Cardio: Good set Flashcards
What are the types of IHD?
Stable angina
Acute Coronary Syndromes (ACS)
- Unstable angina
- NSTEMI
- STEMI
What are the modifiable risk factors for IHD?
Smoking
Obesity
Sedentary lifestyle
Diet
What are the clinical modifiable risk factors for IHD?
Hypertension
Diabetes
Hyperlipidaemia
Depression
What are the non-modifiable risk factors for IHD?
Age
Genetics/Family history - black
Gender (M>F risk)
What are the psychosocial risk factors for IHD?
High demand, low control jobs (high stress),
Low social interaction and support
What are the types of angina?
Stable angina: induced by effort, relived by rest
Unstable angina: angina of increasing frequency or severity, occurs on minimal exertion or at rest, associated with an increased risk of MI
Decubitus angina: precipitated by lying flat
Variant (Prinzmetal) angina: caused by coronary artery spasm
What is definition of angina?
Symptomatic reversible myocardial ischaemia
What are the main causes of angina?
Atheroma
Hypertension
Vasculitis
Anaemia
What is the presentation of angina?
Classical features
Constricting/heavy, central, tight chest pain radiating to jaw, neck, shoulders or arm
Precipitated by exertion
Relived by rest or GTN
Other features
Levine’s sign (clenched fist over the chest to cope with the pain)
Associated symptoms: Dyspnoea, Nausea, Sweatiness, Faintness
What are the classifications of Stable Angina?
Classification: Classical Features
All 3 features = typical angina,
2 features = atypical angina,
0-1 features = non-anginal chest pain
What are features that make angina less likely?
Pain that is continuous, pleuritic or worse with swallowing
Pain associated with palpitations, dizziness or tingling
What precipitating features can lead to angina?
Demand:
Emotion
Cold weather
Heavy meals
HTN
Tachyarrhythmia
VHD
Hyperthyroidism
Supply:
anaemia
Hypoxia
Polycythaemia
Hypothermia
Hypo/Hypervolaemia
What baseline investigations may you do for stable angina?
- ECG – usually normal, may show ST depression and T wave inversion
- FBC (check for anaemia)
- U&Es (prior to ACEi and other meds)
- LFTs (prior to statins)
- Lipid profile
- Thyroid function tests
- HbA1C and fasting glucose
What is the gold standard investigation for stable angina?
CT coronary angiogram
What is the treatment for stable angina?
1: Lifestyle changes
2: Pharmacological
- Secondary Prevention:
- Aspirin (75mg OD)
- Atorvastatin (80mg OD)
- ACEi
- Symptomatic relief: GTN spray
- Anti-anginal Medications:
- Beta Blockers (bisoprolol) OR Rate limiting CCB (verapamil)
- Switch
- Combine (BB + CCB - but would be amlodipine not verapamil as this can cause asystole)
- Add 3rd drug (isosorbide dinitrate)
3: Interventional (revascularisation)
- Percutaneous Coronary Intervention (PCI)
- Coronary Artery Bypass Graft (CABG)
What are the conditions under ACS?
Unstable angina
NSTEMI
STEMI
What is the pathology of ACS?
Plaque Rupture –> Thrombosis –> Inflammation –> Infarction
Rarer causes:
Emboli
Coronary artery Spasm
Vasculitis
Define Myocardial Infarction
Reduced blood supply to myocardial cells resulting in cell death releasing troponin
Define unstable Angina?
ACS defined by the absence of biochemical evidence of myocardial damage
What are the main features of unstable angina presentation?
Cardiac chest pain at rest (lasting >20mins)
Cardiac chest pain with crescendo pattern (gradual increase)
New onset angina
Associated symptoms
Nausea, Sweatiness, Dyspnoea, Palpitations
What are the investigations for Unstable angina?
ECG – ST depression (when in pain)
Cardiac enzymes – normal troponin
FBC – anaemia (precipitating factors)
Coronary angiogram - GS
What is the treatment of Unstable Angina?
