Cardio core conditions Flashcards
What is the presenting complaint for a patient with unstable angina?
Angina with increased frequency , unpredictability or at rest
Pain lasts <20mins
What is the minimum amount of time for chest pain to last to consider the cause being a STEMI or an nSTEMI?
> 20mins
What will an ECG show in unstable angina?
May be normal
May show ST depression or T wave changes
What is acute coronary syndrome?
Unstable angina and an evolving MI (STEMI or NSTEMI)
What will an ECG show in a STEMI?
ST elevation
T wave inversion
What will an ECG show for an NSTEMI
ST depression or T wave inversion
What happens to troponin levels in UA, STEMI, NSTEMI?
UA: normal
STEMI and NSTEMI: elevated
What do the majority of patients with ST elevation develop?
Q wave MI
What are the the symptoms of an MI? 6
1- chest pain >20mins often unresponsive to GTN spray 2-radiates to neck and down left arm 3- nausea 4-sweating 5- dyspnoea 6-palpitations
How do elderly or diabetic patients present with an MI? 9
1- dyspnoae 2-fatigue 3-syncope 4-epigastric pain 5-oliguria 6-pulmonary oedema 7-acute confused state 8-stroke 9- diabetic hyperglycaemic attacks
What will the pulse feel like in an MI?
Thready= a weak pulse that is difficult to feel or obliterated easily with slight pressure
What happens to BP in MIs?
It decreases
What other signs will be seen in an MI (aside from low BP and thready pulse)? 5
1- 4th heart sounds 2- signs of heart failure= increased JVP, 3rd heart sound, basal crepitations 3- pansystolic murmur 4- later a pericardial friction rub 5- later peripheral oedema may develop
What are the risk factors for an MI? 9
1- age >65 2- Male 3- Fh of IHD 3- smoking 4- hypertension 5- DM 6- hyperlipidaemia 7-obesity 8- stress 9- type A personality
What will an ECG show in a STEMI over time?
Hours: T wave peaks, ST segments may begin to rise
within 24 hours: T wave inverts as ST elevation begins to resolve
within a few days: pathological Q waves form, these usually persist
What will a CXR show in a MI?
Cardiomegaly
pulmonary oedema
widened mediastinum
What biochemical markers are tested for an MI? 3
Creatine kinase MB
Troponin
Myoglobin (useful for rapid diagnosis of ACS, but not specific- also found in muscles)
Why is creatine kinase tested less frequently now?
As there are low levles in the serum of normal people and people with skeletal damage, prolonged exercise, Afro-carribeans, hypothermia and hypothyroidism
Which parts of troponin are tested for in an MI?
mAB against troponin T
mAB against troponin I
What do each of the parts of troponin do?
T: attaches the complex to tropomyosin
C: binds calcium during excitation contraction coupling
I: inhibits the myosin binding site of the actin. Isn’t found in normal people
When do Troponin T levels peak and for how long post MI can they be detected?
12-24 hours
for a week
What are the criteria for MI diagnosis?
2/3 of:
chest pain/ typical history
ECG changes
cardiac enzyme ris
How do you manage high death risk patients with an MI?
urgent coronary angiography?
How do you manage low risk MI patients?
aspirin, clopidpgrel, beta blockers and nitrates
Whats the immediate treatment for MI patients?
ROMANCE(E) Reassure Oxygen Morphine + anti-emetic Aspirin- 300mg Nitrates- GTN Clopidogrel- 300mg Enoxaprin ECG
Do you give thrombolysis to STEMI or NSTEMI patients?
STEMI
How do you manage STEMI patients?
Urgent-ish Percutaneous coronary intervention (PCI)= angioplasty
If this isn’t available then TPA (tissue plasminogen activator)/ streptokinase
How do you manage NSTEMI patients?
elective PCI after 48-72hrs stabilisation
Stabilisation= ACE-I, B-blockers, statin, LMWH
What are the complications of an MI? 9
1-Heart failure- LVF 2- myocardial rupture and aneurismal dilation--> death 3- ventricular septal defects 4- mitral regurgitation 5-VF- common in STEMI and reperfusion 6-AF 7-sinus bradycardia (treat with atropine) 8- bundle branch blocks 9-Dressler's syndrome
What is Dressler’s syndrome and how do you treat it?
recurrent pericarditis pleural effusions anaemia increased ESR Fever 1-3 weeks post MI Rx= NSAIDs and steroids
What are the features of angina chest pain?
