Cardio Flashcards
What is hypertension?
Hypertension is a chronic medical condition in which the blood pressure is elevated > 140/90
What is essential hypertension vs secondary?
Primary hypertension = no medical cause is found.
Secondary - other cause
What are the signs and symptoms of hypertension?
Symptoms - usually asymptomatic - headaches - epistaxis - sweating Signs - elevated BP
What are the renal causes of hypertension?
Diabetic nephropathy
Chronic glomerulonephritis
Polycistic kidneys
Renal vascular disease
What drugs can cause hypertension?
NSAIDs
Oral contraceptives
Steroids
Liquorice
What are the endocrine causes of hypertension?
Conn’s syndrome
Phaeochromocytoma
Adrenal hyperplasia
Cushing’s syndrome
What are the risk factors for hypertension?
Lifestyle factors - diet, smoking, obeisty, alcohol, no exercise
age, sex, family history Ethnic group Diabetes Kidney disease High cholesterol
What is the non-pharmacological treatment for hypertension?
Reduce risk factors Lose weight Exercise Reduce salt Stop drinking/smoking
What is the pharmacological treatment for hypertension?
ACI/ARB (first line in under 55s)
CCB/diuretic above (or black/pregnant)
Combination therapy if needed
What are ACEIs?
Angiotensin converting enzyme inhibitors e.g. Ramipril, Captopril • Blocks the conversion of angiotensin 1 into angiotensin 2 which is a potent vasoconstrictor. S/E → Hypotension Dry cough
What are CCBs?
Calcium channel blockers e.g. Amlodipine, nifedipine • Causes arteriole dilatation and reduces the force of heart contractions S/E → Headaches >Sweating >Palpitations >Flushing
What are diuretics (used for hypertension)?
Thiazide type generally used
• Increases water secretion from the body by not absorbing Na therefore Na remains int he filtrate and water follows
S/E → Increases cholesterol levels
>Impaired glucose tolerance
What is malignant hypertension?
Malignant hypertension is a complication of hypertension characterized >very elevated blood pressure that occurs rapidly, >organ damage in the eyes, brain, heart and/or kidneys.
Systolic and diastolic blood pressures are usually greater than 220mmHg and 120mmHg, respectively.
What are the signs of malignant hypertension?
The eyes may show >papilloedema,
>retinal haemorrhage,
>or exudates
• The brain shows
>increased ICP,
• Patients will usually suffer from left ventricular dysfunction
• The kidneys will be affected,
> haematuria,
>proteinuria,
>and acute renal failure.
What is emergency blood pressure control?
Should not bring down the BP too quickly as there is a risk of cerebral, retinal, renal, MI complications
IV Sodium nitroprusside
IV iabetalol
What is angina?
Angina: radiating chest pain caused by insufficient blood flow to an area of the heart.
- STABLE: occurs upon exertion and fades with rest
- UNSTABLE: occurs suddenly and spontaneously with no exertion
What are the signs and symptoms of angina?
Symptoms
- Tight, dull heavy chest discomfort
- Retrosternal or radiating to the left arm, neck, back or jaw
- Breathlessness
- Nausea
- Epigastric discomfort that is not relieved with antacidsSigns
- Usually none!
- Hypercholesterolaemia (xanthalasma, corneal arcus)
- Anaemia (pallor, tachy)
- Thyrotoxicosis (carotid bruits)
- Hypertension
What is the pathogenesis of atheroma?
Increased lipid levels Inflammaotry process - infiltration of macrophages Macrophages form foam cells >Through uptake of mdified LDLs Forms fibrous cap >Reduces blood flow, can rupture
What is the content of atheromatous plaques?
Collagens (produced by smooth muscle cells) in cap provide structural strength
Inflammatory cells (macrophages, lymphocytes, mast cells) reside in fibrous cap: recruited from arterial endothelium
Soft “foamy” macrophages rim (foamy due to uptake)
What are the S&S of major hyperlipidaemia?