Risk factor modification:
- High dose statin e.g. Atorvastatin
- ACE-I (unless CI)
Reduce cardiovascular events:
- Antiplatelet agents: Aspirin and Clopidogrel (DAPT)
- Anti-coagulants: Fondaparinux or LMWH
PRN symptomatic relief:
- Nitrates (PO or IV) – for recurrent chest pain
Anti-anginal medications:
- Beta-blockers e.g. Bisoprolol
- CCB e.g. Amlodipine (if beta-blockers CI)
- Nitrates e.g. Isosorbide dinitrate
Revascularisation:
- Percutaneous coronary intervention (PCI – ‘stenting’)
- Coronary artery bypass graft (CABG) surgery
What is the presentation of an MI?
Acute central chest pain lasting >20mins radiating to jaw, neck, shoulders or arm
Unremitting, usually severe but may be absent, Occurs at rest, 1/3 at night
Associated symptoms
Nausea, Sweatiness, Dyspnoea, Palpitations
What are the investigations for an STEMI?
ECG
Acute changes:
Hyperacute T-waves,
ST elevation or new LBBB
Hours/days:
T-wave inversion and pathological Q waves (deep and wide)
What are the investigations for an NSTEMI?
ECG:
ST depression, T wave inversion, non-specific changes or normal
Cardiac Enzymes:
Troponin (sensitive marker for myocyte injury, not ACS specific)
Bloods – FBC, U&E, Glucose, Lipids
Other – CXR, Echo
What ECG cords are associated with a circumflex MI?
Lateral:
Lead I
aVL
V4-V6
What ECG cords are associated with an LAD MI?
Anteroseptal:
V1-V3
What ECG cords are associated with an Inferior MI?
Lead II
Lead III
Lead aVF
What is the Pre-hospital management of an MI?
Aspirin 300mg and GTN
What is the acute Hospital management of an MI?
MONAC:
Morphine
Oxygen (if hypoxic under 94%)
Nitrates (GTN)
Aspirin
Clopidogrel
+/- Heparin
What is the NSTEMI acute management?
B – Beta-blockers unless contraindicated
A – Aspirin 300mg stat dose
T – Ticagrelor 180mg stat dose (clopidogrel 300mg is an alternative if higher bleeding risk)
M – Morphine titrated to control pain
A – Anticoagulant: Fondaparinux (unless high bleeding risk)
N – Nitrates (e.g. GTN) to relieve coronary artery spasm
Give oxygen only if their oxygen saturations are dropping (i.e. <95%)
Estimate 6 month mortality with GRACE:
Low risk = Ticagrelor
High Risk = PCI within 72 hours + Prasugrel + Heparin
What is the STEMI acute management?
- STEMI identified
- Aspirin (300mg)
- PCI possible within 120 mins within 12 hours of STEMI onset?
3a (yes). Prasugrel + Unfractionated Heparin + PCI
3b (No). Fibrinolysis if within 12 hours STEMI onset. (IV alteplase) + Ticagrelor
What is the Long term management of an MI?
BACAS:
Beta blocker
Aspirin
Clopidogrel
ACEi
Statin
Risk factor modification.
High risk of emboli - Give warfarin (3-6 months)
What are the complications of MI?
Death
Arrythmias
Ruptured Septum
Tamponade
Heart Failure
Valve disease - ruptured papillary muscles
Aneurysm of Ventricles
Dressler’s Syndrome
Embolism
Reoccurrence of ACS
What are some differential Diagnoses for Chest pain?
Cardiac: MI, Angina, Aortic Dissection, Pericarditis
Resp: PE, Pneumonia, Pneumothorax, Pleurisy, Cancer
MSK: Rib fracture, costrochondritis
GI: GORD
Psychological: Anxiety, Panic Attack
Define Heart Failure
‘A state where the heart is unable to pump enough blood to satisfy the needs of metabolizing tissues”
CO is inadequate for body’s requirements (CO=HR x SV)
What is the aetiology of HF?
Ischemic Heart Disease
Valvular Heart Disease (commonly AS)
Hypertension
Arrhythmias (commonly AF)
Cardiomyopathy
What are the risk factors for HF?
65 and older
African descent
Men
Obesity
Previous MI
What are the classifications of HF?
Reduced EF (<40%) - often Systolic failure
Mid Range EF (40-49%)
Preserved EF (>50%) - often Diastolic Failure
What are the cardinal Symptoms of HF?
Shortness of Breath
Fatigue
Ankle swelling
What are the signs symptoms of Left ventricular failure?
