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Phase 2a > Cardio > Flashcards

Cardio Flashcards

1
Q

What happens in atherogenesis?

A

Damage to endothelial cells → endothelium secretes chemoattractants → leukocytes migrate and accumulate in intima → foam cells/macrophages/T-lymphocytes form fatty streaks → foam cells rupture, releasing lipids + SMC migrate from media to intima → dense, fibrous cap w necrotic core formed
This plaque can partially occlude the lumen → blood flood is restricted → ischemia
Plaque can rupture → thrombus formed →lumen is fully occluded → infarction

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2
Q

Which arteries does atherogenesis affect most commonly?

A

LAD, circumflex, RCA

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3
Q

What are the risk factors for IHD?

A

age
smoking
obesity, high serum cholesterol
diabetes
hypertension
family history
M>F

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4
Q

What is IHD?

A

cardiac myocyte damage (and eventual death) due to insufficient oxygen-rich blood
in ascending order of severity: stable angina> unstable angina > NSTEMI > STEMI
can be due to increased myocardial workload + coronary artery occlusion OR due to insufficient oxygen-rich blood supply
main causes: atheroma, valvular disease (aortic stenosis), anaemia (demand & supply)

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5
Q

What is angina?

A

Angina is the result of myocardial ischaemia, where blood supply < metabolic demand

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6
Q

What is stable angina?

A

chest pain precipitated by exposure to cold/exercise

lasts 1-5 minutes

relieved by rest/GTN spray
radiation of pain
induced by exertion
relieved by rest/GTN spray

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7
Q

What is unstable angina/stemi/nstemi?

A

chest pain at rest

prolonged, >20 minutes

no relief by rest/GTN spray
NSTEMI, STEMI: increase in troponin, myoglobin, CK levels

STEMI: ST-elevations on ECG

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8
Q

What is prinzmetal’s angina?

A

caused by coronary artery spasms; occur at rest/night

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9
Q

What are the symptoms of IHD?

A

chest pain: discomfort, heaviness, squeezing, burning
radiation: left arm, shoulder, neck, jaw
NSFW: nausea, sweating, fatigue, weak breathing
Some patients will have atypical presentations!
no pain
low-grade fever
pale, cool, clammy skin
hyper/hypotension

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10
Q

How is IHD diagnosed?

A

history taking, physical examination
investigations
resting ECG
exercise ECG (to induce ischaemia)
Blood tests: HBA1C, FBC, cholesterol profile
CT coronary angiography*
biological markers: troponin, myoglobin, CK

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11
Q

How is IHD treated?

A

BANS
statin: simvastatin
nitrate: GTN spray (to abort attacks)
dual antiplatelet: aspirin + clopidogrel
Acute (UA/NSTEMI): BMOAN
b-blocker, morphine, oxygen, aspirin, nitrate
Acute STEMI
(if available within 120 min of medical contact) PCI
if not, fibrinolysis (alteplase, streptokinase)
surgical interventions
PCI
CABG (preferred in patients with diabetes, >65 years)

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12
Q

What areas of the heart are represented by the ECG leads?

A
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13
Q

What is heart failure?

A

Inability of the heart to deliver blood and thus oxygen at a rate that is commensurate with the requirements of the body

can result from structural/functional cardiac disorder that impairs the heart’s ability to function

when heart begins to fail, other systems try to compensate to maintain CO and perfusion

[sympathetic system activation] BP falls → detected by baroreceptors → sympathetic activation → positively inotropic/chronotropic → CO increases

RAAS system

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14
Q

What causes heart failure?

A

Ischemic heart disease*

cardiomyopathy (heart walls become thickened, stiff or stretched)

valvular heart disease (AS/MR)

hypertension

alcohol excess

cor pulmonale (disease of lung/pulmonary vessels → pulmonary hypertension → RV hypertrophy → RHF with venous overload, peripheral oedema, hepatic congestion)

anemia, arrhythmias, hyperthyroidism

congestive HF = both sided HF

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15
Q

What are the different types of heart failure?

A

systolic HF: inability of ventricle to contract properly

diastolic HF: inability of ventricle to relax and fill

acute/chronic

HF reserved ejection fraction

systolic, EF <40%

HF preserved ejection fraction

diastolic, EF > 40%

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16
Q

What are the risk factors for heart failure?

A

>65, male, obese, people who have previously had an MI, African descent

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17
Q

What are the signs and symptoms of heart failure?

A

SOFA PC

shortness of breath

orthopnea

fatigue

ankle swelling

pulmonary oedema (due to backflow from decreased CO; produced cough with pink frothy sputum)

cold peripheries

Raised JVP

End respiratory crackles

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18
Q

How is heart failure diagnosed?

A

Blood test

brain natriuretic peptide (BNP)*

ECG

Transthoracic ECG

wall motion abnormalities

valvular disease

cardiomyopathies

Chest X-Ray

Alveolar oedema

B-lines

Cardiomegaly

Dilated upper lobe vessels

Effusion (pleural)

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19
Q

How is heart failure treated?