Conreal arcus (premature)
Tendon Xanthomata (knuckles, Achilles)
Xanthelasmata (fatty lumps in skin, often in arms)
Risk/premature/family history MI/athermoa
What are the risk factors for atheroma?
Male Smoking Drinking High cholesterol Obesity Diabetes Hypertension
How do you investigate agina?
ECG/exercise ECG
Myocardial perfusion scans
CT coronary angiogram
What drugs are used to manage angina?
Symptomatic - GTN spray
>Max 3 doses before ambulance should be called
Acute
>Long acting nitrates
Long term >Betablockers >Long acting nitrates >CCBs >K+ channel activators
What are the S&S of unstable angina?
Symptoms:
1) Occurs at rest
2) Severe and new onset
3) Crescendo pattern (more severe & prolonged)
Signs:
1) Heart sound
2) Basal crackles
3) Hypotension
4) Murmurs
What investigations should be done into unstable angina?
ECG: May be normal or show ST depression or T wave inversion
Biochem markers: To assess risk of MI
How do you treat unstable angina?
B blockers
Nitrates
CCBs
Aspirin
Heparin
Angiography/stent if needed
What are PQRS?
P→ atrial depolarisation
QRS → ventricular depolarisation
T → ventricular repolarisation
PR interval → time taken for impulse to pass from SA to AV node.
What are the complications of an MI?
Heart failure
Myocardial rupture
VSD – due to infarct in septum
Mitral regurgitation – MI of inferior wall, due to infarct of pappliary muscle
Cardiac arrhythmias- MI of anterior wall
Conduction disturbances – MI of inferior wall presents as heart block
What can cause heart block?
1st/2nd degree >Acute infection >Myocarditis >Ca blocker/b blocker/digoxin 3rd degree >Coronary ischaemia >SLE >Drug induced >endocarditis
What is first degree heart block?
Prolonged PR interval >0.22 sec
Asymptomatic
What is type 1 2nd degree heart block?
Progressive P-R interval elongation until a P wave fails to conduct at all.
This would show that there is a problem with the A-V node
>Light headedness
>Dizziness
>syncope
What is 3rd degree heart block?
no relation between the QRS and P wave i.e. there is no conduction to the ventricles from the atria.
If QRS is narrow = Bundle of His takes over
If QRS is wide = purkinje takes over
What is type 2 2nd degree heart block?
No P-R wave elongation but P wave fails to conduct to QRS sometimes at a rate of 3:1
>Light headedness
>Dizziness
>syncope
How do you manage bradycardia?
If asymptomatic and rate > 40bpm = no treatment
If rate <40bpm or patient symptomatic:
1) atropine
2) Temporary pacing wire
What are the types of supraventricular tachycardias?
Atrial flutter
Atrial fibrillation
What is atrial flutter?
Rhythm is still regular (interval between QRS complexes) but there are P waves at a rate of >250/min. There is no flat baseline between P waves
What is atrial fibrilation?
Absent P waves and increased and irregular heart rate >Palpitations >Chest pain >Dizzy >SOB
What are the causes of atrial flutter?
Re entrant rhythm
CAD
Hypertension
cardiomyopathy
What are the causes of AF?
Ischaemia
Cardiomyopathy
hypertension
What is VF?
Cardiac arrest
Loss of consciousness
There is no QRS complex and ECG is disorganised
What is VT?
Severe hypotension
≥ 3 consecutive ventricular beats in all leads and QRS complexes are broad.
How do you manage AF?
Maintain sinus rhythym with DC cardioversion
Antiarrhytmic drugs (betablockers 1st line)
Reduce heart rate
Blood thinners to prevent stroke
What are the types of antiarrhythmics?
1 - sodium channel blockers (fast, medium, slow for ABC)
2 - B-adrenergic receptor antagonists
3 - prolong refatorinesss
IV - CCBs
What are class 1 antiarrhythmics?
