Cardio Flashcards
Describe the pathophysiology for IHD
- Damage to endothelial cells ->endo secretes chemoattractants -> leuko migrate and accumulate in intima
- Foam cells/macrophages/T-lymphs form fatty streaks -> foam cells rupture -> release lipids, smooth muscle cells migrate from media to intima -> dense fibrous camp with necrotic core formed
- Plaque = partial occlusion of lumen ->blood flow restricted -> ISCHEMIA
- Plaque rupture -> thrombus formed -> lumen fully occluded -> INFARCTION
Which arteries does atherogenesis affect most?
- Left Anterior Descending (LAD)
- Circumflex
- Right Coronary Artery (RCA)
State in ascending order of severity the consequences of IHD
- Angina
- Unstable angina
- Non ST Elevated Myocardial Infarct (NSTEMI)
- ST Elevated Myocardial Infarct (STEMI)
Define angina
Result of myocardial ischaemia where blood supply < metabolic demand
What is the difference a stable and unstable angina?
- STABLE
- Chest pain has trigger
- 1-5 mins
- Relieved by rest/ GTN spray (Glyceryl
Trinitrate)
- UNSTABLE
- Chest pain at rest
- > 20 mins
- No relief from rest or GTN spray
Define Prinzmetal’s angina
- Caused by coronary artery spasm
- Occurs at rest/night
Diagnosis of stable angina
- Radiation of pain
- Induced by exertion
- Relieved by rest/GTN spray
Diagnosis of unstable angina/NSTEMI/STEMI
- NSTEMI,STEMI
- Elevated troponin
- Elevated myoglobin
- Elevated CK levels
- STEMI
- ST elevation on ECG
Symptoms of IHD
- Chest pain
- Radiation
- Nausea, Sweating, Fatigue, Weak breathing (NSFW)
Diagnosis of IHD
- Resting and exercise ECG
- Bloods: HbA1c, FBC, cholesterol profile
- CT coronary angiography
- Bio markers: troponin, myoglobin, CK
Treatment of angina
- Statin: simvastatin
- Nitrate: GTN spray (abort attack)
- Dual antiplatelet: aspirin + clopidogrel
Treatment of unstable angina/NSTEMI
- B-blocker
- Morphine
- Oxygen
- Aspirin
- Nitrate
Treatment of acute STEMI
- If possible within 120 min of medical contact - Percutaneous Coronary Intervention
- If not possible: fibrinolysis
-alteplase
-streptokinase
State surgical interventions for IHD
- PCI
- Coronary Artery Bypass Grafting (CABG)
- Preferred for diabetes and >65
Define heart failure
Inability of heart to deliver blood and oxygen at a rate in line with the requirements of the body
How does the body compensate for heart failure?
- Sympathetic system activation
- BP falls -> baroreceptors detect -> sympathetic activation -> +ve inotropic/chronotropic -> CO increases
- RAAS system
State aetiology of heart failure
- IHD
- Cardiomyopathy
- Valvular heart disease
- Hypertension
- Excess alcohol
State the different types of heart failure
- Systolic heart failure - inability of ventricle to contract properly
- Diastolic heart failure - inability of ventricle to relax and fill
State risk factors of heart failure
- > 65
- Male
- Obese
- MI history
- African descent
State signs and symptoms of heart failure
- Shortness of breath
- Orthopnea (difficulty breathing when laying)
- Fatigue
- Ankle swelling
- Pulmonary oedema (backflow from decreased CO; pink frothy sputum)
- Cold peripheries
Diagnosis of heart failure
- Blood test
- Brain Natrieuretic Peptide (BNP)
- ECG
- Transthoracic ECG
- Wall motion abnormalities
- Valvular disease
- Cardiomyopathies
- Chest X-ray
- Alveolar oedema
- B-lines
- Cardiomegaly
- Dilated upper lobe vessels
Treatment of heart failure
- ACUTE - OMFG
- Oxygen
- Morphine
- Furosemide
- GTN spray
- Chronic heart failure
- Lifestyle
- Avoid NSAIDs/verapamil
- Medical
- 1st line - RAMIPRIL (ACEi) + PROPANOLOL (beta blocker)
