Cardio Flashcards

Question

Anaemia - Investigations

Answer 1

- FBC -> Hb levels, reticulocyte levels, haematocrit (vol% of RBC in blood), MCV - Prothrombin time/activated partial prothrombin time -> coagulation problems? - Abdominal ultrasound scan -> Intestinal bleeding as cause? - Faecal occult blood testing - Joint x-rays -> Long-bone fractures can be a significant source of bleeding - Hx -> Recent trauma? Diet changes indicating insufficiency? Any chronic diseases? General algorithm: Microcytic anaemia (MCV <80) -> Check serum iron --> Low iron & ferritin + high TIBC (total iron binding capacity) = Iron deficiency anaemia --> Low/Normal iron & Ferritin w/ low TIBC = possibly chronic disease w/ iron deficiency --> Mentzer Index (MCV/RBC) <13 = Thalassaemia Normocytic anaemia (MCV 80-100) -> Check Reticulocyte count --> Hypoproliferative (<2%) = Leukaemias, Aplastic anaemia, Pure red cell aplasia, marrow failure syndromes --> Hyperproliferative (>2%) = Haemorrhage, Haemolytic anaemias Macrocytic anaemia (MCV >100) -> Check Megalocytes & Segmented neutrophils on peripheral smear --> Present (Megaloblastic) = Vitamin B12 and/or Folate deficiency, Drug induced --> Absent (Non-megaloblastic) = Alcohol abuse, Myelodysplastic syndrome, Liver disease, Congenital bone marrow failure syndromes

Answer 2

Addressing Underlying Causes: Dietary Changes: --> If the anaemia is due to a nutritional deficiency (such as iron, vitamin B12, or folate deficiency), dietary changes and supplementation may be recommended. Vitamin and Mineral Supplements: --> Vitamin B12 and Folate: Anaemia caused by vitamin B12 or folate deficiency may require vitamin B12 injections or folate supplements. --> Vitamin C: Vitamin C supplements might be recommended alongside iron supplements to improve iron absorption. Treating Chronic Diseases: --> Anaemia related to chronic conditions, such as chronic kidney disease or inflammatory disorders, often requires managing the underlying disease to improve red blood cell production. Stopping Blood Loss: --> If anaemia is caused by chronic bleeding (e.g., gastrointestinal bleeding), the source of the bleeding needs to be identified and treated, which may involve medications, endoscopy, or surgery. Iron Supplementation: --> Iron Tablets: For iron-deficiency anaemia, iron supplements in the form of tablets or syrups may be prescribed to increase iron levels. It is often advised to take vitamin C alongside iron supplements to enhance absorption. --> Intravenous Iron: In severe cases or when oral iron supplements are not well-tolerated or effective, iron may be given intravenously. Erythropoiesis-Stimulating Agents (ESAs): --> For anaemia associated with chronic kidney disease or cancer, erythropoiesis-stimulating agents can be prescribed to stimulate the production of red blood cells. Blood Transfusions: --> In severe cases of anaemia, especially if it causes significant symptoms or complications, blood transfusions may be necessary to rapidly increase haemoglobin levels. Lifestyle Advice: --> Lifestyle changes might be recommended, such as reducing alcohol consumption and quitting smoking, as these habits can contribute to anaemia.

Answer 3

Aortic regurgitation (AR) is the diastolic (at rest) leakage of blood from the aorta into the left ventricle It occurs due to inadequate coaptation of valve leaflets resulting from either intrinsic valve disease or dilation of the aortic root Presentations: - It can remain asymptomatic for decades before patients present with irreversible myocardial damage - diastolic murmur -> The severity of the AR correlates well with the duration of murmur - dyspnoea/orthopnoea/paroxysmal nocturnal dyspnoea/ tachypnoea - fatigue - weakness - pallor - collapsing (water hammer or Corrigan's) pulse - urine output <30 mL/hour -> Cardiogenic shock

Answer 4

AR can be caused by primary disease of the aortic valve leaflets or dilation of the aortic root: - In developing countries rheumatic heart disease is the most common cause - In developed countries congenital bicuspid aortic valve and aortic root dilation account for most of the cases - Causes of aortic root dilation include Marfan's syndrome, related connective tissue diseases, and aortitis secondary to syphilis - Vegetations on the valvular cusps can also cause inadequate closure of leaflets, resulting in leakage of blood - Aortic root dissection is a cause of acute AR

Answer 5

1) Mitral regurgitation -> CXR: pulmonary oedema, enlarged left atrium and left ventricle, and mitral valve calcification -> The classical murmur of MR is pansystolic at the apex radiating to the axilla 2) Mitral stenosis -> CXR: pulmonary oedema, enlarged left atrium, and mitral valve calcification -> Distinguishing features are a malar flush, low volume pulse, a tapping and undisplaced apex beat, and loud S1 with an opening snap 3) Aortic stenosis -> CXR: left ventricular hypertrophy (LVH), calcified aortic valve -> Characteristic signs are a slow rising pulse, heaving but undisplaced apex bear, left ventricular heave, and an ejection systolic murmur that radiates towards the carotids 4) Pulmonary regurgitation -> CXR: may show dilation of main pulmonary artery with right ventricular dilation -> Diamond-shaped diastolic murmur best heard in the second and third left intercostal spaces & increases w/ inspiration

