cardio Flashcards
1
Q
what is stable angina?
A
a symptom which occurs as a consequence of restricted coronary blood flow which causes a mismatch between oxygen demand and supply
2
Q
what can cause stable angina?
A
atheroma, anaemia, aortic stenosis, tachyarrythmias, HCM
3
Q
how does angina present clinically?
A
- central, crushing chest pain
- comes on with exertion, relieved at rest
- exacerbated by cold, anger, excitement
- radiates to arms and neck
- dyspnoea, nausea, sweating, fitness
4
Q
what are some differential diagnoses of angina?
A
- ACS
- pericarditis
- myocarditis
- aortic dissection
- PE
- GORD
5
Q
How can stable angina be diagnosed?
A
- ECG- normal- used to differentiate from ACS
- exercise ECG
- coronary angiography
- CT angiography
6
Q
how is stable angina treated?
A
- modify risk factors
- low dose aspirin
- clopidogrel
- statins
7
Q
how can stable angina be managed?
A
- nitrates- isosorbide, GTN
- beta blockers
- calcium channel blockers
8
Q
what is ACS?
A
acute coronary syndromes- covers a spectrum of acute cardiac conditions from unstable angina to varying degrees of evolving MI
9
Q
what can cause unstable angina?
A
- rupture of an atherosclerotic plaque
- coronary vasospasm
- drug absue
10
Q
how does unstable angina present clinically?
A
- acute central chest pain not relieved by rest
- chest pain with a crescendo pattern
- new onset
- sweating, dyspnoea, palpitations
11
Q
how is unstable angina treated?
A
MONA morphine Oxygen Nitrates Aspirin
12
Q
how does a patent with a STEMI present clinically?
A
- central crushing chest pain
- occurs at rest, lasts several hours
- sweating, breathlessness, nausea, vomiting, restlessness
- pale and grey appearance
13
Q
how does a STEMI appear on an ECG?
A
ST elevation
tall T waves
pathological Q waves
14
Q
how do you treat a patient with a STEMI?
A
300mg aspirin morphine oxygen antiemetic- e.g. metoclopramide PCI
15
Q
what is the aetiology of a NSTEMI?
A
partial occlusion of the vessel lumen- ischaemia is limited to the subendocardial zone of the myocardium
16
Q
how does a NSTEMI present on an ECG?
A
ST depression, T wave inversion
17
Q
what is heart failure?
A
A complex clinical syndrome of signs and symptoms that suggest the efficiency of the heart as a pump is impaired
18
Q
during heart failure, the body tries to compensate to maintain cardiac output- what are the compensatory mechanisms and what are the consequences of these?
A
- Activation of sympathetic nervous system- increase HR and contractility, however also leads to arteriolar constriction- increasing afterload so decreasing CO
- RAAS- activated due to decreased CO, results in oedema and dyspnoea, angiotensin II causes arteriolar constriction, increasing afterload and the work of the heart
- Ventricular dilatation- failure= reduced volume of blood ejected, so increased vol. remains after systole, stretches fibres, due to Starlings law this restores contractility- in heart failure however compensatory effects are limited- leading to pulmonary and peripheral oedema and increased O2 requirement of myocardium
- Ventricular remodelling- hypertrophy, loss of myocytes, increased interstitial fibrosis
19
Q
what is systolic heart failure?
A
inability of ventricles to contract normally- decreased CO, stroke volume is a small fraction of the total filling volume- low ejection fraction (lower than 40%)
20
Q
what is diastolic heart failure?
A
inability of ventricle to relax and fill normally, causing increased filling pressures, normal ejection fraction- low preload but a normal stroke volume- so the fraction appears higher
21
Q
how does left ventricular heart failure present clinically?
A
presents with poor exercise tolerance, fatigue, pulmonary oedema
22
Q
what does right heart failure present with clinically?
A
peripheral oedema, ascites, nausea, raised jugular venous pressure
23
Q
what is cor pulmonale?
A
right heart failure secondary to lung disease
24
Q
what is decompensated heart failure?
A
occurs when the heart begins to stop responding to compensatory mechanisms as over activation results in a decreased response
25
what can cause low output heart failure?
pump failure, excessive preload, chronic excessive after load
26
what can cause high output failure?
anaemia, pregnancy, hyperthyroidism
27
what can cause heart failure?
