syndrome
Happens after heart attack
When an MI happens lots of necrosis
This also affects the pericardium
What is uremic pericarditis?
Blood levels of urea and nitrogen get high
Due to kidney problems
Iritate serous pericardium
Secrete thick pericardial fluid
Full of fibrin strands and white blood cells
Wall of pericarditis gets a buttered bread apperance
What autoimmune disease are associated with pericarditis?
Rheumatoid arthritis
Scleraderma
SLE
What is the patholgy of pericarditis?
Fluid and immune cells move from tiny blood cells into the fibrous pericardium
What happens when the serous pericardium becomes more and more fibrous?
Hard for the heart to expand and relax
Stroke volume goes down
Heart rate goes up
What is the clinical presentation of somebody with pericarditis?
Fever
Chest pain
Worse with heavy breathing
Better with sitting up and leaning forward
What can a clinical diagnosis of acute pericarditis be diagnosed from?
2 of 4 of:
Chest pain.
Friction rub.
ECG changes.
Pericardial effusion.
What is the differential diagnosis of pericarditis?
Pneumonia
Pleurisy
Pulmonary embolus
Chostocondritis
Gastro-oesophageal reflux
Myocardial ischaemia/infarction.
Aortic dissection
What tests can you do to check if somebody has pericarditis?
Clinical examination
Pericardial rub
Sinus tachycardia
Fever
Signs of effusion (pulsus paradoxus, Kussmauls sign)
ECG
Bloods
CXR
Silouette
Echocardiogram
What does an ECG look like with a patient who has pericarditis?
First few weeks
Diffuse ST segment elevation
Decrease PR
After that
T waves flattened
After that
ECG returns back to normal
What would blood tests show in tests of pericarditis?
FBC
Modest increase in WCC, mild lympocytosis
ESR & CRP
High ESR may suggest aetiology
ANA in young females - SLE
Troponin
Elevations suggest myopericarditis
What management can help with pericarditis?
Sedentary activity
NSAID
Ibuprofen PO or Aspirin PO
Treat cause
Colchicine
PO limited by nausea and diarrhoea, reduces recurrence.
WHAT IS HEART FAILURE?
A symptomatic condition where breathlessness, fluid retention and fatigue are associated with a cardiac abnormality that reduces cardiac output
A state where the heart is unable to pump enough blood to satisfy the needs of metabolising tissues
How do you calculate cardiac output?
CO = HR x SV
What is the most common cause of heart failure? What does this usually result from? What are some other causes?
Myocardial dysfunction.
IHD.
Hypertension.
Alcohol excess.
Cardiomyopathy.
Valvular.
Endocardial.
Pericardial causes.
What is systolic heart failure?
Inability of the ventricle to contract normally, resulting in decreaed cardiac output.
Ejection fraction (EF) is <40%
What are the causes of systolic heart failure?
IHD
MI
Cardiomyopathy.
What is diastolic heart failure?
Inability of the ventricle to relax and fill normally
Causing increased filling pressures.
EF is >50%.
What are the causes of diastolic heart failure?
Constrictive pericarditis
Tamponade
Restrictive cardiomyopathy
Hypertension
How may left and right sided heart failure occur?
Left ventricular failure (LVF) and right ventricular failure (RVF) may occur independently, or together as congestive cardiac failure (CCF).
What are some causes of left sided heart failure?
Hypertension
What are the symptoms of left sided heart failure?
Dyspnoea,
Poor exercise tolerance
Fatigue
Orthopnoea
Paroxysmal nocturnal dyspnoea (PND)
Nocturnal cough (±pink frothy sputum)
What are some causes of right ventricular failure?
LVF, pulmonary stenosis, lung disease.
What are the symptoms of right ventricular heart failure?
Peripheral oedema (up to thighs, sacrum, abdominal wall),
Ascites
Nausea
Anorexia
Facial engorgement
Pulsation in neck and face (tricuspid regurgitation)
Epistaxis.
What tests can you do for heart failure?
History and physical examination
Blood Tests
BNP
LFTS, FBC, U&Es, BNP, TFTs
Cardiac enzymes
Creatinine kinase, troponin I, troponin T
CXR
ECG.
Echocardiography
What would you see on a chest XR for heart failure?
ABCDE
Alveolar oedema
Kerley B lines
Cardiomegaly
Dilated prominant upper lobe vessels
Pleural Effusion
What are the systems involved with protection and survival of the heart?
