Cardio Flashcards
What is angina?
Angina is symptomatic reversible myocardial ischaemia
Features of angina
1 Constricting/heavy discomfort to the chest, jaw, neck, shoulders, or arms.
2 Symptoms brought on by exertion.
3 Symptoms relieved within 5min by rest or GTN.
All 3 features = typical angina; 2 features = atypical angina; 0–1 features = non-anginal chest pain.
Precipitants of angina
Exertion, emotion, cold weather, and heavy meals.
Most common cause of angina
Atheroma
Stable angina
Induced by effort, relieved by rest. Good prognosis.
Unstable angina
Angina of increasing frequency or severity; occurs on minimal exertion or at rest; associated with increased risk of MI.
Basic tests to consider with angina
- ECG
- Blood tests:
- FBC, U&E, TFTs, lipids, HbA1c
- Echo
- Chest X-ray
Investigations for ischaemic heart disease (IHD) include:
- Exercise ECG - assess for ischaemic ECG changes.
- Angiography - either using cardiac CT with contrast, or transcatheter angiography (more invasive but can be combined with stenting)
- Functional imaging - stress echo (echo whilst undergoing exercise or receiving dobutamine), cardiac MRI.
Management of angina
- Address exacerbating factors
- Secondary prevention of cardiovascular disease:
- 75mg aspirin daily if not contraindicated.
- PRN Symptom pain relief
- Glyceryl trinitrate (GTN) spray or sublingual tabs.
- Anti-anginal medication
- First line: beta blocker and/or calcium channel blocker
- Revascularization
- Percutaneous coronary intervention (PCI)
- CABG
Acute coronary syndromes
ACS includes unstable angina and myocardial infarctions (MIs)
What is the common underlying pathology of acute coronary syndromes?
plaque rupture, thrombosis, and inflammation
How could you differentiate between MI and unstable angina?
MIs have raised troponin, unstable angina does not.
Risk factors for acute coronary syndromes
- Non-modifiable:
- age,
- male gender,
- family history of IHD (MI in 1st-degree relative <55yrs).
- Modifiable:
- smoking,
- hypertension,
- DM,
- hyperlipidaemia,
- obesity,
- sedentary lifestyle,
- cocaine use
Classical presentation of MI
Acute central chest pain, lasting >20min, associated with nausea, sweatiness, dyspnoea, palpitations.
Revascularistaion of STEMI patients and very high-risk NSTEMI patients
should receive immediate angiography ± PCI
Medications for MI
- Antiplatelets
- Aspirin (75mg OD) and a second anti-platelet agent (eg clopidogrel)
- Anticoagulant
- Beta-blockade reduces myocardial oxygen demand
- ACE-i in patients with LV dysfunction, hypertension, or diabetes unless not tolerated
(consider ARB). Titrate up slowly, monitoring renal function. - High-dose statin, eg atorvastatin 80mg.
PCI or CABG
Patients with single-vessel coronary artery disease and normal LV function usually undergo PCI, and those with triple-vessel disease and abnormal LV function more often undergo CABG.
Definition of heart failure
Cardiac output is inadequate for the body’s requirements.
Symptoms of left ventricular failure (LVF)
- dyspnoea,
- poor exercise tolerance,
- fatigue,
- orthopnoea,
- paroxysmal nocturnal dyspnoea (PND),
- nocturnal cough (±pink frothy sputum),
- wheeze (cardiac ‘asthma’),
- nocturia,
- cold peripheries,
- weight loss.
Causes of left ventricular failure
- IHD
- MI
- cardiomyopathy
- ventricular hypertrophy
- constrictive pericarditis
- tamponade
Causes of right ventricular failure
- LVF,
- pulmonary stenosis,
- cor pulmonale
RVF symptoms
- peripheral oedema (up to thighs, sacrum, abdomi- nal wall),
- ascites,
- nausea,
- anorexia,
- facial engorgement,
- epistaxis.
Causes of low output cardiac failure
- Excessive preload: eg mitral regurgitation or fluid overload (eg renal failure or too
rapid IV infusions, particularly in the elderly and those with established HF). - Pump failure: systolic and/or diastolic HF, decreased heart rate (eg beta blockers, heart block, post MI), negatively inotropic drugs (eg most antiarrhythmic agents).
- Chronic excessive afterload: eg aortic stenosis, hypertension.
High output heart failure
- This is rare. Here, output is normal or increased in the face of increased needs.
- Causes: anaemia, pregnancy, hyperthyroidism
How is a diagnosis of heart failure made?
Requires symptoms of failure and objective evidence of car- diac dysfunction at rest
What criteria is used for congestive cardiac failure?
Framingham criteria
Signs of heart failure
- cyanosis,
- decreased BP,
- narrow pulse pressure,
- pulsus al- ternans,
- displaced apex (LV dilatation),
- RV heave (pulmonary hypertension),
- signs of valve diseases.
- Severity can be graded using the New York classification
Investigations for heart failure
- ECG and B-type natriuretic peptide
- If either is abnormal, then echocardiography is required.
Drugs used to manage heart failure
- Loop diuretics to relieve symptoms, eg furosemide 40mg/24h
- ACE-inihibitor - Consider in all those with left ventricular systolic dysfunction (LVSD); improves symptoms and prolongs life. If cough is a problem, an angiotensin receptor blocker (ARB) may be substituted
- Beta-blockers decrease mortality in heart failure
- Mineralocorticoid receptor antagonists: Spironolactone (25mg/24h PO) decreases mortality by 30% when added to conventional therapy
- Digoxin helps symptoms
How is a diagnosis of hypertension diagnosed?
