Cardio Flashcards
What happens in atherogenesis?
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
Which arteries does atherogenesis affect most commonly?
LAD, circumflex, RCA
What are the risk factors for IHD?
age
smoking
obesity, high serum cholesterol
diabetes
hypertension
family history
M>F
What is IHD?
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)
What is angina?
Angina is the result of myocardial ischaemia, where blood supply < metabolic demand
What is stable angina?
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
What is unstable angina/stemi/nstemi?
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
What is prinzmetal’s angina?
caused by coronary artery spasms; occur at rest/night
What are the symptoms of IHD?
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
How is IHD diagnosed?
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
How is IHD treated?
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)
What areas of the heart are represented by the ECG leads?
What is heart failure?
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
What causes heart failure?
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
What are the different types of heart failure?
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%
What are the risk factors for heart failure?
>65, male, obese, people who have previously had an MI, African descent
What are the signs and symptoms of heart failure?
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
How is heart failure diagnosed?
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)
How is heart failure treated?
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)
What is stage 1 hypertension?
>140/90 mmHg or ABPM >135/85
How does hypertension present?
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
How is hypertension diagnosed?
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
How is hypertension treated?
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
What is pericarditis?
Inflammation of the pericardium with/ without effusion
Common in young adults (tend to have prior viral infection)
What causes pericarditis?
Causes:
Infectious
Viral (common)
Coxsackievirus
Bacterial
Mycobacterium tuberculosis
Non-infectious
Trauma (common)
Uraemia, MI
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)
How is pericarditis investigated?
ECG (diagnostic)
Saddle- shaped ST elevation
PR depression
Do a echo/ chest X-ray if suspect effusion
How is pericarditis managed?
NSAIDs (ibuprofen) + Colchicine
What are the complications of pericarditis?
Cardiac tamponade
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
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
How is cardiac tamponade investigated?
Echocardiogram
What is the modified Duke’s criteria?
Valvular disease
What is right bundle branch block?
Right Bundle Branch Block
MaRRoW
Wide QRS
What is left bundle branch block?
WiLLiaM
Wide QRS + notched top
T wave inversion in lateral leads