Heavy/tight/ gripping chest pain
can range from mild ache to very severe pain that –>sweating and fever
often associated with breathlessness
Where is the pain in angina?
Central/ retrosternal
radiates to jaw and left arm
What are the features of classical/exertional angina?
Triggered by exercise, especially after meal and in the cold
pain fades within minutes of rest
What are the features of decubitus angina? And what causes it?
Occurs when lying down
Linked with impaired L ventricle function due to severe CAD (coronary artery disease)
What are the features of nocturnal angina? And what causes it?
May wake patient
provoked by vivid dreams
occurs in pts with critical CAD
What are the features of Variant (prinzmetal’s angina)? What causes it? and is it more common in M or F?
Angina without provocation usually at rest due to coronary spasm will have ST elevation during pain F>M
What is Cardiac syndrome X?
A good history of angina
+Ve exercise test but angiographically normal arteries
F>M
Myocardium shows abnormal response to stress
What are the features of unstable angina?
angina of recent onset <1 mnth
worsening angina or angina at rest
What are the signs of angina?
Usually no findings
4th heart sound may be heard
Look for signs of anaemia, thyrotoxicosis
Hyperlipidaemia- corneal arcus, xanthelasma, tendon xanthoma
What will an angiogram show in angina?
That collateral vessels have grown
What is the main cause of angina?
atherosclerosis
what investigations are done in angina?
Exercise ECG- confirms diagnosis and gives severity of CAD
Cardiac scintigraphy- myocardial perfusion scans at rest and exercise
CT coronary angiography- good for diagnosing CAD and excluding other causes e.g. PE, also for helping find out where exactly needs revascularisation
What prognostic therapy is available for angina?
75mg OD aspirin- decreases risk of coronary event in pts with CAD
Statin- if cholesterol >4,8
What is the symptomatic treatment for angina?
GTN spray- works in 5 mins, lasts for 20-30mins
What surgical options are there for angina?
Perutaneous transluminal coronary angioplasty (PTCA)-
dilating coronary artery stenosis using a balloon inserted through the femoral, radial or brachial artery
Coronary artery bypass grafting (CABG)-
autologous veins or arteries are anastomosed to the ascending aorta and to the native coronary arteries distal to the stenosis
What are the symptoms of AF? 6
Highly variable 30% asymptomatic Chest pain palpitations dyspnoea faintness some decrease in exercise capacity
What are the signs of AF? 2
Irregularly, irregular pulse Apical pulse (heard at heart) is greater than radial pulse
What are the causes of AF?
Hypertension= most common cause Rheumatic heart disease alcohol intoxication thyrotoxicosis hyperthyroidism
What is paroxysmal AF?
recurring sudden episodes of symptoms
comes and goes within 7 days but usually <2
What is persistent AF?
Lasts >7days
Unlikely to revert back to normal without cardioversion treatment
Even with treatment it may return
What is permanent/ established AF?
present long term
Heart hasn’t reverted back to normal rhythm
What investigations should you do in AF?
ECG TFTs U&Es Cardiac enzymes Echocardiogram
What will an ECG of AF show?
Absent P waves
Irregular, rapid QRS
fast ventricular rate- 120-180 BPM
What might an echocardiogram show in AF?
L atrial enlargement
Mitral valve disease
structural abnormalities
How do you treat acute AF (<48 hrs)?
Very ill and haemodynamically unstable--> O2 Bloods Cardoversion- if available If not amiodarone
What do you give patients with paroxysmal AF to take PRN (as needed)?
Flecainide an antiarrythmic agent
Who do you offer ventricular rate control to in chronic AF?
>65 primary accepted AF persistent tachycardias failed previous cardioversion attempts AF >1yr On going reversible cause e.g. thyrotoxicosis
What is the ventricular rate control treatment in chronic AF?
B-blocker or Ca2+ channel blocker (diltiazem)
warfarin
How do you check if rate control treatment for chronic AF is working?
ECG in elderly
ambulatory 24hr holter monitor and exercise stress test in younger pts
When do you offer rhythm control therapy in AF?
If symptomatic
in CCF
younger pts presenting for the first time
What are the rythm control options?
Cardoversion:
DV shock
or IV infusion of flecainide or amiodarone} if structural abnormality
Are biphasic or monophasic shocks better in AF?
Biphasic
What is the main risk of AF and how is this managed?
Stroke
Warfarin or NOAC
What is the INR target in AF?
2.0-3.0
What are the indications for giving warfarin in AF?