The sympathetic system
Increases afterload by causing peripheral vasoconstriction
The renin-angiotensin-aldosterone axis
Salt and water retention
Increases afterload and preload (^ volume and vasoconstriction)
Cardiac changes
Ventricular dilatation
Myocytehypertrophy
What does an increase in cardiac norepinephrine produce? What happens in the long term?
Increased adrenergic activation
Direct toxicity to myocytes
Increased HR and contractility causing extra strain on heart
Increased vasocontriction, increased afterload, more strain on heart
What does angiotensin 2 produce?
Increase salt and water retention
Increased preload, extra strain on heart
What is the treatment for heart failure?
Loop diuretics
Furosemide
ACEi
Lisinopril
Beta blockers
Bisoprolol
Aldosterone antagonists
Spironolactone
Calcium glycoside
Digoxin inhibits Na/K
WHAT IS TETRALOGY OF FALLOT?
Pulmonary stenosis
RV hypertrophy
Overriding aorta
VSD
What are the physiology of Tetralogy of Fallot?
The stenosis of the RV outflow leads to the RV being at higher pressure than the left
Therefore blue blood passes from the RV to the LV
The patients are BLUE
Toddlers may squat
What is the presentation of infants in tetralogy of Fallot and why?
Infants may be acyanotic at birth
Pulmonary stenosis murmur as the only initial finding.
Cyanotic due to decreasing flow of blood to the lungs as well as right-to-left shunt across the VSD.
Toddlers may squat
Typical of TOF, as it increases peripheral vascular resistance and decreases the degree of right to left shunt.
Adult patients are often asymptomatic
What are the tests for tetrology of Fallot?
ECG
RV hypertrophy with a right bundle-branch block.
CXR
Boot-shaped heart
Echocardiography
Can show the anatomy as well as the degree of stenosis.
What is the management of tetrology of Fallot?
Surgery
WHAT IS VENTRICULAR SEPTAL DEFECTS?
Hole in the connecting venticles
What are the different pressures in the ventricles and what is the result in VSD?
High pressure LV
Low pressure RV
Blood flows from high pressure chamber to low pressure chamber
Therefore NOT blue
Increased blood flow through the lungs
What are the causes of VSD?
Congenital
Acquired (post-MI).
What are the ventricular septal defects clinical signs?
Large
Pan-systloic murmur varies in intensity
Small breathless skinny baby
Increased respiratory rate
Tachycardia
Big heart on chest X ray
Small
Loud systolic murmur
Thrill (buzzing sensation)
Well grown
Normal heart rate
Normal heart size.
What is the treatment for VSD?
Large
Require fixing in infancy (PA band, complete repair)
Small
Endocarditis risk
Need no intervention
What may VSD lead to?
May lead to Eisenmengers syndrome.
What is Eisenmengers syndrome?
High pressure pulmonary blood flow
Damages to delicate pulmonary vasculature
The resistance to blood flow through the lungs increases
The RV pressure increases
The shunt direction reverses
The patient becomes BLUE.
WHAT IS ATRIAL SEPTAL DEFECT?
Abnormal connection between the two atria (primum, secundum, sinus venosus)
Common
Often present in adulthood.
What are the two types of ASD?
Primum: present earlier, may involve AV valves
Secundum: may be asymptomatic until adulthood
What is the physiology of atrial septal defects?
Slightly higher pressure in the LA than the RA
Shunt is left to right
Therefore NOT blue
Increased flow into right heart and lungs
What is the physiology between large and small atrial septal defects?
Large
Significant increased flow through the right heart and lungs in childhood
Right heart dilatation
SOBOE
Increased chest infections
If any stretch on the right heart should be closed
Small
Small increase in flow
No right heart dilatation
No symptoms
Leave alone
NB. The shunt on small to moderate sized defects increases with age
What are some complications of ASD?
Reversal of left-to-right shunt, ie Eisenmenger’s complex.
Paradoxical emboli (vein to artery via ASD; rare).
What are the clinical signs of atrial septal defects?
Pulmonary flow murmur
Fixed split second heart sound (delayed closure of PV because more blood has to get out)
Big pulmonary arteries on CXR
Big heart on chest X ray
What is the treatment of ASD?
In children closure is recommended before age 10yrs.
In adults, transcatheter closure is now more common than surgical.
WHAT CAN ATRIA-VENTRICULAR SEPTAL DEFECTS INVOLVE?
Hole in the centre. Can involve the ventricular septum, the atrial septum, the mitral and tricuspid valves.
What is the physiology of atria-ventricular septal defect? For a partial and complete defect?
