Cardio Flashcards
what is heart rate
HR = CO X SV
What is the parasympathetic input to the heart and describe the mechanism
- Vagus nerve
- When stimulated ACH binds to M2 receptors –> decrease HR
What is the sympathetic input to the heart and describe the mechanism
- Postganglionic fibres from cardiac plexuses
- release noradrenaline which acts on B1 adrenoreceptors
- Increases HR and force of contraction
How to increase BP
- Baroreceptors detect decrease
- Synpathetic activated
- Cardiac accelerator centre in MO
- HR increased, contraction increased, vasocontriction
How to decrease BP
- Baroreceptors detect
- Parasympathetic activated
- GN and V nerves carry to MO = cardiac decelerator centre
- HR reduced, vasodilation
What is cardiac output
CO = SV X HR
What is stroke volume
Difference between EDV and ESV
What is CVP
pressure in vena cava as it enters RA
What is TPR
pressure in arteries blood must overcome as it passes through them = afterload
Starlings law
the more the heart chambers fill the stronger the ventricular contraction therefore the greater the stroke volume
Mean arterial blood pressure
MAP = CO X TPR
Virchows triad
- Stasis of blood flow
- Hypercoagulability
- Vessel wall injury
Where does the RCA supply?
- Right atrium
- Right ventricle
- Inferior aspect of left ventricle
- Posterior septal area
Where does circumflex artery supply
- Left atrium
- Posterior aspect of left ventricle
Where does LAD supply
- Anterior aspect of left ventricle
- Anterior aspect of septum
S+S of MI
- Central crushing chest pain
- Pain to jaws or amrs
- N+V
- Sweating
- Doom
- SOB and palpitations
STEMI ECG changes
- ST segment elevation
- New LBBB
NSTEMI ECG changes
- ST depression
- T wave inversion
Ix for MI
- ECG
- Troponin
- Baseline bloods
Initial Mx for MI/ACS
MONA/PAIN
- Perform ECG
- Morphine
- Oxygen if sats <94
- Nitrate
- Aspirin 300mg
What to do if suspect ACS in last 72 hrs?
- Refer to hospital for same day assessment
Mx STEMI
- Within 120 minutes = PCI. Prasugrel (clopi of on ac) and aspirin
- > 120 minutes = thrombolysis
Secondary prevention STEMI
ACAB
- Acei
- Clopidogrel
- Aspirin and statin
- BB
NSTEMI mx
BATMAN
- Base decision about angio and PCI on GRACE score
- Aspirin 300mg stat
- Ticagrelor 180mg stat dose
- Morphine
- Antithrombin therapy = fondaparinux
- Nitrate
When is angina stable?
Sx on exertion and relieved by GTN
When is angina unstable?
- Sx at rest = UA is ACS and needs immediate Mx
Gold standard Ix for angina?
CT coronary angiography
Mx angina
- Immediate relief = GTN spray
- Longterm relief = BB and CCB (verapamil if alone, nifedipine if with BB)
- Prevention = aspirin, astorvostatin, Acei
- PCI or CABG if worse
Angina classes
- 1 = angina with strenuous
- 2 = angina during ordinary
- 3 = angina with low levels
- 4 = at rest or any level
Patho of pericarditis
- Inflammation of the pericardium
- Effusion due to inflammation response
Pericarditis S+S
-Sharp central chest pain, better sitting forward
- Pleuritic
- Low grade fever
- Pericardial friction rub
pericarditis Ix
- Raised inflammatory markers
- ECG = saddle shaped ST elevation and PR depression
Pericarditis Mx
- Sedentary until resolution
- NSAIDs
- Colchicine for prophylaxis
What is ejection fraction
- % of blood in LV squeezed out with each ventricular contraction
What is HF woth reduced EF
- WHen the EF is <50%
HF with preserved EF
- clinical features of HF but EF >50%
- this is the result of diastolic dysfunction , where there is an issue with LV filling in diastole
S+S HF
- SOB
- Cough with pink sputum
- Orthopnoea
- PND
- Peripheral oedema
- Fatigue
- 3rd HS, murmurs, crackles, raised JVP
Ix HF
- BNP = >100 HF, >2000 refur urgent, 400-2000 = 6WW
- ECG
- Echo
NYHA HF classes
1 = no limitation
2 = comfortable rest, ordinary activity sx
3 = rest good but sx on any activity
4 = sx at rest
HF Mx
ABAL
- Acei
- BB
- Aldosterone antagonist
- Loop diuretics
what classes as HTN
- > 140/90 clinical
- > 135/85 at home
NICE recommendations for new HTN
- Urine albumin creatinine ratio
- Dipstick urine
- Bloods
- Fundus exam
- ECG
Hypertensive emergency mx
- Fundoscopy
- IV labetalol, GTN, nicardipine
Aortic stenosis patho
endocardial injury initiates and inflammatory response leading to calcium deposition on the valve
- narrow aortic valve = restricts blood flow from LV to aorta
Aortic Stenosis murmur
- Ejection systolic
- crescendo-decrescendo