A

Acute HF: OMFG

oxygen, morphine, furosemide, GTN spray

Chronic HF

lifestyle

stop smoking!

eat less salt, optimise weight and nutrition

avoid NSAIDs/verapamil

medical: AABCDD

1st line: ACE-I + B-blocker

2nd line: ARB + nitrate

3rd line: cardiac resynchronization or digoxin

diuretics: furosemide (symptom relief)

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20
Q

What is stage 1 hypertension?

A

>140/90 mmHg or ABPM >135/85

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21
Q

How does hypertension present?

A

Usually asymptomatic

Malignant: look for damage in brain, eye, heart, kidney

H(ead)-EYE-PE(cs, heart)R(enal)

Head: cerebral oedema, haemorrhage → stroke symptoms, headache

Eye: papilloedema, cotton-wool spots

Pecs/heart: AHF, aortic dissection → chest pain, dyspnoea

Renal: AKI → haematuria, proteinuria

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22
Q

How is hypertension diagnosed?

A

If patient comes in with clinic BP > 140/90

recheck BP on 2-3 occasions over next few weeks/months

if persistently high, offer ABPM

if stage 1 diagnosed → do QRISK to decide treatment

if stage 2 diagnosed → start antihypertensive treatment

If patient has malignant hypertension AND signs of papilloedema and/or signs of renal haemorrhage

same day admission

start antihypertensive drug treatment immediately

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23
Q

How is hypertension treated?

A

First line: ACE-I

Second line: ACE-I + CCB, or ACE-I + Diuretic

Third line: ACE-I + CCB + Diuretic

for diabetics, ACE-I is ALWAYS first line

for black patients, start with CCB as they are not responsive to ACE-I

give CCB before D, unless evidence of oedema/intolerance

ACE-I are CI in pregnancy/if patient is on general anestheia

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24
Q

What is pericarditis?

A

Inflammation of the pericardium with/ without effusion

Common in young adults (tend to have prior viral infection)

