Cardiology Flashcards
1
Q
Define atherosclerosis
A
A build up of fatty deposits leading to plaque formation in blood vessel walls causing the hardening and stiffening of the walls
2
Q
What do the letters in ECGs stand for
A
P : atrial depolarisation
Pr interval : AVN conduction delay
QRS : septal depolarisation + apex depolarisation + outer depolarisation = whole ventricular depolarisation
St segment : isovolaemic ventricular relaxation
T : ventricular repolarisation
3
Q
ECG paper / box sizes
A
Width :
0.2s = big square
0.04s per small box (5 small squares = 1 big square)
Height :
0.5mV = big square
0.1mV per small square
4
Q
What chest leads give you an inferior view of the heart
A
AvF, lead II, lead III
5
Q
Which artery supplies inferior portion of heart
A
RCA
6
Q
What chest leads show anterior view of heart
A
V1 - V4
7
Q
What leads show lateral view of the heart
A
V5-V6, lead 1, aVL
8
Q
What do the 4 heart sounds show
A
S1 : mitral + tricuspid close
S2 : aortic + pulmonary close
S3 : heard straight after S2
rapid ventricular filling in early diastole
normal in pregnant
pathological in mitral regurgitation
AKA pathological “gallop”
S4 :heard straight before S4
due to blood forced into stiff hypertrophic ventricles
seen in LVH / aortic stenosis
Erbs point is where heart sounds best heard
9
Q
Categories of ischamic heart disease
A
Angina
Myocardial infarction
10
Q
What sign is seen as a result of myocardial ischaemia
A
“Angina” (Levine’s sign - fist over chest) central crushing chest pain due to decreased coronary artery blood flow ‘ increased O2 demand
11
Q
3 characteristics / signs of stable angina pain
A
Central crushing chest pain radiating to the neck and jaw
Brought on by exertion
Relived by 5 mins of rest / GTN spray
12
Q
Types of angina
A
Stable
Unstable
Prinzmetal
Dont need to know about angina pectoris - but Decubitus is a variant of this angina and it is induced by lying down
13
Q
Define each type of angina
A
Stable: normal 3 part definition - i.e. about pain & / on exertion, relieved with rest / GTN spray
Unstable: Pain at rest, not relieved by rest or GTN spray
Prinzmetal: Due to coronary Vasospasm (not to do with atherogenesis —> ischaemia)
14
Q
What can coronary vasospasm cause
A
Prinzmetal angina
15
Q
What is seen in Px with Prinzmetal angina (ECG)
A
ECG : ST elevation
Seen in cocaine users
16
Q
What is and when is QRISK score used
A
Predicts risk of CVD in the next 10 years
Score >10% indicates 10prevention - give statins
17
Q
What should you do with QRISK score of >10%
A
Give statin - atorvastatin
primary prevention
18
Q
What’s GRACE score and when is it used
A
Predictor of mortality from MI with the next 6months-3years
Used in ACS cases to help guide Tx
19
Q
What is ACS
A
Umbrella term for :
Unstable angina - severe ischaemia
NSTEMI - partial infarction
STEMI - transmural infarction
20
Q
Risk factors for IHD
A
Obesity
Smoking
Diabetes mellitus T2
Hypertension
Older age
Male
FHx
21
Q
Pathophysiology for IHD
A
ATHEROGENESIS - endothelial injury induces cells to signal chemokines (IL-1,IL-6, IFN-¥) to produce…………..
Fatty streaks — intermediate lesions — fibrous plaques
22
Q
Precursor of a plaque
A
Fatty streaks
23
Q
What is the constituents of a fatty streak
A
T cells
+
Foam cells (lipid laden macrophages)
Fatty streaks can begin to form in less than 10y/o
24
Q
Where can fatty streaks be found
A
In intima wall of vessel
25
What are intermediate lesions and its constituents
Essentially bigger fatty streaks as more lipids are taken up..
You see:
**T cells +
Foam cells
Smooth muscle cells**
*platelets also aggregate at & adhere to site of lesions, inside vessel lumen*
26
What are fibrous plaques and their constituents
Large lesions with the development of a fibrous cap over the lesion - *lipid increased with a necrotic core*
You see:
T cells +
Foam cells +
Smooth muscle cells +
Fibroblasts
27
Nature of the plaque in stable angina
Fibrous cap is strong & less prone to rupture
If plaque prone to rupture —> prothrombotic state; platelet adhesion + accumulation; **progressive lumen narrowing**
28
Percentage of lumen narrowing in stable angina
>70% is when symptoms start to develop
29
Signs and symptoms of stable angina
**Central crushing chest pain radiating to the neck & jaw**
Dyspnoae
Fatigue
Sweating
30
Investigation & diagnosis of stable angina
1st line:
ECG : Resting - normal
Exercise induced (Ischaemic) - change
Gold standard:
CT angiography - stenoses atherosclerotic arteries (>70% occlusion)
31
1st line investigation for stable angina
1st line:
ECG : Resting - normal
Exercise induced (Ischaemic) - change
32
Gold standard investigation for stable angina
Gold standard:
CT angiography - stenoses atherosclerotic arteries (>70% occlusion)
33
Treatment for stable angina
Remember RAMP for stable angina management
**R**efer to cardiologist; **A**dvise on lifestyle modification, **M**edical Tx, **P**rocedural intervention
_Medical Tx:_
**Immediate symptomatic relief** -
GTN sublingual spray
**Long term symptomatic relief** -
All patients:
CCB (CI : heart failure) / BB (CI : asthma)
CCB + BB
CCB + BB + another anti-anginal (ivabradine / longacting nitrates)
**Secondary prevention** -
Aspirin
Atorvastatin
ACEi
34
What procedural interventions are there for stable angina
*given if pharmacological intervention unsuccessful*
_Revascularisation_
**PCI** - balloon stent via femoral artery to coronary artery
**CABG** - bypass graft (LAD bypassed using great saphenous vein)
35
Give a positive and negative for PCI
+ve : Less invasive
-ve : High risk of restenosis
36
What is restenosis
a gradual re-narrowing of the stented segment that occurs requiring further procedural treatment
37
What type of CCB is used in stable angina
Non-rate limiting one - Amlodipine
If others are used(verapamil / diltiazem), causes excessive bradycardia
*Dihydropyridine CCBs have predominantly peripheral vasodilatory actions, whereas nondihydropyridine CCBs have significant sinoatrial (SA) and AV node depressant effects and possible myocardial depressant effects with lesser amounts of peripheral vasodilation.*
38
Give a positive and negative of CABG procedure
+ve: Good prognosis
-ve: more invasive + longer recovery time
39
Clinical classification of unstable angina
Cardiac chest pain at rest
Cardiac chest pain with crescendo pattern
New onset angina
40
Occlusion for unstable angina
partial occlusion of minor coronary artery (>90%)
41
Type of infarction in unstable angina
None - ischaemia only
42
ECG finding in unstable angina
Normal
May show some ST depression / T wave inversion
43
Troponin levels in unstable angina
Normal
44
Level of occlusion for NSTEMI
Major partial occlusion (>90%) / total occlusion of minor coronary artery
45
Type of infarction in an NSTEMI
Subendothelial infarct
I.e. area furthest away from the occlusion dies