- radiates to carotids
AS signs
- thrill
- slow rising pulse
- narrow pulse pressure
- exertional syncope
AS mx
- unstable = medical therapy of balloon valvuloplasty
Aortic regurgitation patho
incompetent aortic valve = blood flows back from aorta to LV
AR murmur and signs
- early diastolic soft murmur
- austin flint = diastolic rumbling at apex
- thrill, collapsing pulse, wide pp
mitral stenosis patho
narrowed mitral valve restricting blood from from LA to LV
MS murmur and signs
- mid diastolic, low pitched rumbling murmur
- tapping apex beat, malar flush
mitral stenosis commonly causes
atrial fibrillation
mitral regurgitation patho
incompetent mitral valve = blood flow from LV to LA in systole
MR murmur and signs v
- pan systolic high pitched whistling
-radiates to left axilla - thrill, HF
Infective endocarditis patho
- Infection of endothelium = inner heart surface
Infective endocarditis RF
- IVDU
- Structural heart patho
- CKD
- Immunocompromised
- IE Hx
- Valve replaced
S+S IE
- Fever and new murmur = IE until proven otherwise
- fever, fatigue, night sweats
- splinter haem, petechiae, janeway lesions, oslers nodes, roth spots
IE Ix
- Blood cultures before abx
- 3 cultures by 6 hrs 3 sites
- Echocardiography
- Dukes = 1 maj 3 min or 5 minor
Major dukes criteria
- Persitently +ve cultures
- Imaging findings
Minor dukes criteria
- Predisposition
- fever >38
- Vascular phenomena
- Immunological phenomena
- Microbiological phenomena
Mx IE
- IV broad abx e.g. amoxicillin and optional gent
- 4 weeks or 6 weeks if prosthetic valves
Most common cause IE
- Staph aureus
AF definition
- Electrical activity in atria becomes disorganised
AF patho
- Chaotic electrical activity overrides SAN activity = passes through the ventricles nd causes irregulary irregular ventricular contraction
AF S+S
- tachy
- irreg irreg pulse
- HF
- SOB, dizzy
AF Ix
- ECG = no p waves,narrow QRS
- Echo
AF Mx
- Rate control = BB 1st line, CCB2nd
- Rhythm control = cardioversion
- DOAC for anticoagulation
ORBIT score
- Older age >75
- Renal impairment = GFR<60
- Bleeding hx
- Iron = low
- Taking antiplatelets
What is SVT
- Abnormal electrical signals from above the ventricles cause tachy
SVT patho
- Electrical signal re-enters atria from ventricles
- Self-perpetuating electrical loop = narow complex tachy
SVT ECG
- P waves often buried in the T waves
- Regular rhythm
WPW def and ECG
- Extra electrical pathway connecting atria and ventricles
- SHort PR , wide QRS, delta
Acute mx SVT
1 = vagal manouvers
2 = adenosine = 6,12,18
3 = verapamil or BB
4 = cardioversion
what are the shockble rhythms
- ventricular tachycardia
- ventricular fibrillation
Atrial flutter
- re-entrant rhythm = round atrium without interruption
- 2:1 conduction
- sawtooth appearance
Prolonged QT
- represents prolonged repolarisation
- medications = antipsychotics, citalopram, flecainide, amiodarone, macrolides
- HypoK,Mg and ca
Torsades
- Height of qrs gets prog smaller then larger
1st degree heart block
- delayed conduction through AV node
- PR >0.2s
- long PR complexes = she does pick up just taking longer
Mobitz type 1
- 2nd degree HB
- conduction through AVN takes longer until fails and resets
- Increasing PR until P not followed by QRS
- she takes longer and longer to answer then wont pick up
Mobitz type 2
- intermittent failure of conduction through AVN
- set ratio of P waves to QRS complexes
- no pr lengthening
3rd degree HB
- complete HB
- no relationship between P and QRS
Aortic dissection definition
- tear in aorta allowing blood to flow between layers
- enters intima and media of aorta and false lumen formed
AD RF
- HTN
- PAD
- conditions that affect aorta
AD S+S
- Ripping tearing chest pain
- anterior chest or back
-HTN - difference in BP between arms
- Radial pulse deficit
- Diastolic murmur
- Abo pain
- Collapse
AD Ix
- ECG = ST depression
- CXR
- CT angiogram
- MRI angiogram
AD Mx
- surgical emergency
- Fluid resus, inotropes, noradrenaline
- analgesia
- BB
- Surgery
Hypertrophic obstructive cardiomyopathy
- LV becomes hypertrophic
- = Blood flow can block out of left ventricle
- Autosomal dominant
Findings for HOCM
- ES murmur
- 4th HS
- thrill
Mx HCOM
- BB
- surgery
- septal ablation
VTE prophylaxis
- LMWH = aparins
- Stockings
Ix DVT
- Wells
- D Dimer
- Doppler USS
- CTPA = PE
DVT Mx
- treatment dose apixaban or rivaroxaban immediate if sspected
How long anticoagulation for in DVT?