- IHD
- Valvular disease- mitral regurgitation, aortic stenosis, tricuspid regurgitation, venricular septal defect
- Pericardial disease- pericarditis, pericardial effusion
- Drugs- alcohol, cocaine, beta blockers
- Myocarditis
- Thyrotoxicosis
- Arrhythmias
- Cardiomyopathies- dilated, hypertrophic, restrictive
- Anaemia
- Pulmonary hypertension
28
what are the clinical signs of heart failure?
cardiomegaly
3rd heart sound- active filling of the left ventricle
4th heart sound- pathological- heart becomes stiff so vibrates
pleural effusion
elevated JVP
29
how can heart failure be classified?
I.Class I- no limitation to exercise
II.Mild limitation- exercises produces some mild symptoms
III.Marked limitation- symptoms produced on gentle exercise
IV.Symptoms occur at rest and are exacerbated by any activity
30
how can heart failure be diagnosed?
- CXR- alveolar oedema, cardiomegaly
| - ECG- underlying cause
31
how can heart failure be treated?
- lifestyle modification
- diuretic
- spironolactone
- ACE inhibitor
- beta blockers
32
what can cause aortic stenosis?
- Senile calcification
- Rheumatic heart disease
- Compensatory heart failure- LVH- results in increased myocardial oxygen demand, ischaemia of myocardium- angina, arrhythmias and LV failure
- Congenital abnormal valve
33
how does aortic stenosis present clinically
- asymptomatic
- angina, syncope, dyspnoea
- narrow pulse pressure
systolic ejection murmur
34
what is the main differential diagnosis of aortic stenos?
hypertrophic cardiomyopathy
35
how can aortic stenosis be diagnosed?
- ECG- P mitrale, LVH, ST depression T wave inversion
| - CXR- valvular calcification
36
how can aortic stenosis be managed?
- dental care
| - IE prophylaxis
37
what can cause mitral regurgitation?
- Backflow through the mitral valve during systole
- Caused by a volume overload
- Compensatory mechanisms- left atrial enlargement, LVH and increased contractility
- Rheumatic heart disease
- Infective endocarditis
- LV dilatation
- Caridomyopathy
38
how does mitral regurgitation present clinically?
- dyspnoea, fatigue, palpitations
| - soft S1
39
how can mitral regurgitation be diagnosed?
- ECG- AF and P mitrale
| - CXR- enlarged LA and LV
40
what can cause aortic regurgitation?
- Combined pressure and volume overload
- Compensatory mechanism- LV dilation, LVH- progressive dilation leads to heart failure
- Rheumatic fever
- Infective endocarditis
- Dissection of aorta
- Severe hypertension
- Aortic endocarditis
- Aneurysmal change of the aortic annulus- area surrounding the valve widens so the valve cannot fully close
41
what are the clinical signs of aortic regurgitation?
collapsing pulse
wide pulse pressure
displaced apex beat
42
how can aortic regurgitation be diagnosed?
- CXR- cardiomegaly
- pulmonary oedema
- ECG- LVH
43
how can aortic regurgitation be treated?
- ACE inhibitors
| - valve replacement
44
what can cause mitral stenosis?
- Rheumatic heart disease
- Congenital
- Cardial fibroelastosis
- Prosthetic valve
- Infective endocarditis
45
what are the signs and symptoms of mitral stenosis?
```
Symptoms:
-Exertional dyspnoea
-Fatigue
-Palpitations
-Chest pain
-Haemoptysis
Signs:
-Malar flush on cheeks
-Low-volume pulse
-Irregular pulse
```
46
how can mitral stenosis be diagnosed?
- ECG- AF, P mitrale
| - CXR- pulmonary oedema, LVH
47
what is cardiomyopathy?
A cardiomyopathy is a heart muscle disease of uncertain cause, which typically have an autosomal dominant pattern of inheritance
48
what can cause HCM?
sarcomeric gene mutations
49
what stage of the hearts contraction does HCM affect?
diastole- heart cannot relax properly due to thickening of the ventricular walls
50
how does HCM present on an ECG?
large QRS, inverted T waves
51
how is HCM treated?
beta blockers, calcium channel blockers, septal myectomy
52
how does DCM present clinically?
breathlessness, tiredness, oedema
53
what is the most common cause of restrictive CM?