Causes Pulmonary Congestion:
Symptoms:
- Exertional dyspnoea
- Fatigue
- Paroxysmal nocturnal dyspnoea (PND)
- Nocturnal cough – (+/-) pink frothy sputum
Signs:
- Cardiomegaly (displaced apex beat)
3rd and 4th heard sounds
What are the signs symptoms of Right ventricular failure?
Causes Systemic Congestion:
Symptoms:
- Peripheral oedema
- Ascites
Signs:
- Raised JVP
- Hepatomegaly
- Pitting oedema
- Weight gain (fluid)
What system is used to classify HF?
NYHA:
Stage 1 - No limitation (asymptomatic)
Stage 2 - Slight limitation (mild HF)
Stage 3 - Marker Limitation (symptomatic HF)
Stage 4 - Severe Symptomatic HF
What are the investigations for HF?
Blood tests:
NT-pro B-type Natriuretic peptide (BNP) – secreted by ventricles in response to increased myocardial wall stress
Cardiac enzymes: Creatinine kinase, troponin I, troponin T
Others:
FBC (anaemia), LFTs (hepatomegaly), U&Es, BNP, TFTs, Glucose (DM)
CXR – ABCDE
ECG
Echocardiography – Gold standard
What is seen on CXR in HF?
ABCDE:
Alveolar Oedema (Batwings)
Kerley B Lines (interstitial Oedema)
Cardiomegaly
Dilation of upper Lobe Vessels
Pleural Effusions
What is the Management of HF?
- Lifestyle Management
- Education
- Smoking cessation
- Reduce alcohol
- Reduce salt intake
- Exercise and Obesity control
- Symptomatic Management:
- Diuretics - Loop (furosemide)
- Disease Altering Medication (ABAL):
- 1st Line - ACEi (ramipril) + - Beta Blockers (bisoprolol)
- 2nd Line - Aldosterone Antagonist (Eplerenone)
- 3rd Line - Ivabradine, ARNI, Hydralazine, Digoxin
What is the acute Treatment of HF?
- IV Furosemide – reduce fluid afterload
- Oxygen
- Nitrates e.g., GTN (spray or tablets)
- Severe: consider inotropic drug (e.g., dobutamine) or vasopressors (e.g., norepinephrine) or mechanical circulatory assistance
What is the Chronic Treatment of HF?
ABCD
- ACE-I (e.g., Ramipril)/ARB (e.g., Candesartan, Valsartan)
- Beta-blockers (e.g., Atenolol)
- CCB and other vasodilators (e.g., Amlodipine, Hydralazine)
- Diuretics and Digoxin (loop – Furosemide, aldosterone antagonist – Spironolactone)
When should you avoid using ACE inhibitors?
In patients with valvular heart disease
Why is Eplerenone preferred over Spironolactone?
Spironolactone causes gynaecomastia
What are the causes of Acute left ventricular failure and pulmonary oedema?
Iatrogenic (aggressive IV fluids in frail elderly patient with impaired LV function)
Sepsis
Myocardial Infarction
Arrhythmias
What is the Treatment of Acute left ventricular failure and pulmonary oedema?
Pour SOD (acute LVF):
Pour away (stop) their IV fluids
Sit up
Oxygen – oxygen saturations are falling (<95%)
Diuretics – Furosemide
What is Cor Pulmonale?
Right heart failure and abnormal enlargement (of the right ventricle) caused by chronic pulmonary arterial hypertension
What are the causes of Cor Pulmonale?
COPD
Bronchiectasis
PF
Chronic Asthma
PE
Pulmonary Vasculitis
etc
How does Cor Pulmonale Present?
Symptoms:
- Dyspnoea
- Fatigue
- Syncope
Signs:
- Cyanosis
- Tachycardia
- Raised JVP
What are the investigations for Cor Pulmonale?
GS - right heart catheterisation
Bloods: FBC (Hb and haematocrit ↑ – secondary polycythaemia)
ABG: hypoxia +/- hypercapnia
CXR: enlarged right atrium and ventricle, prominent pulmonary arteries
ECG: P-pulmonale, Right axis deviation, Right ventricular hypertrophy/strain
What is the treatment for Cor Pulmonale?
Treat underlying cause
Treat respiratory failure – acute situation give 24% oxygen
Treat cardiac failure – Diuretic e.g., Furosemide
Heart-lung transplant (if young patient)
What is the most important risk factor for premature death and CVD?