- Reversible cause = 3 months
- Unclear cause = >3m
- active cancer = 3-6m
Peripheral arterial disease definition
- Narrowing of arteries supplying limbs
- Claudication
PAD main symptoms
- Claudication intermittent
Features of acute limb ischaemia
- Pain
- Pallor
- Pulseless
- Paralysis
- Paraesthesia
- Perishing cold
PAD Ix
- ABPI
- Duplex USS
- Angiography
Claudication mx
= Lifestyle changes
- Exercise training
- Statin, clopidogrel, naftidrofuryl oxalate
AAA definition
- Dilation of abdominal aorta >3cm
AAA screening
- Men = USS at age 65
- Yearly scan if 3-4.4cm
- 3M if 4.5-5.4cm
Px AAA
- Non specific abdo pain
- Pulsatile and expansile mass in abdomen
Ix AAA
- USS
- CT angiogram
AAA Mx
- Treat reversible RF
- Surgical repair
- > 6cm inform DVLA and stop driving if 6.5
Ruptured AAA S+S
- severe abdo pain radiating to back
- Haemodynamic instability
- Pulsatile mass
- Collapse, LOC
pericardial effusion
- potential space of pericardial cavity fills with fluid
- Inward pressure on heart = difficult to expand during diastole
Pericardial tamponade definition
- effusion large enough to raise intra-pericardial pressure
- reduced filling of heart during diastole
- emergency
S+S effusion
- Queit heart sounds
- Pulsus paradoxus
- Hypotension
- Raised JVP
- Fever
- Pericardial rub
Cause of arterial ulcers
- Insufficient blood supply to the skin due to PAD
Cause of venous ulcers
- pooling of blood and waste products in the skin secondary to venous insufficiency
Features of arterial ulcers
- Distal = toes or dorsum of foot
- Absetn pulses, pallor, intermittent claud
- smaller and deeper than venous
- well defined borders, punched out
- pale and less likely to bleed
- painful
- worse at night
venous ulcers
- occur between top of foot and bottom of calf
- Chronic venous changes
- After minor injury
- Larger and more superficial
- Irregular borders
- Less painful, more bleeding
Mx arterial ulcers
- Surgical revascularisation
- treat underlying arterial disease
Mx venous ulcers
- tissue viability
- cleaning, debridement and dressing
- Compression therapy
myocarditis
- inflammation of middle muscular layer of heart
- differential for chest pain
- infection can cause
Becks Triad
Seen in tamponade
- Hypotension
- Raised JVP
- Muffled heart sounds
what drug if 49 yo black african male with T2DM HTN
losartan
- ARB over ACEi for african/carribean origin
Anteroseptal MI ECG and artery
- V1 - V4
- LAD
Inferior MI ECG and artery
- II, III, aVF
- Right coronary
Anterolateral MI
- V1 - 6, I, aVL
- LAD proximal
Lateral MI
- I, aVL +/- V5-6
- Left circumflex
Posterior MI
- V1-3
- Left circumflex
Mx if shocked and bradycardia
- atropine 500mcg IV up to 3mg
- isoprenaline or adrenaline
- Transcutaneous pacing
- transvenous pacing
shockable arrest rhythms
- ventricular fibrillation
- pulseless ventricular tachycardia
non shockable rhythms
- asystole
- pulseless electrical activity
mitral stenosis causes
left atrial hypertrophy
- because muscle has to try harder to push against stenotic valve
aortic stenosis causes
left ventricular hypertrophy
mitral regurg causes
left atrial dilatation
- because leaky valve allows blood flow back into chamber = stretches the muscle
aortic regurg causes
left ventricular dilatation