46
ECG finding for NSTEMI
ST depression
T wave inversion
**no Q waves! - seen in STEMI, only after some time**
47
Troponin levels for NSTEMI
Raised
Due to infarct obviously
48
Level of occlusion in STEMI
Complete occlusion of major coronary artery
49
Type of infarction in STEMI
Transmural infarction
50
ECG finding of STEMI
ST segment elevation
Pathological Q waves - develop after some time
51
Troponin levels seen in STEMI
Raised
52
Signs and symptoms of ACS
Same as stable (more severe) - dyspnoea, chest pain radiating to neck and jaw, sweating + nausea
+
Pain at rest, prolonged with no relief
often described as - *’impeding doom’* +
Palpitations
53
What is a silent MI
**Diabetic patients** may not experience typical chest pain during an acute coronary syndrome
Due to diabetic neuropathy; don’t feel the anginal pain so could miss the diagnosis and Px could die with sudden collapse
54
Investigations & diagnosis of ACS
ECG
Bio markers
CT coronary angiogram
55
Treatment for ACS
_**Acute - remember MONAC**_
- **M**orphine
- **O**xygen (if SATs <94%; COPD: 88-92%)
- **N**itrates (GTN spray)
- **A**spirin
- **C**lopidogrel
Then…
For unstable / NSTEMI = GRACE score
- low risk : monitored
- high risk : coronary angiogram - may need PCI
For STEMI
- PCI **if within 12hr Sx onset / <2hr of first medical contact**
- Thrombolysis using _alteplase / streptokinase_ **if >12hrs of Sx onset**, then consider PCI
_**Long-term prevention**_
**A**spirin
**A**atorvastatin (life)
**A**CEi (life)
**B**eta blocker (life)
56
Role of alteplase
Thombolytic agent - activates plasmin to break down fibrin
57
In what conditions is troponin elevated in…
MI
But also…
Myocarditis
PE
Aortic dissection
Sepsis
Chronic renal failure
58
Complications of ACS
**Acutely (<2 weeks)**
H.F - due to ventricular fib
Mitral incompetence
LV wall rupture
Cardiogenic shock
**>2 weeks**
_Dressler’s syndrome_ (autoimmune pericarditis)
H.F
LV aneurysm (heart becomes saggy)
59
Define heart failure
Inability for the heart to pump sufficient Oxygen in order to meet the demand of the tissue metabolism
**A syndrome** not a diagnosis
60
Causes of heart failure
**IHD** - most common
Hypertension
Valvular heart disease (aortic stenosis)
Arrythmias (AF)
61
Risk factors for heart failure
Age (>65y/o)
Smoking
Obesity
**Previous MI**
Male > female
62
Pathophysiology of heart failure
**Normally…**
Increased preload = increased afterload (frank starlings law)
But, in **failing heart…**
Decreased cardiac output due to dysfunctional frank starling law so
1) Compensatory mechanism activation: RAAS + SNS (to temporarily increase BP) - increased aldosterone — increased ADH ; increased Ad/NAd
2) compensation then fails as heart undergoes **cardiac remodelling**. (Decreasing C.Output)
• Heart becomes less adapted to function so increased RAAS +SNS causes fluid overload
• In response to the increased work of the heart, both left and right circuits are affected - **Congestive heart failure**
63
Classification of heart failure
Time classified: acute / chronic
Ejection fraction (normal EF = 50-70%)
64
> 40% ejection fraction suggests what
_Preserved ejection fraction_
(Heart pump function is preserved)
**Diastolic failure**
- Filling issues due to **stiffness**
E.g. hypertrophic cardiomyopathy, Ventricular hypertrophy
65
What can cause diastolic heart failure
hypertrophic cardiomyopathy, ventricular hypertrophy
66
What does < 40% ejection fraction suggest
_Reduced ejection fraction_
Heart pumping has failed
**Systolic heart failure**
- reduced C.Output due to **inability** to pump
E.g. IHD
67
Give a cause for Systolic heart failure
**IHD**
68
Left sided heart failure causes what
Results in **pulmonary vessel backlog**
- therefore, **pulmonary oedema**
69
What does right sided heart failure cause
Causes backlog in systemic venous system
- leading to **peripheral oedema**
70
Cardinal signs of heart failure
**Dyspnoea
Fatigue
Ankle oedema**
71
Signs / symptoms of heart failure
Oedema
3, 4 heart sound
**Increased JVP** (backlog in jugular veins) - i.e. RHF
Orthopnoea (worse when lying flat) / paroxysmal nocturnal dyspnoea
Bibasal crackles** (pul. Oedema) - i.e. LHF
Hypotensive + tachycardic
72
What classification describes severity of heart failure
NY heart association class 1-4 of HF severity:
1) **No limit** on physical activity
2) **Slight limit** on moderate activity
3) **Marked** on moderate / gentle activity
4) **symptoms even at rest**
73
Key marker found in Heart failure
BNP
**B type- natriuretic peptide**
(> 400µg/mL)
*Inactive BNP = NT-proBNP
it is x5 higher than BNP so (> 2000µg/mL) is high level indicating HF*
74
Investigation / diagnosis of heart failure
**Bloods** - Raised BNP
ECG - Abnormal: may show signs of LVH
**Chest X-ray** - **_ABCDE_**
•**A**lveolar ‘batwing’ oedema
• kerley **B**-lines
•**C**ardiomegaly
•**D**ilated upper lobes
• pleural **E**ffusion
Echocardiogram - shows dimension of heart chambers
75
Types of treatment available for heart failure
Conservative
Pharmacological
Surgical
76
Type of conservative treatment for HF
Lifestyle ∆’s
(Reduce BMI, exercise, diet, smoking + alcohol cessation)
77
Pharmacological treatment for HF
**_L.A.B.A_** - first line medical Tx
**A**CEi - ramipril
**ß** Blocker - atenolol
+
**A**ldosterone antagonist - Spironolactone
**L**oop diuretic - Furosemide
*Consider cardiac resynchronisation therapy (to improve AV conduction)*
78
Surgical treatment for heart failure
Consider revascularisation, valve surgery
Heart transplant = last resort
79
Role of BNP
Released by ventricular myocardium - opposes affect of RAAS
BNP act on blood vessels, causing them to dilate, or widen.
They also work on the kidneys, causing them to excrete more salt and water.
Reduce the production of adrenaline, angiotensin, and aldosterone.
BNP is therefore secreted when there’s increased pressure on heart - **elevated in heart failure**
80
Define Cor pulmonale
Right sided heart failure **caused by** respiratory disease.
81
Cause of Cor pulmonale
Remember it is RHF due to **a resp disease**
• COPD - most common cause
• PE
• Interstitial lung disease
• CF
82
Pathophysiology of cor pulmonale
**Increased pressure and resistance** in the pulmonary arteries (pulmonary hypertension) results in the right ventricle being unable to effectively pump blood out of the ventricle and into the pulmonary arteries.
This leads to **back pressure** of blood in the **right atrium**, the vena cava and the **systemic venous system**.
83
Signs / symptoms of cor pulmonale
Raised JVP
Cynosis
**peripheral oedema**
3rd Heart sound
Murmurs : **Tricuspid** regurg - **Pan systolic**
84
Define abdominal aortic aneurysm
Permanent aortic dilation exceeding 50% where diameter > 3cm
> 5.5cm is urgent (significant rupture risk)
Rupture - surgical emergency!
