Cardio Flashcards
What is the cause of ischaemic heart disease?
Atherosclerosis
Non modifiable risk factors for IHD?
Family history, Age, ethnicity (S.Asian)
Modifiable risk factors for IHD?
Smoking, Poor nutrition, sedentary lifestyle, alcohol, stress, HTN, obestiy, DM
How does IHD present?
With angina
What do patients describe with stable angina?
Constricting discomfort in front of chest, neck, shoulders, jaw or arms
Precipitated by physical exertion
Relieved by rest/GTN spray after 5 mins
What does an ECG show with stable angina?
Normal
Investigations for stable angina?
ECG, Lipid profile (increased LDL), FBC to exclude anaemia, HbA1c to exclude DM
Whats the gold standard investigation for stable angina>
CT coronary angiography
How to treat IHD?
ASPIRIN/Clopidogrel
STATINS
How to treat angina?
GTN spray, B blocker or CCB.
2nd: Aspirin, Atorvostatin, ACEi
What is unstable angina?
Pain not releived by rest or GTN spray. Comes on at rest
Which patients are most at risk of a silent MI?
Diabetics
What are the 3 conditions in acute coronary syndrome?
Unstable angina, STEMI, NSTEMI
Presentation of ACS?
Central constricting chest pain radiating to jaw or arms.
Sweatng
SOB
greater than 20mins
What does an ECG show in a STEMI?
ST segment elevation
What does troponin show in unstable angina?
Troponin normal as its ischaemia not infarction
What does an ECG show in Unstable angina and NSTEMI?
ST depression and deep T wave inversion
What is the immediate management for ACS?
M - Morphine O - oxygen N - Nitrates (GTN spray) A - Aspirin C - Clopidogrel
How to manage a STEMI>
PCI within 2 hours
Clopidogrel and aspirin
Fibrinolysis if PCI not possible, Alteplase
How to manage Unstable angina/NSTEMI?
GRACE score predicts 6 month risk
Low: ticagrelor and aspirin
Med: angiography and PCI, prasugrel and aspirin.
Secondary prevention for ACS.
ACAB
What does ACAB stand for?
ACEi
Clopidiogrel
Aspirin and atorvastatin
Beta blockers
Post MI complications?
DREAAD
Death, Rupture of heart septum/papillary muscles
Edema, Arrhythmias, Aneurysm, Dresslers syndrome
What is the most common cause of HTN?
Idiopathic (95%)
What are some of the underlying causes of hypertension?
Renal disease
Obestity
Pregnancy
Endocrine (conn’s syndrome)
What’s the definition of hypertension in clinic?
> 140/90 in clinic
Whats the definition of hypertension with ambulatory blood pressure monitoring?
> 135/85
Modifiable risk factors for HTN?
Alcohol intake, sedentary lifestyle, DM, sleep apnoea, smoking
What are the non-modifiable risk factors for HTN?
Age >65, FHx, ethnicity
Investigations for HTN?
Clinic BP and at home bp monitoring
What medication for HTN would you put a patient on who’s 45 and of northern European origin?
ACEi or ARB
What medication for HTN would you put a patient on who’s 50 and of black African origin?
CCB
What is the second step for HTN medication if the first didn’t work?
Try the other so: ACEi or ARB or CCB, can also try thiazide like diuretic.
What is a AAA?
Abdominal aortic aneurysm, the weakening of the vessel wall of the abdominal aorta.
What is the pathogenesis of a AAA?
Inflammation of smooth muscle cells Loss of structural integrity Widening of the vessel Mechanical stress (HTN) acts on weakened wall Dilation and rupture may occur
What are the risk factors for AAA?
Smoking, family history, connective tissue disorders, age, atherosclerosis, male
What is the presentation of a AAA?
Asymptomatic, usually discovered on routine examination
Where are AAA’s commonly found?
Below the renal arteries
What symptoms can an AAA cause if expanding rapidly?
Lower back/abdominal pain
How to diagnose an AAA?
ultrasonography
When do you repair an AAA?
If ruptured, for a symptomatic AAA regardless of size.
For asymptomatic >5.5cm in men >5cm in women
What are the complications of AAA?
