Cardiology Flashcards
What is angina?
The result of myocardial ischaemia, where blood supply < metabolic demand
Describe stable angina
- Chest pain precipitated by exposure to cold/exercise
- Lasts 1-5 minutes
- Relieved by rest/GTN
Describe unstable angina
- Chest pain at rest
- Prolonged, lasts longer than 20 minutes
- No relief by rest/GTN spray
- No significant rise in troponin levels
Give 7 features of a myocardial infarction
- Cardiac chest pain
- Unremitting
- Occur at rest
- Associated with sweating, breathlessness, nausea and/or vomiting
- One third occur in bed at night
- Non-Q-wave or Q-wave MI
- NSTEMI or STEMI
What will most likely lead to pathological Q-wave formation, heart failure or death?
STEMI or MI associated with LBBB as they are associated with larger infarcts unless effectively treated
Describe NSTEMI
- Non-ST-elevation myocardial infarction
- Increase in troponin, myoglobin and creatine kinase levels
- Retrospective diagnosis - no ST elevations on ECG (nearly complete blockage)
Describe STEMI
- ST-elevation myocardial infarction
- Increase in troponin, myoglobin and creatine kinase levels
- Diagnosis at presentation - ST elevations on ECG (complete blockage)
Describe Prinzmetal’s angina
- Caused by coronary artery spasms
- Occur at rest/night
Describe initial management of ACS
- Call 999/get to hospital quickly
- Take aspirin 300mg immediately
- Take pain relief if required
Describe hospital management of ACS
- Confirm/make diagnosis
- Oxygen therapy
- Pain relief (opiates/nitrates)
- Aspirin +/- P2Y12 inhibitor (clopidogrel) (dual antiplatelet therapy)
- Antianginal therapy (beta blockers, nitrates, calcium antagonists)
- PPCI if STEMI (fibrinolytic therapy if not available)
- Revascularisation
- Cardiac monitoring for arrhythmias
What is required to confirm/make a diagnosis of ACS?
- History
- ECG
- Troponin levels (potentially also myoglobin and CK levels)
- Sometimes coronary angiography
When should you give oxygen therapy in ACS?
If the patient is hypoxic
Why might you choose to use opiates over nitrates and vice versa?
- Opiates my delay the absorption of P2Y12 inhibitors
- Nitrates used for unstable angina/coronary vasospasm but may be ineffective for MI
What might you use in addition to dual antiplatelet therapy?
An anticoagulant e.g. fondaparinux or heparin
Describe PPCI
- Primary percutaneous coronary intervention
- Treatment choice for STEMI
- Predilate occluded coronary artery
- Position stent
- Deploy stent
- Repeat angiogram 3 months later
Describe CABG
- Coronary artery bypass graft surgery
- Used in about 10% of patients with NSTE ACS
What are reasons for patients not having obstructive coronary artery disease?
- The actual diagnosis is not ACS
- Plaque rupture occurs without significant stenosis and obstructed thrombus is resolve by time of angiography
- Stress induced (Tako-Tsubo) cardiomyopathy without obstructive CAD
What are acute coronary syndromes?
- Unstable angina
- NSTEMI
- STEMI
What are 11 predisposing factors for IHD (ischaemic heart disease)?
- Age
- Smoking
- Family history
- Diabetes mellitus
- Being Male
- Hyperlipidaemia
- Hypertension
- Kidney disease
- Obesity
- Physical inactivity
- Stress
What are 4 pros and 4 cons of PCI?
Pros - less invasive, convenient, repeatable and acceptable
Cons - risk stent thrombosis, risk restenosis, can’t deal with complex disease, dual antiplatelet therapy
What are 2 pros and 6 cons of CABG?
Pros - better prognosis, deals with complex disease
Cons - invasive, risk of stroke/bleeding, can’t do if frail/comorbid, one time treatment, length of stay, time for recovery
What is acute pericarditis?
An inflammatory pericardial syndrome with or without effusion
What are infectious causes of pericarditis?
- Viral (enteroviruses (coxsackie), adenoviruses etc.)
- Bacterial (mycobacterium tuberculosis)
- Fungal (histoplasma spp)
What are 5 non infectious causes of pericarditis?
- Trauma/iatrogenic
- Uraemia
- MI
- Secondary metastatic tumour
- Autoimmune (rheumatoid arthritis, Sjogren’s syndrome, systemic lupus erythematosus)
What are 4 signs of pericarditis?
- Pericardial friction rub (auscultation)
- Tachycardia
- Peripheral oedema
- Increased JVP
What are 2 extra signs of pericarditis if there is pericardial effusion?
- Bronchial breathing at left base
- Muffled heart sounds
What are 6 symptoms of pericarditis?
- Chest pain (relieved by sitting/leaning forward, exacerbated by inspiration)
- Fever
- Shortness of breath/dyspnoea
- Cough
- Hiccups
- Myalgia
What are 3 investigations for patients with pericarditis?
- ECG - tachycardia
- Echo/CXR if suspect effusion
- Blood tests (FBC, ESR & CRP, troponin)
What does an ECG look like in patients with pericarditis?
- Saddle shaped ST elevation
- PR depression
What will blood test results look like in patients with pericarditis?
- FBC - modest increase in WCC and mild lymphocytosis
- ESR & CRP - high ESR may suggest aetiology, ANA in young females indicates SLE
- Troponin - elevations suggest myopericarditis
What is the treatment for pericarditis?