Membrane-stabilizing agents
A - quinidine
B - lidocaine
C - flecainide
What are the signs of digoxin toxicity?
Nausea and vomiting Xanthopsia Bradycardia Tachycardia Arrhythmias: VT and VF
What is the clinical presentation of cardiac failure?
Symptoms:
- dysopnea/orthopnea
- Fatigue
Signs:
- Cardiomegaly
- 3rd/4th heart sounds
- ↑ JVP
- Tachycardia/Hypotension
- Bi basal crackles
- ascities
- Pleural effusion
- ankle odema
- Hepatomegaly
What can cause left sided heart failure?
Commonly IHD but can also occur with
valvular heart disease &
hypertension,
dilated cardiomyopathy.
Mainly IHD, cardiomyopathy and hypertension
What can cause right sided heart failure?
Left sided heart failure
right ventricular cardiomyopathy,
right ventricular infarction,
pulmonary hypertension.
Mainly IHD, cardiomyopathy and hypertension
What drugs affect preload?
Diuretics decrease
What drugs affect aferload?
ACEI decrease by vasodilation
ARBs decrease
CCBs
What drugsd affect cardiac contracability?
Anti-arrhytmics
What are the types of shock?
Hypovolaemic Septic Anaphylactic Disruptive Obstructive
What are the signs of shock?
↓BP, Pale, Clammy hands, Tachycardia, Tachypnoea, Confusion, ↓Urine output, ↑ Capillary refill
What drugs are used to treat shock?
Adrenaline/neuroadrenaline
Dopamine (precurosor to adrenaline)
Dobutamine (increases CO)
What are the clinical signs of infective carditis?
Valve destruction: heart failure +/- new heart murmurs • Vascular phenomena: embolisation of vegetation + metastatic abscess formation in brain, spleen +kidney • Immune complex deposition: >Vascalitis >petechia >Splinter haemorrhage >Roth spots >Oslers nodes >arthralgia >glomerulonephritis
What causes infective carditis?
Staph A
Alpha haemolytic strep. viridans
Due to prosthetic valve/valve surgery
Soft tissue infections
IV drug users
Prolonged catheter/antibiotic use
What is the pathogenesis of infective carditis?
Endocarditis is usually the consequence of two factors:
• The presence of organism in the blood stream
• Abnormal cardiac endothelium facilitating adherence and growth
> Damaged endocardium promotes platelet and fibrin deposition which allows organisms to adhere and grow leading to an infected vegetation.
Valvular lesions may create non laminar flow and jet lesions from septal defects or patent ductus arteriosus
Aortic and mitral valves are usually affected
>IV drug users – tricuspid!
What are the complications of infective carditis?
Cardiac failure (destruction of heart valve)
• Embolism
• Glomerulonephritis
How do you investigate infective carditis?
Blood cultures (Before antibiotics) >3 different sites in 24 hours Echo Serological tests if blood cultures negative Chest X-ray ECG Blood count (WBC raised)
What are the indications for a valve replacement?
Severe heart failure
• Infection of prosthetic material
• Worsening renal failure
• Extensive damage to valve
What are the characteristics of pericardial disease?
Sharp central chest pain which is exacerbated by movement, respiration and lying down and is characteristically relieved by leaning forward
What are the causes of pericarditis?
Most commonly due to viral infection & MI
- viral: Cox sackle B
- post MI
- bacterial: Staph aureus in HIV
- Malignant: carcinoma of the bronchus, breasts and hodgkins lymphoma
What are the clinical features of pericarditis?
Sharp chest pain
• Pericardial friction rub
• +- fever
What are the ECG changes in pericarditis?
Concave upwards, (saddle shaped) ST segment elevation which then changes to T wave flattening or inversion – then normalizes
How do you treat pericarditis?
Underlying cause
Then NSAIDs, if no improvement corticosteroids
What causes Pericardial Effusion?