1 of the major factors or 2 of the moderate ones:
Major:
Prosthetic heart valve
rheumatic mitral valve disease
history of CVA/TIA
Moderate: age >75yo Congestive heart failure Hypertension Diabetes mellitus
What is the CHADS2 score?
To determine whether to give warfarin or aspirin in AF Congestive heart failure Hypertension Age >75 DM Previous stroke/ TIA- scores 2 score 0= aspirin score 1= use clinical judgement 2= warfarin
What are the symptoms of hypertension?4
often asymptomatic
sweating
palpitations
headaches
What are the symptoms of severe hypertension? 5
headaches epistaxis nocturia SOB angina
What is normal BP?
<120/<80
What is pre HTN?
130-139 and/or 85-89
What is grade 1 (mild) HTN?
140-159/ 90-99
what is grade 2 (mod) HTN?
160-179/ 100-109
What is grade 3 (severe) HTN?
> 180/ >110
What will be seen in fundoscopy of grade 1 HTN?
Tourtuous renal arteries with increased reflectiveness (silver wiring)
What will be seen in fundoscopy of grade 2 HTN?
Grade 1 + AV nicking
What will be seen in fundoscopy of grade 3 HTN?
Grade 2 + splinter haemorrhages and soft exudates (cotton wool) due to infarcts
What will be seen in fundoscopy of grade 4 HTN?
Grade 3 + pailloedema (blurring margins of optic disc)
What are grade 3 and 4 HTN diagnostic of?
malignant hypertension
Is HTn more common in F or M?
M
What are the risk factors for HTN? 6
Age obesity smoking alcohol stress sodium/salt
What are the metabolic causes/risk factors of HTN? 5
DM Glucose intolerance decrease HDL hypertriglyceridaemia central obesity
What are the congenital causes of HTN? 3
adrenal hyperplasia
aortic coarctation
II hydroxylase deficiency
What are the renal causes of HTN? 5
diabetic nephropathy chronic glomerulonephritis adult polycystic kidney disease chronic tubulointestinal nephritis renovascular disease e.g. renal artery stenosis
What are the endocrine causes of HTN? 5
Conn’s syndrome (primary hyperaldosterone)
Adrenal hyperplasia
Phaeochromocytoma- tumour of the adrenal gland
Cushing’s syndrome- high cortisol
acromegaly
Which drugs cause HTN? 4
The pill
NSAIDs
cyclosporine
steroids
What are the signs of pre-eclampsia?
preganncy induced HTN + proetinuria
What investigations should you do in HTN?
ECG
urine dipstick- protein and blood
Fasting blood for lipids (total and HDL) and glucose
serum urea
creatinine and electrolytes
CXR- if coarctation of the aorta is suspected
When do you not treat severe HTN?
if it’s malignant
when do you treat moderate HTN?
If CV complications
DM
Target organ damage
Once HTN has been confirmed over 4 weeks
(if mild HTN do the same but confirm over 12 weeks)
Who is likely to have low-renin HTN?
Black pts and >55yo
What is the first line Rx for <55s?
ACEis e.g. inopril, benazepril, captopril
If this isn’t tolerated the ARBs e.g. candesartan, losartan
When do you use ARBs preferentially?
Chronic kidney disease
What is the first line for black pts and >55s?
Calcium channel blockers e.g. amlodipine, diltiazem
or Thiazide diuretics e.g. hydochlorothiazide, chlorthalidone
What is the second line therapy for anyone with HTN?
ACEIs+ thiazide diuretics
or ACEIs+ Ca channel blockers
What are the complications of HTN?
Cerebrovascular disease CAD prone to renal failure Peripheral vascular disease PAD
What are the symptoms of a DVT? 7
65% asymptomatic Calf pain swelling redness warmth engorged superficial veins ankle oedema
What is Homan’s sign?
Dorsiflexion of the foot in the presence of a DVT –> calf pain
Shouldn’t be done as may dislodge the clot
What happens if a DVT completely occludes the vein?
cyanotic discolouration
severe oedema
What does chronic venous obstruction in DVT lead to?
single swollen limb and may lead to ulceration= post phlebitis syndrome
where do the majority of DVTs occur?
in deep veins of the legs around the valves
What are the majority of the thrombi?
