Cardio 2 Flashcards
B-type Natriuretic Peptide
- a) What causes it to be raised?
b) In what conditions will this be seen? - a) Why is this useful in acute dyspnoea?
b) When else is it useful?
- a) in response LV strain
b)
- heart failure
- ischaemia
- valvular disease
also in CKD because of reduced excretion - a) low levels can rule out heart failure
b) for determining both prognosis and the response to treatment for heart failure
(If treatment effective levels will lower)
NOTE: as they are treatments for HF, BNP may be falsely lowered if patients had previously been on the following drugs for another reason
- ACE inhibitors + ARBs
- beta blockers
- aldosterone antagonist
diuretics (assuming increased excretion) and obesity can also falsely lower BNP
Brugada Syndrome
- What clinical features are seen?
- What investigation can be carried out?
- How is it managed?
- more common in asians
- sudden death
- ECG changes:
ST elevation followed by T wave inversion in >1 of leads V1-3
partial RBBB
- give flecainide or ajmaline to make the ECG changes more apparent
- implant cardioverter-defibrillator
Buerger’s Disease (AKA thromboangiitis obliterans)
- What is it?
- What clinical features are seen?
- small + medium vessel vasculitis strongly associated with smoking
- extremity ischaemia: intermittent claudication + ischaemic ulcers
- superficial thrombophlebitis
- Raynaud’s
Cardiac enzymes and protein markers
- What is the first to rise?
- What will still be raised at day 6?
- What is said to be useful at identifying reinfarction?
- When does troponin:
a) begin to rise
b) reach its peak
c) return to normal
- myoglobin (after 1-2 hrs)
- LDH and troponin T
- CK-MB (as elevated for 2-3 days but troponin could take until day 10 to return to normal)
- a) 4-6 hrs
b) 12-24 hrs
c) 7-10 days
- a) What is the gold standard imaging for providing structural images of the heart?
b) When can this be of particular use? - When can myocardial perfusion also be assessed in this imaging?
1.
a) cardiac MRI (AKA CMR)
b)
- assessing congenital heart disease
- differentiating between forms of cardiomyopathy
- following administration gadolinium
Cardiac Tamponade
- What clinical features can be seen?
- How is it managed?
- Beck’s triad: hypotension, raised JVP, muffled heart sounds
- pulsus paradoxus
- absent Y descent on JVP (due to restricted RV filling)
- dyspnoea
- tachycardia
- electrical alternans on ECG (alternating magnitude of QRS complex)
- kussmaul’s sign (rise in JVP during inspiration)
mnemonic: padtek - evil corporation creating technology to pad the pericardium causing tamponade
2. urgent pericardiocentesis
How can you differentiate between cardiac tamponade and constrictive pericarditis?
Tamponade
JVP absent Y descent + pulsus paradoxus (decrease in BP on inspiration)
constrictive pericarditis
Kussmaul’s sign (increase in JVP on inspiration) + pericardial calcification on CXR
Peripartum Cardiomyopathy
- When does it typically develop?
- When is it more common?
- between last month of pregnancy and 5 months postpartum
- older women
- multiparity
Takotsubo Cardiomyopathy
- When does this occur?
- What happens in the heart?
NOTE: treatment is supportive
- stress-induced
e. g. patient has just found out family member has died then develops chest pain and HF - transient apical ballooning of the myocardium
Chest Pain Assessment
- What should you do if in the GP in the following scenarios:
a) current chest pain / in the last 12 hrs
b) chest pain 12-72 hrs
c) >72 hrs ago
1
a) emergency admission
b) refer to hospital for same day assessment
c) full assessment incl. ECG and troponin measurement
Angina
- What clinical features are seen?
- If angina cannot be ruled out, what investigation should be carried out?
- tightness in chest / neck / jaw / arms
- precipitated by physical exercise
- relieved by GTN
all 3 = typical angina
2 = atypical
1 is not angina
- 1st line: CT coronary angiography
2nd line: non-invasive coronary imaging
3rd line: invasive
Chronic Heart failure Diagnosis
- a) What blood test should be ordered?
b) When is this
i) normal
ii) raised
iii) high - What should be done if
a) raised
b) high
- a) B natriuretic peptide
(NT-proBNP - N-terminal pro-B-type natriuretic peptide)
b)
i) BNP <100 or NT-proBNP <400
ii) BNP 100-400 or NT-proBNP 400-2000
iii) BNP >400 or NT-proBNP >2000
2.
a) specialist review (incl. trans thoracic echo) in <6 weeks
b) specialist review (incl. trans thoracic echo) in <2 weeks
Chronic Heart Failure Treatment
- Describe the management.
- What other treatments should be offered?
NOTE: furosemide plays a role in symptom management of fluid overload
- ACE inhibitor AND beta blocker
- should be started one at a time
2nd line / can add aldosterone antagonist (AKA mineralocorticoid receptor antagonist) (e.g. spironolactone or eplernone)
NOTE: both aldosterone antagonists and ACEs cause hyperkalaemia therefore potassium should be monitored
- one off pneumococcal vaccine
- annual flu vaccine
(think same as COPD)
Describe New York Heart Association classification of Heart failure
Class I - no symptoms
Class II - mild symptoms: slight limitation of exercise
Class III - moderate symptoms: marked limitation of physical activity
Class IV - severe symptoms: symptoms at rest and unable to carry out physical activity
Coarctation of the aorta
- What clinical features are seen?
- What is it associated with?
- infancy: heart failure
- radio-femoral delay
- adult: hypertension
- mid systolic murmur (maximal over back)
- apical click from the aortic valve
- notching of the inferior border of the ribs (due to collateral vessels) is not seen in young children
- turners syndrome (although overall more common in males)
- berry aneurysms
- bicuspid aortic valve
- neurofibromatosis
