Cardio conditions Flashcards
Cardio s1-s4 sounds
S1 - AV valves close - Tricuspid and mitral valves
S2 - Semilunar valves close - Aortic and pulmonary valves
S3 - Rapid ventricular filling (pathological in mitral regurgitation and heart failure)
S4 - Pathological gallop
- Blood forced into a stiff hypertrophic ventricle (LVH + aortic stenosis)
Which ECG leads would you see abnormalities in during a:
- Right coronary artery pathology
- Left anterior descending
- Left circumflex artery
RCA - Inferior leads
II, III, aVF
LAD - anterior and septal leads
V1 - V4
Left circumflex - Lateral leads
V5,V6, aVL and I
What is the amplitude and time units on ECG paper of 1 big square (encompassing 5 small squares)?
Amplitude - 0.5mv
Time - 0.2s
Mitral stenosis
RF
Pathology
Symptoms
Investigations
Treatment
Narrowing of the mitral valve orifice, obstructing LV inflow, preventing proper filling during diastole.
RF - Rheumatic heart disease, post streptococcal infection, women
PATHOLOGY
RHEUMATIC CARDITIS is the predominant cause (fusion and thickening of the valve leaflets lead to narrowing of the valve orifice)
Other causes: calcification due to ageing, SLE, IE
2 consequences:
- Increased LA pressure is referred to the lungs where it leads to pulmonary congestion.
- Limited filling of the LV, reducing CO
SYMPTOMS
- MALAR FLUSH
- Jugular vein distension (A wave)
- Dyspnoea
- Orthopnea
- Loud S1 snap (thick valve cusps slap each other)
- Rumbling low pitched, mid diastolic murmur (at the apex)
Best heard on expiration with patient lying on left side
INVESTIGATIONS
1st line - Chest X-ray –> Enlarged LA
ECG - Atrial fibrillation, P mitrale - broad, bifid P wave(indicates left atrial enlargements)
GS - Transthoracic echocardiography
Treatment
Surgical
- Percutaneous balloon valvotomy (stent open Mitral valve opening)
- Mitral valve replacement
Mitral regurgitation
RF
Pathology
Symptoms
Investigations
Treatment
Backflow of blood from the LV to the LA during systole (insufficient mitral valve)
RF - Mitral valve prolapse (valve flaps don’t fit), IE, Rheumatic heart disease
PATHOLOGY
Causes
- Myxomatous mitral valve
(Accumulation of connective tissue leading to thickened and redundant valve leaflets - which may lead to prolapse) - MAIN CAUSE
- Connective tissue disorders - Marfan’s, Ehler danlos
SYMPTOMS
- Exertional dyspnoea
- Fatigue
- Pansystolic blowing murmur radiating to the axilla
(Possible S3 sound- rapid ventricular filling to compensate for leaked blood)
INVESTIGATIONS
1st line - Chest X-ray
ECG
GS - Transoesophageal echocardiogram (assess severity of valve dysfunction, LV size and function)
TREATMENT
If not severe
Rate control - BB, CCB
+
Serial echocardiogram for monitoring
(IE prophylaxis)
Severe
Valve replacement surgery
Aortic stenosis
RF
Pathology
Symptoms
Investigations
Treatment
Narrowing of the aortic valve, obstructing blood flow out of the LV.
RF - >60 years (calcification of valve), congenital bicuspid aortic valve, RHD
PATHOLOGY
Mainly due to ageing calcification.
Also can be due to congenital bicuspid aortic valve.
