Cardio 1 Flashcards
1
Q
what is angina pectoris?
A
chest pain arising from the heart as a result of myocardial ischaemia
2
Q
name 3 types of angina
A
classic/stable, unstable/crescendo, Prinzmetal’s.
decibitus, nocturnal.
3
Q
what are the differences between stable and unstable angina
A
stable angina is induced by effort + relieved by rest.
unstable angina occurs at rest.
4
Q
what is Prinzmetal’s (variant) angina?
A
angina that occurs without provocation, usually at rest - due to coronary artery spasm.
5
Q
what causes angina?
A
atheroma of coronary arteries leading to myocardial ischaemia
6
Q
give 5 risk factors for angina
A
diabetes, smoking, hyperlipidaema, hypertension, family history, lack of exercise
7
Q
list the differential diagnoses of central chest pain
A
angina, ACS, pericarditis, myocarditis, aortic dissection, massive PE, musculoskeletal, GORD
8
Q
describe the presentation of angina
A
central, crushing, retrosternal chest pain - comes on with exertion, relieved by rest.
may radiate to arms and neck
9
Q
list some things that can exacerbate angina
A
exercise, cold weather, anger, excitement, heavy meals
10
Q
give some clinical features, apart from pain, of angina
A
dyspnoea, nausea, sweating, faintess
11
Q
what investigation would you carry out on a patient with angina? what would you find?
A
exercise ECG test - ST depression, flat/inverted T waves
12
Q
how would you manage stable angina?
A
modify risk factors.
secondary prevention - aspirin, statins.
symptomatic treatment - GTN spray, CCBs, beta blockers, nitrates.
13
Q
how does aspirin work as a method of secondary prevention in angina?
A
inhibits COX2 and formation of thromboxane A2 - a platelet aggregating agent.
reduces risk of coronary events.
14
Q
name an alternative to aspirin in secondary prevention of coronary events.
A
clopidogrel
15
Q
give some examples of beta-blockers
A
bisoprolol, atenolol, propranolol, metoprolol
16
Q
describe the mechanism of action of beta blockers in improving symptoms of angina
A
by acting on beta1 receptors in the heart, they reduce the force of contraction and speed of conduction in the heart - relieves myocardial ischaemia by reducing cardiac work and oxygen demand
17
Q
what is the major contra-indication of beta-blockers? why?
A
asthma - beta blockers also act on beta2-receptors which are found in the smooth muscles of airways - cause bronchoconstriction!
18
Q
give some examples of calcium channel blockers
A
diltiazem, amlodipine, nifedipine, verapamil
19
Q
describe the mechanism of action of calcium channel blockers in controlling symptoms of stable angina
A
they decrease calcium entry into vascular and cardiac cells. they reduce myocardial contractility and suppress cardiac conduction - reduce heart rate, contractility and afterload - reduces myocardial oxygen demand - prevents angina.
20
Q
what are the major side effects of calcium channel blockers?
A
postural hypotension/dizziness, headache, ankle oedema - due to systemic vasodilation
21
Q
describe the mechanism of action of short-acting (GTN) nitrates and long-acting nitrates in acute angina
A
Nitrates are converted to NO, which increases cGMP and reduces intracellular calcium in vascular smooth muscle cells - vasodilation of venous capacitance vessels reduces preload and LV filling.
reduced cardiac work and myocardial oxygen demand - relieve angina
22
Q
what interventions may be used in worsening angina?
A
Percutaneous coronary intervention (PCI) - balloon used to dilate atheromatous arteries (stents can be placed) - via catheter.
Coronary artery bypass grafting (CABG)
23
Q
what is involved in a coronary artery bypass graft (CABG)?
A
internal mammary artery used to bypass stenosis in the LAD or RCA.
24
Q
what does the term acute coronary syndromes (ACS) include?
A
unstable angina.
NSTEMI.
STEMI.
25
how would you differentiate between NSTEMI and unstable angina?
NSTEMI involves enough occlusion to cause myocardial damage - elevation of serum troponin and creatinine kinase.
unstable angina doesn't cause myocardial damage.
26
describe the common pathology behind acute coronary syndromes
1) rupture/erosion of fibrous cap of an atheroma plaque in a coronary artery
2) platelet-rich clot forms
3) vasoconstriction due to chemicals released by platelets
27
name 3 non-modifiable risk factors for ACS
age.
male gender.
FHx of IHD
28
name 3 modifiable risk factors for ACS
smoking, hypertension, DM, hyperlipidaemia, obesity, sedentary lifestyle, cocaine use
29
list 3 symptoms and 3 signs of ACS
symptoms - central chest pain, sweating, dyspnoea, palpitations.
signs - sweating, anxiety, tachycardia, pallor.