Complete defect –Breathless as neonate –Poor weight gain –Poor feeding –Torrential pulmonary blood flow –Needs repair or PA band in infancy –Repair is surgically challenging
Partial defect –Can present in late adulthood –Presents like a small VSD / ASD –May be left alone if there is no right heart dilatation
WHAT IS PATENT DUCTUS ARTERIOSUS?
Failure of ductus arterioles to close.
What are the clinical signs of ductus arterioles?
Continuous ‘machinery’ murmur
If large, big heart, breathless
Eisenmenger’s syndrome
–Differential cyanosis (clubbed and blue toes, but pink not clubbed fingers)
What is the physiology of patent ductus arterioles with a large and a small?
Large –Torrential flow from the aorta to the pulmonary arteries in infancy –Breathless, poor feeding, failure to thrive –More common in prem babies –Need to be closed (surgically) •Small –Little flow from the aorta to Pas –Usually asymptomatic –Murmur found incidentally –Endocarditis risk
How do you close the ductus arterioles?
Surgical or percutaneous.
Local anaesthetic.
Venous approach.
WHAT IS COARCTATION OF THE AORTA?
Narrowing of the aorta at the site of insertion of the ductus arterioles.
What is the physiology for coarctation of the aorta?
Severe
Complete or almost complete obstruction to aortic flow
Collapse with heart failure
Needs urgent repair
Mild
Presents with hypertension
Incidental murmur
Should be repaired to try to prevent problems in the long term
What are the clinical signs of coarctation of the aorta?
Right arm hypertension
Bruits (buzzes) over the scapulae and back from collateral vessels
Murmur
What are the long term problems of coarctation of the aorta?
Hypertension
Early coronary artery disease
Early strokes
Sub arachnoid haemorrhage
Re-coarctation requiring repeat intervention
Aneurysm formation at the site of repair
What is the treatment of coarctation of the aorta?
Surgery, or balloon dilatation ± stenting.
WHAT IS BICUSPID AORTIC VALVE?
Normal AV valves has three cusps.
This has two
what are the problems associated with bicuspid AVs?
Can be severely stenotic in infancy or childhood
Degenerate quicker than normal valves
Become regurgitant earlier than normal valves
Are associated with coarctation and dilatation of the ascending aorta
How can you treat bicuspid aortic valve?
Surgery
WHAT IS PULMONARY STENOSIS?
Narrowing of the outflow of the right ventricle.
Valvar.
Sub valvar.
Supra valvar.
Branch.
What are the problems with pulmonary stenosis?
Severe
–Right ventricular failure as neonate
–Collapse
–Poor pulmonary blood flow
–RV hypertrophy
–Tricuspid regurgitation
Moderate / mild
–Well tolerated for many years
–Right ventricular hypertrophy
What is the treatment for pulmonary stenosis?
Treatment
–Balloon valvuloplasty
–Open valvotomy
–Open trans-annular patch
–Shunt (to bypass the blockage)
WHAT IS HYPERTENSION?
Over 140/90
What are the two types of hypertension?
Essential hypertension (primary, cause unknown). ~95% of cases.
Secondary hypertension ~5% of cases.
What are some causes of secondary hypertension?
Renal
CKD
Endocrine disease
Conn’s syndrome
Others
Coarctation, pregnancy
What are the tests for hypertension?
24hr ambulatory BP monitor
Multiple home BP monitoring
Fundoscopy–in severe HTN
Bilateral retinal haemorrhages
Papilloedema
Overall CVD risk
Fasting glucose
Cholesterol
End Organ Damage
12 lead ECG –past MI, LV hypertrophy
Urine analysis –protein, blood
What are some lifestyle to lower blood pressure?
Stop smoking
Low-fat diet
Reduce alcohol and salt intake
Increase exercise
Reduce weight if obese
What do you give for hypertension if they are over 55 or afro-carribean?
Calcium channel blocker
Amlodipine
Nifedipine
Verapamil
What do you give for hypertension if they are below 55 and not afro-carribean?
ACE inhibitor
Ramapril
Peridopril
OR
Angiotensin receptor blocker
Candesartan
Valsartan
What do you give them if their drug doesn’t work?
The other one
What do you give them if all their drugs don’t work?
Thiazide like diuretic
Chlorothiazide
Hydrocholrothiazide
How can renal artery stenosis cause hypertension?
Less blood flow to kidneys
Secretes Renin
More water and salt retention
Higher BP
What is a pheochromocytoma? How does it cause hypertension?
Tumour on adrenal glands
Constantly produce catecholamines
Increase heart rate and peripheral vascular resistance
Increase BP
How does cushing’s cuase hypertension?
Enhances adrenalines effect on blood vessels to constrict them
Also can act as a mineralacorticoid (aldosterone)
Increase BP
How does Conn’s syndrome cause hypertension?