Amyloidosis- extra-cellular deposition of an insoluble fibrillar protein (amyloid)
54
what can cause arryhthmogenic right/left ventricular CM?
desmosome gene mutations- Desmosomes attach cells via intermediate filaments, mutation leads to myocytes being pulled apart and ventricles are replaced by fatty fibrous tissue
55
how does arryhthmogenic right/left ventricular CM present on an ECG?
ventricular tachycardia and epsilon waves
56
what is a ventricular septal defect?
This an abnormal connection between the 2 ventricles- since there is high pressure in the left ventricle and low pressure in the right ventricle blood flows from left to right.
57
what can cause a VSD?
congenital, post MI (acquired)
58
how does VSD present clinically?
- symptoms- severe in infants, detected later in adults
| - signs- loud murmurs= small hole, large hole= pulmonary hypertension
59
how does a large VSD present on ECG and CXR?
ECG- LVH and RVH
| CXR- cardiomegaly, large pulmonary arteries
60
what is an atrial septal defect?
hole that connects the atria- classified as either ostium secundum (high in the septum) or ostium primum (opposing the endocardial cushions)
61
how does an atrial septal defect present clinically?
- pulmonary hypertension
- cyanosis
- arrhythmia
- haemoptysis
- chest pain
- AF, raised JVP, pulmonary ejection systolic murmur
62
how does an atrial septal defect present on an ECG?
RBBB with LAD and prolonged PR interval
63
how does the presentation of an atrioventricular septal defect differ between a complete and a partial defect?
```
•Complete defect
oBreathless as neonate
oPoor weight gain
oPoor feeding
oTorrential pulmonary blood flow
oNeeds repair or PA band in infancy
oRepair is surgically challenging
```
•Partial defect
oCan present in adulthood
oPresents like small ASD/VSD
oMay be left alone if no right heart dilatation
64
what is a patent ductus arteriosus?
Persistent communication between the proximal left pulmonary artery and the descending aorta – continuous left to right shunt
65
what are the clinical signs of a patent ductus arteriosus?
bounding pulse, continuous ‘machinery murmur’, pulmonary hypertension in a large PDA
66
how does coarctation of the aorta present clinically?
radio femoral delay, weak femoral pulse, high BP, systolic murmur
67
what are the 4 key feats fo the tetralogy of fallot?
1. Ventricular septal defect
2. Pulmonary stenosis
3. Right ventricular hypertrophy
4. The aorta overriding the VSD
68
how does the tetralogy of fallot present clinically?
- gradually becomes cyanotic due to decreasing. blood flow to lungs
- hypoxic spells
- toddlers may squat
69
how can tetralogy of fallot be diagnosed?
- CXR- boot shaped heart
| - echo shows degree of stenosis
70
what is cardiac tamponade?
when fluid in the pericardium builds up, resulting in compression of the heart.
71
why does chronic pericarditis rarely cause cardiac tamponade?
In chronic pericarditis, chronic accumulation of fluid in the pericardial sac allows for adaptation of the parietal pericardium- this compliance reduces the effect on diastolic filling of the chambers
72
what can cause pericarditis?
- Usually idiopathic
- Dressler’s syndrome- occurs after an MI
- Viral- e.g. EBV, influenza, herpes simplex
- Bacterial- e.g. mycobacterium tuberculosis
- Autoimmune- rheumatoid arthritis, systemic lupus erythematosus
- Neoplastic- secondary metastatic tumours
73
how does pericarditis present clinically?
Chest pain- severe, sharp, pleuritic, rapid onset, radiates to arm, relieved by sitting forward
74
how can you diagnose pericarditis?
- examination- pericardial rub, sinus tachycardia
- ECG- diffuse ST segment elevation
- ESR, CRP raised
75
how is pericarditis treated and managed?
- anti-inflammatory drugs
- avoid strenuous activity
- NSAIDs/ aspirin
- colchicine for 6-8 weeks
76
what is Dressler's syndrome?
secondary form of pericarditis- Myocardial injury stimulates formation of autoantibodies against the heart. Cardiac tamponade may occur
- occurs 2-10 weeks after and MI
77
how does Dressler's syndrome present clinically?