30
what biochemical markers would you test for in ACS?
troponin, creatinine kinase, myoglobin
31
what would you expect to see on a 12 lead ECG in ACS?
hyperacute (tall) T waves
ST elevation (STEMI) or ST depression (NSTEMI/unstable angina).
new LBBB.
after hrs-days - T wave inversion, Q waves.
32
what would be your immediate management of ACS?
MONA:
Morphine, Oxygen, Nitrates, Aspirin
± clopidogrel/ticragelor
33
what drugs might a patient be put on after an ACS, for secondary prevention?
beta-blockers, ACE inhibitors, statins, aspirin
34
what might the non-medical management of ACS be?
PCI - percutaneous coronary intervention
35
list some possible complications following a MI
heart failure, rupture of interventricular septum, mitral regurg, arrhythmias, heart block, pericarditis, thromboembolism, ventricular aneurysm
36
give 3 causes of heart failure
ischaemic heart disease; valvular disease; pericarditis; pericardial effusion; alcohol; cocaine; myocarditis; arrhythmias; cardiomyopathies; anaemia; pulmonary hypertension
37
what are the types of heart failure?
systolic/diastolic, low output/high output, left/right
38
what compensatory mechanisms are activated as the heart begins to fail?
sympathetic nervous system, RAAS, ventricular dilatation, ventricular remodelling
39
what causes the oedema and dyspnoea seen in heart failure?
activation of the RAAS by decreased renal perfusion (due to low CO) - salt/water retention - peripheral/pulmonary congestion
40
describe the ventricular remodelling seen in heart failure
initial dilatation.
| hypertrophy, loss of myocytes, increased interstitial fibrosis.
41
what is the difference between systolic and diastolic failure?
```
systolic = inability of ventricles to contract normally
diastolic = inability of ventricles to relax and fill normally
```
42
give 3 symptoms of heart failure
exertional dypnoea, orthopnoea (SOB on lying down), paroxysmal nocturnal dyspnoea, fatigue, oedema, weight loss, wheeze
43
give 5 signs of heart failure
cold peripheries, cyanosis, displaced apex, wheeze, RV heave, valve disease, hypotension, pleural effusion, oedema, ascites
44
what are 5 features of heart failure seen on CXR?
```
ABCDE:
Aleveolar oedema (bats wings)
Kerly B lines (interstitial oedema)
Cardiomegaly
Dilated upper lobe vessels
pleural Effusion
```
45
list 2 major criteria on the Farmingham criteria for heart failure diagnosis
```
SAW PANIC
S3 heart sound - gallop.
Acute pulmonary oedema.
Weight loss
Paroxysmal nocturnal dyspnoea
Abdominojugular reflux
Neck vein distension
Increased cardiac shadow on CXR (cardiomegaly)
Crepitations (crackles heard in lungs)
```
46
list 2 minor criteria on the Farmingham criteria for heart failure diagnosis
```
HEART ViNo:
Hepatomegaly
Effusion, pleural
Ankle oedema bilaterally
exeRtional dyspnoea
Tachycardia
Vital capacity decrease by 1/3rd
Nocturnal cough
```
47
describe the NHYA classification of heart failure
```
class I = no limitation
class II = mild limitation (comfort at rest, fatigue and dyspnoea on normal physical activity)
class III = marked limitation (comfort at rest, dyspnoea on gentle physical activity)
class IV = symptomatic at rest, exacerbated by any physical activity
```
48
what investigations would you do in heart failure?
ECG - underlying cause.
CXR.
Bloods - BNP (B type natriuretic peptide - if normal, HF is excluded).
echocardiography.
49
describe the medical management of heart failure
loop diuretics (furosemide) ± spironolactone ± thiazide.
ACE inhibitors (or ARB).
beta blockers.
± digoxin, vasodilators (e.g. hydralazine)
50
name 2 ACE inhibitors
ramipril, lisinopril
51
what causes the common cough side effect of ACE inhibitors? what drug class are a good alternative?
increased levels of bradykinin, which is usually inactivated by ACE.
ARBs
52
how do ACE inhibitors act?
prevent conversion of angiotensin I to angiotensin II.
| Angiotensin II is a vasoconstrictor and stimulates aldosterone secretion - blocking this reuces afterload, lowering BP.
53
name 2 angiotensin receptor blockers (ARBs)?
losartan, candesartan
54
how do angiotensin receptor blockers work?
block action of angiotensin II on the AT1 receptor. similar effects as ACE inhibitors.
55
give 3 causes of mitral stenosis
rheumatic heart disease (most), congenital, cardial fibroelastosis, malignant carcinoid, prosthetic valve.
56
what is mitral stenosis?
thickening and immobility of valve leaflets - leads to obstruction of blood flow from left atrium to left ventricle.