85
Risk factor for aortic aneurysm
Idiopathic
Connective tissue disorder — **Marfan syndrome**, Ehler danlos synderom
**Smoking**(biggest RF), obesity, HTN (those RF for atherosclerosis)
86
Pathophysiology for aortic aneurysm
Smooth muscle, elasticity and structural degeneration in **all 3 layers** of vascular tunic (intima, media, adventitia) with leukocyte infiltration
If not all 3 layers affected - **pseudoaneurysm**
*Note*: Most aortic aneurysm = Abdominal (infrarenal), but
Can occur as thoracic
• Main cause = Marfan syndrome / Ehler’s Danlos / Atherogenesis
• Monitor with CT / MRI
• Any Sx: surgery immediately
87
Signs / symptoms of AAA
Asymptomatic till increased rupture risk / ruptured
**Sudden epigastric pain** radiating to flank
Pulsatile mass in abdomen
Hypotensive + tachycardic
88
Differential diagnosis for AAAneurysm
**Acute pancreatitis**
• Non-pulsatile + more associate with Grey turner (flank discolouration) / Cullen Sx (superficial oedema/bruising)
89
Investigation & diagnosis of AAA
1st line + diagnostic
**ABDO USS**
90
Tx for AAA
Conservative management - ∆ modifiable risk factors
aSx and <5.5cm : monitor
Sx, >5.5cm &/ rapidly expanding : **Surgery**
• Endovascular repair - stent inserted through femoral artery (less invasive)
• Open surgery (more invasive)
91
Complication of abdominal aortic aneurysm
**Rupture**
Stabilise: ABCDE, fluids + transfusions
Then, consider surgery
• AAA graft surgery; replacing weakened walls with graft
• 100% mortality if not treated immediately
92
Define aortic dissection
Tear in the intima of the aorta resulting in blood dissecting through the media of the aorta, separating the layers apart - due to mechanical wall stress; **surgical emergency**
93
Who is aortic dissection most commonly seen in
50-70y/o **men**
94
Risk factors for aortic dissection
HTN (most common)
Connective tissue disorder - Marfan syndrome, EDS
FHx
AAA
Trauma
Smoking
95
Common locations of aortic dissection
1) **Sinotubular junction** - where the aortic root becomes tubular; near aortic valve. (*Ascending aorta*)
• Aortic dissection A
2) **Distal to left subclavian artery** - thoracic descending aorta. (*Descending aorta*)
• Aortic dissection B
96
Types of aortic dissection + the classification
**_Stanford’s classification_**
Type A : **Ascending aorta**
*Sinotubular junction* - 2/3 (more common)
Type B : **Descending aorta**
*Distal to left subclavian artery* - 1/3
**_Debakey system_**
Type I : ascending + descending aorta
Type II : ascending aorta
Type III : descending aorta
97
Pathophysiology of aortic dissection
Blood dissects media + intima, where it pools in a **false lumen** which can propagate forwards (anterograde) and backwards (retrograde; towards aortic root)
**Decreased perfusion** to end organ —> organ failure + shock
98
Signs and symptoms of aortic dissection
**Sudden onset ripping/tearing chest pain**
Anterior pain - ascending
Posterior pain - descending
Hypotension/shock
Syncope
Diastolic murmur
Radial pulse deficit
99
Differential diagnosis of aortic dissection
**MI**
Central crushing chest pain with gradual worsening intensity
100
Investigation & diagnosis of aortic dissection
**CXR** shows widened mediastinum (> 8cm = suspicious)
**_Gold standard_** -
TOE (Transoesophageal echocardiogram) : shows intima flap / false lumen - more invasive than TTE but is more specific to aortic dissection + v.sensitive;
then classify AD as A / B
**OR**
CT angiogram : shows intima flap / false lumen / leak or rupture (also v. Specific & sensitive) - used more when Px is haemodynamically stable
101
Treatment for aortic dissection
**Surgery** - open surgery (type A) / endovascular aortic repair (type B)
— if they’re hypotensive: consider IV fluid, blood transfusion, adrenaline
**Medical (prevention)** -
1) *Special beta blocker* : **esmolol / labetolol**
— ß-Blocker and partial ∂-blockers prevent reflex tachycardia + decrease BP
• Aim: systolic BP (100-120) + HR: ≈ 60
2) Vasodilator : Sodium Nitroprusside
102
Give 3 complications of aortic dissection
(Haemorrhagic) Cardiac tamponade
Ischaemic stroke
Pre-renal AKI
103
Types of beta blockers used in aortic dissection
Esmolol / labetolol
104
Define hypertension
Abnormally high BP
≥ 140/90 mmHg (clinical)
≥ 135/85 mmHg (ambulatory / home readings)
105
Types of hypertension
Primary (Essential) - idiopathic HTN (95% of cases)
Secondary - known underlying cause
106
Causes of hypertension
Primary = idiopathic
Secondary = **Remember ROPE**
**R**enal disease
**O**besity
**P**regancy / eclampsia
**E**ndocrine disorder:
- Conn’s (most common cause of HTN)
- Phaemochromocytoma
- Cushing’s
107
Risk factors for hypertension
Older age
Obesity
Black ethnicity
Smoking
Diabetes
Increased salt intake
FHx
108
Describe the different stages of HTN
1) 140/90 … 135/85
2) 160/100 … 150/95
3) 180/120 - **start immediate Tx**
109
Pathophysiology of HTN
Ultimately all mechanisms stimulate RAAS + SNS (increasing cardiac output) + TPR … Increasing BP
110
Signs / symptoms of HTN
**Mostly aSx**
May have _pulsatile headaches_
**Malignant hypertension** :
180/120 (usually marked more by diastolic BP ≥ 120)
Px : typically seen in 30-40y/o black males
**M.HTN causes:**
Heart failure
Blurred vision
Haematoma
Headache
Consider signs of 2º cause
111
Investigation & diagnosis of hypertension
BP reading in hospital (≥140/90)
— Then ABPM for 24hr to confirm diagnosis (≥135/85)
Assess end organ damage
— Fundoscopy (papilloedema)
— eGFR (renal function + risk of diabetes)
— Echo/ECG (heart function; check for LVH)
112
Treatment for hypertension
——— **< 55y/o / T2DM ——— ≥ 55y/o / black African**———
1 —————ACEi————or———— CCB—————
2 —————————ACEi + CCB—————————
3 ———— ACEi + CCB + Thiazide diuretic —————
4 —— ACEi + CCB + Thiazide ± diuretic + K+ sparring——
113
What do you give if ACEi is contraindicated
ARB - Candesartan
114
4th line for HTN has you add which drug and what drug is given if contraindicated
In 4th line, the 4th drug given is **K+ sparring diuretic**
But **if K+ > 4.5, give ∂/ß blocker**
115
If Px is Black & has T2DM, what is 1st line treatment
ACEi
Because T2DM takes precedence over being black
116
A 60y/o black man has hypertension and T2DM, what is the first line treatment
ACEi
Having T2DM takes precedence
117
Complications for hypertension
Heart failure
CKD
IHD
Cerebrovascular accident risk increases
118
Define DVT and a PE
**DVT**
- Thrombus formation in deep leg vein
*When in calf, less concerning - more common*
*When in thigh, life threatening - less common*
**PE**
- When DVT emobolise and lodges in pulmonary artery circulation
119
Risk factors for DVT ± a PE
Remember **Virchow’s Triad**:
• _Hypercoagulability_
Pregnant
**Antiphospholipid syndrome**
DIC
• _Venous stasis_
Immobility
Long haul flights
Surgery
• _Endothelial injury_
Trauma / Surgery
Smoking
HTN
120
What can a PE cause / lead to
**Cor pulmonale**
(Right sided heart failure due to a resp condition);
*Increased PVR —> increased right ventricle strain to overcome it —> RVH —>R.Ventricle fails, 2º to Pulmonary artery pressure*
121
Give 3 conditions that present with pleuritic chest pain
PE
Pneumothorax
Pneumonia
122
Differential diagnosis between: PE, Pneumothorax, Pneumonia
Do CxR:
PE - normal
Pneumonia + pneumothorax - diagnostic
123
Signs / symptoms of DVT
**Unilateral, swollen, warm + oedematous calf** with dilated superficial veins.
124
What is phlegmasia cerulea dolens
Complete occlusion of a large being —> severe DVT
Severe ischaemia —> presents a s cyanosis (blue, not red like DVT)
125
Which scoring system is used in DVT / PE
Wells score
126
Diagnosis + investigation of DVT
Wells score ≥ 2 is likely of DVT
If **D-dimer** - elevated (**1st line**) —>
Do **Duplex USS** (**Gold standard - diagnostic**)
If D-dimer not elevated - not a DVT/PE
127
Is D-dimer specific or sensitive
Sensitive (95%)
Not specific
*Measures **clot burden** - a small protein released into the blood when a clot is fibrinolysed*
- Will always (95% of the time) be seen in DVT/PE - sensitive
but can also be raised in other conditions - not specific
128
Conditions D-dimer can be elevated in
**DVT / PE**
Heart failure
Pneumonia
Pregnancy
Malignancy
129
Treatment for DVT
**DOAC**
- Rivaroxaban / Apixaban
**LMWH** - if DOAC is contraindicated (e.g in renal impairment )
+ mobilisation, compression stockings (unless contraindicated - Peripheral Arterial Disease)
130
Differential diagnosis for DVT
_Cellulitis_
• Skin infection
*Typically **Staph. Aureus** / Strep. Pyogenes*
• Tender, inflamed, swollen calf with pronounced demarcation (Bullae: fluid-filled blisters + golden-yellow crust - indicate a staphylococcus aureus)
*Typically show **leukocytosis** - sign of infection on FBC*
**BUT**
*Not seen in DVT : D-dimer and D.USS used for DVT diagnosis*
131
Complication of DVT
PE
132
Signs and symptoms of PE
**Sudden onset pleuritic chest pain**
Dyspnoea ± haemoptysis (streaky blood)
Tachycardic + tachypnoea (respiratory alkalosis), hypotensive, increased JVP
+ *evidence of DVT : swollen, red, oedematous & tender leg*
133
Prophylaxis for VTE: DVT/PE
LMWH - Enoxaparin
Warfarin
DOAC
134
Diagnosis + investigation of PE
Wells score ≥ 4 : PE likely
If likely —> CT Pulmonary Angiogram *(CTPA - Gold standard)* = **Diagnostic**
*This is because CTPA is **specific** for Pulmonary Embolism*
If unlikely (Wells score < 4) —> D-dimer *(1st line)*
- if raised, do CTPA
- if not raised, not PE
135
Treatment for pulmonary embolism
If massive PE (hypotensive:< 90 systolic BP):
**Thrombolytics - Alteplase**
If non-massive PE:
**1st line - DOAC (Rivaroxaban / Apixaban)**
• if contraindicated (renal impairment) - give LMWH
136
Define pericarditis
Inflammation of the pericardium ± effusion; typically acute, can be chronic
137
Cause / aetiology of pericarditis
**Idiopathic**
**Viral** - Coxsackie virus (most common cause)
**Bacterial** - TB
**Autoimmune** - SLE, Rheumatoid.A (common)
**Dressler’s syndrome** (>2 weeks post MI)
138
Pathophysiology of pericarditis
• Inflamed pericardial layer rub against each other - because of narrowed pericardial space due to the inflammation
• Further exacerbating inflammation
Can either present as:
• **Dry** - no extra fluid; not as bad because friction doesn’t need to be overcome
• **Effusive** - extra fluid needed to compensate for friction
139
Signs and symptoms of pericarditis
**sharp severe pleuritic chest pain** with referral to left shoulder tip (at trapezius ridge)
**Relieved sitting forward**
**Worse laying flat or on inspiration**
**Pericardial friction rub on auscultation** - heard when patient leans forward *squeaky leather to and fro* sound
May show signs of right sided HF (constrictive pericarditis) —> SoB, peripheral oedema, tachycardia (chronic inflammation of pericardium)
140
What is constrictive pericarditis
Late complication of acute pericarditis + there’s a sign of poor heart prognosis.
Granulation tissue formation in pericardium —> impaired diastolic filling.
141
Investigation and diagnosis of pericarditis
**ECG (diagnostic):**
- Widespread saddle shaped ST elevation
- PR depression
CXR:
- “Water-bottle” heart (cardiomegalic)
- Pneumonia commonly seen (bacterial pericarditis - TB)
Increased ESR
- Seen in autoimmune pericarditis
Increased WCC
- in infective pericarditis
142
Treatment of pericarditis
Idiopathic + viral:
NSAID’s (aspirin)
+
Colchicine (anti inflammatory - used in gout too)
+ antibiotic if bacterial (R.I.P.E Abx for TB)
143
Complication of pericarditis
Pericardial effusion
Cardiac tamponade
Myocarditis
Constrictive pericarditis
144
Define pericardial effusion
Pericardial effusion
When the potential space of the **pericardial cavity fills with fluid**. This creates an **inward pressure** on the heart, making it more difficult to expand during **diastole** (filling of the heart).
Cardiac tamponade
Where the **pericardial effusion is large enough** to raise the intra-pericardial pressure. This increased pressure squeezes the heart and affects its ability to function. It leads to reduced filling of the heart during diastole, resulting in decreased cardiac output during systole
145
Types of effusion and their causes
_Transudative effusion:_
*Due to increased hydrostatic pressure*
**Less protein
Transparent fluid**
••• Congestive heart failure
••• Pulmonary hypertension
_Exudative effusion:_
*Occur in any inflammatory process; via infection / malignancy*
**More protein
Cloudy fluid**
••• Infection; pneumonia / pancreatitis
••• PE
••• Medication - methotrexate
146
Signs and symptoms of pericardial effusion & cardiac tamponade
Sx related to pericarditis (chest pain)
**Phrenic nerve** compression can cause _hiccups_
**Oesophageal compression** may cause _dysphagia_ (difficulty swallowing)
**Recurrent laryngeal nerve** compression may cause a _hoarse voice_
For cardiac tamponade:
**Beck’s triad** - hypotension, increased JVP, muffled s1-s2 sound
**Pulses paradoxicus** - fall in systolic BP of 10+ mmHg on inspiration (good indicator of cardiac tamponade) —> kussmaul’s sign
147
Investigation and diagnosis of pericardial effusion + cardiac tamponade
ECG : may show electrical
CxR : big globular heart
**Echo : diagnostic**
148
Treatment of pericardial effusion + cardiac tamponade
Pericardial effusion - Tx underlying cause (NSAIDs + Colchicine —> pericarditis)
Cardiac tamponade - urgent pericardiocentesis
149
Define Peripheral vascular disease
Essentially IHD of lower limb arteries.