Answer 6

1) ECG -> Provides only supportive evidence. Echocardiography is required to confirm the presence of AR 2) CXR -> may show cardiomegaly 3) Echocardiogram -> Most important 4) M-mode and 2-dimensional imaging -> Two-dimensional echocardiography 5) Colour flow Doppler -> detection and quantification of regurgitant flow 6) Pulsed wave Doppler -> detection and quantification of holodiastolic flow reversal 7) Continuous wave Doppler

Answer 7

Acute: - Inotropes + vasodilators + urgent aortic valve replacement/repair -> dobutamine: 0.5 micrograms/kg/min intravenously initially, titrate to effect, maximum 20 micrograms/kg/min -> nitroprusside: 0.3 to 0.5 micrograms/kg/min intravenously, titrate to effect, maximum 10 micrograms/kg/mins 1) Valve replacement/repair is first line and should be done ASAP 2) As Prosthetic valve patients are at high risk for thromboembolism they need antithrombotic therapy Chronic: - Asymptomatic with normal left ventricular (LV) function do not require treatment and can be reassured - If they are getting surgery for other cardiac diseases they can get a valve replacement/repair at the same time - If LVEF <55% and/or LVESD >50mm/symptomatic, they become eligible for surgery

Answer 8

The outcome and prognosis of patients depends on the magnitude of left ventricular (LV) function and symptoms 5-year survival in patients with normal LV function has been reported as 96% whereas that in patients with reduced LV function is 62% Patients who have an immediate reduction in LV dilatation following surgery are more likely to have short- and long-term improvements in the ejection fraction The EF is unlikely to improve in patients who do not have an improvement in EF within the first 6 months of surgery Complications: - 4% chance of operative mortality - Heart Failure - Arrythmias - Infective endocarditis -> complication in patients with underlying structural valvular defects, but unusual in AR

Answer 9

AS represents obstruction of blood flow across the aortic valve due to pathological narrowing It is a progressive disease that presents after a decades-long subclinical period Presentations: - exertional dyspnoea -> One of most common symptoms - fatigue -> One of most common symptoms - chest pain - exertional syncope - ejection systolic murmur - S2 diminished and single

Answer 10

Calcification and fibrosis of normal trileaflet valves is the most common cause of AS in adults - Calcific aortic disease represents a spectrum ranging from aortic sclerosis (defined as leaflet thickening without obstruction) to severe AS Risk Factors: - smoking - hypertension - low-density lipoprotein (LDL)-cholesterol - elevated C-reactive protein - elevated lipoprotein - age >60 years - congenitally bicuspid aortic valve - rheumatic heart disease - chronic kidney disease

Answer 11

1) Aortic sclerosis -> Transthoracic Doppler echo will demonstrate no significant pressure gradient (<5 mmHg) across the aortic valve with aortic sclerosis 2) Ischaemic heart disease -> In ischaemic heart disease, common ECG findings include Q waves in contiguous leads, and the echocardiogram often shows segments of the myocardium with abnormal systolic thickening or wall motion abnormalities -> In AS, Q waves are absent in the ECG; regional wall motion abnormalities are absent on the echocardiogram 3) Hypertrophic cardiomyopathy -> Typical echocardiography findings include asymmetrical hypertrophy with the septal wall most prominently affected. Dynamic obstruction is observed at the sub valvular level, and calcification of the valve is often absent, especially in younger patients

Answer 12

1) Transthoracic echocardiogram (including Doppler) -> best test for the initial diagnosis and subsequent evaluation of AS -> elevated aortic pressure gradient; measurement of valve area and left ventricular ejection function 2) ECG -> may demonstrate left ventricular hypertrophy and absent Q waves, atrioventricular block, hemiblock, or bundle branch block 3) CXR -> may be normal; may show pulmonary congestion or other lung pathology

Answer 13

Acute if clinically unstable: 1) Balloon valvuloplasty -> Re-stenosis rates are high at 6 months, more of an immediate measure Once stable but symptomatic: 1) surgical aortic valve replacement 2) long-term infective endocarditis antibiotic prophylaxis -> Due to prostatic valve + Consider Long-term anticoagulation -> Anticoagulation with a vitamin K antagonist (DOACs NOT recommended for a mechanical valve) 1) transcatheter aortic valve implantation -> If >80 or if life expectancy <10 years

Answer 14

It is important to note that the rate of progression is extremely variable and so the recommended follow-up periods may vary between individuals The onset of symptoms is a significant milestone and portends a poor prognosis, with an average survival of only 2 to 3 years without surgery Surgical replacement of the aortic valve is extremely effective therapy - Surgical replacement of the aortic valve is extremely effective therapy Complications: 1) Acute heart failure -> occurs when the afterload burden created by the AS limits the ability of the left ventricle to pump blood to the body 2) Sudden cardiac death in symptomatic patients -> Ventricular arrhythmia -> Very rare but a significant concern in symptomatic patients