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SJ Phase 2a > Cardio > Flashcards

Cardio Flashcards

1
Q

Describe the pathophysiology for IHD

A
  1. Damage to endothelial cells ->endo secretes chemoattractants -> leuko migrate and accumulate in intima
  2. 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
  3. Plaque = partial occlusion of lumen ->blood flow restricted -> ISCHEMIA
  4. Plaque rupture -> thrombus formed -> lumen fully occluded -> INFARCTION
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2
Q

Which arteries does atherogenesis affect most?

A
  1. Left Anterior Descending (LAD)
  2. Circumflex
  3. Right Coronary Artery (RCA)
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3
Q

State in ascending order of severity the consequences of IHD

A
  1. Angina
  2. Unstable angina
  3. Non ST Elevated Myocardial Infarct (NSTEMI)
  4. ST Elevated Myocardial Infarct (STEMI)
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4
Q

Define angina

A

Result of myocardial ischaemia where blood supply < metabolic demand

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5
Q

What is the difference a stable and unstable angina?

A
  1. STABLE
    • Chest pain has trigger
    • 1-5 mins
    • Relieved by rest/ GTN spray (Glyceryl
      Trinitrate)
  2. UNSTABLE
    • Chest pain at rest
    • > 20 mins
    • No relief from rest or GTN spray
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6
Q

Define Prinzmetal’s angina

A
  1. Caused by coronary artery spasm
  2. Occurs at rest/night
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7
Q

Diagnosis of stable angina

A
  1. Radiation of pain
  2. Induced by exertion
  3. Relieved by rest/GTN spray
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8
Q

Diagnosis of unstable angina/NSTEMI/STEMI

A
  1. NSTEMI,STEMI
    • Elevated troponin
    • Elevated myoglobin
    • Elevated CK levels
  2. STEMI
    • ST elevation on ECG
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9
Q

Symptoms of IHD

A
  1. Chest pain
  2. Radiation
  3. Nausea, Sweating, Fatigue, Weak breathing (NSFW)
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10
Q

Diagnosis of IHD

A
  1. Resting and exercise ECG
  2. Bloods: HbA1c, FBC, cholesterol profile
  3. CT coronary angiography
  4. Bio markers: troponin, myoglobin, CK
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11
Q

Treatment of angina

A
  1. Statin: simvastatin
  2. Nitrate: GTN spray (abort attack)
  3. Dual antiplatelet: aspirin + clopidogrel
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12
Q

Treatment of unstable angina/NSTEMI

A
  1. B-blocker
  2. Morphine
  3. Oxygen
  4. Aspirin
  5. Nitrate
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13
Q

Treatment of acute STEMI

A
  1. If possible within 120 min of medical contact - Percutaneous Coronary Intervention
  2. If not possible: fibrinolysis
    -alteplase
    -streptokinase
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14
Q

State surgical interventions for IHD

A
  1. PCI
  2. Coronary Artery Bypass Grafting (CABG)
    • Preferred for diabetes and >65
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15
Q

Define heart failure

A

Inability of heart to deliver blood and oxygen at a rate in line with the requirements of the body

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16
Q

How does the body compensate for heart failure?

A
  1. Sympathetic system activation
    • BP falls -> baroreceptors detect -> sympathetic activation -> +ve inotropic/chronotropic -> CO increases
  2. RAAS system
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17
Q

State aetiology of heart failure

A
  1. IHD
  2. Cardiomyopathy
  3. Valvular heart disease
  4. Hypertension
  5. Excess alcohol
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18
Q

State the different types of heart failure

A
  1. Systolic heart failure - inability of ventricle to contract properly
  2. Diastolic heart failure - inability of ventricle to relax and fill
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19
Q

State risk factors of heart failure

A
  1. > 65
  2. Male
  3. Obese
  4. MI history
  5. African descent
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20
Q

State signs and symptoms of heart failure

A
  1. Shortness of breath
  2. Orthopnea (difficulty breathing when laying)
  3. Fatigue
  4. Ankle swelling
  5. Pulmonary oedema (backflow from decreased CO; pink frothy sputum)
  6. Cold peripheries
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21
Q