Males
150
Risk factor for Peripheral vascular disease
Smoking
HTN
Ageing
Obesity
CKD
T2DM
151
Pathophysiology for peripheral vascular disease
**Intermittent claudication (least severe)** —>
Atherosclerotic, **partial lumen occlusion**, pain on exertion as blood flow < demand
**Critical limb ischaemia (more severe)** —>
Occlusion is V. Big; blood supply barely adequate to meet metabolic demand
Pain at rest + increased risk of gangrene / infection
Limb ischaemia can be acute / chronic!!
152
Define peripheral arterial disease
Peripheral arterial disease (PAD) refers to the **narrowing of the arteries** supplying the limbs and periphery, reducing the blood supply to these areas
153
Define intermittent claudication
Intermittent claudication is a **symptom of ischaemia** in a limb, occurring during exertion and relieved by rest. It is typically a **crampy, achy pain in the calf, thigh or buttock**
Reduced blood to muscle —> reduced O2 —> ischaemia —> this causes cells to release adenosine (signalling molecule for nerve cells) —> feel the signal as pain —> pain = claudication
154
Define critical limb ischaemia
Critical limb ischaemia is the **end-stage of peripheral arterial disease**
Pain at rest; non-healing ulcers + gangrene
155
Difference between PVD & PAD
Pretty much the same thing
156
Risk factors for PVD
Same as atherosclerosis:
Smoking
HTN
Ageing
Obesity
CKD
T2DM
157
Define acute limb ischaemia
**rapid onset of ischaemia in a limb**.
*Typically, this is due to a thrombus (clot) blocking the arterial supply of a distal limb, similar to a thrombus blocking a coronary artery in myocardial infarction.*
158
Define gangrene
the death of the tissue, *specifically due to an inadequate blood supply.*
159
Features of limb ischaemia
**Remember 6P’s** - found in both acute and critical (chronic is more limb threatening)
Pain
Pallor
Perishingly cold
Paralysis
Paraesthesia
Pulselessness
In critical limb ischaemia - causes _burning pain_. It is worse at night when the leg is raised
160
Mention 3 things that can occur if blood vessels to a region is occluded in PVD
1) Irreversible nerve damage (within 6hrs)
2) Irreversible muscle damage (6-12hrs)
3) Skin ∆’s are last to appear **therefore likely to be gangrenous**
161
Investigations and diagnosis of PVD
_Ankle brachial pressure index **(ABPI)**_ = 1st line
[•] < 0.9 indicates PVD
[•] 0.9 - 1.3 = Normal;
[•] 0.5 - 0.9 = intermittent claudication;
[•] < 0.5 = critical limb ischaemia;
[•] When absent / v. Low = high risk of Acute limb ischaemia
*Ratio / comparison of systolic BP of lower limb * upper limb*
_Duplex ultrasound scan_
[•] Assesses degree of stenosis
_CT Angiography_ = Gold standard
[•] Highlights arterial circulation
_Buerger’s test_
[•] +ve
[] Elevate leg 45˚ for a minute; Pallor.lower the leg; reactive hyperaemia (blue initially, then red)
162
What classification used in PAD/ PVD
Fontaine’s classification (stages 1-4):
Classification of the pain experienced after a particular distance.
1) Asymptomatic
2) Intermittent claudication:
• 2a - > 200m pain free walking
• 2b - < 200 m
3) Critical limb ischaemia (pain at rest)
4) Ischaemic ulcers —> gangrene formation
163
Treatment for PVD
**Intermittent claudication**
- RF management
**Critical limb ischaemia**
- Revascularisation surgery (PCI if small; CABG if big occlusion)
**Acute limb threatening ischaemia**
- Surgical emergency (do within 4-6hrs) —> risk of amputation
164
Complications of PVD
Amputation
Permanent limb weakness
Rhabdomyolysis (increased ca2+ and k+ release in blood - Arrhythmias / AKI)
Risk of Cerebrovascular accident + CKD
165
Define virulence
Ability of microbe to cause damage to host
166
Define infective endocarditis
Inflammation of the endocardium
- causative bacteria; colonise abnormally in the endothelium (leading to vegetation)
167
Cause of infective endocarditis
**Staph. Aureus** - most common; **IVDU** / T2DM / Surgery
**Strep. Viridans** - **Poor dental hygiene**; Gram +ve haemolytic Optochin resistant strep.
**Staph epidermidis** - **Prosthetic valve / infected IV catheters**
168
Types of infective endocarditis
Acute
S. Aureus; high virulence. Sx onset days-weeks
Subacute
S. Viridans; lower virulence. Sx onset weeks-months
169
Risk factors for infective endocarditis
**Male**, elderly; with **prosthetic valves**
Young **IVDU**
Young with congenital heart defect
**Rheumatic heart disease**
170
Pathophysiology of infective endocarditis
Abnormal / damaged endocardium have increased platelet deposition; bacteria adheres to this & causes vegetation.
- Around valves - *typically mitral valve (highest turbulence; more damage), but in IVDU more so tricuspid valve is affected*\
- causes regurgitation (+ left side more affected so get aortic & mitral insufficiency; increased risk of HF)
171
Signs and symptoms of infective endocarditis
**FEVER + NEW MURMUR = I.ENDOCARDITIS**
Symptoms: vague; fever, fatigue, SoB
Signs:
**ROTH SPOTS
JANEWAY LESIONS
SPLINTER HAEMORRHAGES
OSLER NODES**
172
What criteria is used in infective endocarditis
DUKE criteria
173
Investigation and diagnosis of infective endocarditis
Diagnosis made using a **DUKE criteria**
ECG (prolonged PR —> aortic root abcess)
Increased ESR / CRP + neutrophilia
**TOE** = gold standard
**Blood culture —> over 3 sites over 24hr**
- 2 major / 1 major + 2 minor
— Major:
*≥2 +ve blood cultures*
*echo TOE - shows vegetations*
— Minor:
*IVDU*
*1 +ve blood culture*
*Pyrexia*
*Immunological signs*
174
Treatment of infective endocarditis
Staph Aureus: vancomycin + rifampicin
Strep Viridans: Benzylpenicillin + gentamicin
*For 4 - 6 weeks*
Surgery —> remove valve if incompetent & replace with prosthetic
175
Complication of infective endocarditis
Heart failure
Aortic root abscess
Septic emboli (± sepsis)
176
The effects of regurgitation of heart muscle
**Insufficiency** + proximal chamber **dilation**
(Regurgitation - defective valve, floppy)
• Loss of structural chamber integrity + strength
**Stenosis** causes increase upstream pressure + proximal chamber **hypertrophy**
(Stenotic - narrowed valve lumens)
• Heart becomes huge and rigid; poorly compliant