Rupture, thromboembolisms, fistula formation
What is the presentation of a ruptured AAA?
Acute onset of severe, tearing abdominal pain, radiation to the back, flank and groin
Painful pulsatile mass, hypovolemic shock, syncope, nausea and vomiting
What is the treatment for a ruptured AAA called?
EVAR (endovascular aneurysmal repair)
What is an aortic dissection?
A tear in the intimal layer, resulting in blood pooling between the intima and medial layers
What ages does an aortic dissection most commonly occur in?
Men 40-60
Which part of the aorta does an aortic dissection most commonly occur?
Ascending aorta (65%)
What is the consequence of an aortic dissection?
Flow through the false lumen can occlude flow through the branches of the aorta, including coronary, brachiocephalic, intercostal etc
What are the risk factors for aortic dissection?
Hypertension, trauma, vasculitis, cocaine use, connective tissue disorder
Clinical features of an aortic dissection?
Sudden and severe tearing pain in chest radiating to back, hypotension, asymmetrical blood pressure, syncope
How to diagnose an aortic dissection?
ECG, CXR, CT scanning
How to manage an aortic dissection?
Fluid resuscitation, inotropes, noradrenaline, opiods,
Endovascular stent graft repair
Antihypertensives after surgery
What is PVD?
Atherosclerosis of vessels, leading to poor circulation ad tissue ischaemia
What are the 6 p’s of end stage PVD?
Pain, paraesthesia, pulselessness, pallor, paralysis, perishingly cold
What are the risk factors for PVD?
Smoking, diabetes, HTN, sedentary lifestyle, hyperlipidaemia, history of CAD, over 40
What is the presentation of PVD?
Pain in lower limbs on exercise,
Intermittent claudication
Severe: unremitting pain in foot especially at night
Legs may be pale, cold, loss of hair and skin changes
What investigation do you do for PVD?
ABPI, ankle brachial pressure index.
Provides a measure of blood flow at the level of the ankle, this should be 1.
less than 0.9 indicates PVD
How to treat PVD?
Control risk factors:
Smoking cessation, exercise, weight reduction, BP and DM control, statins.
APIRIN/CLOPIDOGREL
What to do in critical limb ischaemia?
Revascularisation, (stenting, angioplasty, bypassing)
Amputation if unsuitable
Causes of mitral stenosis?
Rheumatic heart disease, infective endocarditis
Presentation of mitral stenosis?
Malar flush, AF
Sound on auscultation with mitral stenosis?
Mid diastolic, low pitches rumbling murmur.
Causes of mitral regurgitation?
Idiopathic, IHD, infective endocarditis, rheumatic heart disease, EDS, marfans
whats the murmur for mitral regurgitation?
Pan systolic, high pitched whistling murmur
What are the consequences of mitral regurgitation?
Congesitve heart failure
Waht are the causes of aortic regurgitation
Idiopathic, EDS, MArfans
What does the murmus sound like for aortic regurgitation?
early diastolic soft rumbling murmur and austin flint murmur at the apex, collapsing pulse
Causes of aortic stenosis?
Idiopathic, rheumatic heart disease,
Presnetation of aortic stenosis?
Exertional syncope, slow rising pulse, narrow pulse pressure
What does the murmur sound like for aortic stenosis>
Crescendo-decrescendo murmur radiating to carotids
What is BNP>
A hormone secreted by the cardiac cells in response to pressure in the heart
What is the function of BNP>
Helps to regulate the fluid levels in the body, by monitoring salt and pressure.
What is the definition of heart failure?
Cardiac output is inadequate for the body’s requirements
What is systolic heart failure?
Inability of the ventricle to contract normally
What is diastolic heart failure?
Inability of the ventricle to relax and fill normally
What is chronic heart failure?
Develops and progresses slowly arterial pressure is well maintained until late
What are the causes of left sided heart failure?
CAD, myocardial infarction, cardiomyopathy, congenital heart defects
What are the causes of right sided heart failure?
Right ventricular infarct, pulmonary hypertension, pulmonary emobolism, COPD, cor pulmonale
Causes of diastolic HF?