As narrowing of valve gets more severe, LVH will develop –> overtime, LV will become less complication and will decline in function
SYMPTOMS
Triad (SAD)
- Syncope (Exertional)
- Dyspnoea (Exertional)
- Angina
(S4 heart sound)
Narrow pulse pressure + slow rising carotid pulse (Decreased systolic pressure caused by AS)
Ejection systolic, crescendo decrescendo murmur - radiating to the carotid arteries
S4 will be seen in LVH
INVESTIGATIONS
1st line - Chest X-ray, ECG
GS
Transoesophageal echocardiography
TREATMENT
Surgical
Young, clinically stable, healthy patient
- Surgical aortic valve replacement (IE prophylaxis)
Severe AS and clinically unstable, older patient
- TAVI - Transcatheter aortic valve implant
Aortic regurgitation
RF
Pathology
Symptoms
Investigations
Treatment
The diastolic leakage of bloodflow from the aorta into the LV due to inadequate coaptation of the valve leaflets (insufficiency)
RF - Bicuspid aortic valve, rheumatic fever, Marfans, ehler danlos
PATHOLOGY
Caused by congenital bicuspid aortic valve or connective tissue disorders (Marfan’s - results in aortic root dilation, causing valve leaflets to stretch resulting in incomplete coaptation)
(Aortic regurgitation –> Increase LV volume and pressure –> increase LA pressure –> backlog of blood to pulmonary vasculature –> pulmonary oedema and cardiogenic shock)
SYMPTOMS
Dyspnoea, fatigue, pallor, cysnosis
- Early diastolic, high pitched blowing murmur (right 2nd ICS)
- Widened pulse pressure
- Collapsing corrigan’s pulse / water hammer pulse
- Quincke’s sign - Capillary pulsation upon compression of nailbed
- De Muset’s sign - Head bobbing with heart beat
INVESTIGATIONS
1st line - Chest X-ray, ECG
GS - Transoesophageal echocardiogram (possible aortic root dilation, evaluate severeity of regurgitation + LV function)
TREATMENT
Chronic - IE prophylaxis (serial echocardiogram to monitor patients)
(For Acute - surgical aortic valve replacement) - Rare
Stable angina
RF
Pathology
Symptoms
Investigations
Treatment
Chest pain caused by insufficient blood supply to the myocardium and induced by physical exertion or emotional stress.
RF - Advancing age, smoking, hypertension, diabetes, obesity, males
PATHOLOGY
Primarily caused by atherosclerosis (narrowing of coronary arteries resulting in ischemia)
SYMPTOMS
1) Central crushing chest pain that radiates to the arm, neck or jaw
2) Chest pain provoked by exercise or emotional stress (or cold weather)
3) Chest pain relieved by Glyceryl trinitrate or with 5 mins of rest
(palpitations, dyspnoea, syncope)
INVESTIGATIONS
1st line - Resting ECG - Normal
GS - CT coronary angiography - Shows stenosed atherosclerotic arteries (narrowing of artery)
TREATMENT
Symptomatic - GTN spray
Lifestyle modification –> Increase physical activity, smoking cessation, healthy diet
Pharmacological
1st line - Beta blockers (CI in asthma) in which case you give CCB (CI in heart failure)
2nd line - CCB + BB
(Consider: Antiplatelets, statins)
If symptoms not controlled –> Revascularisation with :
PCI - Balloon stent coronary artery
or CABG - bypass graft (more invasive, better prognosis)
Acute coronary syndrome
RF
Pathology
Symptoms
Investigations
Treatment
Umbrella term for unstable angina, NSTEMI, STEMI
RF - Old age, diabetes
PATHOLOGY
STEMI - Complete and persistent blockage of coronary artery resulting in myocardial necrosis with ST elevation
Unstable angina + NSTEMi - Partial blockage of coronary artery usually resulting in myocardial necrosis in NSTEMI, but NOT in Unstable angina (which you differentiate with serum troponin)
SYMPTOMS
- Central crushing, heavy chest pain that can occur at rest with radiation to the arm, jaw or neck (feeling of impending doom)
- More severe Diaphoresis, dyspnoea, syncope, palpitations
INVESTIGATIONS
1st line - 12 lead ECG
UA - usually no changes (possible ST depression)
NSTEMI - T wave inversion + ST depression
STEMI - ST elevation in at least 2 contiguous ECG leads
Serum troponin
UA - Normal
NSTEMI - Elevated
STEMI - Elevated
GS - CT coronary angiogram - shows extent of occlusion
TREATMENT
Acute - MONA
IV Morphine
Oxygen if SATS <94%
GTN spray
Aspirin (+ clopidogrel)
Based on the Grace score - (risk of death within 6 months of discharge in patients with ACS)
If NSTEMI/UA –>
Low risk - Dual antiplatelet therapy - clopidogrel and aspirin
High risk - Immediate angiogram + consider PCI
STEMI –>
PCI - If within 12 hours of symptom onset
Thrombolysis with alteplase if >12 hours of symptom onset
What do you give for long term prevention of ACS
Beta blocker
Aspirin + clopidogrel
Statin (Atorvastatin)
Ace-inhibitor - Enalapril
What is prinzmetal (variant) angina briefly
It results from coronary artery spasm often occuring at rest.