- Fever
- Chest pain
- Pericardial rub
78
what is the definition of hypertension?
BP over 140/90mmHg based on over 2 readings on separate occasions
79
what is the aetiology of hypertension?
Essential hypertension (hypertension with no known underlying cause):
- Genetics
- Low birth weight
- Obesity
- Excess alcohol intake
- High salt intake
- Metabolic syndrome
Secondary hypertension (result of a specific, treatable cause)
- Renal disease
- Diabetic neuropathy
- Endocrine disease- Conns, adrenal hyperplasia, phaeochromocytoma, Cushing's syndrome, acromegaly
- Coarctation of the aorta
- Pregnancy
- OCP
80
how can hypertension be diagnosed?
- Fasting glucose and cholesterol tests
- U&E’s and Ca2+ checked to rule out underlying causes
- 24H ambulatory BP monitoring-
81
what is the pharmacological treatment of hypertension?
- ACE inhibitors- prevent production of angiotensin II (potent vasoconstrictor), also prevent degradation of bradykinin (a vasodilator)
- Diuretics- increase sodium and water retention
- Beta blockers- reduce renin production and sympathetic nervous activity
- ARBS- selectively block receptors for angiotensin II
- Calcium channel blockers- dilate peripheral arterioles
82
what is the first line of treatment for a patient under 55 and over 55?
```
under= ACE inhibitor
over= CCB
```
83
what is atrial fibrillation?
The atrial muscle fibres contract independently- producing no P waves- as a result of this the ventricles contract irregularly due to the ‘all-or-nothing’ principle- however QRS complexes are of normal shape as the conduction through the ventricles passes by the same route, however QRS complexes are irregular
84
what is the aetiology of atrial fibrillation?
- Heart failure/ ischaemia
- Hypertension
- MI
- PE
- Mitral valve disease
- Pneumonia
- Hyperthyroidism
- Caffeine
- Alcohol
- Hypokalaemia
- Hypomagnaesaemia
85
how can atrial fibrillation be diagnosed?
- ECG- absent P waves, irregular QRS complexes ‘irregularly irregular’
- Bloods- U&E, cardiac enzymes, thyroid function tests
86
how can atrial fibrillation be treated?
acute- O2, cardioversion, LMWH
| chronic- warfarin, beta blocker, calcium channel blocker
87
how does an atrial flutter present on an ECG?
sawtooth baseline
88
what can cause heart block?
oCoronary artery disease
oCardiomyopathy
oFibrosis of conducting tissue (elderly people)
89
what is first degree AV block?
delayed AV condition resulting in a prolonged PR interval
90
what is mobtiz type 1 heart block?
progressive PR elongation until a P wave fails to conduct, the PR interval then returns to normal
91
what is a Mobitz Type 2 block?
dropped QRS isn't preceded by progressive PR prolongation
92
what is a 3:1 advanced heart block?
o When only every third P wave conducts to ventricles- so the ratio of P waves to QRS complexes
93
what is third degree heart block?
P waves and QRS complexes occur independently of eachother
94
what is a RBBB?
oSequential spread of an impulse from L to R
oRemember MaRRoW (m shape in VI, W shape in v6)
oProduces late activation of right ventricle
95
What is a LBBB?
```
oProduces a deep S wave in VI and tall R in leads I and V6
oRemember WiLLiaM (W in V1, M in V6)
```
96
What can cause sinus tachycardia?
exercise, fever, anaemia, heart failure, acute pulmonary thromboembolism, hypovolaemia
97
how can ventricular tachycardia be managed?
```
oConnect to monitor, have defib to hand
oHigh flow O2
oIV access – U&Es, cardiac enzymes, Ca2+, Mg2+
oABG
oAmiodarone IV
```
98
what can cause prolonged QT syndrome?
Congenital – mutations in sodium/potassium channel genes
Electrolyte disturbances – hypokalaemia, hypocalcaemia, hypomagnesaemia
Drugs – tricyclic antidepressants
99
what can cause Wolf-Parkinson-White syndrome?
Due to congenital accessory conduction pathway between atria and ventricles
100
what is the most common cause of a dissecting aortic aneurysm?
results from a tear in the intima- blood under high pressure creates a false lumen in the diseased media
101
how does a dissecting aortic aneurysm present clinically?