Most commonly due to pericarditis
Viral
Post MI
And malignant
What are the clinical features of pericardial effusion?
Heart sounds soft and distant
• Apex beat obscured
• Cardiac tamponade: ↑JVP, ↓BP, ↑HR
What is the treatment for pericardial effusion?
Treat underlying cause
PERICARDIOCENTESIS – When fluid is aspirated from the pericardium with US guidance
What are the causes of constrictive pericarditis?
Infection– TB
-Inflammation– Chronic pericarditis
Usually - IDIOPATHIC
What are the clinical features of constrictive pericarditis?
↑JVP • Ascites • Hepatomegaly • Dyspnoea • Cough • Orthopnoea • ↓BP • fatigue
How do you treat constrictive pericarditis?
Complete resection of pericardium
What is the presentation of myocarditis?
Chest pain Palpitations Fatigue Dysopnea Congestive heart failure Soft heart sounds 3rd heart sound Tachycardia Pericardial friction rub
What is cardiomyopathy, and what are its types?
Cardiomyopathy: is a group of diseases of the myocardium that affect the mechanical or electrical function of the heart. They are not secondary to anything and frequently genetic
Dilated, hypertrophic and restrictive
What can cause dilated cardiomyopathy?
Hypertension
Ischaemia
Congenital heart disease
Infections
What is the presentation of dilated cardiomyopathy?
- SOB
- Embolism
- Arrhythmia
- Heart failure symptoms (dyspnoea, orthopnoea, fatigue)
How do you investigate dilated cardiomyopathy?
CXR: Cardiac enlargement
ECG: ST segment and T wave changes
ECHO: dilated ventricles
“dilated left ventricle which contracts poorly”
How do you manage dilated cardiomyopathy?
Treat heart failure and arrhythmias
- Disease progression is slowed down with ACE, ARB’s, spironolactone and B-blockers. - ICD’s given if risk of VT
What are the causes of hypertrophic cardiomyopathy?
genetic disorder caused by mutations in genes coding for proteins that regulate contractions
What is the presentation of hypertrophic cardiomyopathy?
Usually asymptomatic • SOB, chest pain, syncope • Jerky carotid pulse • Ejection systolic murmur • Pansystolic murmur
How do you investigate hypertrophic cardiomyopathy, and its results?
ECG: Let ventricular hypertrophy
ECHO: ventricular hypertrophy with involvement of the septum
How do you manage hypertrophic cardiomyopathy?
If increased risk of sudden death then implant ICD
- If ok the give amiadarone - Treat symptoms with b-blockers and verapamil
What are the causes of restrictive cardiomyopathy?
amyloidosis
sarcoidosis.
famlial
What is the presentation of restrictive cardiomyopathy?
Dyspnoea • Fatigue and embolitic symptoms • ↑JVP • Hepatomegaly • Ascites • 3rd and 4th heart sounds
What are the investigations for restrictive cardiomyopathy?
Cardiac catheter: Characteristic pressure changes
“rigid myocardium”
What are the systolic murmurs?
Aortic stenosis
Pulmonary stenosis
Mitral regurgitation
Tricuspid regurgitation
What are the septal defects?
VSD - left ventricular pressure greater than right, leads to central cyanosis
ASD - left atrial pressure greater than right, blood moves left to right
>Increases overload and leads to heart failure
What is aortic stenosis?
Outflow of blood from LV is obstructed
>increases LV pressure –> causing LV hypertrophy
Caused by
•Congenital stenotic valve
• Rheumatic fever
• Calcific valvular disease
What is the presentation of aortic stenosis?
Mid systolic murmur in aortic area
Radiates to carotid
- usually no symptoms until severe
- Syncope (exercise)
- Angina
- Dyspnoea
- slow rising carotid pulse
What is pulmonary stenosis?
Outflow of blood from the RV obstructed by pulmonary valve
>reduces blood flow to lungs, –>leads to RV hypertrophy
Caused by
• Congenital
• Carcinoid syndrome
• Rubella during pregnancy
How does pulmonary stenosis present?