Aortic stenosis, chronic hyertension
Causes of systolic HF?
IHD, Cardiomyopathy, myocardial infection
Why is there hypertrophy of the myocardium in HF?
Due to increased preload. As the myocardium fails there is less blood ejected and so the preload increases.
to compensate there is hypertrophy of the myocardium
Why does hypertrophy of the myocardium lead to ischaemia?
An increased number and size of cells leads to an increased demand for oxygen which the heart cannot sustain, this leads to ischaemia and reduced contractility of the myocardium
Why do the ventricles become dilated in HF?
There is a decreased contractility, but increased workload for the amount for blood remaining, this leads to stretching and dilation of the ventricles.
The cells then become tired and this is pathological
What are the common symptoms of HF?
SOB, fatigue, peripheral oedema
Signs of HF
Tachycardia, ascites, elevated jugular venous pressure, cardiomegaly
What investigations can you do for HF?
ECG, may indicate cause such as MI or ventricular hypertrophy
BNP (released when the ventricular walls are under stress.
WHat would you see on a CXR in HF?
A - alveolar oedema (bat wings) B - Kerley B lines C - Cardiomegaly D - Dilated upper lobe vessels of lungs E - effusions pleural
How do diuretics work in HF?
Reduces preload and pressure on the ventricles
Name an aldosterone antagonist?
Spironolactone
Heart failure treatment
Dieuretics, ACEi, B-blocker, aldosterone antagonist, digoxin
What is cor pulmonale?
Right sided HF caused by chronic pulmonary hypertension
Symptoms of cor pulmonale?
Dyspnoea, fatigue and syncope
Investigations for cor pulmonale?
ABG - hypoxia and hypercapnia
Management of cor pulmonale?
Treat underlying cause, give O2, treat cardiac failure, heart lung transplant
A patient with recently diagnosed heart failure comes to your GP practice for a check-up and medication review. He tells you that he has felt a little weaker and more tired than usual recently. His current medications include: Furosemide, Ramipril, Bisoprolol
His blood results show: Sodium: 142 (135-145) Potassium: 2.4 (3.5-5.5)
Which of the following drugs is the most likely cause of the electrolyte abnormality?
A. Furosemide
B. Ramipril
C. Bisoprolol
D. None of the above
Furosemide, give spironolactone instead as this avoids hypokalaemia
What is the heart rate for tachycarida?
> 100bpm
What heart rate is bradycardia?
<60bpm
What is atrial fibrillation?
Chaotic irregular rhythm with an irregular ventricular rate
What is seen on an ECG with AF?
No P waves, irregularly irregular QRS
What are the causes of AF?
Idiopathic, HTN, HF, CAD, valvular heart disease
What is the pathophysiology of AF?
Continuous rapid activation of the artira with no organised mechanical action
Risk factors for AF?
60+, DM, high BP, CAD, past MI, structural heart disease.
What is the presentation of AF?
Asymptomatic, palpitations, dyspnoea, chest pains, fatigue
How to treat AF?
Shock with a defibrillator, give LMWH
What is atrial flutter?
Organised atrial rhythm at a rate of 250-350bpm
Causes of atrial flutter?
Idiopathic, CHD, obesity, hypertension, HF, COPD, pericarditis
Presentation of Atrial flutter?
Palpitations, breathlessness, chest pain, dizziness, syncope, fatigue
Treatment for atrial flutter
LMWH, shock with defibrillator, catheter ablation, IV amiodarone
What is a bundle branch block?
A block in conduction of one of the bundle branches so the ventricles don’t receive impulses at the same time
What pattern is seen in leads V1 and V6 in RBB?
MarroW
What is the pathophysiology of RBB?
RBB doesnt conduct
Impulse spreads from left to right ventricle
Late activation of RV
What are the causes of RBB?
PE, IHD, atrial ventricular septal defect
Treatment of RBB?
Pacemaker, cardiac resynchronisation therapy, reduce blood pressure
What pattern is seen on V1 and V6 in LBB?
WilliaM
What are the causes of RBB?
IHD and Aortic valve disease
Presentation of long QT syndrome?
Syncope, palpitations, may progress to VF
What is Wolff parkinson white syndrome?