Diagnosis of heart failure

A
  1. Blood test
    • Brain Natrieuretic Peptide (BNP)
  2. ECG
  3. Transthoracic ECG
    • Wall motion abnormalities
    • Valvular disease
    • Cardiomyopathies
  4. Chest X-ray
    • Alveolar oedema
    • B-lines
    • Cardiomegaly
    • Dilated upper lobe vessels
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22
Q

Treatment of heart failure

A
  1. ACUTE - OMFG
    • Oxygen
    • Morphine
    • Furosemide
    • GTN spray
  2. Chronic heart failure
    • Lifestyle
      • Avoid NSAIDs/verapamil
    • Medical
      • 1st line - RAMIPRIL (ACEi) + PROPANOLOL (beta blocker)
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23
Q

State the 3 types of Hypertension

A
  1. Stage 1 - >140/90 mmHg or ABPM > 135/85
  2. Stage 2 - >160/100 mmHg or ABPM 150/95
  3. Malignant - >180/110
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24
Q

Aetiology of hypertension

A
  1. Primary = unknown
  2. Secondary
    -renal disease
    -pregnancy
    -endocrine disease
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25
State signs and symptoms of hypertension
1. Malignant - look for damage to: brain - cerebral oedema, haemorrhage eye - papilloedema, cotton wool spots heart - AHF, aortic dissection -> chest pain kidney - AKI -> haematuria, proteinuria
26
Diagnosis of hypertension
1. 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 2. If malignant hypertension AND signs of papilloedema and/or renal haemorrhage - same day admission - hypertensive drug treatment stat
27
Treatment of hypertension
1. 1st line - ACEi 2. Second line - ACEi + CCB (calcium channel blockers) or ACEi + diuretic 3. Third line - ACEi + CCB + diuretic 4. DIABETES - ACEi ALWAYS first line 5. BLACK - CCB before ACEi 6. CCB before diuretics unless oedema/intolerance 7. ACEi = contraindication in pregnancy/general anaesthesia
28
Define pericarditis
Inflammation of pericardium with/without effusion
29
Aetiology of pericarditis
1. Infection - Viral - coxsackievirus - Bacterial - mycobacterium TB 2. Trauma - Uraemia - MI
30
Signs and symptoms of pericarditis
1. Chest pain - worse by inspiration - relieved by sitting forward 2. Fever/ shortness of breath -> sign of infection
31
Diagnosis of pericarditis
1. ECG - saddle shaped ST elevation - PR depression 2. echo/chest x-ray if effusion suspected
32
Management of pericarditis
NSAIDs + PPI (brufen) colchicine
33
What is a possible complication of pericarditis?
Cardiac tamponade
34
Define cardiac tamponade
1. Life threatening 2. Accumulation of fluid in pericardial space 3. Compression of heart chambers 4. Decrease in venous return 5. Decrease in heart filling 6. Reduced CO
35
Signs and symptoms of cardiac tamponade
1. Beck's triad - Falling BP - Rising JVP - Muffled heart sound 2. Pulsus paradoxus - Large decrease in SV -> systolic BP drops >10 mmHg on inspiration
36
Diagnosis of cardiac tamponade
Echo
37
Treatment of cardiac tamponade
Pericardiocentesis - removal of fluid of pericardial space
38
Define infective endocarditis
Infection of inner lining of heart/valves
39
State the organism involved in infective endocarditis
1. Staph. aureus (most common IVDU (intravenous drug use)) 2. Strep. viridans (mouth/oral surgery) 3. Staph. epidermis (prosthetic valves)
40
Signs and symptoms of infective Endocarditis
1. Signs of infection (usual suspects) 2. Fever + new murmer = IE 3. Splinter haemorrhages 4. Osler nodes (tender nodules in finger) 5. Janeway lesions (nodules on palm) 6. Roth spots (haemorrhage with clear centre on fundoscopy)
41
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
