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 ANGINA?
Chest pain brought on either:
By exertion which resloves with rest
Or at 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?
Atheroma
Anaemia
Spasm
Tachycardia
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
Pathological Q waves in particular, LBBB, and ST-segment and T wave abnormalities (for example, flattening or inversion).
Bloods
May show anaemia
CXR
May show increased heart size and pulmonary vessels
Angiogram
Gold standard, shows luminal narrowing
What are the management options for stable angina pectoralis?
Drugs
Glyceryl Trinitrate (SL) (GTN Spray)
Aspirin to prevent clots
Statin to lower cholesterol
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
Percutaneous Intervention (PCI)
Coronary Artery Bypass Graft (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 e.g. Clopidogrel
Anti-coagulants e.g. Heparin, Warfarin
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 of bleeding; angiography, clopidogrel and aspirin
Low risk of bleeding; ticagralor, 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 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 anaphylatic shock?
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
- Erythem
- Urticaria
- Oedema
- Wheeze
- Laryngeal obstruction
- Cyanosis
- Tachycardia
- Hypotension
What is the management of anaphylatic shock?
- Oxygen
- Remove the cause
- Adrenaline IM - 500 micrograms - 1 in 1000
Repeated every 5 minutes if necessary
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 ACUTE RESPIRATORY DISTRESS SYNDROME?
- Increase in alveolar permeability
- Fluid accumilation in the alveoli
- Not associated with cardiac causes
- Impaired oxygenation
What are some causes of ARDS?
- Infection: sepsis, pneumonia
- Massive blood transfusion
- Trauma
- Smoke inhalation
- Acute pancreatitis
- Cardio-pulmonary bypass
What are the clinical features of ARDS?
- Dyspnoea
- Elevated respiratory rate
- Bilateral lung crackles
- Low oxygen saturations
What are the investigations for ARDS?
- Chest x-ray
- ABG
What is the management for ARDS?
- ITU - Oxygenation/ventilation to treat the hypoxaemia
- General organ support e.g. vasopressors as needed
- Treatment of the underlying cause e.g. antibiotics for sepsis
- Certain strategies such as prone positioning and muscle relaxation have been shown to improve outcome in ARDS
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 angina + SOB.
Amiodarone for arrhythmias (AF, VT) DIGOXIN IS CONTRAINDICATED
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?
- Stop drinking
-
Treatment of cardiac failure
- ACE inhibitors
- Beta Blockers
- Diuretics + Digoxin -
Anti-arrythmic drugs
Amiodarone - Cardiac transplantation and cardiomyoplasty
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
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 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