57
give 3 symptoms of mitral stenosis
exertional dyspnoea, fatigue, palpitations, chest pain, systemic emboli, haemoptysis
58
what is the heart murmur heard in mitral stenosis?
rumbling mid-diastolic murmur
59
what diagnostic tests would you perform in mitral stenosis? what would you see?
ECG - AF, bifid P waves.
CXR - LA enlargement, pulmonary oedema, mitral valve calcification.
Echo - diagnostic.
60
how would mitral stenosis be treated?
diuretics - decrease pre load.
| balloon valvuloplasty / valve replacement.
61
give 2 complications of mitral stenosis
pulmonary hypertension.
emboli (dilated LA).
pressure from large LA on local structures e.g. hoarseness due to compression of L recurrent laryngeal
62
give 3 causes of mitral regurgitation
prolapsing mitral valve + rheumatic heart disease = most common.
infective endocarditis, annular calcification, LV dilatation, ruptured chordae tendinae, papillary muscle rupture.
connective tissue disorders (Ehlers-Danos, Marfan's).
cardiomyopathy, congenital.
63
give 3 symptoms of mitral regurgitation
dyspnoea, fatigue, palpitations, infective endocarditis
64
what murmur is heard in mitral regurgitation?
pansystolic murmur
65
what does a bifid P wave indicate on ECG?
bifid P waves = p mitrale - mitral valve disease
66
what investigations would you perform in valvular heart disease?
ECG, CXR, echo ± cardiac catherization
67
what would you see on CXR in mitral regurgitation?
enlarged LA and LV, mitral valve calcification, pulmonary oedema
68
how would you treat mitral regurgitation?
asymptomatic = echo every 1-5yrs.
anticoagulate with warfarin if - AF, hx of embolism, prosthetic valve, additional mitral stenosis.
diuretics.
surgery - valve replacement or repair.
69
give 3 causes of aortic stenosis
degeneration and calcification of normal valve (in the elderly).
calcification of congenital biscuspid valve (middle age).
rheumatic heart disease.
70
what is the classical triad of symptoms in aortic stenosis?
SAD:
Syncope
Angina
Dyspnoea - heart failure
71
what murmur is heard in aortic stenosis?
ejection systolic murmur
72
what would you expect to see on an ECG in aortic stenosis?
p mitrale, LVH with strain pattern (depressed ST and T wave inversion in I, AVL, V5 and V6)
73
what would you see on a CXR of a patient with aortic stenosis?
normal heart size, prominent ascending aorta, valvular calcification
74
how would you treat aortic stenosis?
prompt valve replacement
75
what are the most common causes of aortic regurgitation?
rheumatic fever and infective endocarditis
76
give 3 causes of acute aortic regurgitation
infective endocarditis, acute rheumatic fever, dissection of the aorta, AAA dissection, prosthetic valve failure
77
give 3 causes of chronic aortic regurgitation
chronic rheumatic heart disease, syphilis, rheumatoid arthritis, severe hypertension, biscupid aortic valve, aortic endocarditis, Marfan's, osteogenesis imperfecta
78
give 3 symptoms of aortic stenosis
exertional dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, palpitations, angina, syncope, CCF
79
what murmur is heard in aortic regurgitation?
early diastolic murmur.
"at L sternal edge in 4th intercostal space"
80
what would you see on CXR/ECG in aortic regurgitation?
CXR - cardiomegaly and dilatation of the ascending aorta, pulmonary oedema.
ECG - LVH.
81
how would you treat aortic regurgitation?
reduce systolic hypertension - ACE inhibitors.
echo every 6-12/12.
valve replacement.
82
what are the 3 main cardiomyopathies?
hypertrophic (HCM), dilated (DCM) and restrictive
83
what is hypertrophic cardiomyopathy?
ventricular hypertrophy in absence of abnormal loading conditions - LV outflow tract obstruction.
84
what causes hypertrophic cardiomyopathy?
```
50% = autosomal dominant
50% = sporadic.
```
85
what is the major consequence of hypertrophic cardiomyopathy?
sudden cardiac death in young people
86
name 2 clinical features of hypertrophic cardiomyopathy
can be asymptomatic.
| angina, syncope, sudden death, systolic thrill.
87
what investigations might you carry out in cardiomyopathy?
CXR, ECG, echo.
| cardiac MR.
88
how would you treat hypertrophic cardiomyopathy?
beta blockers/CCBs to control symptoms.
anticoagulate to prevent emboli.
implantable defib.
89
give 3 causes of dilated cardiomyopathy
alcohol, hypertension, haemachromatosis, viral infection, autoimmune, congenital.
90
give 3 clinical features of dilated cardiomyopathy
dyspnoea, emboli or arrhythmia, displaced apex beat, S3 gallop, pleural effusion, oedema, jaundice, ascites.