- Lifestyle
State the 3 types of Hypertension
- Stage 1 - >140/90 mmHg or ABPM > 135/85
- Stage 2 - >160/100 mmHg or ABPM 150/95
- Malignant - >180/110
Aetiology of hypertension
- Primary = unknown
- Secondary
-renal disease
-pregnancy
-endocrine disease
State signs and symptoms of hypertension
- Malignant - look for damage to:
brain - cerebral oedema, haemorrhage
eye - papilloedema, cotton wool spots
heart - AHF, aortic dissection -> chest pain
kidney - AKI -> haematuria, proteinuria
Diagnosis of hypertension
- If patient comes to clinic with > 140/90
- Recheck BP on 2-3 occasions over period of time
- If persistently high - offer ABPM
- If stage 1 diagnoses -> do QRISK for treatment
- If stage 2 diagnosed -> start hypertensive treatment
- If malignant hypertension AND signs of papilloedema and/or renal haemorrhage
- same day admission
- hypertensive drug treatment stat
Treatment of hypertension
- 1st line - ACEi
- Second line - ACEi + CCB (calcium channel blockers) or ACEi + diuretic
- Third line - ACEi + CCB + diuretic
- DIABETES - ACEi ALWAYS first line
- BLACK - CCB before ACEi
- CCB before diuretics unless oedema/intolerance
- ACEi = contraindication in pregnancy/general anaesthesia
Define pericarditis
Inflammation of pericardium with/without effusion
Aetiology of pericarditis
- Infection
- Viral - coxsackievirus
- Bacterial - mycobacterium TB
- Trauma
- Uraemia
- MI
Signs and symptoms of pericarditis
- Chest pain
- worse by inspiration
- relieved by sitting forward
- Fever/ shortness of breath -> sign of infection
Diagnosis of pericarditis
- ECG
- saddle shaped ST elevation
- PR depression
- echo/chest x-ray if effusion suspected
Management of pericarditis
NSAIDs + PPI (brufen)
colchicine
What is a possible complication of pericarditis?
Cardiac tamponade
Define cardiac tamponade
- Life threatening
- Accumulation of fluid in pericardial space
- Compression of heart chambers
- Decrease in venous return
- Decrease in heart filling
- Reduced CO
Signs and symptoms of cardiac tamponade
- Beck’s triad
- Falling BP
- Rising JVP
- Muffled heart sound
- Pulsus paradoxus
- Large decrease in SV -> systolic BP drops >10 mmHg on inspiration
Diagnosis of cardiac tamponade
Echo
Treatment of cardiac tamponade
Pericardiocentesis - removal of fluid of pericardial space
Define infective endocarditis
Infection of inner lining of heart/valves
State the organism involved in infective endocarditis
- Staph. aureus (most common IVDU (intravenous drug use))
- Strep. viridans (mouth/oral surgery)
- Staph. epidermis (prosthetic valves)
Signs and symptoms of infective Endocarditis
- Signs of infection (usual suspects)
- Fever + new murmer = IE
- Splinter haemorrhages
- Osler nodes (tender nodules in finger)
- Janeway lesions (nodules on palm)
- Roth spots (haemorrhage with clear centre on fundoscopy)
Diagnosis of IE
MAJOR CRITERIA
1. Blood culture positive for IE
- Consistent result from 2 separate blood cultures
OR
- Persistently positive blood culture (3, >12h apart)
2. Evidence of endocardial involvement
- Echocardiogram = positive for IE,abscess,dehiscence of prosthetic valve
- New valvular regurgitation
MINOR CRITERIA
1. Predisposing heart condition/injected drug use
2. Fever
3. Vascular/immunological signs
4. +ve blood culture that does not meet major criteria
5. +ve echo that does not meet major criteria
DEFINITE IE = 2/1 mAJOR + 3 MINOR OR ALL 5 MINOR
Treatment of IE
Antibiotics (4-6weeks)
- 1st line if organism unknown = FAG (flucloxacillin + ampicillin + gentamicin)
- If staph = Flucloxacillin + rifampicin + gentamicin