Confirm with 24hr ambulatory BP monitoring (ABPM); or a week of home readings.
NB: the diagnostic threshold is lower ~135/85mmHg.
Essential Hypertension
Cause unknown
~95% of cases
Causes of secondary hypertension
- Renal disease
- glomerulonephritis, chronic pyelonephritis, or polycystic kidneys
- Endocrine disease
- Cushing’s, pheochromocytoma, acromegaly, hyperparathyroidism
- Other
- Coarctation, pregnancy
- Drugs: steroids, MAOIs, oral contraceptive pill, cocaine, amphetamines
Lifestyle changes to treat hypertension
- stop smoking;
- low-fat diet.
- Reduce alcohol and salt intake;
- increase exercise;
- reduce weight if obese.
Hypertension drug treatment if ≥55yrs, and in black patients of any age
1st choice is a Ca2+ channel antagonist or thiazide
Hypertension drug treatment if <55
ACE inhibitor or ARB
Consider beta blockers in younger people
Mitral regurgitation (MR)
Backflow through the mitral valve during systole.
Causes of mitral regurgitation
- Functional (LV dilatation);
- annular calcification (elderly);
- rheumatic fever;
- infective endocarditis;
- mitral valve prolapse;
- ruptured chordae tendinae;
- papillary muscle dysfunction/rupture (eg post-MI)
Symptoms of mitral regurgitation
- Dyspnoea;
- fatigue;
- palpitations;
- symptoms of causative factor (eg fever).
Signs of mitral regurgitation
- AF;
- displaced, hyperdynamic apex;
- pansystolic murmur at apex radiating to axilla;
Mitral regurgitation investigations
- ECG:
- AF; LVH.
- CXR:
- big LA & LV; mitral valve calcification; pulmonary oedema.
Mitral regurgitation management
- Control rate if fast AF.
- Diuretics improve symptoms.
- Surgery for deteriorating symptoms; aim to repair or replace the valve before LV is irreversibly impaired.
Causes of mitral stenosis
- Rheumatic fever
- Congenital
- Prosthetic valve
Mitral stenosis presentation
- Normal mitral valve orifice area is ~4–6cm2. Symptoms usually begin when the orifice becomes <2cm2.
- Pulmonary hypertension causes dyspnoea, haemoptysis, chronic bronchitis-like picture;
- pressure from large left atrium on local structures causes hoarseness (recurrent laryngeal nerve), dysphagia (oesophagus), bronchial obstruction;
- also fatigue, palpitations, chest pain, systemic emboli, infective endocarditis (rare).
Signs of mitral stenosis
- Malar flush on cheeks (due to decreased cardiac output);
- low-volume pulse;
- AF common (due to enlarged LA);
- tapping, non-displaced, apex beat (palpable S1);
- RV heave.
- On auscultation: rumbling mid-diastolic murmur (heard best in expiration, with patient on left side)
Mitral stenosis investigations
- ECG: AF; RVH;
- CXR: left atrial enlargement (double shadow in right cardiac silhouette); pulmonary oedema; mitral valve calcification.
- Echo is diagnostic
Mitral stenosis investigations
- If in AF, rate control is crucial; anticoagulate with warfarin
- Diuretics decrease preload and pulmonary venous congestion.
- If this fails to control symptoms, balloon valvuloplasty (if pliable, non-calcified valve), open mitral valvotomy, or valve replacement.
Aortic stenosis causes
- Senile calcification is the commonest
- Others:
- congenital (bicuspid valve, Williams syndrome)
- rheumatic heart disease.
Presentation of aortic stenosis
- The classic triad includes angina, syncope, and heart failure.
- Also: dyspnoea; dizziness; faints; systemic emboli if infective endocarditis; sudden death.
Aortic stenois signs
- Slow rising pulse with narrow pulse pressure;
- heaving, non-displaced apex beat;
- LV heave;
- aortic thrill;
- ejection systolic murmur
Aortic stenosis investigations
- ECG
- CXR: LVH; calcified aortic valve; post- stenotic dilatation of ascending aorta
- Echo: diagnostic
Managemenet of aortic stenosis
- If symptomatic, prognosis is poor without surgery: 2-3yr survival if
angina/syncope; 1-2yr if cardiac failure. - Prompt valve replacment
- If the patient is not medically fit for surgery, transcatheter aortic valve implantation may be attempted
Causes of aortic regurgitation
- Acute:
- Infective endocarditis,
- ascending aortic dissection,
- chest trauma.
- Chronic:
- Congenital,
- connective tissue disorders (Marfan’s syndrome, Ehlers–Danlos),
- rheumatic fever,
- rheumatoid arthritis,
- SLE,
- hypertension,
- osteogenesis imperfecta.
Aortic regurgitation symptoms
- Exertional dyspnoea,
- orthopnoea,
- paroxysmal nocturnal dyspnoea
Signs of aortic regurgitation
- Collapsing pulse;
- wide pulse pressure;
- displaced, hyperdynamic apex beat;
- high-pitched early diastolic murmur (heard best in expiration, with patient sat forward)
Investigations for aortic regurgitation
- ECG: LVH.
- CXR: cardiomegaly; dilated ascending aorta; pulmonary oedema.
- Echo is diagnostic.
- Cardiac catheterisation to assess: severity of lesion; anatomy of aortic root; LV function; coronary artery disease; other valve disease.
Management of aortic regurgitation
- The main goal of medical therapy is to reduce systolic hypertension; ACE-i are helpful.
- Echo every 6–12 months to monitor.
- Indications for surgery: severe AR with enlarged ascending aorta, increasing symptoms, enlarging LV or deteriorating LV function on echo; or infective endocarditis refractory to medical therapy.
