Cardiology Flashcards
Angina
term which is used to describe symptomatic chest pain which is due to myocardial ischaemia.
Angina pathophysiology
- Coronary Circulation allows blood filling in diastole
- Atherosclerosis over time →Coronary arteries occluded → less blood flow
- Areas of myocardium are ischaemic→ especially during exertion
- To counteract , body increases sympathetic Stimulation → increase HR → Increase force of contraction
- O2 demand increases even more
Angina occurs as blood supply can’t meet demand
Atherosclerosis process
Step 1 - endothelial dysfunction
Endothelial injury causes a local inflammatory response → accumulation of LDL → become oxidised by waste products creating reactive oxygen species.
Step 2 - plaque formation
Endothelial cells attract macrophages → phagocytose the LDLs swelling to become foam cells and ‘fatty streaks’.
Step 3 - plaque rupture
Continued inflammation triggers smooth muscle cell migration → forms a fibrous cap + fatty streaks → develops into an atheroma. It causes vessel narrowing and leads to angina.
Stable Angina
Full occlusion
i) Constricting discomfort in the front of the chest/neck/shoulders/arms
ii) It is precipitated by physical exertion
iii) Relieved by rest or GTN spray in 5 minutes
Unstable Angina
Chest pain that occurs at rest, Partial occlusion
– due to rupture of plaque →incomplete occlusion of coronary artery
– ST-segment depression
Prinzmetal’s angina = ST elevation. Treated with CCB
Angina diagnosis
CT Coronary Angiography
- Myocardial perfusion imaging (if patient has renal impairment)
- ECG
- Physical examination
Angina Treatment
Lifestyle management….
- GTN Spray
Secondary:
- Aspirin
- Statin
- Beta Blocker (bisoprolol) - Give CCB for Asmatics
- Ca2+ channel blocker ( amlodipine)
- ACE-I (for diabetic & hypertensive Patients)
- Isosorbide Mononitrate (long acting nitrate)
Surgical Intervention : (Stable)
→ PCI with coronary angioplasty
→ Coronary Artery Bypass Graft (CABG)
Revascularisation (PCI)
Percutaneous Coronary Intervention (PCI) involves insertion of a stent into a coronary artery to improve blood flow.
Revascularisation (CABG)
Coronary artery bypass grafting aims to restore flow within a coronary vessel
Angina Risk factors (Modifiable & Non- Modifiable)
-> Modifiable risk factors: High cholesterol Hypertension Smoking Diabetes Obesity -> Non-modifiable risk factors: Age Family history Male sex Premature menopause
Myocardial Infarction
irreversible death of cardiac myocytes, which occurs due to ischaemia
MI Cause
– It is due to the rupture of a plaque which leads thrombosis and complete / Partial occlusion of the artery
MI risk factors
Non - Modifiable= Age, FH, Male
Modifiable = Smoking, Alcohol, Poor diet, low exercise
Co- morbidities = Diabetes, Hypertension, CHD
MI symptoms
– Acute crushing central chest pain that comes on rest – Pain radiates – Sweaty and clammy – Nausea, Vomiting and epigastric pain - Dyspnoea
MI Diagnosis
- ECG: ST elevation or New left bundle branch block = STEMI
- No ST elevation = Do Troponin blood tests
- Raised troponin levels & ST depression, T wave inversion = NSTEMI
- Normal troponin levels & ST depression = Unstable Angina
STEMI
caused by a complete and persistent blockage of the artery resulting in myocardial necrosis
NSTEMI
NSTEMI and unstable angina a partial or intermittent blockage of the artery occurs, which usually results in myocardial necrosis in NSTEMI but not in unstable angina.
STEMI management
M = Morphine
M = Metoclopramide
O = Oxygen
N = Nitrates (IV)
A = Aspirin (300mg)
C = Clopidogrel or Trigalor (contra-ind. for haemorr.)
→ PCI (offered within 2hrs of symptoms)
→ CABG
NSTEMI management
GRACE score
– High risk = coronary angiography (with 96 hrs)
- Low risk = Aspirin with Trigalor
Heart Failure
cardiac output which is inadequate to meet the body’s requirements.