High aldosterone
Increased sodium and water retention
Increased BP
WHAT IS AORTIC STENOSIS?
Hardening of the aorta
What is the normal aorta valve area?
3-4 cm2
When do aortic stenosis symptoms occur?
When the valve area is 1/4th of normal.
What are the different types of aortic stenosis?
Supravalvular
Subvalvular
Valvular.
What can congenital aortic stenosis occur with?
Unicuspid, bicuspid and tricuspid valve.
What is the cause of aortic valve stenosis
Congenital bicuspid valve
Degenerative calcification
Rheumatic Heart disease
What is rheumatic heart disease?
Fusion of cusps.
How does a person with aortic stenosis present?
Syncope
Angina
Dyspnoea
Sudden death
What physical signs would you hear on aortic stenosis?
Slow rising carotid pulse (pulsus tardus)
& decreased pulse amplitude (pulsus parvus)
Heart sounds- soft or absent second heart sound, S4 gallop due to LVH.
Ejection systolic murmur- crescendo-decrescendo character.
What tests would you do for someone with aortic stenosis?
Echocardiography
Two measurements obtained are:
Left ventricular size and function: LVH, Dilation, and EF
Doppler derived gradient and valve area (AVA).
ECG
CXR –LVH, calcified aortic valve
What is the management for aortic stenosis?
General:
Fastidious dental hygiene / care
Consider IE prophylaxis in dental procedures
Medical - limited role since AS is a mechanical problem. Vasodilators are relatively contraindicated in severe AS
Surgical Replacement: Definitive treatment
TAVI – Transcatheter Aortic Valve Implantation
WHAT IS MITRAL VALVE REGURGITATION?
Definition: Backflow of blood from the LV to the LA during systole
Mild (physiological) MR is seen in 80% of normal individuals.
What are the aetiologies of chronic mitral valve regurgitation?
Myxomatous degeneration (MVP)
Ischemic MR
Rheumatic heart disease
Infective Endocarditis.
What is the pathophysiology of mitral valve regurgitation?
Pure Volume Overload
Compensatory Mechanisms: Left atrial enlargement, LVH and increased contractility
Progressive left atrial dilation and right ventricular dysfunction due to pulmonary hypertension.
Progressive left ventricular volume overload leads to dilatation
What are the symptoms of mitral valve regurgitation?
Exertion dyspnoea –exercise intolerance
Palpitations
Fatigue
What are the signs of mitral valve regurgitation?
Pansystolic murmur at apex radiating to axilla
Soft S1
Displaced hyperdynamic apex
What do imaging studies for mitral regurgitation show?
ECG: May show, LA enlargement, atrial fibrillation and LV hypertrophy with severe MR
CXR: LA enlargement, central pulmonary artery enlargement.
ECHO: Estimation of LA, LV size and function. Valve structure assessment TOE v helpful
What are the medications/management for MR?
Vasodilator –ACEi, hydralazine
Rate control for AF –BB, CCB, Digoxin
Anticoagulant for AF and flutter
Diuretics –to control symptoms
Surgery for deteriorating symptoms –aim to replace valve
What are the indications for surgery of severe MR?
ANY Symptoms at rest or exercise with (repair if feasible)
Asymptomatic:
If EF <60%, LVESD >45mm
If new onset atrial fibrillation/raised PAP.
WHAT IS AORTIC VALVE REGURGITATION?
Leakage of blood into LV during diastole due to ineffective coaptation of the aortic cusps.
What is the cause of AR?
Bicuspid aortic valve
Rheumatic
Infective endocarditis.
What is the pathophysiology of AR?
Combined pressure AND volume overload
Compensatory Mechanisms: LV dilation, LVH
Progressive dilation leads to heart failure
What are the symptoms of aortic valve regurgitation?
Exertional dyspnoea
Orthopnoea
Paroxysmal nocturnal dyspnoea
What are the signs or aortic regurgitation?
Collapsing (water hammer) pulse
Wide pulse pressure
Displaced hyperdynamic apex beat
Early diastolic murmur
Notable eponyms
Corrigans sign (ear movements)
De Musset’s sign (head movements)
Duroziez’s sign (Femoral artery murmur)
Austin flint murmur (cardiac apex murmur)
Traube’s sign (pistol shot over femoral)
What would cardiac tests show you for AR?
CXR
Cardiomegaly
ECHO
LV dilation and hypertrophy
What is the management for AR?
Vasdilators
ACEi only if symptomatic or HTN
Surgical
Replace valve before LV dysfunction
WHAT IS MITRAL VALVE STENOSIS?