Accessory pathway for conduction, impulses can travel quicker to the AVN and ventricle.
Causes of WPW?
Congenital, hypokalaemia/calcaemia, amiodarone,
What is pericarditis?
Inflammation of the pericardium with or without effusion
Infection causes of pericarditis?
Enteroviruses, adenoviruses, mycobacterium tuberculosis, histoplasma
Autoimmune causes of pericarditis?
RA, sjogrens, SLE
Pathophysiology of pericarditis?
Inflammation of the pericardium causes narrowing of pericardial space.
If untreated this causes a friction and a build up of exudate and adhesions in the pericardial space
This can put pressure on cardiac myocytes and lead to dysfunction
Symptoms of pericarditis?
Severe chest pain, sharp, pleuritic, rapid onset. relieved by sitting forward Dyspnoea, cough hiccups fever myalgia
Signs of pericarditis?
Pericardial rub on auscultation, tachycardia, peripheral oedema, increased JVP
What is the diagnostic test for pericarditis?
ECG
What does pericarditis show on ECG?
Saddle shaped ST elevation, diffuse ST elevation in all leads, PR depression
How to treat pericarditis?
Reduce phyisical activity
NSAIDS with gastric protection
Cochicine for 3 months
treat the cause
What is dilated cardiomyopathy?
Left ventricle is dilated with thin muscle and so contracts poorly
What are the causes of dilated cardiomyopathy?
Ischaemia, alcohol, thyroid disorder, genetic
What do investigations show for dilated cardiomyopathy?
CXR: cardiac enlargment
ECG: tachycardia, arrhythmia, T-wave changes
What is hypertrophic cardiac myopathy?
Ventricular hypertrophy causing obstruction of the outflow tract
What are the signs of hypertrophic cardiomyopathy?
Ejection systolic murmur, jerky carotic pulse, left ventricular outflow obstruction
What is restrictive cardiomyopathy?
Scar tissue replaces the normal heart muscle and the ventricles become rigid so they don’t contract properly
Which of the following differential diagnoses is the most common cause of sudden cardiac death in young people (and the most likely differential)? Restrictive cardiomyopathy Dilated cardiomyopathy Hypertrophic cardiomyopathy Pericarditis
Hypertrophic cardiomyopathy
A patient has a fever and new murmur, what diagnosis is this until proven otherwise?
Infective endocarditis
What is infective endocarditis?
An infection of the endocardium or vascular endothelium of the heart
What is the pathophysiology of infective endocarditis?
Platelet and fibrin deposition onto heart valves.
Organisms in the bloodstream adhere and grow on the valves.
Organisms destroy the valve causing regurgitation and worsening heart failure
Which valves are most commonly affected in IE?
Aortic and mitral
Risk factors of IE?
Prosthetic valve, valve disease
Symptoms of IE?
Fever, rigors, night sweats, malaise, weight loss
Signs of IE
Embolic skin lesions (fun little dots on the foot)
Splinter haemorrhages
Oslers nodes and janeway lesions on hands
Roth spots on eyes
Petechiae on skin (red rash)
What is the dukes criteria for IE?
Positive blood culture from 3 different spots at peak points of fever
Echocardiogram showing vegetation, transoesophageal echo
Which antibiotics to trwat IE?
Staph: vancomycin
What to do if valve cant be treated with antibiotics?
Replace the valve if infection can’t be treated
How to prevent IE?
Good oral health, no IV drug use, educcate surgery patients on symptoms
What is rheumatic fever?
A systemic infection common in developing countries, from streptococci
Can cause permenant damage to heart valves
Symptoms of rheumatic fever?
Fever, arthrits, chest pain, SOB, fatigue, Chorea (jerky movements)
Signs of rheumatic fever/
Tachycardia, murmur, pericardial rub, red rash on trunk, thigh or arms, prolonged PR interval.
Investigations for rheumatic fever?
Recent strep infection plus some of the signs and symptoms
Treatment for rheumatic fever?
Bed rest until CRP is normal for 2 weks consistently
IV benzylpenicilin
Aspirin
Findings on CXR in aortic dissection?
Wide mediastinum
