Cardio Flashcards
What is angina?
constricting chest pain caused by reduced blood flow (and hence oxygen supply) to the myocardium due to atherosclerosis narrowing the lumen of coronary arteries
What is stable angina?
symptoms only come on with exertion
relieved by rest or glyceryl trinitrate (GTN)
What is unstable angina?
symptoms appear randomly whilst at rest
type of acute coronary syndrome (ACS)
requires immediate management
What are the main signs and symptoms of aortic stenosis?
chest pain
SoB
syncope
exertional dizziness
ejection systolic murmur radiating to the carotids
What kind of murmur is associated with aortic stenosis?
ejection systolic murmur
radiating to the carotids
decreased during Valsalva maneuvre
What features are associated with severe aortic stenosis?
narrow pulse pressure
thrill
LV hypertrophy
What are the main causes of aortic stenosis?
degenerative calcification - most common cause in >65y.o.
bicuspid aortic valve - most common cause in < 65y.o.
William’s syndrome - supravalvular
post-rheumatic disease
subvalvular - hypertrophic cardiomyopathy
What is the management of aortic stenosis in asymptomatic patients?
conservative - observation
What is the management of aortic stenosis in symptomatic patients?
valve replacement
When do you consider surgery in asymptomatic patients with aortic stenosis?
if the valvular gradient is > 40mmHg and has features of left ventricular systolic dysfunction
What are the options for aortic valve replacement (AVR) in aortic stenosis?
surgical AVR
transcatheter AVR
What patients are suitable for surgical AVR?
young
low-medium operative risk
may have cardiovascular disease (combined surgery)
When should mechanical vs bioprosthetic valve be used?
mechanical
- younger patients (< 65 in aortic, <70 in mitral)
bioprosthetic
- older patients
- tend to last shorter
What patients are suitable for transcatheter AVR?
high operative risk
What patients are suitable for aortic balloon valvuloplasty?
children with aortic stenosis with no calcification
adults with critical aortic stenosis who are not fit for valve replacement
What is aortic regurgitation?
leaking of the aortic valve
What are the main causes of aortic regurgitation?
valve disease
aortic root disease
What are some causes of aortic regurgitation due to valve disease with chronic presentation?
rheumatic fever - most common cause in the developing world
calcific valve disease
connective tissue disease - SLE, rheumatoid arthritis
bicuspid aortic valve
What is the most common cause of aortic regurgitation in the developing world?
rheumatic fever
What are some causes of aortic regurgitation due to aortic root disease with chronic presentation?
bicuspid aortic valve
spondyloarthropathies - e.g. ankylosing spondylitis
HTN
syphilis
Marfan’s
EDS
What are some causes of aortic regurgitation due to valve disease with acute presentation?
infective endocarditis
What are some causes of aortic regurgitation due to aortic root disease with chronic presentation?
aortic dissection
What are some features of aortic regurgitation?
early diastolic murmur - loudest at left sternal edge
wide pulse pressure
collapsing pulse
Quincke’s sign - nailbed pulsation
Austin flint murmur - low pitched rumbling mid-diastolic murmur heard best at the apex (in severe AR)
How is aortic regurgitation assessed?
echocardiography
How is aortic regurgitation managed?
medical management of heart failure (if associated)
surgery if
- symptomatic with severe AR
- asymptomatic with severe AR and LV systolic dysfunction
What is mitral stenosis?
obstruction of blood flow across the mitral valve from LA to LV
leads to increases in pressure within the left atrium, pulmonary vasculature and right side of the heart
What is the most common cause of mitral stenosis?
rheumatic fever
What are the features of mitral stenosis?
SoB - due to pulmonary hypertension
haemoptysis - due to pulmonary hypertension
mid-late diastolic murmur - best heard in expiration over the apex
loud S1
malar flush
AF
opening snap - indicates mobility of mitral valve leaflets
What features can be seen in CXR in mitral stenosis?
LA enlargement
How is mitral stenosis managed?
if associated AF - anticoagulation
if asymptomatic - monitoring (conservative), regular echo
if symptomatic - percutaneous mitral balloon valvotomy OR mitral valve surgery
What are the two most common valve diseases?
aortic stenosis
mitral regurgitation
What are the risk factors for mitral regurgitation?
female
lower BMI
age
renal dysfunction
prior MI
prior mitral stenosis/prolapse
collagen disorders - Marfan’s, EDS
What murmur is associated with mitral regurgitation?
pansystolic murmur
loudest over mitral area
radiating to axilla
What are the causes of mitral regurgitation?
post MI / coronary artery disease - due to damage to papillary muscles
mitral valve prolapse
infective endocarditis - vegetations prevent closure of valve leaflets
rheumatic fever
congenital
What are the features of mitral regurgitation?
mostly asymptomatic
symptoms usually from LV failure - fatigue, SoB, oedema
What investigations are useful in suspected mitral regurgitation? What will they show?