Spasms cause temporary narrowing of arteries leading to reduced blood flow to the heart
Abdominal aortic aneurysm
RF
Pathology
Symptoms
Investigations
Treatment
Permanent pathological dilation of the aorta >3cm.
This is typically infrarenal (below the renal arteries)
RF - Old men who smoke, marfan’s, ehler danlos
PATHOLOGY
Occurs due to smooth muscle, elastic and structural degradation in the aorta. (Involves all 3 layers)
1) Proteolytic degradation of aortic wall
2) Inflammation and immune responses - Leukocyte infiltrate
> 3cm is AAA
5.5cm is considered emergency with increased risk of rupture
SYMPTOMS
Non ruptured –> Palpable pulsatile abdominal mass (PPAM)
Ruptured –> PPAM + Sudden epigastric pain radiating to the flank/back
- Hypotension + Tachycardia
A DDX is acute pancreatitis but pancreatitis has a NON PULSATILE mass.
INVESTIGATIONS
1st line + GS - Abdominal ultrasound
TREATMENT
Asymptomatic + unruptured –> Manage RF: Stop smoking, decreased BP, decrease BMI
Growing rapidly ,>5.5cm + unruptured –> EVAR (Endovascular aneurysm repair) or open surgery - laparotomy(more invasive)
Ruptured –>
STABILISE - ABCDE (resuscitate)
+
EVAR
SURGICAL EMERGENCY (100% mortality if not treated immediately)
Heart failure
RF
Pathology
Symptoms
Investigations
Treatment
A clinical syndrome that can result from a structural or functional cardiac disorder, impairing the ability of the ventricles to fill with blood, reducing pre-load and cardiac output –> (Cardiac output is not sufficient to meet demands of the body)
RF - previous MI, hypertension, smoking, valve disorder, cor pulmonale, >65
PATHOLOGY
Main cause - Ischemic heart disease
Frank starling law (Normally) - Increased preload –> increased afterload –> increased cardiac output
Failing hearts have a decreased cardiac output –> initial compensatory mechanism via RAAS and sympathetic nervous system –> compensatory mechanisms fail and heart undergoes CARDIAC REMODELLING –> RAAS + SNS leads to fluid overload –> Heart failure
Can be classified into 2
1) HF with reduced ejection fraction
2) HF with preserved ejection fraction
SYMPTOMS
3 cardinal signs
1) Dyspnoea/orthopnea (difficulty breathing when lying flat)/paroxysmal nocturnal dyspnoea (patients must stand up or sit up in the middle of the night to relive discomfort)
2) Fatigue
3) Ankle swelling (oedema)
(3rd+4th heart sound, increased JVP, bibasal crackles - pulmonary oedema)
INVESTIGATIONS
1st line - Bloods
BNP levels - elevated (released from stressed ventricles)
ECG - abnormal, possible signs of LVH
Chest X-ray -
A - Alveolar oedema
B - Kerly B lines - interstitial oedema
C - Cardiomegaly
D - Dilated vessels
E - Pleural effusion
GS - Echocardiogram
TREATMENT
Conservative
- Lifestyle changes - Decrease BMI, exercise, stop smoking
Pharmacological (ABAL)
1st line - Ace inhibitor
- Beta blocker
- Aldosterone antagonist
- Loop diuretic
(Chronic heart failure/worsening heart failure - Ivabradine)
Last resort
Surgery
- Revascularise
- Heart transplant
What are some types of heart failure, explain them briefly
(Just have an idea no need to know in depth)
Left sided heart failure - Occurs when the LV is unable to effectively pump blood to the body, leading to inadequate perfusion of organs and tissues.