Red cells + fibrin= red thrombi
what are the risk factors for DVT? 19
- varicose veins
- age
- obesity
- stasis
- pregnancy
- thrombophilia
- Any blood clotting disorder eg. thrombphilia, protein C or S deficiency, factor V leiden etc
- Sickle cell anaemia
- recent MI or stroke
- IBD
- nephrotic syndrome
- central venous catheter
- paroxysmal nocturnal haemoglobinuria
- paraproteinaemia
- myeloproliferative disorders
- resp failure
- surgery
- malignancy
- trauma
What does a negative D-dimer test show?
rules out thrombosis
What should be done following a positive D-dimer test?
Compression USS of leg
Lung scintigraphy/CT
What might cause false positives of D-Dimer tests? 8
Liver disease high rheumatoid factor inflammation malignancy trauma pregnancy recent surgery age
When should you do a thrombophilia test in DVT?
If there are no known risk factors
if they have recurrent DVTs
or FH of DVTs
How do you treat DVTs?
LMWH then warfarin
LMWH is kept until INR is in the correct range (2-3 normally)
Warfarin is normally continued for 3 months
What happens in LV failure?
decreased cardiac output and increased pulmonary venous pressure
What are the symptoms of LV failure? 10
Productive cough- frothy or blood tinged mucus decreased urine output sleep with several pillows- reduce SOB fatigue, weakness, faintness Irregular or rapid pulse palpitations SOB paroxysmal nocturnal dyspnoea fluid retention Displaced apex beat
What are the signs of LV in infants? 3
failure to thrive
weight loss
poor feeding
What are the two types of LVF?
Systolic and diastolic
What happens in systolic LVF?
The left ventricle loses it’s ability to contract normally.
The heart can’t pump with enough force to push enough blood into circulation
What happens in diastolic LVF?
The LV can’t relax (muscles are stiff).
Heart can’t properly fill with blood during the resting period between each beat
What are the causes and risk factors of LVF? 7
Alcohol MI Myocarditis hypertension hypothyroidism narrowed or leaking heart valves Children- congenital causes
What investigations should you do in LVF? 7
TFTs LFTs Kidney function coronary angiogram ECG heart stress test echocardiogram
What is are the consequences of LVF? 3
RVF
pulmonary oedema
circulatory collapse
What is backward cardiac failure?
Ventricle fails to pump blood rapidly enough to prevent the atria from overfilling
–> backpressure in the pulmonary system rises
What is forward failure>
Ventricles fail to pump enough blood to maintain normal circulation
–> Renin-angiotensin system retains sodium and water
What causes acute failure?
happens within mins of an MI, often due to valvular collapse
What is a common cause of chronic RH failure?
Mitral stenosis
Chornic obstructive lung disease= Cor pulmonale
What is a common cause of chronic failure?
ischaemia
Which occurs first LVF or RHF?
LHF
What is low output cardiac failure?
decreased cardiac output that fails to increase normally on exercion
What are the symptoms of RHF? 5
Increase JVP (due to tricuspid regurg) Gravitational oedema- ankle oedema, sacral if lying down Hepatic congestion= nutmeg liver --> ascites RV parasternal heave
What are the signs of CCF? 8
elevated JVP tachycardia at rest tachypnoea hypotension bi-basal end-inspiratory crackles/ wheeze ankle oedema ascites tender hepatomegaly- in triscupid regurg
What is the most common causes of CCF?
Coronary heart disease and hypertension
What are the cardiac causes of CCF? 4
valvular heart disease
Coronary heart disease
MI
ischaemia
What drugs can cause CCF? 4
B-blockers
Calcium antagonists
anti-arrhythmics
cytotoxics
What are the endocrine causes of CCF? 6
DM Hypo and hyperthryoidism Cushing's adrenal insufficiency excessive growth hromone phaeochromocytoma
What are the nutritional deficiencies that can cause CCF? 3
Thiamine
selenium
Carnitine
What are the infiltrative causes of CCF? 5
Sarcoidosis amyloidosis haematochromatosis Loffler's eosinophilia connective tissue disease
What are the infective causes of CCF? 2
Chaga’s disease
HIV
What are the causes of high output failure? 6
anaemia pregnancy hyperthyroidism Paget's bone disease arteriovenous malformations Beri-Beri
What investigation should be done in CCf with previous MI?