- If MRSA = vancomycin + rifampicin + gentamicin
- Non staph = Benzylpenicillin + gentamicin
Define mitral stenosis
- Obstruction of left ventricle inflow
- Prevents proper filling during diastole
Epidemiology of mitral stenosis
- M>F
- Most common cause = rheumatic heart disease
Risk factors of mitral stenosis
- History of rheumatic fever
- Untreated strep infections
Signs and symptoms of mitral stenosis
- Progressive dysponea
- Haemoptysis (coughing up blood)
- Right heart failure
- AF
- Malar flush
Diagnosis of mitral stenosis
- CXR (chest radiography)
- LA enlargement
- Pulmonary oedema/congestion
- calcified mitral valve
- ECG
- AF
- LA enlargement
- ECHO
- GOLD STANDARD for diagnosis
- Assess mitral valve mobility, gradient and mitral valve area
Treatment of mitral stenosis
- Mechanical problem = medical therapy does not prevent progression
MEDICAL - Beta blockers - control heart rate = prolong diastolic filling
- Diuretics for fluid overload
SURGICAL - Percutaneous mitral balloon valvotomy
- Mitral valve replacement
Heart sound for mitral stenosis
- Diastolic murmur
- Low pitched diastolic rumble at apex
- Loud opening S1 snap; heard at apex
Define mitral regurgitation
- Backflow of blood from LV -> LA during systole
- Mild MR present in 80% normal individuals
Aetiology of mitral regurgitation
- Abnormalities of the valve leaflets, chordae tendinae, papillary muscles or LV
- Most common = myxomatous degeneration (weakening of chordae tendinae) -> floppy mitral valve
- Ischaemic mitral valve
- Infective Endocarditis
- DIlated cardiomyopathy
Risk factors of mitral regurgitation
- Females
- Lower BMI
- Age
- Renal dysfunction
- Prior MI
Pathophysiology of mitral regurgitation
- Regurgitation in LA -> LA dilation
- Compensatory mechanism - LA enlargement, LV hypertrophy
- Progressive LA dilation and RV dysfunction due to pulmonary hypertension
Signs and symptoms mitral regurgitation
- Soft S1 and pan systolic murmur at apex radiating to axilla
- Prominent third extra heart sound (S3)
- Exertion dysponea (due to pulmonary venous hypertension)
- Fatigue
- Increased SV causes palpitation
Diagnosis of mitral valve regurgitation
- ECG
- May show LA enlargement
- AF
- LV hypertrophy in severe MR
- Echo
- Estimation of LA and LV size and function
- Valve structural assessment
Treatment of mitral valve regurgitation
- Vasodilator - ACEi (Ramipril/hydralazine)
- HR control for AF with beta blockers (atenolol), CCB and digoxin
- Anticoagulants
- Diuretics for fluid overload (Furosemide)
- Surgical intervention
Define peripheral vascular disease (PVD)
- Partial blockage of leg or peripheral vessels by an atherosclerotic plaque
- Resulting in thrombus and inefficient perfusion of the lower limb
Risk factors of PVD
Usual suspects
Diagnosis of PVD
- Exclude arteritis by looking at ESR/CRP (would be raised for arteritis)
- FBC - Check Hb to exclude anaemia or polycthaemia
- ECG - cardiac ischemia
- Ankle/brachial pressure index (ABPI) - indicate severity of disease
- Measure cuff pressure at which blood flow detectable
- In posterior tibial or anterior tibial arteries vs brachial artery
- Intermittent claudication (pain in limbs upon use) = ABPI 0.5-0.9
- <0.5 ABPI = critical leg ischaemia
- Colour duplex ultrasound - first line
- MR/CT angiography
Symptoms of PVD
Pain
Palor
Perishing cold
Pulseless
Paralysis
Paraesthesia - (pins & needles)
Treatment of PVD
- Risk factor modification
- Revascularisation for critical ischaemia
- Surgical removal of embolus
What is the difference between intermittent claudication and critical ischaemia?