42
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
43
Define mitral stenosis
1. Obstruction of left ventricle inflow 2. Prevents proper filling during diastole
44
Epidemiology of mitral stenosis
1. M>F 2. Most common cause = rheumatic heart disease
45
Risk factors of mitral stenosis
1. History of rheumatic fever 2. Untreated strep infections
46
Signs and symptoms of mitral stenosis
1. Progressive dysponea 2. Haemoptysis (coughing up blood) 3. Right heart failure 4. AF 5. Malar flush
47
Diagnosis of mitral stenosis
1. CXR (chest radiography) - LA enlargement - Pulmonary oedema/congestion - calcified mitral valve 2. ECG - AF - LA enlargement 3. ECHO - GOLD STANDARD for diagnosis - Assess mitral valve mobility, gradient and mitral valve area
48
Treatment of mitral stenosis
1. Mechanical problem = medical therapy does not prevent progression MEDICAL 2. Beta blockers - control heart rate = prolong diastolic filling 3. Diuretics for fluid overload SURGICAL 4. Percutaneous mitral balloon valvotomy 5. Mitral valve replacement
49
Heart sound for mitral stenosis
1. Diastolic murmur 2. Low pitched diastolic rumble at apex 3. Loud opening S1 snap; heard at apex
50
Define mitral regurgitation
1. Backflow of blood from LV -> LA during systole 2. Mild MR present in 80% normal individuals
51
Aetiology of mitral regurgitation
1. Abnormalities of the valve leaflets, chordae tendinae, papillary muscles or LV 2. Most common = myxomatous degeneration (weakening of chordae tendinae) -> floppy mitral valve 3. Ischaemic mitral valve 4. Infective Endocarditis 5. DIlated cardiomyopathy
52
Risk factors of mitral regurgitation
1. Females 2. Lower BMI 3. Age 4. Renal dysfunction 5. Prior MI
53
Pathophysiology of mitral regurgitation
1. Regurgitation in LA -> LA dilation 2. Compensatory mechanism - LA enlargement, LV hypertrophy 3. Progressive LA dilation and RV dysfunction due to pulmonary hypertension
54
Signs and symptoms mitral regurgitation
1. Soft S1 and pan systolic murmur at apex radiating to axilla 2. Prominent third extra heart sound (S3) 3. Exertion dysponea (due to pulmonary venous hypertension) 4. Fatigue 5. Increased SV causes palpitation
55
Diagnosis of mitral valve regurgitation
1. ECG - May show LA enlargement - AF - LV hypertrophy in severe MR 2. Echo - Estimation of LA and LV size and function - Valve structural assessment
56
Treatment of mitral valve regurgitation
1. Vasodilator - ACEi (Ramipril/hydralazine) 2. HR control for AF with beta blockers (atenolol), CCB and digoxin 3. Anticoagulants 4. Diuretics for fluid overload (Furosemide) 5. Surgical intervention
57
Define peripheral vascular disease (PVD)
1. Partial blockage of leg or peripheral vessels by an atherosclerotic plaque 2. Resulting in thrombus and inefficient perfusion of the lower limb
58
Risk factors of PVD
Usual suspects
59
Diagnosis of PVD
1. Exclude arteritis by looking at ESR/CRP (would be raised for arteritis) 2. FBC - Check Hb to exclude anaemia or polycthaemia 3. ECG - cardiac ischemia 4. 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 5. Colour duplex ultrasound - first line 6. MR/CT angiography
60
Symptoms of PVD
Pain Palor Perishing cold Pulseless Paralysis Paraesthesia - (pins & needles)
61
Treatment of PVD
1. Risk factor modification 2. Revascularisation for critical ischaemia 3. Surgical removal of embolus
62
What is the difference between intermittent claudication and critical ischaemia?
1. Tissue just suffering, oxygen debt when exerted 2. Tissue is DYING and suffering at rest, blood supply inadequate for basal metabolism, gangrene risk