Mid systolic ejection murmur
Left of sternum 2nd intercostals space
fatigue
- syncope
- right heart failure
- raised JVP
- thrill
What is mitral regurgitation?
Regurg into LA causes LA dilatation.
causes LV hypertrophy and pulmonary congestion
Caused by
• Rheumatic fever
• Prolapsing miitral valve
• Rupture of pap muscle or chordate due to MI
How does mitral regurgitation present?
Pan systolic murmur
loudest at the apex and radiates to the axilla
palpitations
- dyspnoea
- Fatigue
- Displaced apex
What is tricupsid regurgitation?
Occurs when there is RV dilatation leading to a change in anatomy
Caused by • Cor pulmonale • MI • Pulmonary hypertension • Infective endocarditis
How does tricupsid regurgitation present?
Pan systolic murmur
Best heard on inspiration
right heart failure
- raised JVP
- palpable liver
What are the diastolic murmurs, what causes them?
Mitral stenosis
>Rheumatic fever
Aortic regurgitation
>Rhemuatic fever + infective endocarditis
What is mitral stenosis?
Outflow of blood form the LA is obstructed
>causes LA hypertrophy as pressure increases.
pulmonary pressure then increases
>Causes right heart failure
How does mitral stenosis present?
Mid diastolic murmur with opening snap
low pitched rumbling with bell at apex with patient on the left side
Pulmonary hypertension: malar flush, dyspnoea, cough, haemoptysis
• Right heart failure: fatigue, oedema, raised JVP (a wave)
• AF: palpitations
What is aortic regurgitation?
Reflux of blood from aorta into the LV. LV has to work harder to pump blood >LV hypertrophy >increases demand of cardiac perfusion >leads to cardiac ischaemia
How does aortic regurgitation present?
Early diastolic murmur
High pitched
Left sternal edge (4th intercostals space) patient leaning forward and holding breath in expiration
Increased pulsation/pounding of the heart
• Angina
• dyspnoea
What are the risk factors for congenital cardiac disease?
Maternal rubella (PDA) Foetal alcohol syndrome Maternal SLE Downs syndrome (trisomy 21) Turner’s syndrome (coarctation of the aorta)
What are the common congenital heart diseases?
VSD ASD PDA Fallots tetralogy Coarcation of aorta
What is the presentation of VSD?
Small VSD: Asymptomatic
Moderate VSD: Fatigue, dyspnoea, cardiac enlargement
Pan systolic murmur
What is the presentation of ASD?
Palpatations/AF
Dyspnoea
Pulmonary infection
What is the presentation of PDA?
No signs
The ductus arteriosus conncets the pulmonary artery to the descending aorta. If it remains patent = LV hypertrophy
What is the presentation of fallots tetraology?
Dyspnoea Fatigue Cyanotic Syncope Squatting Clubbing polycythaemia
What is fallot’s tetraology?
1)Overriding aorta
2) RV outflow obstruction
3) Ventricular septal defect
4) RV hypertrophy
= right to left shunt
What is coarctation of aorta?
Hypertension
Weak delayed pulses
Radial to radial delay
What are the types of aortic aneurysm?
Saccular
Fusiform
False
Dissecting
What are the symptoms of a PE?
Severe dyspnoea of sudden onset Collapse Blue lips and tongue- cyanosis Tachycardia Low blood pressure Raised jugular venous pressure Altered heart sounds
What are the risk factors for AAA?
male sex
advancing age
smoking
COAD
What is the presentation of AAA?
Asymptomatic
- incidental finding on examination
>Or on ultrasound
Emergency - imending/actual rupture
What is the presentation of aortic dissection?
Tearing, severe chest pain (radiating to back)
Collapse (tamponade, acute AR, external rupture)
Beware inferior ST elevation
Hypotension (severe)
Pulmonary odema