- Tissue just suffering, oxygen debt when exerted
- Tissue is DYING and suffering at rest, blood supply inadequate for basal metabolism, gangrene risk
Signs and symptoms of type of ischaemia from PVD
- Nocturnal pain in all toes of left foot, relieved from hanging foot off the bed = critical ischaemia
- Loss of use f right side of body + fast irregular pulse = acute ischaemia
Define heart block
- Block in AV node or bundle of his = AV BLOCK
- Block lower in conduction system = BUNDLE BRANCH BLOCK
What are the 3 types of AV block
- 1st degree AV block
- 2nd degree AV block
- 3rd degree AV block
Define 1st degree AV block
- Simple prolongation of PR interval greater than 0.22 s
- Atrial depolarisation followed by conduction to ventricles with delay
Aetiology of 1st degree AV block
- Hypokalaemia
- Myocarditis
- Inferior MI
- AVN blocking drug (beta blockers, CCB, digoxin)
Treatment of 1st degree AV block
Asymptomatic -> no treatment
Define 2nd degree AV block
- Only SOME P waves conduct
- Mobitz I and Mobitz II
Define Mobitz I 2nd degree AV block
- aka Wenckebach block phenomenon
- Progressive PR interval prolongation until beat is ‘dropped’
- P wave then fails to conduct; excitation fails to pass through AVN/bundle of His
- PR interval before blocked P wave»_space; PR interval after blocked P wave
Aetiology of Mobitz I 2nd degree AV block
- AVN blocking drug (beta blockers, CCB, digoxin)
- Inferior MI
Signs and symptoms of Mobitz I 2nd degree AV block
- Light headedness
- Dizziness
- Syncope
Treatment of Mobitz I 2nd degree AV block
- NO pacemaker required unless poorly tolerated
Define Mobitz II 2nd degree heart block
- PR interval = constant
- Some P waves don’t conduct
- Failure of conduction through His-Purkinje system
Aetiology of Mobitz II 2nd degree AV block
- Anterior MI
- Mitral valve surgery
- SLE and lyme disease
- Rheumatic fever
Signs and symptoms of Mobitz II 2nd degree AV block
- Shortness of breath
- Postural hypotension
- Chest pain
Treatment of Mobitz II 2nd degree AV block
High risk of sudden complete AV block -> pacemaker should be fitted
Define 3rd degree AV block
- Complete heart block
- All atrial activity fails to conduct ventricles
- P waves completely independent of QRS complex
Aetiology of 3rd degree AV block
- Structural heart disease
- Ischaemic heart disease
- Hypertension
- Endocarditis or lyme disease
Define narrow-complex escape rhythm
- QRS complex < 0.12 s
- Implies block in His bundle
- Recent-onset narrow-complex AV block, may be relieved from IV atropine
- Requires permanent pacemaker if chronic
Define broad-complex escape rhythm
- QRS complex > 0.12 s
- Implies block BELOW bundle of his
- Dizziness and blackouts
- Permanent pacemaker
Define incomplete bundle branch block
Bundle branch conduction delay -> slight widening oof QRS complex (up to 0.11 s)
Define complete bundle branch block
Wider QRS complex (larger than 0.12 s)
Aetiology of right bundle branch block
- PE
- IHD
- Atrial/ventricular septal defect
Pathophysiology of RBBB
- Right bundle no longer conducts
- Both ventricles do not get impulses at same time
- Instead, left to right .˙. late activation of right ventricle
Diagnosis of RBBB
- Deep S wave in leads I & V6
- Tall rate R wave in lead V1
- ECG
- V1 - QRS - M shape
- V5 & V6 - QRS - W shape
Define LBBB
Late activation of LV
Aetiology of LBBB
- IHD
- Aortic valve disease
Diagnosis of LBBB
- Deep S wave in lead V1