177
When are murmurs best heard
Remember “RILE”
Right side valve defect —> Inspiration
Left side valve defect —> Expiration
*A.R-M.S - Diastolic murmur
A.S-M.R - systolic murmur*
178
Most common valve disorder
Aortic stenosis
179
Normal area of aortic valve vs. Pathological
3-4cm normal
Sx at 1/4 lumen size
180
Effects of aortic stenosis on heart
Results in LV dilation + hypertrophy
181
What causes aortic stenosis
Ageing calcification
Rheumatic heart disease
182
Signs / symptoms of aortic stenosis
**Remember S.A.D**
**S**yncope (exertional)
**A**ngina
**D**yspnoea (related to heart failure)
*- Murmur: Ejection systolic crescendo decrescendo radiating to carotids*
- Prominent S4: seen in LVH
- narrow pulse pressure + slow rising pulse (NOT collapsing corrigan’s pulse)
183
Investigation and diagnosis of aortic stenosis
ECG
CXR
**ECHO (Gold standard)** - shows LV size + function, aortic valve area (Doppler derived)
184
Treatment of aortic stenosis
Surgical (if Px = symptomatic);
*Healthy Px — open repair / valve replacement (definitive)
In a risky Px (>75y/o) — TAVI; transcutaneous aortic valve implant = less invasive; just a stent valve open
185
Type of sound heard in a hypertrophic cardiomyopathy
Causes S4 (sound just before S1)
*Associated with sudden death in young men*
186
Define aortic regurgitation
Leaky aortic valve, insufficient
187
What causes aortic regurgitation
Congenital bicuspid valve
Rheumatic heart disease
Connective tissue disorders; Marfan’s / Ehler’s Danlos
**INFECTIVE ENDOCARDITIS**
188
Signs and symptoms of aortic regurgitation
Murmur: Early diastolic blowing murmur (@ right sternal border)
Severe form = **Austin flint murmur** - a mid diastolic low pitched rumble; Heard when regurgitation is so severe the blood bounces off mitral valve cusps + makes sound
**Collapsing corrigon pulse** with wide pulse pressure
189
Investigation and diagnosis aortic regurgitation
ECG
CXR
**Echo (Gold standard)** - evaluate aortic valve, root and dimension
190
Treatment of aortic regurgitation
Consider IE prophylaxis
Surgical valve replacement is symptomatic
191
Differential diagnosis for aortic regurgitation
Infective endocarditis
192
Define mitral stenosis
Mitral lumen 4-6cm
Symptoms appear at < 2cm
193
Risk factors for mitral stenosis
Rheumatic fever Hx
men
ageing
194
Causes of mitral stenosis
Rheumatic heart disease - *most common, post strep. Pyogenes infection*
Valve calcification - *seen in older Px*
Infective endocarditis
195
Pathophysiology of mitral stenosis
Rheumatic heart disease causes mitral reactive inflammation; over the years its exacerbated with calcification —> leading to left atria hypertrophy
196
Signs / symptoms of mitral stenosis
**Malar flush**
Dyspnoea
A wave on JVP
Associated with AFib - *M. Stenosis leads to LA hypertrophy so more chance of embolisation as blood being pumped out harder*
**Murmur: low pitched, mid-diastolic murmur**
- loudest at apex
- best heard on expiration (lying on LHS)
*Loud S1 snap *
197
Investigation and diagnosis for mitral stenosis
ECG - may show AFib / p mitrale - ‘m’ shaped p wave seen in LA enlargement
CXR - LA enlargement
(Gold standard) - echocardiogram
198
Treatment for mitral stenosis
Surgical
- Percutaneous balloon valvotomy (a stent)
- Mitral valve replacement
199
Define mitral regurgitation
Insufficient mitral valve function
200
Causes of mitral regurgitation
**myxomatous mitral valve** (most common; mass of cells in valves connective tissue making leaflet heavier & prolapse)
Connective tissue disorders; Marfan / Ehlers Danlos
201
Risk factors for mitral regurgitation
Females
Older
Decreased bmi
Prior MI
Connective tissue disorder
202
Signs / symptoms of mitral regurgitation
Exertion dyspnoea (pulmonary hypertension, from back log of blood)
**Murmur - pan-systolic murmur** - radiating to axilla
- soft S1, prominent S3 if prolonged and lead to heart failure (severe form)
203
Investigation and diagnosis of mitral regurgitation
ECG
CXR
Gold standard - Echocardiogram
204
Treatment for mitral regurgitation
ACEi, BBlockers + monitoring using Echo
If severe - valve replacement / repair
205
Mitral stenosis murmur
Mid diastolic low pitched ‘rumbling’ murmur
Loud S1
206
What might malar flush indicate
Mitral stenosis
207
Which valvular heart disease might cause atrial fib
Mitral stenosis
208
Which valvular disease might cause congestive heart failure
Mitral regurgitation
209
Mitral regurgitation murmur
Pan-systolic high pitched whistling murmur
Radiates to axilla
With S3 heart sound
210
Aortic stenosis murmur
Ejection systolic high pitched crescendo-decrescendo murmur
Radiates to the carotids
Slow-rising pulse with narrow pulse pressure
211
Aortic regurgitation murmur
Early diastolic ‘rumbling’ murmur
With collapsing pulse (aka corrigans pulse)
Austin flint murmur heard best at apex of the heart (severe for of aortic regurgitation)
212
Where are the 4 valve murmurs heard from
Pulmonary: 2nd I.C.S left sternal border
Aortic: 2nd I.C.S right sternal border
Tricuspid: 5th I.C.S left sternal border
Mitral: 5th I.C.S mid clavicular line (apex area)
213
Define tachycardia
> 100 bpm
214
Types of tachycardia
_Supraventricular tachycardia (SVT)_
*Atrial fib*
*Atrial flutter*
*AVRT* (non-junctional) - *wolff-Parkinson’s white syndrome*
*AVNRT*
_Ventricular tachycardia_
*prolonged QT syndrome*
*Ventiricular fibrillation*
215
What is the most common SVT
AVNRT
- re-enterant pathway goes through AVN
216
Difference between AVRT and AVNRT
AVRT - re-enterant pathway through accessory pathway
(Bundle of kent)
AVNRT - re-enterant pathway goes through AVN
217
Define bradycardia
< 60 bpm
218
Types of bradycardia
*Bundle branch block*
- RBBB / LBBB
*1˚/2˚/3˚ heart blocks*
219
Atrial fib rhythm
Irregularly irregular
220
Causes of atrial fibrillation
**Heart failure, HTN**
2˚ to mitral stenosis
Idiopathic
221
Risk factors for atrial fibrillation
60+
Valvular heart defect
Hx of MI
T2DM
HTN
222
Pathophysiology of atrial fib
Rapid re-entrant ectopic foci (over 300 beats) causes **atrial spasm** - not coordinating contraction like normal .