Hypertension
Define White Coat Hypertension
Elevated clinic BP but normal ABPM
Define Malignant Hypertension
Rapid rise in BP leading to vascular damage
(fibrinoid necrosis is pathological hallmark)
What are the causes of Hypertension?
Primary/Essential Hypertension (95%) – cause unknown
Secondary Hypertension
R – Renal disease - Renal Artery Stenosis, CKD, Tubular Necrosis
O – Obesity
P – Pregnancy
E – Endocrine - Acromegaly, Cushing’s, Conns, Phaeochromocytoma
What are the risk factors for Hypertension?
Family history
Old age
Male
Afro-Caribbean
Lack of physical activity
Unhealthy diet (high salt intake, alcohol, smoking)
Obesity
Diabetes mellitus
Stress
What is the presentation of Malignant Hypertension?
Headaches
Visual Disturbances
What are some complications of malignant Hypertension?
Eyes - Retinopathy
Cardiac - LVH, HF, IHD, PVD
Kidney - Renal failure, Proteinuria
Neurological - Headache, Nausea, Vomiting, Stroke/TIA
GU - Impotence
What is the treatment for Malignant Hypertension?
Hypertensive Urgency: (no end organ damage)
oral Nifedipine
Oral Nifedipine and Oral Amlodipine
Hypertensive Emergency (end organ damage):
IV Labetalol
IV GTN
What are the investigations for Hypertension?
High BP in clinic
24 hr Ambulatory BP monitoring (ABPM)
Multiple home BP monitoring (twice daily for 4-7 days)
What are the tests for End organ damage in new hypertension diagnosis?
Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria to assess for kidney damage
Bloods for HbA1c, renal function and lipids
Fundoscopy examination for hypertensive retinopathy
ECG for cardiac abnormalities
What are the stages of Hypertension?
Stage 1: (low risk)
Clinical = 140/90 to 160/100mmHg
Home = 135/85 to 150/95mmHg
Stage 2: (high risk)
Clinical = >160/100mmHg
Home = >150/95mmHg
Severe:
Clinical systolic >180mmHg or Clinical diastolic >110 mmHg
When should you consider starting Hypertension treatment?
Stage 1 - Treat if >80yrs or if signs of end organ target damage or QRISK2 score 10%
Stage 2 - start Treatment
What is the life style management of hypertension?
Weight loss
Reduce alcohol intake
Reduce salt intake
Stop smoking
Regular exercise
Stress reduction
What is the pharmacological management of hypertension in under 55 years or DM?
- ACE inhibitor / ARB
- Add CCB
- Add Thiazide Diuretic
- Resistant Hypertension
4a. If K+ < 4.5 - Add Spironolactone
4b. If K+ > 4.5 - Add alpha or beta blocker
What is the pharmacological management of hypertension in over 55 years or Afro-Caribbean?
- CCB
- Add ACE inhibitor / ARB
- Add Thiazide Diuretic
- Resistant Hypertension
4a. If K+ < 4.5 - Add Spironolactone
4b. If K+ > 4.5 - Add alpha or beta blocker
What are the heart sounds?
S1 = mitral and tricuspid valve closure
S2 = aortic and pulmonary valve closure
S3 = in early diastole during rapid ventricular filling, normal in children and pregnant women, associated with MR and HF
S4 = Contraction of atria forcing blood against a stiff non-compliant ventricle
What are the Systolic Heart Valve Murmurs?
ASMR
Aortic Stenosis:
- Crescendo-decrescendo Ejection Systolic Murmur
- Loudest at Aortic Area, Radiates to Carotids
Mitral Regurgitation:
- Pansystolic High-Pitched “Blowing Murmur”
- Loudest at Apex and Radiates to Axilla
What are the Diastolic Heart Valve Murmurs?
ARMS:
Aortic Regurgitation:
- High-Pitched “Blowing” Early Diastolic Decrescendo Murmur
- Best Heard Sitting Forward
Mitral Stenosis:
- Opening Snap then Delayed Rumbling Mid-Diastolic Murmur
What is the murmur of a Patent Ductus Arteriosus?
Continuous Machine Like Murmur
What is the Aetiology of Mitral Stenosis?
Rheumatic Heart Disease
Infective Endocarditis
What is the murmur Like in Mitral Stenosis?
Mid-diastolic, low pitched “rumbling” murmur
Loud S1 due to thick valves
What are the associations of Mitral Stenosis?