Left ventricular failure features
Causes:
- Pulmonary congestion
- Systemic hypoperfusion (reduced left heart output)
Left ventricular failure Symptoms
– Dyspnoea - Paroxysmal nocturnal dyspnoea - Orthopnoea (breathlessness lying down) - Peripheral oedema – Gives a 3rd heart sound
Right Ventricular failure features
- can occur due to Left heart failure
Causes:
→ venous congestion
→ Pulmonary hypoperfusion (reduced right heart output)
Right Ventricular failure symptoms
– Raised JVP
- Pitting ankle & Pulmonary oedema (bi-basal) and ascites
- Abdo. distension & discomfort
– Hepatosplenomegaly with a smooth “nutmeg” liver which is pulsatile
Heart Failure Diagnosis
i) Blood tests:
raised natriuretic peptides secreted from cardiac ventricles
(BNP, NT-proBNP)
ii) Echocardiogram
iii) ECG : abnormal, signs of Ischaemia
iv) Chest X-ray: Alveolar oedema, Kerly B lines, Cardiomegaly, Pleural effusion
First line management for Heart Failure
- A = ACE-I (e.g. Ramipril) or ARB (e.g. Candesartan)
- B = Beta - blockers ( e.g.Bisoprolol)
- A = Aldosterone antagonist (e.g. Spironolactone) - manage oedema
- L = Loop diuretics (e.g. furosemide)
→ Cardiac Resynchronisation Therapy
treatments which can worsen heart failure
– Thiazide diuretic in diabetics
– Calcium channel blockers
– NSAIDs and COX2 inhibitors
– MRA with both ARB + ACEi –> too high risk of hyperkalaemia and renal dysfunction
Which arteries does atherogenesis affect most commonly?
LAD, circumflex, RCA
ECG leads
1 & aVL & V5 & V6 = Lateral
2 & 3 & aVF = Inferior
V3 & V4 = Anterior
V1 & V2 = Septal
What happens when BP falls in heart failure?
[sympathetic system activation] BP falls → detected by baroreceptors → sympathetic activation → positively inotropic/chronotropic → CO increases
Causes of Heart Failure
- Ischaemia
- Valvular Heart Disease
- Atrial Fib.
- Hypertension
Cor pulmonale + causes
cor pulmonale = Right -sided heart failure caused by resp. disease.
Increased pressure & resistance in pulmonary arteries → Right ventricle unable to Pump blood properly → back pressure of blood in RA, Vena Cava & systemic venous system
causes:
- COPD
- Pulmonary embolism
- CF
- Pulmonary hypertension
Hypertension
Stage 1: >140/90 mmHg
Stage 2: >160/100 mmHg
Malignant: >180/110
Essential Hyp. = no identifiable cause
Secondary Hyp. = has a identifiable cause
Hypertension causes
R- Renal Disease
0 = Obesity
P= Pregnancy
E= Endocrine e.g. Conn’s (hyperaldosteronism) - most common
Hypertension symptoms
Asymptomatic
Malignant = Cerebral oedema, Papilloedema, AHF, AKI
Hypertension Diagnosis
Primary = Recheck BP over few weeks
Give ABPM
QRISK ( give statin > 10% )
Hypertension Treatment
A = ACE - I (e.g. Ramipril) if <55yrs or T2 DM B = Beta -blocker (e.g. Bisoprolol) C = Calcium channel blocker (e.g. Amlodipine) if African or >55 yrs D = Diuretics (e.g. Indapamide) A = ARBs (e.g. Candesartan) if not ACE-I
K+ < 4.5 mmol/L = Spironolactone
Alpha- blocker = Doxazosin
Pericarditis
Inflammation of the pericardium with/ without effusion
Pericarditis Causes
Infectious: -> Viral (common) Coxsackievirus -> Bacterial Mycobacterium tuberculosis
Non-infectious:
- > Trauma
- > Uraemia, MI
Pericarditis Symptoms/ Signs
Retrosternal Chest pain (sharp & pleuritic)
Relieved by sitting forward/ worse when lying down
Worsened by inspiration
Fever/ shortness of breath → sign of infection
Pericardial friction rub
Pericarditis Diagnosis
ECG (diagnostic)
Saddle- shaped ST elevation
PR depression
Pericarditis Management
NSAIDs (ibuprofen) + Colchicine
Pericarditis Complications
Cardiac Tamponade
Cardiac Tamponade
Accumulation of fluid in the pericardial space → compression of the heart chambers → decrease in venous return → decrease in filling in the heart → reducing cardiac output
Cardiac Tamponade signs
-> Beck’s triad falling BP rising JVP muffled heart sound -> Pulsus paradoxus (large decrease in stroke volume
Cardiac Tamponade diagnosis
Echo
Cardiac Tamponade Treatment
pericardiocentesis (removal of the fluids from the pericardial space)
Infective Endocarditis
Infection of the inner lining of the heart/ valves (endocardium)
Infective Endocarditis Causes
Stahpylococcus aureus (most common → IVDU)
Streptococcus viridans (mouth/ oral sugery, most common→ non-IVDU)
Staphylococcus epidermis (prosthetic valves)
Streptococcus pyogenes (Rheumatic heart disease)
Infective Endocarditis Symptoms
Fever, New murmur
- nail bed haemorrhages
- Osler nodes
- Janeway lesions
- Roth spots
Infective Endocarditis Diagnosis
Transesophageal Echo
Blood cultures
Duke’s criteria (Major = +ve) (Minor = Signs/ Symptoms)
Infective Endocarditis Treatment
If staphylococcus
(Flucloxacillin + rifampicin + gentamicin)
*MRSA → vancomycin + rifampicin + gentamicin
Not staphylococcus
Benzylpenicillin + gentamicin
Not sure which organism (first line)
FAG (flucloxacillin + ampilicin + gentamicin)
Aortic stenosis Murmur
Ejection systolic murmur loudest over aortic region, radiating to carotids and apex
Aortic Regurg. Murmur
Early diastolic (best heard when leaning forward) at left Sternal edge.
