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