Cardio Pathology Flashcards
Define Atrial Fibrillation:
Tachycardia
- lack of P waves
- Narrow QRS
- Variable QRS rate
- regularly irregular
What are the three isoforms of AF?
Paraoxysmal
- <48hrs
- usually spontaneously stops
Persistent
Permanent
Signs and symptoms of AF?
Palpitations
Dyspnoea
Chest pain
Reduced ejection fracture
- *usually due to tachycardiomyopathy
- increased metabolic demand that can’t be sustained
Investigations into AF:
ECG
Echocardiogram
Thyroid function
- hyperthyroidism
LFTs
Whats the management of AF?
- Prevention of symptoms
- rate control
- Correction of rhythm
What is the management of AF rate control?
1st line:
- beta blockers
- Ca2+ antagonists (verapamil)
**verapamil not okay for heart failure
2nd line:
- Digoxin
What is the management of Rhythm control?
<48hours then:
Class I: Na2+ blockers
- Flecainide 100mg
- Propafenone 150-300mg
- *not in Coronary heart disease
Class III: K+ channel blockers
- Amiodarone
- *only option for heart failure patients
> 48hours then:
Anti-coagulation treatment first for 4-6 weeks.
- Dabigatran
- Rivaroxaban
- Apixaban
- Edoaxban
*warfarin only when mitral stenosis or replaced valve.
What is the scoring system used to work out coagulation use in AF?
CHA2DS2VASC
Define heart failure:
Abnormal Cardiac function/ structure, leading to failure of deliver of oxygen and metabolic demands of tissue, despite normal filling pressures.
What are the key symptoms in heart failure?
Breathlessness
Fatigue
Ankle Swelling
What are the two main sub-stypes of heart failure?
Reduced Ejection fraction HF.
- impaired myocardial contraction
- males
- younger patients
- Coronary aetiologies
Preserved ejection fraction:
- poor ventricular filling due to poor compliance of the ventricles
- LVH
- Hypertension
- Amyloid depositions
- elderly
- females
- diabetics
What is associated with left sided heart failure?
Dyspnoea
Paraoxysmal nocturnal dyspnoea
Sputum red cough
What is associated with right sided heart failure?
- Raised JVP
- Hepatomegaly
- Nut meg liver
- pitting oedema
In investigations, what is a major Lab finding, which without basically rules out Heart failure?
BNP
Pro- BNF
Investigations for heart failure?
ECG
- hypertrophy
- QRS duration
Bloods
- BNP
- pro-BNP
- full blood count
- LFTs (damaged liver)
- Urea (renal damage)
Chest x-ray
- Pulmonary oedema
- Cardiomegaly
- Kerley B lines
Echocardiogram
Haemotology
Outline the pharmacological management of heart failure:
- Beta blocker + ACE inhibitors (or ARB)
- Mineralcorticoid Receptor antagonist + ACE (or ARB)
(Plus diuretic if fluid overloaded) - Sacubitril/ Valsartan
+ MRA + Beta blocker
(this is level of specialist) - ICD or CRT -P + Ivabradine
(ICD and CRT given if ejection fraction is low)
(Ivabradine given if >75bpm in sinus) - digoxin
- Heart transplant
Define M.I
Any elevation of Troponin with clinical presentation suggesting M.I
What are the types of M.I?
Type I:
- coronary event (classical)
Type II: Failure of demand - no blood clots. increased demand, or decreased supply - sepsis - arrhythmia
Type III:
Sudden Cardiac Arrest
Type IVa:
- PCI
Type IVb:
M.I stent
Type V:
Cardiovascular surgery
What is the term where there is ballooning of the heart due to emotional stress?
Takosubo cardiomyopathy
sudden weakening of the heart due to emotional distress
How long till there is irreversible death of cardio cells in ischemia of the heart?
40mins
Outline the changes in the heart tissue after M.I
12-24 hours:
- neutrophil infiltration
- hyper eosinophilic necrosis
1-3 days
- loss of stiations
3-7 days
- macrophages involvement
7-10 days
- granulation tissue
> 2 months
- dense collagen scar formation
M.I in the inferior of the heart is caused by blockage to?
RCA
M.I in the posterior of the heart is caused by blockage to?