Mitral Stenosis Murmur
Rumbling mid-diastolic with opening snap (best heard when lying on left side) at apex.
Mitral Regurg. Murmur
Panasystolic murmur loudest in mitral area, radiating to left axilla
Aortic Stenosis Symptoms/ Sign
- Syncope
- Angina
- Dyspnoea
- > Slow rising pulse
- > Soft S2
Mitral Stenosis Symptoms/ Sign
- Exertional dyspnoea
- Palpitations
- Chest pain
- Haemoptysis
- > Atrial fib.
- > Loud S1
Aortic Regurg. Symptoms/ Sign
- Palpitations
- Angina
- Dyspnoea
- > Displaced apex
- > De Musset’s, Quincke’s, Corrigan’s
Mitral Regurg. Symptoms/ Sign
- Palpitations
- Fatigue
- Weakness
- > Atrial fib.
- > Displaced Apex
- > Soft/ No S1
Cardiac Tamponade
fluid collects within the pericardial sac and which compresses the ventricles impeding cardiac output.
Cardiac Tamponade Causes
– Pericarditis
– Myocardial rupture
– Aortic dissection
– Malignancy
Cardiac Tamponade Diagnosis
– CXR shows enlarged, globular heart
– Echocardiogram
– ECG
Cardiac Tamponade Symptoms
– Classic Beck’s triad –> Hypotension, Raised JVP, Muffled heart sound
- Kussmaul’s Sign
Cardiac Tamponade Treatment
Pericardiocentesis
Deep Vein Thrombosis
formation of a clot which occurs usually in the femoral, popliteal or iliac veins in the leg
Deep Vein Thrombosis Causes
due to the stasis of blood which brings pro-coagulants in contact with each other
Deep Vein Thrombosis Symptoms
- Leg swelling
Pain, Pallor, Pulselessness, Paraesthesia
Deep Vein Thrombosis diagnosis
- D-dimer
- Doppler US (Gold)
- Wells score
Deep Vein Thrombosis treatment
– Anticoagulation with a DOAC (e.g. apixaban or rivaroxaban)
- Low molecular Weight Heparin is 1st Line in Pregnancy
Pulmonary Embolism
embolus which becomes lodged in the pulmonary circulation
Pulmonary Embolism Cause
deep vein thrombosis (DVT) in the femoral, iliac or popliteal veins.
Pulmonary Embolism Symptoms
– Pleuritic unilateral chest pain, shortness of breath and haemoptysis
– Tachycardia + Tachypnoea
– Pleural rub
Pulmonary Embolism Diagnosis
- Wells Score
- CT Pulmonary Angiogram - Gold
- D-dimer = High sensitivity, low specificity
– Pulse oximeter –> Low SpO2
– ABG
Pulmonary Embolism Treatment
thrombolysis - alteplase
LMWH (e.g. Dalteparin) & Warfarin
DOAC (Direct acting Oral AntiCoagulant)
e.g. Apixaban / Rivaroxaban
Atrial fibrillation
chaotic irregularly irregular atrial rhythm at over 400bpm. Asymptomatic
Atrial fibrillation Pathophysiology
- contraction of atria is uncoordinated, rapid & irregular
- Due to disorganised electrical activity that overrides the normal activity from SA node
Atrial fibrillation Cause
S = sepsis M = Mitral value I = Ischaemic HD T= (Hyper) Thyroidism H= Hypertension
Atrial fibrillation symptoms
Irregularly irregular ventricular contractions
Tachycardia - Palpitations
Heart failure - Dyspnoea
Syncope (Fainting)
Atrial fibrillation Diagnosis
ECG: same as in hyperkalaemia P waves absent – replaced by f waves. – Rhythm is irregularly irregular – Patient usually tachycardic – narrow QRS complexes
Atrial fibrillation Treatment
- Beta-blocker = (e.g. Bisoprolol/ Atenolol) -not for asthmatics.