63
Signs and symptoms of type of ischaemia from PVD
1. Nocturnal pain in all toes of left foot, relieved from hanging foot off the bed = critical ischaemia 2. Loss of use f right side of body + fast irregular pulse = acute ischaemia
64
Define heart block
1. Block in AV node or bundle of his = AV BLOCK 2. Block lower in conduction system = BUNDLE BRANCH BLOCK
65
What are the 3 types of AV block
1. 1st degree AV block 2. 2nd degree AV block 3. 3rd degree AV block
66
Define 1st degree AV block
1. Simple prolongation of PR interval greater than 0.22 s 2. Atrial depolarisation followed by conduction to ventricles with delay
67
Aetiology of 1st degree AV block
1. Hypokalaemia 2. Myocarditis 3. Inferior MI 4. AVN blocking drug (beta blockers, CCB, digoxin)
68
Treatment of 1st degree AV block
Asymptomatic -> no treatment
69
Define 2nd degree AV block
1. Only SOME P waves conduct 2. Mobitz I and Mobitz II
70
Define Mobitz I 2nd degree AV block
1. aka Wenckebach block phenomenon 2. Progressive PR interval prolongation until beat is 'dropped' 3. P wave then fails to conduct; excitation fails to pass through AVN/bundle of His 4. PR interval before blocked P wave >> PR interval after blocked P wave
71
Aetiology of Mobitz I 2nd degree AV block
1. AVN blocking drug (beta blockers, CCB, digoxin) 2. Inferior MI
72
Signs and symptoms of Mobitz I 2nd degree AV block
1. Light headedness 2. Dizziness 3. Syncope
73
Treatment of Mobitz I 2nd degree AV block
1. NO pacemaker required unless poorly tolerated
74
Define Mobitz II 2nd degree heart block
1. PR interval = constant 2. Some P waves don't conduct 3. Failure of conduction through His-Purkinje system
75
Aetiology of Mobitz II 2nd degree AV block
1. Anterior MI 2. Mitral valve surgery 3. SLE and lyme disease 4. Rheumatic fever
76
Signs and symptoms of Mobitz II 2nd degree AV block
1. Shortness of breath 2. Postural hypotension 3. Chest pain
77
Treatment of Mobitz II 2nd degree AV block
High risk of sudden complete AV block -> pacemaker should be fitted
78
Define 3rd degree AV block
1. Complete heart block 2. All atrial activity fails to conduct ventricles 3. P waves completely independent of QRS complex
79
Aetiology of 3rd degree AV block
1. Structural heart disease 2. Ischaemic heart disease 3. Hypertension 4. Endocarditis or lyme disease
80
Define narrow-complex escape rhythm
1. QRS complex < 0.12 s 2. Implies block in His bundle 3. Recent-onset narrow-complex AV block, may be relieved from IV atropine 4. Requires permanent pacemaker if chronic
81
Define broad-complex escape rhythm
1. QRS complex > 0.12 s 2. Implies block BELOW bundle of his 3. Dizziness and blackouts 4. Permanent pacemaker
82
Define incomplete bundle branch block
Bundle branch conduction delay -> slight widening oof QRS complex (up to 0.11 s)
83
Define complete bundle branch block
Wider QRS complex (larger than 0.12 s)
84
Aetiology of right bundle branch block
1. PE 2. IHD 3. Atrial/ventricular septal defect
85
Pathophysiology of RBBB
1. Right bundle no longer conducts 2. Both ventricles do not get impulses at same time 3. Instead, left to right .˙. late activation of right ventricle
86
Diagnosis of RBBB
1. Deep S wave in leads I & V6 2. Tall rate R wave in lead V1 3. ECG - V1 - QRS - M shape - V5 & V6 - QRS - W shape
87
Define LBBB
Late activation of LV
88
Aetiology of LBBB
1. IHD 2. Aortic valve disease
89
Diagnosis of LBBB
1. Deep S wave in lead V1 2. Tall late R wave in leads I and V6 3. Abnormal Q waves 4. ECG - V1 & V2 - QRS - W shape - V4 - V6 - QRS - M shape
90