RCA
M.I in the anterior of left ventricle of the heart is caused by blockage to?
LAD
M.I in the lateral part of left ventricle of the heart is caused by blockage to?
Left circumflexed artery
M.I in the anteroseptal of the heart is caused by blockage to?
LAD
M.I in the right ventricle of the heart is caused by blockage to?
RCA
Investigations of M.I?
ECG
Chest X-ray
Troponin
Full blood count
Immediate management of M.I?
**emergancy transfer to heart centre
**defibrillator placed on
Morphine - 10mg IV
Metoclopramide - 10mg
Oxygen
Nitrates
Aspirin
Clopidogrel
*changed to Ticagrelor when in hospital
Whats the time line for PCI?
90mins
40mins driving to centre
What is the alternative to PCI?
Thrombolysis
Tenecteplase
- bolus
Heparin
- un fractioned
- bolus
What the post M.I pharmacological treatment?
ACE inhibitors Beta blockers Statins Aspirin Ticagrelor
Eplerenone (diabetics, LV dysfunction and heart failure)
What are the treatments post M.I?
90 minute ECG
Pharmcology
Bloods
Echo
Cardiac rehabilitation
What are some complications of M.I?
Arrhythmias
- VT/ VF
- AF
Heart failure
- damaged wall
- damaged valves
Cardiogenic shock
Myocardial Rupture
- 3-5days
Pyschological
What is the treatment of NSTEMI?
Aspirin
Clopidogrel/ Ticagrelor
Heparin
Secondary: ACE inhibitors Beta blockers Statins Eplerenone (subjective)
Echo
Cardiac rehabilitation
What valve is most commonly associated with endocarditis?
Mitral
Which drug is mainly cleared by the renal system and may be implicated in renal failure?
Dabigatran
Preserved ejection fracture is also known as? and why is this?
Diastolic heart failure:
due o the fact the heart is literally not filling up much i.e. LVH
thus the ejection fracture is normal, but the overall volume is not!
Who typically gets Reduced ejection fracture heart failure?
- young
- male
- Coronary heart disease associated
What type of heart block is characterised by continually increasing lengths of the P-Q interval until it stops, then repeats?
Second Degree Heart block, Type I (Mobitz type I)
In third degree heart block, what occurs?
Widden of the QRS complex.
If a home monitoring kit is used to analyse blood pressure, what does there need to be for diagnosis of high blood pressure?
2 readings
twice a day
taken over 4-7 days
What is the cut off level for home readings for hypertension?
135/ 85
What are the cut offs for nighttime hypertension?
> 120/ >70
In patients with grade 1 hypertension who are low risk for systemic disease, when do you treat them with medication?
after 3-6 months of life style changes
Which stage do you treat all patients with medication?
Grade 2
> 160-179/ 100-109
What is high output heart failure?
This is where the cardiac output is increased well past that of normal valves for that setting. Results in massive stress to the heart.
for example severe anaemia reduces the viscosity of the blood - increasing pre-load - massively impacting the stress on the heart
List some common causes of heart failure:
Coronary heart disease
Hypertension
Toxins
- chemotherapy
- alcohol
Idiopathic
What is acute heart failure?
Worsening of chronic
or
New in de novo cause
What are the stages of heart failure?
I: no symptoms
II: symptoms, shortness of breath when doing certain activities
III: Marked symptoms when doing certain activities. Comfortable at rest
IV: Severe symptoms, uncomfortable when at rest. bed bound
What investigations need to be done for HF?
ECG Chest x-ray Bloods U&Es BNPs and Pro BNPs Echo
What is a ICD?
Implantable cardioverter defibrillator
Many patients with heart failure can go into VT - which this senses and stops via a shock
What is valsartan?
Angiotensin II blocker
What does a CRT device do?
Enable the heart to pump more efficiently by co-ordinating the ventricles and helping time them
Used for Left bundle branch - which is often associated with HF.
At which stage of the management of HF, do you seek expert advice?
After Mineral-corticosteroid diuretic therapy has been used.
In the setting of acute/ decompensated HF, what needs to be given?
Furosemide
Nitrates
- dilates V&As
CPAP
- increases O2
- reduces preload by increasing intrathoracic pressure
Morphine
- pain
- dilates venous - reduces preload
Dobutamine
- inotropic stimulation
What is BNP?
