Cardio

Question 1

Pathophysiology of Acute coronary syndrome

Answer 1

Includes -

ST elevation myocardial infarction (STEMI)
non-ST elevation myocardial infarction (NSTEMI)
unstable angina

Caused by ischaemic heart disease-

Endothelial dysfunction caused by hypertension, smoking and hyperglycaemia
Leads to pro-inflammatory, pro-oxidant, proliferative and reduced nitric oxide bioavailability
LDL infiltration into subendothelial space
Monocyte migrate and differentiate into macrophages
Phagocytosis of oxidized LDL leads to foam cell
smooth muscle proliferation and migration from the tunica media into the intima results in formation of a fibrous capsule covering the fatty plaque

Signs and symptoms -

central/left sided chest pain (crushing heavy pain)
may radiate to jaw or left arm
diabetics/elderly may not experience any chest pain

dyspnoea
sweating
nausea and vomiting

patient may appear pale and clammy

Question 2

Investigation for ACS

Answer 2

ECG
Troponin 3hrs after pain started
Bloods
Lipid profile
FBC + CRP to rule out infection)
CXR (Look for pulmonary causes)
D Dimer may be used to rule out PE

Question 3

Management for ACS

Answer 3

MONA

IV morphine/diamorphine
Targeted oxygen therapy (aiming for sats >90%)
Sublingual GTN spray
Loading dose of PO aspirin 300mg

Post MI management -

Aspirin 75mg OM
second anti-platelet (clopidogrel 75mg OD or ticagrelor 90mg OD)
Beta blocker (normally bisoprolol)
ACE-inhibitor (normally ramipril)
High dose statin (e.g. Atorvastatin 80mg ON)

ECHO performed to assess systolic function and any evidence of heart failure should be treated

All patients should be referred to cardiac rehabilitation.

Question 4

Pathophysiology and presentation of aortic regurgitation

Answer 4

Aortic regurgitation (AR) is the leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole.

Caused by valves disease or aortic root disease.

Valve disease -

Chronic causes:
rheumatic fever
calcific valve disease
connective tissue diseases e.g. rheumatoid arthritis/SLE
bicuspid aortic valve (affects both the valves and the aortic root)
Acute:
infective endocarditis

aortic root-

chronic:
bicuspid aortic valve
spondylarthropathies (e.g. ankylosing spondylitis)
hypertension
syphilis
Marfan’s, Ehler-Danlos syndrome

acute- aortic dissection

Features-

early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre
collapsing pulse
wide pulse pressure
Quincke’s sign (nailbed pulsation)
De Musset’s sign (head bobbing)
mid-diastolic Austin-Flint murmur in severe AR - due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams

Question 5

What is the investigation and management for a patient with aortic regurgitation?

Answer 5

Suspected AR should be investigated with echocardiography.
Cardiac MRI is indicated in patients with suboptimal or inconclusive echocardiogram findings

TAVI (Transcatheter aortic valve implantation)
surgery: aortic valve indications include
symptomatic patients with severe AR
asymptomatic patients with severe AR who have LV systolic dysfunction

Question 6

Pathophysiology and presentation of aortic stenosis

Answer 6

Clinical features of symptomatic disease
chest pain
dyspnoea
syncope / presyncope (e.g. exertional dizziness)
murmur
an ejection systolic murmur (ESM) is classically seen in aortic stenosis
classically radiates to the carotids
this is decreased following the Valsalva manoeuvre

Causes of aortic stenosis
degenerative calcification (most common cause in older patients > 65 years)
bicuspid aortic valve (most common cause in younger patients < 65 years)
William’s syndrome (supravalvular aortic stenosis)
post-rheumatic disease
subvalvular: HOCM

Question 7

Investigation and management for aortic stenosis

Answer 7

if asymptomatic then observe the patient is a general rule
if symptomatic then valve replacement

aortic valve replacement (AVR) include:
surgical AVR is the treatment of choice for young, low/medium operative risk patients. Cardiovascular disease may coexist. For this reason, an angiogram is often done prior to surgery so that the procedures can be combined
transcatheter AVR (TAVR) is used for patients with a high operative risk
balloon valvuloplasty
may be used in children with no aortic valve calcification
in adults limited to patients with critical aortic stenosis who are not fit for valve replacement