- Calcium - channel blocker = (e.g. Verapamil or Amlodipine) - for asthmatics.
- Cardiac Glycoside = Digoxin
- Anti - arrhythmic = Amiodarone
- Factor Xa inhibitor anticoagulant = Apixaban/ Rivaroxaban
Atrial flutter
supraventricular tachycardia characterized by a fast atrial rate of around 200-400bpm.
Due to acute MI, mitral disease
Atrial flutter symptoms
asymptomatic or cause chest pain, palpitations, hypotension
Atrial flutter Diagnosis
ECG:
- NO P waves
– They give a “saw-toothed” appearance and are called flutter (F) waves.
– Normal QRS waves
C = Congestive heart failure H = Hypertension A2 = Age> 75 D = Diabetes S2 = Stroke / TIA v = Vascular disease A = Age - 65-74 S = Sex (female)
Atrial flutter Treatment
Short- term :
Beta-blocker or CCB
Then add Digoxin
Definitive - Catheter Ablation
1st degree heart block
impulses from the atria are consistently delayed by a certain amount at the AV node.
Exertional chest tightness relieved with rest.
1st degree heart block Cause
- MI
- Hyperkalaemia
- Drugs : Digoxin, Beta-blockers, CCB
1st degree heart block ECG
PR interval is prolonged, no missed beats.
PR > 200ms
2nd degree Mobitz 1 heart block + Cause
Due to reversible conduction block at the AV node.
Characterised by Progressive PR interval → P wave fails to conduct QRS
Cause :
→ MI
→ Drugs (Beta-Block., CCB, Digoxin)
2nd degree Mobitz 1 heart block ECG
– PR interval is more and more prolonged each beat, until you miss a beat completely, drop in QRS complex.
2nd degree Mobitz 2 heart block + Symptoms
impulses from the SAN are occluded at the AV node and fail to pass to the ventricles.
Dyspnea, fatigue, light-headedness, pain, hypotension
2nd degree Mobitz 2 heart block ECG
– Constant PR interval but many P waves are not followed by QRS
3rd degree heart block
impulses from SAN are completely blocked at AV node.
– Patient becomes very bradycardic and go into hypotension and cardiogenic shock
3rd degree heart block Cause
Inferior wall MI, congenital, aortic valve calcification + digoxin toxicity
3rd degree heart block Symptom
Dyspnea, fatigue, light-headedness, pain, hypotension
3rd degree heart block ECG
No relation between P waves and QRS waves
Abdominal Aortic Aneurysm
dilation of the abdominal aorta > 3cm.
Commonly between renal & inferior mesenteric arteries.
Abdominal Aortic Aneurysm Symptoms
central abdominal pain radiating to back
Abdominal Aortic Aneurysm Management
> 65 - Screening using abdo. ultrasound scan
if < 3cm = Discharge (offer yearly repeat)
if > 3cm = Repeat in 12 weeks & Refer
if > 5.5 cm = Open Surgery
or Endovascular Aneurysm Repair
Chronic MI management
- Aspirin
- Another Antiplatelet = Clopidogrel
- Atorvastatin
- ACE -I = Ramipril
- Beta blocker = Atenolol
- Aldosterone antagonist = Spironolactone
STEMI & NSTEMI ECG changes
STEMI= ST elevation , New Left Bundle Branch block
NSTEMI= ST depression, T wave inversion, Q waves
Arteries involved in MI, supply and ECG leads
LCA → circumflex & LAD = I, aVL, V3-6
RCA - Supplies the: RA, RV, Inferior aspect of LV, Posterior septal area = II,III, aVF
Circumflex - Supplies the: LA, Posterior aspect of LV = l, aVL, V5-6
LAD - Supplies the: Anterior aspect of LV, Anterior aspect of septum = V1-4
Coarctation of Aorta
Congenital condition where there’s narrowing of aortic arch usually around the ductus arteriosus.