91
how would you treat dilated cardiomyopathy?
bed rest.
diuretics, digoxin, ACE inhibitors.
biventricular pacing/implantable cardiac defibs.
heart transplant.
92
what is restrictive cardiomyopathy?
rigid myocardium restricting diastolic ventricular filling.
93
give 2 causes of restrictive cardiomyopathy
amyloidosis. haemachromatosis. sarcoidosis. scleroderma. idiopathic.
94
give 3 clinical features of restrictive cardiomyopathy
constrictive pericarditis. raised JVP. oedema, ascites, features of RVH.
95
what investigation would you perform in order to diagnose restrictive cardiomyopathy?
cardiac catheterisation.
96
what are the 2 causes of ventricular septal defect?
congenital.
| acquired post-MI.
97
how might a ventricular septal defect present?
severe heart failure in infancy.
| OR - asymptomatic, detected later in life
98
does a smaller ventricular septal defect produce louder or quieter murmurs?
louder
99
what murmur is heard in VSD?
harsh pansystolic murmur at left sternal edge, with systolic thrill
100
give 2 complications of a ventricular septal defect
aortic regurgitation, infundibular stenosis, IE, pulmonary hypertension, Eisenmenger's complex.
101
what is seen on a CXR of someone with a ventricular septal defect?
Small VSD - normal sized heart ± enlarged pulmonary blood vessels.
Large VSD - cardiomegaly, large pulmonary arteries, marked enlargement of pulmonary vessels.
102
how would you manage a ventricular septal defect?
medical support until spontaneous closure.
| OR - surgical patch repair or device closure.
103
what are the different types of atrial septal defect?
ostium secundum defects - most common - present in adulthood.
ostium primum defects - associated with AV valve abnormalities - present early.
104
give 3 clinical features of an atrial septal defect
pulmonary hypertension, cyanosis, arrhythmia, haemoptysis, chest pain, AF, raised JVP.
pulmonary ejection systolic murmur.
105
what investigations are used to diagnose most structural heart defects?
echo.
| cardiac catheter.
106
how would you treat an ASD?
transcatheter or surgical closure
107
what genetic disorder is associated with atrioventricular septal defects?
Downs syndrome
108
what structures are involved in an atrioventricular septal defect?
atrial septum, ventricular septum, mitral and tricuspid valve
109
what are the clinical features and management of a complete AVSD?
breathless neonate, failure to thrive, poor feeding, torrential pulmonary blood flow.
repair with PA band.
110
what are the clinical features and management of a partial AVSD?
presents in adulthood, similar to small ASD/VSD.
| treatment not necessary.
111
what is a patent ductus arteriosus?
persistent communication between left pulmonary artery and descending aorta - L to R shunt.
normally the ductus arteriosus closes within hrs of birth.
112
what are the clinical features of a PDA?
3 classic signs: bounding pulse, 'machinery murmur', pulmonary hypertension.
also - breathless, poor feeding, failure to thrive, Eisenmenger's syndrome
113
how would you treat a PDA?
indometacin (prostaglandin) can stimulate closure.
| if large - surgical or percutaneous closure.
114
what is Eisenmenger's syndrome?
cyanosis - clubbed and blue toes, pink not clubbed fingers.
115
what is coarctation of the aorta?
congenital narrowing of the descending aorta
116
what are the clinical features of coarctation of the aorta? name 2 complications.
radiofemoral delay, weak femoral pulse, high BP, systolic murmur.
heart failure + IE.
117
how would you treat coarctation of the aorta?
surgery or balloon dilation ± stenting
118
what are the consequences of a biscupid aortic valve?
go on to develop aortic stenosis - requiring valve replacement.
higher risk of IE.
119
give some clinical features of pulmonary stenosis
RV failure as neonate. collapse. poor pulmonary blood flow. RVH. tricuspid regurg.
120
how would you treat pulmonary stenosis?
ballon valvuloplasty.
| open vavlotomy.
121
what are the 4 features of tetralogy of Fallot?
1 - VSD.
2 - pulmonary stenosis.
3 - RVH.
4 - aorta overriding the VSD
122
what causes tetralogy of Fallot?
abnormalities in separation of truncus arteriosus into the aorta and pulmonary arteries early in gestation
123
describe the presentation of tetralogy of Fallot
acyanotic at birth. gradually become cyanotic.
| Fallow (hypoxic) spells - go blue, restless, inconsolable crying - toddlers may squat.
124
what is the characteristic feature of a CXR in tetralogy of Fallot?
boot shaped heart
125
how is tetralogy of Fallot managed?
oxygen. knee-chest position. morphine.
long-term beta blockers.
surgery at less than 12 months.