- Tall late R wave in leads I and V6
- Abnormal Q waves
- ECG
- V1 & V2 - QRS - W shape
- V4 - V6 - QRS - M shape
Define abdominal aortic aneurysm (AAA)
Permanent dilation of abdominal aortic artery exceeding 3cm
Aetiology + risk factors of AAA
- severe atherosclerotic damage
- Smoking
- Male
- Age
- Hypertension
Clinical presentation of unruptured AAA
- Often asymptomatic
- Pain in abdomen, back, loin and groin
- Pulsatile abdominal swelling
What factors increase risk of AAA rupture
- Hypertension
- Female
- Smoker
- Strong family history
Clinical presentation of ruptured AAA
- Intermittent/continuous abdominal pain
- Pulsatile abdominal swelling
- Collapse
- Hypotension
- Tachycardia
Differential diagnosis of AAA
- GI bleed
- Ischaemic bowel
- Appendicitis
Diagnosis of AAA
- Abdominal ultrasound
- CT/MRI angiography scans
Treatment of AAA
- Small (<5.5cm) just monitored
- Surgery
- Enovascular repair: stent
Define aortic dissection
- Tear in intima
- Blood penetrates diseases medial layer
- Flows between layers of aorta
- Layers forced apart -> dissection
Aetiology of aortic dissection
- Genetic
- Degenerative
- Atherosclerotic
- Inflammatory
- Trauma
Clinical presentation of aortic dissection
- Sudden onset of severe central chest pain
- Radiates to the back and down the arms
- Hypertension
- Pain = maximal from onset unlike MI
- Aortic regurgitation, coronary ischaemia, cardiac tamponade
Diagnosis of aortic dissection
CXR
- Widened mediastinum
Treatment of aortic dissection
- Urgent antihypertensive medication to less than 120mmHg
- IV beta blockers (IV metoprolol) or vasodilators
- Analgesia
- Surgery to replace aortic arch
- Endovascular intervention with stent
Define atrial fibrillation
- Chaotic irregular atrial rhythm at 300-600 bpm
- AV node responds intermittently
- .˙. irregular ventricular rate
Clinical classification of AF
- Onset within previous 48h
- Paroxysmal - stops spontaneously within 7d
- Recurrent - 2 or more episodes
- Persistent - continues for more than 7 days
- Permanent
Aetiology of AF
- idiopathic
- Hypertension
- Heart failure
- Any condition that results in:
- Raised atrial pressure
- Atrial hypertrophy
- Cardiac surgery
Pathophysiology of AF
- Atria have no coordinated mechanical action
- Proportion of impulses conducted to the ventricles
- .˙. NO UNIFIED ATRIAL CONTRACTION; instead atrial spasm
Clinical presentation of AF
- May be asymptomatic
- Palpitations
- Dysnoea
- Fatigue
- No P waves on ECG
- Rapid irregular QRS rhythm
Diagnosis of AF
ECG
- Absent P waves
- Irregular and rapid QRS complex
Treatment of AF
- Treat provoking cause
- Electrical conversion to sinus rhythm (defib)
- Anti-arrhythmic drug (felcainide and amiodarone)
- Ventricular rate control
- AV node blocking drug
- CCB (verapamil)
- Beta blockers (Bisoprolol)
- Digoxin
- Anti-arrhythmic (Amiodarone)
Define atrial flutter
- Organised atrial rhythm
- Atrial rate 250-350 bpm
Aetiology of atrial flutter
- Idiopathic
- CHD
- Obesity
- Hypertension
- Heart failure
Clinical presentation of atrial flutter
- Palpitations
- Breathlessness
- Chest pain
- Dizziness
- Fatigue
Diagnosis of atrial flutter
- ECG
- Regular sawtooth atrial flutter waves (F waves) between QRS complexes
Treatment of atrial flutter
- Anticoagulate first (low mw heparin)
- Electrical cardioversion
- Catheter ablation - create conduction block
- IV Amiodarone - restore sinus rhythm
- Bidoprolol - suppress further arrhythmia