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25
What causes pericarditis?
Causes: Infectious Viral (common) Coxsackievirus Bacterial Mycobacterium tuberculosis Non-infectious Trauma (common) Uraemia, MI
26
How does pericarditis present?
Chest pain Relieved by sitting forward/ leaning forward Worsened by inspiration Fever/ shortness of breath → sign of infection Pericardial friction rub (high pitched scratchy sound heard loudest on the midline during inspiration)
27
How is pericarditis investigated?
ECG (diagnostic) Saddle- shaped ST elevation PR depression Do a echo/ chest X-ray if suspect effusion
28
How is pericarditis managed?
NSAIDs (ibuprofen) + Colchicine
29
What are the complications of pericarditis?
Cardiac tamponade
30
What is cardiac tamponade?
Life threatening condition whereby there is an accumulation of fluid in the pericardial space → compression of the heart chambers → decrease in venous return → decrease in filling in the heart → reducing cardiac output
31
How does cardiac tamponade present?
Beck’s triad falling BP rising JVP muffled heart sound Pulsus paradoxus (large decrease in stroke volume → systolic blood pressure drops by \> 10mmHg on inspiration
32
How is cardiac tamponade investigated?
Echocardiogram
33
How is cardiac tamponade managed?
pericardiocentesis (removal of the fluids from the pericardial space)
34
What is infective endocarditis?
Infection of the inner lining of the heart/ valves (endocardium)
35
What causes infective endocarditis?
Stahpylococcus aureus (most common → IVDU) Streptococcus viridans (mouth/ oral sugery, most common→ non-IVDU) Staphylococcus epidermis (prosthetic valves)
36
How does infective endocarditis present?
signs of infection (fever, fatigue, loss of appetite) Splinter haemorrhages Osler nodes (tender nodules in finger) Janeway lesions (nodules on palms) Roth spots (haemorrhage with clear centre on fundoscopy) \*If someone comes in with fever and a new murmur, suspect IE
37
How is infective endocarditis diagnosed?
Modified Duke’s Criteria Echo (gold standard)
38
What is the modified Duke's criteria?
39
How is infective endocarditis treated?
Antibiotics (4-6 weeks) If staphylococcus (Flucloxacillin + rifampicin + gentamicin) \*MRSA → vancomycin + rifampicin + gentamicin Not staphylococcus Benzylpenicillin + gentamicin Not sure which organism (first line) FAG (flucloxacillin + ampilicin + gentamicin)
40
Valvular disease
41
What is tachycardia?
Fast heart rate \>100 bpm
42
What is atrial tachycardia?
Abnormal P waves Normal QRS \>150bpm
43
What is AV nodal re-entrant tachycardia?
Absent P wave Normal QRS
44
What is ventricular tachycardia?
No P waves Regular wide QRS No T waves
45
What is bradycardia?
Slow heart rate \<60bpm PR interval between 0.12 and 0.20 seconds QRS complex \<0.12
46
What is atrial fibrillation?
Chaotic irregular rhythm with an irregular ventricular rate No P waves Irregularly irregular QRS ●Stroke risk increase due to static blood in the atria – it pools and it remains still, causing it to clot and embolise
47
What causes atrial fibrillation?
* Idiopathic * Hypertension * Heart failure * Coronary artery disease * Valvular heart disease * Cardiac surgery * Cardiomyopathy * Rheumatic heart disease
48
What are the risk factors for atrial fibrillation?
* 60+ * Diabetes * High BP * Coronary artery disease * Past MI * Structural heart disease
49
How does atrial fibrillation present?
* Asymptomatic * Palpitations * Dyspnoea * Chest pains * Fatigue * NO P WAVES ON ECG * Rapid/irregular QRS * Apical pulse\>radial
50
What is the pathophysiology of atrial fibrillation?
continuous rapid activation of the atria with no organised mechanical action at 300-600bpm.
51
How is atrial fibrillation treated?
Cardioversion * Give a LMWH * Shock with defibrillator ●LMWH = low molecular weight heparin e.g. dalteparin to prevent thromboembolism
52
What is atrial flutter?
organised atrial rhythm at a rate of 250-350bpm Sawtooth pattern on ECG (F-waves) - definitive diagnosis
53
What causes atrial flutter?
* Idiopathic * Coronary heart disease * Obesity * Hypertension * Heart failure * COPD Pericarditis
54
What are the risk factors for atrial flutter?
Atrial fibrillation
55
How does atrial flutter present?
* Palpitations * Breathlessness * Chest pain * Dizziness * Syncope * Fatigue
56
How is atrial flutter treated?
Cardioversion * Give a LMWH * Shock with defibrillator * Catheter ablation – creates a conduction block * IV Amiodarone – restore sinus rhythm
57
What is the pathophysiology of atrial flutter?
the P wave produces a sawtooth patten with regular conduction to the ventricles - Wave of contraction around the atria causing the repolarisation of the AV node
58
What is bundle branch block?
a block in the conduction of one of the bundle branches, so the ventricles don’t receive impulses at the same time
59
What is right bundle branch block?
Right Bundle Branch Block MaRRoW Wide QRS
60
What causes right bundle branch block?
* Pulmonary embolism * IHD * Atrial Ventricular Septal Defect
61
What is the pathophysiology of right bundle branch block?
* Right bundle doesn’t conduct * Impulse spreads from left ventricle to right * Late activation of RV
62
How is right bundle branch block diagnosed?
ECG
63
How does right bundle branch block present?
* Asymptomatic * Syncope/Presyncope
64
How is right bundle branch block treated?
* Pacemaker * CRT – cardiac resynchronisation therapy * Reduce blood pressure
65
What is left bundle branch block?
WiLLiaM Wide QRS + notched top T wave inversion in lateral leads
66
What causes left bundle branch block?
* IHD * Aortic valve disease
67
What is the pathophysiology of left bundle branch block?
* Left bundle doesn’t conduct * Impulse spreads from right ventricle to left Late activation of LV
68
How is LBBB diagnosed?
ECG
69
How does LBBB present?
* Asymptomatic * Syncope/Presyncope
70
How is LBBB treated?
* Pacemaker * CRT – cardiac resynchronisation therapy * Reduce blood pressure
71
What is heart block?
a block at any level of the conduction system in which conduction seizes
72
What is 1st degree heart block?
PR interval \>200ms Asymptomatic
73
What is 2nd degree heart block: Mobitz I?
Progressive lengthening of PR interval One non-conducted P wave Next PR interval is shorter Light headedness Dizziness Syncope
74
What is 2nd degree heart block: Mobitz II?
Constant PR Occasional non-conducted P-waves Wide QRS
75
What is 2nd degree hear block: 2:1?
Two waves per QRS Normal consistent PR intervals SOB Postural hypotension Chest pain
76
What is 3rd degree heart block?
P waves and QRS at different rates Dissociation Abnormally shaped QRS Dizziness Blackouts Permanent pacemaker IV atropine
77
What causes heart block?
* Athletes * Sick sinus syndrome * IHD – esp MI * Acute myocarditis * Drugs * Congenital * Aortic valve calcification * Cardiac surgery/trauma
78
How do you investigate heart block?
ECG
79
How do you treat heart block?
Cardioversion * Give a LMWH * Shock with defibrillator * Catheter ablation – creates a conduction block * IV Amiodarone – restore sinus rhythm
80
What is stage 2 hypertension?
\>160/100 or ABPM 150/95
81
What is malignant hypertension?
\>180/110
82
What causes hypertension?
Primary: unknown Secondary: renal disease/pregnancy/endocrine diseases/coarctation/drugs and toxins

Phase 2a (25 decks)

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