Cor pulmonale which leads to right sided heart failure –> Pulmonary hypertension leading to increased resistance, causes the right ventricle to work harder to pump blood to the lungs, eventually leading to RVH and later right sided heart failure
Ischaemic heart failure - resulting from coronary artery disease and reduced blood supply to the heart
Myopathic - Cardiomyopathy due to intrinsic muscle dysfunction e.g. sarcomere/cytoskeleton
Hypertensive - due to increased BP –> LVH –> impaired relaxation and compliance –> decreased preload and cardiac output
What are the 2 categories of heart failure, name some causes of each
Can be classified into 2
1) Heart failure with preserved ejection fraction –> LV ejection fraction >50%
(Inability to relax and fill, issue is with filling so reduced preload)
Caused by: LVH, Constrictive pericarditis, cardiac tamponade
2) Heart failure with reduced ejection fraction –> LV ejection fraction <40%
(Failure to contract, issue with the pump itself)
Caused by: IHD, MI, (Because of damage to the heart muscle)
What is the classification system used for determining the severity of heart failure?
NEW YORK HEART ASSOCIATION CLASSIFICATION
1 - No limit on physical activity
2 - Slight limit on moderate activity
3 - Marked limit on moderate activity
4 - Inability to carry out physical activity without discomfort.
Aortic dissection
RF
Pathology
Symptoms
Investigations
Treatment
A tear in the intima layer of the aorta, resulting in blood flowing into the media at high pressure, dissecting the media and creating a false lumen.
RF - Marfan syndrome, Ehler-Danlos syndrome, smoking, hypertension
PATHOLOGY
With a false lumen
1) Blood from the false lumen can flow back up the aorta and cause a cardiac tamponade.
2) Blood can puncture a hole through the tunica media and adventitia, bleeding into the mediastinum
3) Blood in the false lumen can compress branches of the aorta, decreasing blood flow to organs –> causing shock.
SYMPTOMS
- Sudden onset severe tearing/ripping chest pain (back pain if descending aorta involved)
- Absent peripheral pulse
- Difference in BP between 2 arms (>10mm Hg difference) – also pulse difference
INVESTIGATIONS
1st line - Chest X-ray –> Widened mediastinum
GS - CT angiogram
(TROPONINS, CT angiogram)
Classify AD as type A or B via Stanford classification
A - Ascending aorta affected before the left subclavian artery
B - Descending aorta distal to the left subclavian artery
Treatment
Type A - Open surgery
Type B - Endovascular aneurysm repair
Medical prevention
+ Special Beta blocker - Labetolol
or if BB doesn’t work - Sodium Nitroprusside.
Where does aortic dissection most commonly occur?
Areas of high pressure.
Commonly:
At the sinotubular junction (where the aortic root transitions to the ascending aorta) or distal to the left subclavian artery.
What are the differential diagnosis of Tachycardia?
(Hint: Regards to the ECG)
Narrow QRS + Regular rhythm - Sinus tachycardia
Narrow QRS + Irregular rhythm - Atrial fibrillation
Wide QRS + Regular rhythm - Ventricular tachycardia
Wide QRS + Irregular rhythm - Polymorphic ventricular tachycardia
(Seems like Wide QRS - ventricles pathology)
Path of electrical conduction in the heart
SAN –> AVN –> Bundle of his –> purkinje fibres
What are the 2 shockable and 2 non shockable rhythms?
(In cardiac arrest)
Shockable
- Ventricular tachycardia
- Ventricular fibrillation
Non Shockable
- Pulseless electrical activity
- Asystole