ECG - broad P waves - atrial enlargement
CXR - cardiomegaly (enlarged LA and LV)
echocardiography
How is mitral regurgitation managed?
medical - in acute cases - nitrates, diuretics, intra-aortic balloon pump
if heart failure - ACE inhibitors, beta blockers, spironolactone
surgery - in acute and severe MR
surgical repair over replacement preferred in degenerative causes
What murmur does tricuspid regurgitation cause?
pansystolic
What are some features of tricuspid regurgitation?
thrill in tricuspid area
raised JVP with big C-V waves
pulsatile liver (regurgitation into the venous system)
peripheral oedema
ascites
What are the possible causes of tricuspid regurgitation?
“functional” - due to L-sided heart failure or pulmonary hypertension
infective endocarditis
carcinoid syndrome
Ebstein’s anomaly
connective tissue disorders (e.g. Marfan’s)
What murmur does pulmonary stenosis cause?
ejection systolic murmur
loudest in pulmonary area in deep inspiration
What are some features of pulmonary stenosis?
thrill on palpation
raised JVP with big A waves (RA contracting against hypertrophic RV)
peripheral oedema
ascites
What are the most common causes of pulmonary stenosis?
congenital
-> Noonan syndrome
-> tetralogy of Fallot
What is tetralogy of Fallot?
congenital pathology; four coexisting pathologies:
- ventricular septal defect
- overriding aorta
- pulmonary valve stenosis
- RV hypertrophy
What is infective endocarditis?
infection of the inner surface of the heart (endothelium)
mostly affects the valves
What are the risk factors for infective endocarditis?
IVDU
structural heart pathology
CKD (esp. dialysis)
immunocompromised
Hx of infective endocarditis
What structural heart pathologies can increase the risk of infective endocarditis?
valvular disease
congenital heart disease
hypertrophic cardiomyopathy
prosthetic valves
implanted cardiac devices
What organisms can cause infective endocarditis? And what is the most common one?
Staphylococcus aureus - most common
streptococcus
enterococcus
How does infective endocarditis present?
non-specific infective symptoms (fever, night sweats, fatigue)
new / changing murmur
splinter haemorrhages
Osler’s nodes / Janeway lesions
Roth spots
splenomegaly
finger clubbing (if chronic)
How is infective endocarditis investigated?
blood cultures - before ATB
echocardiography (transoesophageal is more sensitive - can see vegetations)
if prosthetic valves - special imaging:
- SPECT CT
- 18F-FDG CT/PET
What is the name of the tool used to diagnose infective endocarditis?
Duke Criteria
What score (from the Duke Criteria) is required to diagnose infective endocarditis?
1 major + 3 minor criteria
OR
5 minor criteria
What are the major criteria in Duke Criteria?
persistently positive blood cultures
specific imaging findings (e.g. vegetations on echo)
What are the minor criteria in Duke Criteria?
predisposition (e.g. valve pathology, IVDU)
fever above 38
vascular phenomena (e.g. intracranial haemorrhage, Janeway lesions, splenic infarction)
immunological phenomena (e.g. Osler’s nodes, Roth spots, glomerulonephritis)
microbiological phenomena (e.g. positive cultures not qualifying as major criteria)
How is infective endocarditis managed?
hospital admission
IV broad-spectrum ATB (e.g. amoxicillin) for 4 weeks (6 weeks if prosthetic valve)
surgery - if HF related to valve pathology / large vegetations / not responding to ATB
What are the key complications of infective endocarditis?
high mortality rate
heart valve damage -> regurgitation
HF
infective and non-infective emboli (-> stroke, splenic infarction)
glomerulonephritis -> renal impairment
What is pericarditis?
inflammation of pericardium - membrane surrounding the heart
What are the most common causes of pericarditis?
idiopathic
viral
other causes:
autoimmune
uraemia
medications - e.g. methotrexate
How does pericarditis present?
low-grade fever
chest pain
- pleuritic
- sharp
- central / anterior
- worse when lying down, better when sitting forward
What examination finding is typical for pericarditis?
pericardial friction rub - rubbing sound occuring alongside heart sounds
What is the potential space between the two layers of pericardium called? How is it relevant to pericarditis? What complications can arise from it?