This leads to atrial blood pooling instead of pumping efficiently to the ventricles
So, decreased CO and increased risk of thromboembolic events
223
Signs / symptoms of atrial fibrillation
**Palpitations
Irregularly irregular pulse**
Chest pain
Syncope
Hypotensive
*Sx can be paroxysmal (episodic), persistent (> 7 days), permenant - sinus rhythm unrestorable*
224
Investigation and diagnosis of atrial fibrillation
ECG (diagnostic) - irregularly irregular, narrow QRS complex
No P waves
225
Treatment of atrial fibrillation
Acute / unstable - (*syncope, shock, chest pain, heart failure*):
DC synchronised cardioversion
If stable (/prevent further episodes) - ß-blockers/CCB (like verapamil) + anticoagulant
Surgical radiofrequency ablation - restores normal rhythm by targeting misfiring heart tissue and killing it
226
Which scoring system is used in Atrial Fib
CHA2DS2 VASc score is used
*Because high stroke risk + anticoagulation needed*
HASBLED score
*Assesses risk of major bleeds in AF patients on anticoagulant*
≥ 3 score (max 9) - regular reviews required
227
What does CHADS VASc stand for
Congestive heart failure
HTN
Age > 75y/o (2 points)
DM type2
Stroke (2 points)
Vascular disease
Age 65-74y/o
Sex category = female
228
Complication of atrial fibrillation
Heart failure
Ischaemic stroke
229
Define atrial flutter
Irregular regular atrial firing
*Less common and less severe that atrial fib*
230
Risk factor of atrial flutter
Same as atrial fib:
60+
Valvular heart defect
Hx of MI
T2DM
HTN
231
Causes of atrial flutter
Similar to atrial fibrillation -
**Heart failure, HTN**
2˚ to mitral stenosis
Idiopathic
232
Pathophysiology of atrial flutter
Fast atrial ectopic firing causes atrial spasm but not as uncoordinated as A. Fib
Pathway typically from around tricuspid annulus (opening of valve)
233
Signs and symptoms of atrial flutter
Dyspnoea, palpitations…
Irregularly regular
234
Investigation and diagnosis of atrial flutter
ECG (diagnostic) - F wave ‘Saw-tooth’ pattern
Often seen with 2:1 block (2 P waves for every QRS )
235
Treatment of atrial flutter
Acute: unstable —> DC synchronised cardioversion
Stable —> rhythm / rate control (ß-blocker) with oral anticoagulation (prevent thromboemboli)
Radiofrequency ablation
236
Define Wolff Parkinson’s white (AVRT)
AVRT - means an *accessory pathway* exists for impulse conduction, not re-entry though the AVN.
Hereditary
Most common example of AVRT = Wolff Parkinson’s white; accessory pathway for conduction I.e. via bundle of Kent.
- pre-excitation syndrome (excites ventricles earlier than typical pathway) - seen as delta waves
237
Signs / symptoms of AVRT
Palpitations, dyspnoea, dizziness
238
Investigation and diagnosis of AVRT
_ECG_
**Slurred delta waves
Short PR interval
Wide QRS**
239
Treatment of AVRT
1st line:
Valsalva (blow into syringe vs. Resistance) /
Carotid massage
2nd:
IV adenosine (will temporarily cease conduction) - warn patient as they will “feel like they’re dying”
3rd:
Consider surgical radiofrequency ablation of bundle of Kent
240
Define long QT syndrome
Ventricular tachyarrhythmia; usually congenital channelopathy disorder
*Where mutations affects cardiac ion channels therefore heart conduction*
- QT interval > 480ms
241
Causes of long QT syndrome
Romano ward syndrome (autosomal dominant)
Jarvell-Lange-Neilson syndrome (autosomal recessive)
Hypokalaemia + hypocalcaemia (non-inherited)
Drugs - Amiodarone, magnesium
242
Define Torsades de pointes
Polymorphic ventricular tachycardia in patients with prolonged QT
Rapid irregular QRS complex which ‘twist’ around baseline, can cease spontaneously or develop to ventricular fibrillation
243
Define ventricular fibrillation
Shapeless rapid oscillations on ECG
Px becomes pulseless + goes into cardiac arrest (no effective cardiac output)
244
1st line treatment for ventricular fibrillation
**Electrical defibrillation**
Non-synchronised as patient is pulseless
245
Define Primary AV block
PR prolongation (> 200ms) - every P wave is followed by a QRS
Asymptomatic / stable, therefore no Tx
Causes:
drugs (ß-blocker, CCB, Digoxin—> blocks AVN conduction)
Post MI
SLE
Complication: atrial fibrillation
246
Cause of primary av block
Drugs (ß-blocker, CCB, Digoxin—> blocks AVN conduction)
Post MI
SLE
247
Complication of primary AV block
Atrial fibrillation
248
Define secondary AV block
When some P waves conducted and others aren’t
2 types:
Mobitz 1 (Wenkebach’s)
Mobitz 2
249
Define Mobitz 1
Mobitz 1 (2˚ AV block)
**PR prolongation until a QRS is dropped** (PR interval *progressively* elongates)
250
Causes of AV block mobitz 1
Drugs - ß-blocker, CCB, Digoxin
Previous MI
SLE
251
Treatment for Mobitz type 1
No Tx unless v. Symptomatic
- syncope / reduced consciousness
Give Tx: Pacemaker
252
Define mobitz 2
Persistent PR interval prolongation with random dropped QRS
253
Causes of mobitz type 2
Drugs - ß-blocker, CCB, Digoxin
Previous MI
Rheumatic fever
254
Signs / symptoms of secondary AV block mobitz 2
Syncope
SoB
Chest pain
255
Treatment of mobitz 2
Pacemaker
256
Define tertiary AV block
Complete AV dissociation
I.e. atria and ventricles beat independently of each other
- ventricular *escape rhythm* is what sustains the heartbeat
SAN (best - 60-100)
—> AVN (then takes over: 40-60)
—> If dysfunctional, ventricular pacemakers take over (Worst firing rate: 20-40)
257
Cause of tertiary AV block
Acute MI
HTN
Structural heart disease
258
Tx for 3˚ AV block
IV atropine
+
Permanent pacemaker
259
Define bundle branch block
Blocking of the bundle of His
2 types:
RBBB
LBBB
260
Cause of RBBB
Pul emboli
IHD
Ventricular Septal Defect
*RV later activated than LV*
261
Dx of RBBB
ECG: **MarroW**
- “M” in V1 (RSR wave)
- “W” in V2 (deep S wave)
Hear: Wide physiological S2 splitting heart sound
262
Cause of LBBB
IHD
Valvular disease
*LV is activated later than RV*
263
Dx of LBBB
ECG: **WilliaM**
- “W” in V1 (RSR wave)
- “M” in V2 (deep S wave)
Hear: Reversed S2 splitting heart sound
264
Define cardiomyopathy
Disease of the myocardium (muscular / conduction defects)
Types:
Hypertrophic
Dilated
Restrictive
265
Which cardiomyopathy is most common cause of death in young people
Hypertrophic cardiomyopathy
266
Most common cardiomyopathy
Dilated
267
Cause of hypertrophic cardiomyopathy
Familial (inherited) - autosomal dominant mutation of sarcomere protein (troponin T, myosin B)
Exercise
Aortic stenosis
268
Pathophysiology for hypertrophic cardiomyopathy
Thick non-complaint heart = leads to impaired diastolic filling
Therefore, reducing C.O
269
Sx of hypertrophic cardiomyopathy
May present with **sudden death**
Chest pain
Palpitations
SoB
Syncope
270
Investigation and diagnosis of hypertrophic cardiomyopathy
Echocardiogram (definitive)
Abnormal ecg
Genetic testing
271
Treatment for hypertrophic cardiomyopathy
ß blocker
CCB
Amiodarone
272
Cause of dilated cardiomyopathy
Familial: Autosomal dominant - cytoskeleton gene mutation
IHD
Alcohol
273
Pathophysiology of dilated cardiomyopathy
Thin cardiac walls poorly contract therefore reduced CO
274
Sx of dilated cardiomyopathy