Doppler echocardiograpphy within 2 weeks
If there is no obvious abnormality test serum natriuretic peptides
What investigations should be done in CCF? 16
b-type natiruretic peptide (BNP)
N-terminal pro-BNP (NT-proBNP)
^ both are released into blood when myocardium is stressed
12 lead ECG
Echocardiography- if raised BNP or NT-proBNP or abnormal ECG
FBC, U&Es, creatinine, fasting lipids, glucose, TFTs
Cardiac enzymes if MI possible
CXR
Urinalysis
Lung function tests
Cardiac MRI
exercise testing
Ct angiography
What will a CXR show in CCF? 7
Cardiomegaly Ventricular hypertrophy prominent upper lobe veins peribronchial cuffing Diffuse interstitial or alveolar shadowing- bats wings Fluid in fissures pleural effusions
How do you treat stage a, high risk with no symptoms, CCF?
reduce risk factors
treat hypertension, DM, dyslipidaemia
May star ACEis or ARBs in some
How do you treat stage B, structural heart disease no symptoms?
ACEis or ARBs in all patients
B-blockers in selected ones
How do you treat stage C, structural disease previous or current symptoms?
ACEis and ARBs in all patients Dietary Na restriction Diuretics digoxin (if they have AF) Cardiac resynchronisation if they have bundle branch block revascularisation Mitral valve surgery
What is the most prevalent valvular disease?
aortic stenosis
the mitral regurg, aortic regurg, mitral stenosis
What are the causes of aortic stenosis? 3
Degenerative
congenital
rheumatic
What are the causes of aortic regurg? 5
congenital rheumatic infective endocarditis aortic dissection Marfan's3
What are the causes of mitral stenosis?4
mainly rheumatic
malignancy
rheumatoid arthrtis
SLE
What are the causes of mitral regurg? 6
Mitral valve prolapse rheumatic fever infective endocarditis IHD Marfan's SLE
What are the risk factors for valvular disease? 3
age
IHD
heart failure
Which of AS, AR, MS and MR are more in common in M or F?
AS and MR= M (Mr looks like mister)
AR and MS and rheumatic heart disease= F
What are the signs and symptoms of atrial stenosis? 6
Angina exertional syncope exertional dyspnoea small and slow rising pulse 4th heart sound Ejection systolic murmur radiating to both carotids
What are the signs and symptoms of atrial regurgitation? 6
exertional dyspnoea paroxysmal nocturnal dyspnoea orthopnea collapsing pulse pistol shots heard over femoral artery De Musset sign- head nodding with every heart beat
What are the signs of mitral stenosis? 10
Dyspnoea cough haemoptysis chest pain systemic embolism AF raised JVP diastolic thrill Mid diastolic murmur- opening snap and low pitched rumbling
What are the signs of mitral regurgitation? 3
Dyspnoea
Pansystolic murmur
Systolic click due to mitral valve prolapse
What investigations should you do in valvular disease?
ECG-
AF can complicate valvular lesions and worsen symptoms in AS and MS
AS shows LV hypertrophy
CXR
-may show cardiomegaly or pulmonary congestion
What is the commonest organism to cause infective endocarditis?
Strep viridans
What other organisms cause infective endocarditis? 3
enterococci
staph A
epidermidis
What are the risk factors for infective endocarditis? 6
Poor dental hygiene IVDU soft tissue infection dental treatment cannulas Heart surgery
What are the symptoms of infective endocarditis? 15
Fever + new murmur= infective endocarditis until proven otherwise
Septic signs: Fever rigors night sweats weight loss anaemia splenomegaly clubbing
Embolic events e.g. RHS may –> pulmonary abscess
Haematuria
glomerulonephritis
janeway lesions
Osler’s nodes
splinter haemorrhages
Roth spots
What investigations should be done in infective endocarditis?
FBC- normocytic, normochromic anaemai and leucocytosis
U&Es- renal dysfunction common in sepsis
LFTs
CRP
ESR- all raised
Urine dipstick- haematuria, proteinuria
CXR- HF or in RHS pulmomnary emboli or abscess
Echo
How do you manage infective endocarditis?
Long course 4-6weeks ABx:
Penicillins
or vancomycin or teicoplanin if allergic
Surgery if: in HF valve obstruction repeated emboli fungal endocarditis persistent bacteraemia myocardial abscess unstable prosthetic valve
What is postural hypotension?
Drop in systolic BP >20mmHg or diastolic >10mmHg after standing for 3mins
What causes postural hypotension? 9
Hypovolaemia- early sign
Drugs:
nitrates
diuretics
antihypertensives
Addison's disease Hypopituitarism- decrease in ACTH DM Multisystem atrophy idiopathic orthostatic hypotension
When is postural hypotension worse?
After prolonged bed rest
and in the mornings
How do you do a lying and standing BP?
Lie patient down for 5 mins - take BP
stand for 1 min- Take BP