This reduces pressure of blood to arteries that are distal to narrowing
Increases pressure in areas proximal to narrowing
Presentation of Coarctation of aorta
- Tachypnoea
- Grey and floppy baby
- Poor feeding
Management of Coarctation of dorita
Surgery to correct coarctation & to ligate ductus arteriosus
Tetralogy of Fallot pathologies
- ventricular septal defect
- Overriding aorta
- Pulmonary value stenosis
- Right ventricular hypertrophy
Tetrology of fallot Risk factors
- Rubella infection
- Increased age of mother
- Alcohol during pregnancy
- Diabetic mother
Tetralogy of Fallot Signs & Symptoms
- Cyanosis
- Clubbing
- Poor feeding & sweating
Tetrology of Fallot Treatment
- Supplementary oxygen
- Beta -blockers
- IV fluids
- Morphine
- Sodium bicarb
- Phenylephrine infusion
Neonates = Prostoglandin infusion - to maintain ductus arteriosus
Aortic Dissection
Tear forms in inner layer of aorta → allowing blood to Flow between intima & media layers of wall of aorta.
Stanford Type A = Ascending & arch of aorta
Stanford Type B = Descending of aorta
Aortic dissection Risk factors
- Hypertension
- Bicuspid aortic value
- Coarctation of aorta
- Aortic valve replacement
- CABG
Aortic dissection presentation
-hypertension
- Radial pulse delay
- Diastolic murmur
- Chest & abdo. pain
- Syncope
Aortic dissection Diagnosis
- CT angiogram
- Echo
- MRI angiogram
- ECG & Chest X-Ray
Aortic dissection Management
- Analgesia (e.g. Morphine)
- Beta - blockers IV (e.g. Atenolol & Bisoprolol)
- Surgical intervention (for Type A)
Aortic dissection complications
- MI
- Stroke
- Cardiac tamponade
Peripheral arterial disease - Intermittent
Claudication
Differential Diagnosis:
Symptoms
Investigation
Management
D.D = DVT (but DVT causes swelling not cramping)
Sym. = Cramping, goes away at rest, walking limited on stairs (inclined). Affects Popliteal Artery
Inves. = Ankle Brachial Pressure Index (ABPI) & Duplex Ultrasound scan
Man. = Stop smoking, Exercise, Stents, Bypass grafts
Supraventricular Tachycardia
Symptoms
ECG
Management
Symp. = Palpitations, SOB, Dizziness, Chest pain
ECG = Narrow. complex tachycardia of regular rhythm
Man.:
1= Valsalva Manoeuvre 2= Carotid sinus massage 3= Adenosine (gives feeling of impending doom) or CCB (Verapamil) 4= Direct current cardioversion
ACE-I adverse effects
- Inhibits angiotensin-II
- leads to vasodilation
- S. E= Dry cough
- Causes hyperkalaemia ( Tall- tented T waves )
Right Bundle Branch Block
ECG leads
Features
Cause
ECG L. = V1 - V6
Features = MaRRoW (M shape)
- Wide QRS
- rSR pattern in V1 & QRS in V6
Cause: Pulmonary Embolism
Left Bundle Branch Block
ECG leads
Features
ECG L. = V1-V6
Features = WiLLiaM (W shape)
- Wide QRS width
- notched top in V5
- RS in V1
Atrial septal Defect murmur
Soft mid-systolic with wide fixed splitting of S2.
Coagulation Cascade Meds
Warfarin = Inhibits Synthesis of factor 9, 8, 2, 10 - by blocking vit. K.
Heparin = Inhibits thrombin lla & 10a
Rivaroxaban = Inhibits 10a
Hypertrophic Cardiomyopathy
⇒ Genetic disorder where left ventricular hypertrophy causes diastolic ventricular dysfunction.
Due to thick Septum below aortic valve.
Types of Shock
- Hypovolaemic (blood loss)
- Septic
- Anaphylactic
- Cardiogenic (Poor cardiac output)
- Neurogenic
- Obstructive
Septic Shock Management
- Bloods
- Oxygen <94%
- IV Antibiotics
- Blood cultures
- Crystalloid
- Catheterisation
Hypovolaemic Shock in trauma management
- IV Crystalloid
2. Blood transfusion
6 p’s of limb ischaemia
P: Pulselessness p: Pain p: Pale P: Paralysis P: Paraesthesia P: Perishingly cold