Obstruction of LV inflow that prevents proper filling during diastole
What is the aetiology of mitral valve stenosis?
Rheumatic heart disease
Infective endocarditis
Mitral annular calcification.
What is mitral valve stenosis pathophysiology?
LA dilation incerease pulmonary congestion (reduced emptying)
Increased Transmitral Pressures
Leads to left atrial enlargement and atrial fibrillation.
Right heart failure symptoms: due to Pulmonary venous HTN
What are the symptoms of MS?
Dyspnoea
Fatigue
Palpitations
Chest pain…
What are the signs in MS?
Malar flush on cheeks
Low volume pulse
Tapping, non displaced apex beat
Rumbling mid-diastolic murmur
Loud opening S1
What tests can you do on MS and what will they show?
ECG
May show atrial fibrillation and LA enlargement
CXR
LA enlargement and pulmonary congestion
Occasionally calcified
MV ECHO
The GOLD STANDARD for diagnosis
Asses mitral valve mobility, gradient and mitral valve area
How would you manage a patient with MS?
If in AF, rate control
Anticoagulatewith warfarin
Diuretics
Percutaneous mitral balloon valvotomy
WHAT IS INFECTIVE ENDOCARDITIS?
Infection of heart valve/s or other endocardial lined structures within the heart (such as septal defects, pacemaker leads, surgical patches, etc). It’s like a really bad infection, but with the added extras of showering infectious crap all around your bloodstream, and/or eating holes in your heart valves.
What are the different types of infective endocarditis?
Left sided native IE (mitral or aortic) Left sided prosthetic IE Right sided IE (rarely prosthetic as rare to have PV or TV replaced) Device related IE (pacemakers, defibrillators, with or without valve IE Prosthetic; can be Early (within year) or Late (after a year) post op Each type can have different presentations, pathogens and outcomes.
How do you catch infective endocarditis?
Have an abnormal valve; regurgitant or prosthetic valves are most likely to get infected. Introduce infectious material into the blood stream or directly onto the heart during surgery Have had IE previously
Who does infective endocarditis affect?
the elderly (in an ageing population) the young i.v. drug abusers the young with congenital heart disease. Anyone with prosthetic heart valves.
What is the clinical presentation of infective endocarditis?
Depends on site, organism, etc Signs of systemic infection (fever, sweats, etc) Embolisation; stroke, pulmonary embolus, bone infections, kidney dysfunction, myocardial infarction Valve dysfunction; heart failure, arrythmia
How do you diagnose somebody with infective endocarditis?
2 Major Criteria Bugs grown from blood cultures evidence of endocarditis on echo, or new valve leak 5 Minor Criteria Predisposing factors Fever Vascular phenomena Immune phenomena Equivocal blood cultures. Definite IE 2 major, 1 major+3 minor, 5 minor Possible IE 1 major, 1 major+3 minor, 5 minor.
What test can you do for infective endocarditis?
ECG (ischemia or infarction, new appearance of heart block) Transthoracic echo (TTE). Safe, non-invasive, no discomfort, often poor images so lower sensitivity. Transoesophageal (TOE/TEE). Excellent pictures as long as you don’t mind having a big tube pushed down your throat. Patients rarely want to have a second TOE. Generally safe but risk of perforation or aspiration. Easiest if ventilated (but never ventilate just for TOE)
What are some peripheral stigmata of infective endocarditis?
Petechiae 10 to 15%, Splinter hemorrhages Osler’s nodes (small, tender, purple, erythematous subcutaneous nodules are usually found on the pulp of the digits) Janeway lesions are erythematous, macular, nontender lesions on the fingers, palm, or sole Roth spots on fundoscopy.
How can you diagnose infective endocarditis?
Cultures may remain negative in 2% to 5% of patients with IE. Certain organisms: cell media; special media or microbiological methods, or may require long incubtion 7-21/7. The most common cause for negative blood cultures in patients with IE is prior antimicrobial therapy. WBC is rarely helpful. Raised CRP is almost always present.
How can you treat infective endocarditis?
Antimicrobials; intravenous for around 6weeks; choice of agent/s based on culture sensitivities Treat complications; arrhythmia, heart failure, heart block, embolisation, stroke rehab, abscess drainage etc Surgery.
When do you operate on somebody with infective endocarditis?
the infection cannot be cured with antibiotics (ie recurs after treatment, or CRP doesn’t fall) complications (aortic root abscess, severe valve damage to remove infected devices (always needed) to replace valve after infection cured (may be weeks/months/years later To remove large vegetations before they embolise