Define abdominal aortic aneurysm (AAA)
Permanent dilation of abdominal aortic artery exceeding 3cm
91
Aetiology + risk factors of AAA
1. severe atherosclerotic damage 2. Smoking 3. Male 4. Age 5. Hypertension
92
Clinical presentation of unruptured AAA
1. Often asymptomatic 2. Pain in abdomen, back, loin and groin 3. Pulsatile abdominal swelling
93
What factors increase risk of AAA rupture
1. Hypertension 2. Female 3. Smoker 4. Strong family history
94
Clinical presentation of ruptured AAA
1. Intermittent/continuous abdominal pain 2. Pulsatile abdominal swelling 3. Collapse 4. Hypotension 5. Tachycardia
95
Differential diagnosis of AAA
1. GI bleed 2. Ischaemic bowel 3. Appendicitis
96
Diagnosis of AAA
1. Abdominal ultrasound 2. CT/MRI angiography scans
97
Treatment of AAA
1. Small (<5.5cm) just monitored 2. Surgery - Enovascular repair: stent
98
Define aortic dissection
1. Tear in intima 2. Blood penetrates diseases medial layer 3. Flows between layers of aorta 4. Layers forced apart -> dissection
99
Aetiology of aortic dissection
1. Genetic 2. Degenerative 3. Atherosclerotic 4. Inflammatory 5. Trauma
100
Clinical presentation of aortic dissection
1. Sudden onset of severe central chest pain - Radiates to the back and down the arms 2. Hypertension 3. Pain = maximal from onset unlike MI 4. Aortic regurgitation, coronary ischaemia, cardiac tamponade
101
Diagnosis of aortic dissection
CXR - Widened mediastinum
102
Treatment of aortic dissection
1. Urgent antihypertensive medication to less than 120mmHg - IV beta blockers (IV metoprolol) or vasodilators 2. Analgesia 3. Surgery to replace aortic arch 4. Endovascular intervention with stent
103
Define atrial fibrillation
1. Chaotic irregular atrial rhythm at 300-600 bpm 2. AV node responds intermittently 3. .˙. irregular ventricular rate
104
Clinical classification of AF
1. Onset within previous 48h 2. Paroxysmal - stops spontaneously within 7d 3. Recurrent - 2 or more episodes 4. Persistent - continues for more than 7 days 5. Permanent
105
Aetiology of AF
1. idiopathic 2. Hypertension 3. Heart failure 4. Any condition that results in: - Raised atrial pressure - Atrial hypertrophy 5. Cardiac surgery
106
Pathophysiology of AF
1. Atria have no coordinated mechanical action 2. Proportion of impulses conducted to the ventricles 3. .˙. NO UNIFIED ATRIAL CONTRACTION; instead atrial spasm
107
Clinical presentation of AF
1. May be asymptomatic 2. Palpitations 3. Dysnoea 4. Fatigue 5. No P waves on ECG 6. Rapid irregular QRS rhythm
108
Diagnosis of AF
ECG - Absent P waves - Irregular and rapid QRS complex
109
Treatment of AF
1. Treat provoking cause 2. Electrical conversion to sinus rhythm (defib) 3. Anti-arrhythmic drug (felcainide and amiodarone) 4. Ventricular rate control - AV node blocking drug - CCB (verapamil) - Beta blockers (Bisoprolol) - Digoxin - Anti-arrhythmic (Amiodarone)
110
Define atrial flutter
1. Organised atrial rhythm 2. Atrial rate 250-350 bpm
111
Aetiology of atrial flutter
1. Idiopathic 2. CHD 3. Obesity 4. Hypertension 5. Heart failure
112
Clinical presentation of atrial flutter
1. Palpitations 2. Breathlessness 3. Chest pain 4. Dizziness 5. Fatigue
113
Diagnosis of atrial flutter
1. ECG - Regular sawtooth atrial flutter waves (F waves) between QRS complexes
114
Treatment of atrial flutter
1. Anticoagulate first (low mw heparin) 2. Electrical cardioversion 3. Catheter ablation - create conduction block 4. IV Amiodarone - restore sinus rhythm 5. Bidoprolol - suppress further arrhythmia

SJ Phase 2a (13 decks)

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