Bodies natural diuretic
- dilates
- promotes diuresis
What is Pro-BNP?
a cleaved part of the BNP
What investigations are done in the setting of acute heart failure?
ECG Chest x-ray Echo Thyroid functions Troponin BNP
What are the two presentations of infective endocarditis? and what pathogens are most associated with them?
Acute
- staph aureus
Sub - acute
- strep viridans
What are the symptoms of infective endocarditis?
- fever
- heart murmur
- Fatigue malasia
- embolic events
- splinter haemorrahges
What investigations need to be done when there is suspected endocarditis?
- echo
- transthoracic
- transesophageal
- Blood cultures
- 3 samples
- peripheral locations
- pre-antibiotics
- 10mls in each
- sterile technique
- FBC
- ESR
- U&Es
- ECG
- Sputum
- heart failure
What is the duke criteria? and what is needed for diagnosis?
Major:
- typical 2 organisms
- positive echo
Minor:
- risk factor - IV user, prosthetic valve
- Fever
- Vascular phenomena
- Immunological phenomena
- positive cultures (but outwith major)
- Echo (but outwith major)
2 Majors or 1 Major + 3 minors or 5 minors
What is the treatment of Infective endocarditis?
Native valves: *Amoxicillin \+ *Flucloxacillin \+ Gentamicin
Prosthetic valves:
*Vancomycin
+
*gentamicin
What is the most significant factor for diagnosis of endocarditis?
Volume of blood
If you have a diagnosis of Streptococcal for endocarditis, what antibiotics should be used?
Benzylpenicillin
+
Gentamicin
for 4 weeks
How do the bacteria in endocarditis cause vegetations?
Through quorum sensing
What are the main types of endocarditis?
IVDU - Staph Aureus
Native valve - Strep Viridans
Prosthetic Valve - Staph Epidermis/ MRSA
Name some causes that are not STEMI but increase troponin levels:
P.E
Sepsis
Tachyarrhythmias
Renal Failure
What can cause saddle shape of the ST segement on most of the leads?
Pericarditis
What are the inferior leads of the ECG? what vessel do they correlate with?
II, III and aVF
- right coronary artery
What are the anteroseptal leads, and what ones specifically look at the septum?
V1, V2, V3, V4
- Left atrioventricular descending
V1 and V2 look specifically at septum
- Circumflex
What leads look at the left lateral leads?
I, aVL, V5, V6
- Left circumflex
What things outwith the valves themselves can lead to valvular disease?
Valvular annular stretching open
Valve apparatus being damaged
What type of hypersensitivity is rheumatic fever, what is the pathogen and what is the antibodies produced?
type II
Pyogenes
Antistreptolysin antibodies
What murmur causes head popping? and why?
Aortic regurgitation
- due to the changes in pressures as systolic is high, but diastolic is low
Which leaflet of the mitral stenosis is more prone to damage?
Anterior
- because its larger
What are the space changes that occur in mitral stenosis?
5cm2 > 1cm2
- symptomatic
What murmur gets quieter as it gets worse, and what is this called?
aortic stenosis
- low flow gradient
What is the 6ps of critical limb ischemia?
What is a good diagnostic factor for differentiated between poor limb ischemia and potential limb loss?
Pallor Painful Paraesthesia Pulseless Paralysis/ paretic Perishingly cold
Muscle tenderness is good at differentiating between really bad ischemia and potential limb loss.
- with muscle tenderness being likely to loose limb
What are the investigations done into limb threatening ischemia?
ABPI
CT Angiogram
Pulses
Arteriogram
- embolectomy
- thrombolysis
**good thing about arteriogram is that whilst there you can carry invasive surgery such as angioplasty and stenting
What are the treatments for critical limb ischemia?
The limb must be assessed to see if it is able to be saved, if not it will be amputated.
if viable limb then: *thrombolysis - alteplase - PCI (depending on patient)
Heparin - Low molecular weight
Analgesics
What is the long term management of PVD:
Statins
Fibrates
- reduce tricycles in liver
Aspirin
Anti-hypertensives - not Beta blockers
life style changes
In order to get renal failure from renal stenosis, what must be present?
Stenosis of both arteries