- Severe, tearing central chest pain which radiates through the back
- Involvement of branch arteries may result in neurological signs, absent pulses and unequal BP in both arms
102
what can cause an aortic aneurysm?
- atherosclerosis
| - connective tissue diseases
103
what are the symptoms of an aortic aneurysm?
- Epigastric/ back pain due to pressure effects
- May rupture- presents with epigastric pain and hypovolaemic shock
- asymptomatic
104
how would you treat an aortic aneurysm?
if abdominal- surgical replacement with prosthetic graft
105
how would you manage an aortic aneurysm?
hypotensives to keep systolic BP at 100-110mmHg- e.g. lanetalol
106
how can PVD present clinically?
- Intermittent claudication- cramping pain felt in calf, thigh or buttock after walking a given distance which is relieved at rest
- Critical ischaemia- ulceration, gangrene and foot pain at rest
- Acute limb ischaemia (sudden limb ischaemia)- pain, pale, paralysis, paraesthesia, perishing cold, pulseless
107
how can PVD be diagnosed?
- ESR/ CRP can exclude diabetes mellitus
FBC- anaemia and polycythaemia
thrombophillia screen
MRI and CT angiography
108
how would you treat PVD?
- risk factor modification
- clopidogrel- prevent progression and reduce CV risk
- revascularisation- percutaneous balloon angioplasty
109
what are the 3 stages of ischaemia?
- Stress- induced physiological malfunction (exercise-induced angina, intermitted claudication)
- Structural and functional breakdown (ischaemic cardiac failure, critical limb ischaemia, vascular dementia)
- Infarction- gangrene
110
what are some risk factors for infective endocarditis?
poor dental hygiene, systemic sepsis, diabetes mellitus, long-term haemodialysis, immunosuppression
111
what is the aetiology of IE?
- GRAM-POSITIVE BACTERIA
- Mostly staphylococcus
- Some streptococcus- e.g. strep. Viridans
- Dental treatments increase the risk of bacteria being introduced into the blood stream- results in bacteraemia
- Candida on skin can be introduced into the blood stream via cannulation
112
how does IE present clinically?
- Fever
- Weight loss
- Malaise
- Clubbing
- Signs- splinter haemorrhages (small haemorrhages seen on the nails- like red lines), osler’s nodes (tender nodules in the digits of the patient), janeway lesions (haemorrhages and nodules in the fingers- dark red dots), roth spots, heart murmurs
113
what is shock?
Shock is the term used to describe acute circulatory failure with inadequate or inappropriately distributed tissue perfusion- meaning there is inadequate oxygen and glucose for aerobic cellular respiration. This results in generalised hypoxia and an inability of cells to utilise oxygen
114
what is haemorrhagic shock and what can cause it?
-Shock due to blood loss
AETIOLOGY
- Caused by an internal or external haemorrhage
- Increased vascular permeability
- Loss of fluid- dehydration, burns, vomiting, pancreatitis
115
what are the classes of haemorrhagic shock?
```
Class I:
• 15% blood loss
• Pulse below 100 bpm
• BP normal
• Pulse pressure normal
• Resp rate; 14-20
• Urine output greater than 30ml/hr
• Slightly anxious
```
```
Class II:
• 15-30% blood loss
• Pulse greater than 100 bpm (tachycardia - earliest sign)
• BP normal due to autonomic response (increased sympathetic activity)
• Pulse pressure decreased
• Resp rate; 20-30
• Urine output: 20-30ml/hr
• Mental status: mildly anxious
```
Class III:
- 30-40% blood loss
- Pulse above 120 bpm
- BP decreased
- Pulse pressure decreased
- Resp rate; 30-40
- Urine output: 5-15ml/hr
- Mental status: confused
116
what can cause cardiogenic shock?
- cardiac tamponade
- PE
- acute MI
- myocarditis
117
what can cause neurogenic shock?
- spinal cord injury
- epidural
- spinal anaestheisa
118
what is an anaphylactic shock?
the release of IgE due to an allergic response
119
how does a patent with anaphylactic shock present clinically?
warm peripheries, hypotension, urticarial, angio-oedema
120
what is septic shock?
Septic shock exists when sespsis is complicated by persistent hypotension that is unresponsive to fluid resuscitation