Malar flush
Atrial fibrillation
What are the complications of Mitral Stenosis?
Left atrial Hypertrophy
Can lead to AF
What is the Aetiology of Mitral Regurgitation?
Idiopathic weakening of the valve with age
Ischaemic heart disease
Infective Endocarditis
Rheumatic Heart Disease
Connective tissue disorders such as Ehlers Danlos syndrome or Marfan syndrome
What is the murmur like in Mitral Regurgitation?
Pan-systolic, high pitched “whistling” murmur
Radiates to left axilla
What are the complications of Mitral Regurgitation?
Left atrial dilatation
Congestive cardiac failure
What is the Aetiology of Aortic Stenosis?
Bicuspid Aortic Valve >70 yrs
Idiopathic age-related calcification >70 yrs
Rheumatic Heart Disease
What is the murmur like in Aortic Stenosis?
Crescendo-decrescendo ejection-systolic, high-pitched murmur
Radiates to the carotids
What are the associations of Aortic Stenosis?
Slow rising pulse
Narrow pulse pressure
Exertional syncope
Breathlessness
What are the complications of Aortic Stenosis?
Left Ventricular Hypertrophy
What is Aortic Sclerosis?
Senile degeneration of the heart valve
Ejection systolic murmur but no carotid radiation and normal pulse
What is the Aetiology of Aortic Regurgitation?
Idiopathic age-related weakness
Connective tissue disorders such as Ehlers Danlos syndrome or Marfan syndrome
What is the murmur like in Aortic Regurgitation?
Early Diastolic
Soft Murmur
What are the associations of Aortic Regurgitation?
Corrigan’s pulse (collapsing Water- hammer pulse)
Wide pulse pressure
“Austin-Flint” murmur – heard at the apex and is an early diastolic “rumbling” murmur
Quince
De Musset
What are the complications of Aortic regurgitation?
left Ventricular Dilation
What is the investigation for heart valve defects?
Echocardiogram
What is the aetiology of Rheumatic Heart Fever?
Group A Beta-haemolytic Streptococcus (GABHS) – Streptococcus pyogenes infection
What is the pathology of Rheumatic heart Fever?
Type 2 Hypersensitivity Reaction (autoantibodies against cells of joints/heart/skin/nervous system)
Results in:
leaflet thickening
commissural fusion
shortening and thickening of the tendinous cords
Define Tachycardia?
A heart rate >100 BPM
Define Bradycardia?
A heart rate <60 bpm
How can tachycardias be classified?
Narrow Complex Tachycardias (QRS <120ms)
Broad Complex Tachycardias (QRS >120ms)
What are the narrow complex tachycardias?
Often occur Above the ventricles (supra ventricular)
In Atria:
Sinus Tachycardia
Atrial Fibrillation (Irregular Irregular Rhythm)
Atrial Flutter (Regular Irregular Rhythm)
Focal Atrial Tachycardia
In Atrioventricular Node:
AV Re-entry Tachycardia (AVRT)
AV nodal Re-entry Tachycardia (AVNRT)
What are the broad complex tachycardias?
Ventricular Tachycardia (Regular Irregular Rhythm)
Ventricular Fibrillation (Irregular Irregular Rhythm)
What are the types of Bradycardia?
SAN Dysfunction (followed by QRS):
Sinus Bradycardia
1st Degree heart Block
AVN Dysfunction (not followed by QRS):
2nd Degree Heart Block (Mobitz Type I and II)
3rd Degree Heart Block
What is Sinus Tachycardia?
> 100 bpm + Sinus Rhythm
What is the Aetiology of Sinus Tachycardia?
Physiological response to exercise and excitement
Anaemia, Infection, Fever, HF, Thyrotoxicosis, Acute PE, Hypovolemia, Atropine
What is the ECG in Sinus Tachycardia?
P waves piggyback onto the T waves = camel hump T waves
What is the treatment of Sinus Tachycardia?
Correct the cause
Beta Blockers to slow sinus rate e.g., atenolol
What is a supraventricular Tachycardia?
Any tachycardia that arises from the atrium or atrioventricular junction
What are the 4 Main types of SVT?
Atrial fibrillation
Atrial flutter
Atrioventricular nodal re-entry tachycardia (AVNRT)
Atrioventricular reciprocating tachycardia (AVRT)