SoB
Heart failure
Atrial fib
Thromboemboli
275
Investigation and diagnosis of dilated cardiomyopathy
ECG
Echo (definitive)
276
Treatment for dilated cardiomyopathy
Treat underlying cause like AFib / HF
277
Cause of restrictive cardiomyopathy
Granulomatous disease (sarcoidosis / amyloidosis)
Idiopathic
Post MI
278
Pathophysiology of restrictive cardiomyopathy
Rigid fibrotic myocardium fills poorly + contracts poorly
Reducing CO
279
Sx of restrictive cardiomyopathy
If severe:
Dyspnoea, S3+4
Oedema, congestive heart failure
Narrow pulse pressure
280
Investigation + diagnosis of restrictive cardiomyopathy
ECG
Echo
Cardiac catheterisation (definitive)
281
Tx for restrictive cardiomyopathy
None;
Consider transplant
Px typically die within a year
282
Define shock
Medical emergancy - hypoperfusion, life threatening, due to acute circulation on failure
Leads to tissue hypoxia + risk of organ dysfunction
283
General Sx to recognise shock
Skin; pale, cold, sweaty
Reduced GCS
Increased capillary refill time
Decreased urine output
Prolonged hypotension
284
Define hypovolaemic shock
As a result of **fluid loss** — dehydration
Or
As a result of **blood loss** — trauma / GI bleed
285
Sx of hypovolaemic shock
Hypotension + tachycardia
Confusion
Clammy pale skin
286
Treatment for hypovolaemic shock
ABCDE
*Airway
Breathing (give O2)
Circulation
Disability
Exposure*
**IV Fluids**
287
Define Septic shock
Due to uncontrolled bacterial infection
288
Sx of septic shock
Pyrexia
Warm peripheries
Bounding pulse
Tachycardic
289
Treatment for septic shock
Broad spec antibiotics
290
Define cardiogenic shock
Due to heart pump failure; MI, cardiac tamponade, pulmonary embolism
291
Sx of cardiogenic shock
Sx of heart failure — (ankle) Oedema, SoB and fatigue
Increased JVP, S4
292
Treatment of cardiogenic shock
ABCDE
+
Treat underlying cause
293
Define anaphylactic shock
Due to **IgE mediated type 1 hypersensitivity** vs allergen;
Histamine release - constriction causes excess vasodilation and bronchoconstriction
Leads to **decreased MAP and hypoxia**
294
Sx of anaphylactic shock
Hypotension + tachycardia
**Urticaria**
**puffy face + flushing of the cheeks**
Dyspnoea
295
Treatment of anaphylactic shock
IM adrenaline - for SNS activation; stress response
Inflammatory response dampens down
296
Define neurogenic shock
Due to spinal cord trauma
E.g. RTA
- get disrupted SNS but intact PsNS
297
Sx of neurogenic shock
Hypotension + **Bradycardia**
Hypothermic
298
Treatment for neurogenic shock
ABCDE
+
**IV Atropine** (blocks fatal tone; allows more PsNS inhibition, more chance for SNS to work)
299
Which organs at highest risk of failure
Kidney
Lungs
Brains
Heart
300
Define rheumatic fever
A systemic response to ß haemolytic group A strep
- Almost exclusively I developing countries only
301
Causes of rheumatic fever
Post strep pyogenes infection (group A, ß haemolytic strep)
- typically **pharyngitis**
**50%** of cases affect the heart —> **Rheumatic heart disease**
302
Pathophysiology of rheumatic disease
M protein from S. Pyogenes reaches heart valve tissue; antibodies attack this ‘cross-link’ (*molecular mimicry*)resulting in autoantibody mediated destruction ± inflammation
- mitral valves most affected (70% just mitral; 25% mitral and aortic)
- typically thickens leaflets; mitral stenosis
303
Signs and symptoms of rheumatic fever
**New murmur** - mitral stenosis
**Arthritis**
Pyrexia
**Syndentiams chorea** - uncoordinated jerky movements
304
Investigation and diagnosis of of rheumatic fever
CXR - cardiomegaly / heart failure / mitral stenosis
*Echo* - details extent of valvular damage
*Jones criteria*: recent pyogenes infection
+
2 major
or
1 major + 2 minor
305
Treatment for rheumatic fever
Antibiotics:
**IV benzylpenicillin** then phenoxypenicillin for 10 days
For syndenhams chorea:
Haloperidol
306
What are Aschoff bodies
Histological finding for rheumatic heart disease from valves
307
What conditions make up tetralogy of Fallot
1) Ventricular Septal Defect
2) Over-riding aorta
3) Right ventricular hypertrophy
4) Pulmonary stenosis *Right ventricular outflow obstruction*
308
What does Px with tetralogy of Fallot present as
**Cyanotic**; VSD with RV outflow obstruction (therefore, oxygen systemically shunted)
Infants often seen in **knee to chest squatting position** - increases preload + afterload, therefore improves cyanosis
So can Px in clinic if put into the squat position they become less cyanotic
309
Investigation and diagnosis of tetralogy of Fallot
Echo
CXR - boot shaped heart
310
Treatment for tetralogy of Fallot
Full surgical repair within 2 years of life
311
Define coarctation of aorta
Aorta narrows at or just distal to ductus arteriosus
*Blood is diverted massively through aortic arch branches, so increased upper body perfusion vs lower body*
312
Sx of coarctation of aorta
**Scapular bruits** - HTN in collaterals
Upper body hypertension
313
Investigation and diagnosis of coarctation of aorta
CXR : **Notched ribs** - dilated intercostal vessels
CT angiogram
314
Treatment for coarctation of aorta
Surgical repair or stenting
315
What is the most common inherited heart defect
Bicuspid aortic valve
*Typically tricuspid, Px ends up with bicuspid valve instead which degenerates quicker than normal + becomes regurgitative earlier*
316
Define atrial septal defect
Aka patent foreman Ovale
Shunt of blood L—>R, therefore NOT CYNOTIC
May overload right side circulation; right ventricular hypertrophy (if severe; Eisenmenger syndrome)
317
What’s Eisenmenger syndrome
When pulmonary hypertension causes reversal shunt; R—>L shunt of blood
So deoxygenated blood is pumped systemically
In younger Px the heart is more compliant… but… in older, more shunting so causes dyspnoea
318
Investigation / test for atrial septal defect
ECHO
319
Tx for atrial septal defect
Spontaneous closure sometimes / surgical
320
Define ventricular septal defect
Shunt of blood L—R (non-cynotic; just like atrial septal defect)
321
Sx of ventricular septal defect
Small VSD: asymptomatic
Large VSD: exercise intolerant, failure to thrive, harsh pansystolic murmur
322
Investigation and diagnosis of ventricular septal defect
ECHO
323
Treatment for ventricular septal defect
Spontaneous closure / surgical
324
Define atrioventricular septal defect
Hole in the middle of the heart
*Essentially, no atria*
325
What is atrioventricular septum associated with
Down syndrome
326
Sx of atrioventricular septal defect
Shortness of breath
Exercise intolerance
Eventually leads to Eisenmenger syndrome
327
Define patent ductus arteriosus
When the ductus arteriosus fails to close post birth
Blood shunts from aorta —> pulmonary trunk; risk of pulmonary overload + Eisenmenger
328
Sx of patent ductus arteriosus
Dyspnoea
Failure to thrive
Machine like murmur
329
Investigation and diagnosis of patent ductus arteriosus
Echo
CXR
ECG
330
Tx for patent ductus arteriosus
Prostaglandin inhibitor - indomethacin
May induce closure
Otherwise consider closure
331
3 cardinal signs of aortic stenosis
Syncope
Angina
Dyspnoea