pericardial cavity
in pericarditis - can fill up with fluid -> pericardial effusion
if pericardial effusion big enough to raise the intra-pericardial pressure -> cardiac tamponade
What is the function of the pericardial cavity?
contains small amount of fluid -> provides space to allow heart to beat without friction
What is cardiac tamponade? Why is it a problem?
large pericardial effusion that raised intra-pericardial pressure - > affects the heart’s ability to function
reduced heart filling during diastole -> decreases cardiac output during systole
emergency - requires quick drainage
How is pericarditis investigated?
blood tests - raised inflammatory markers
ECG changes
- saddle-shaped (concave) ST elevation
- PR depression
echocardiogram - to diagnose pericardial effusion
How is pericarditis managed? What are the first and second line treatment options?
first line:
NSAIDs
colchicine - longer-term treatment, prevents recurrence
second line:
steroids - if recurrent / associated with inflammatory condition
pericardiocentesis - removal of pericardial fluid if effusion/tamponade
treatment of underlying causes
What is the prognosis of pericarditis?
resolves within a month
may be recurrent
may become chronic
What is ejection fraction? What is the normal value?
% of blood in LV squeezed out with each ventricular contraction
normal is above 50%
What is systolic dysfunction?
problem with ventricle contracting during systole
What is diastolic dysfunction?
issue with ventricle relaxing and filling with blood during diastole
What are the main types of chronic heart failure? (2 answers correct)
preserved LVEF (LVEF > 50%)
reduced LVEF (LVEF < 50%)
OR
systolic HF (typically reduced LVEF)
diastolic HF (typically preserved LVEF)
What are some common causes of systolic dysfunction HF?
ischaemic heart disease
dilated cardiomyopathy
myocarditis
arrhythmias
What are some common causes of diastolic dysfunction HF?
hypertrophic obstructive cardiomyopathy
restrictive cardiomyopathy
cardiac tamponade
constrictive pericarditis
What are the potential causes of left-sided heart failure?
increased LV afterload - e.g. due to arterial HTN, aortic stenosis
increased LV preload - e.g. aortic regurgitation
What are the potential causes of right-sided heart failure?
increased RV afterload - e.g. pulmonary HTN
increased RV preload - e.g. tricuspid regurgitation
What does LV failure typically result in?
pulmonary oedema -> leads to signs and symptoms:
- dyspnoea
- orthopnoea
- paroxysmal nocturnal dyspnoea
- bibasal fine crackles
- wheeze
What does RV failure typically result in?
peripheral oedema
raised JVP
hepatomegaly - due to backflow
weight gain - due to fluid retention
anorexia - cardiac cachexia
What is “high-output heart failure”? What are some examples?
when a normal, healthy heart is unable to pump enough blood to meet the metabolic demands of the body
e.g. in
- anaemia
- arteriovenous malformation
- Paget’s disease
- pregnancy
- thyrotoxicosis
What are some examination signs in heart failure?
tachycardia
tachypnoea
HTN
murmurs
3rd heart sound
bilateral basal crackles
raised JVP
peripheral oedema
What are some symptoms of chronic heart failure?
SoB, worse on exertion
cough - can produce white/pink frothy sputum
cardiac wheeze (due to pulmonary oedema)
orthopnoea
paroxysmal nocturnal dyspnoea
peripheral oedema
fatigue
How is heart failure diagnosed?
clinical assessment - Hx, examination
NT-proBNP blood test
ECG
echocardiogram
+bloods - to check for anaemia, U&Es, LFTs, TFTs, lipids, diabetes
+CXR + lung function tests (spirometry)
How is severity of HF symptoms graded? What are the grades?
NYHA - New York Heart Association Classification
Class 1: no limitation on activity
Class 2: comfortable at rest, symptomatic with ordinary activities
Class 3: Comfortable at rest, symptomatic with any activity
Class 4: Symptomatic at rest
How is chronic heart failure managed? What are the main principles?
RAMPS:
R: Refer to cardiology
A: Advise about condition
M: Medical treatment
P: Procedural and surgical management
S: Specialist heart failure MDT input
How urgently are patients with HF refered to echocardiography?
NT-proBNP between 400-2000 - within 6 weeks
NT-proBNP > 2000 - within 2 weeks
What is the first-line medical treatment for chronic heart failure?
ABAL
A: ACE inhibitor - e.g. ramipril - up to 10mg
B: Beta blocker - e.g. bisoprolol - up to 10mg
A: Aldosterone antagonist (if symptoms still persist) - e.g. spironolactone, eplerenone
L: Loop diuretics - e.g. furosemide, bumetanide