- NSAIDs with gastric protection (ibuprofen, aspirin)
- Colchicine for 3 months
- Reduce physical activity until symptoms resolve
- Treat the cause
- Pericardiocentesis (if effusion)
What is the main complication of pericarditis?
Cardiac tamponade
What is cardiac tamponade?
Accumulation of fluid in pericardial space - life threatening condition
Describe the pathophysiology of cardiac tamponade
- Build up of fluid in pericardial space
- Compression of heart chambers
- Decrease in venous return
- Decrease in filling in the heart
- Reduced cardiac output
What are 2 signs of cardiac tamponade?
- Beck’s triad:
- Falling BP
- Rising JVP
- Muffled heart sounds - Pulsus paradoxus (large decrease in stroke volume - systolic BP drops by >10mmHg on inspiration)
What is the gold standard investigation for patients with cardiac tamponade?
Echocardiogram
What is the treatment for cardiac tamponade?
Pericardiocentesis
What is pericardial effusion?
Build up of fluid in the pericardium
What are 6 exacerbating factors (decreased supply) for chronic coronary syndromes?
- Anaemia
- Hypoxemia (low oxygen in blood)
- Polycythemia (high conc of RBC in blood)
- Hypothermia
- Hypovolaemia (result of major blood/fluid loss)
- Hypervolaemia (too much fluid volume)
What are 5 exacerbating factors (increased demand) for chronic coronary syndromes?
- Hypertension
- Tachyarrhythmia
- Valvular heart disease
- Hyperthyroidism
- Hypertrophic cardiomyopathy
What does OPQRST stand for regarding pain in chronic coronary syndromes?
Onset
Position
Quality
Relationship (with exertion/posture/meals/breathing)
Radiation
Relieving/exacerbating factors
Severity
Timing
Treatment
What is the treatment for chronic coronary syndromes?
- Lifestyle advice (smoking cessation, weight loss, exercise more)
- Medication (aspirin, GTN spray, beta blockers, long acting nitrates, calcium channel blockers, ACE inhibitors)
Who should you not give beta blockers to?
Someone with severe asthma
What do nitrates do?
Venodilators. Reduce the preload on heart and dilates the coronary arteries
What is an atrial septal defect?
Abnormal connection between the two atria due to failure of the septal tissue to form between the atria
Describe the epidemiology of ASD
- Common
- Often present in adulthood
- 10% of all congenital abnormalities of the heart
Describe the pathophysiology of ASD
- Higher pressure in the LA
- Blood shunted from left to right
- Increased flow into the right side of the heart and lungs
What occurs in large ASDs that doesn’t occur in small ASDs?
Right heart dilatation
What is the difference between ostium primum and secundum ASD?
Ostium primum ASD = associated with AV valve anomalies and presents early
Ostium secundum ASD = usually asymptomatic until later in life
What are 3 signs of ASD?
- Pulmonary flow murmur
- Fixed split second heart sound (due to delayed closure of pulmonary valve)
- Ejection systolic murmur on auscultation
What are 3 symptoms of ASD?
Usually asymptomatic
1. Dizziness
2. Palpitations
3. SOBOE (shortness of breath on exertion)
What are 3 investigations for patients with ASD?
- Echocardiogram
- ECG
- CXR
What does an ECG look like in patients with ASD?
- RBBB with left axis deviation (primum)
- Prolonged PR interval (primum)
- Right axis deviation (secundum)
What does a CXR look like in patients with ASD?
Big heart and pulmonary arteries
Describe the treatment for ASD
- Most close spontaneously
- Surgical/percutaneous closure (before 10 in children, in adults if symptomatic)
What is a complication of ASD?
Eisenmenger’s syndrome (pulmonary hypertension –> shunt reversal –> cyanosis)
What is cyanosis?
Poor blood circulation
What is Eisenmenger’s syndrome?
- High pressure pulmonary flow
- Damage to delicate pulmonary vasculature
- Resistance to blood flow through the lungs increases
- RV pressure increase
- Reversal of shunt direction (right to left)
- Deoxygenated blood enters patient’s circulation
What is ventricular septal defect?
Abnormal connection between the two ventricles
Describe the epidemiology of VSD
- Common
- 20-25% of all congenital heart defects
Describe the pathophysiology of VSD
- Higher pressure in LV
- Blood moves from high to low pressure (left to right) chambers
- Increased blood flow through the lungs
What are 7 signs of a large VSD?
- Small, breathless, skinny baby
- Increased respiratory rate
- Tachycardia
- Harsh systolic murmur
- Severe heart failure in infancy
- Poor weight gain/feeding
- Failure to thrive
What is a sign of a small VSD?
Loud pansystolic murmur
What are 2 symptoms of a large VSD?
- Exercise intolerance
- Breathless
What is a symptom of a small VSD?
Thrill (buzzing sensation)
What are the investigations for patients with VSD?
- Echocardiogram
- CXR
- ECG
What does an ECG look like in patients with VSD?
- Normal (small VSD)
- Left axis deviation and left ventricular hypertrophy (medium/large VSD)
What does a CXR look like in patients with VSD?
- Pulmonary plethora
- Cardiomegaly and large pulmonary arteries (large VSD)
Describe the treatment for VSD
- Many close spontaneously during childhood
- No intervention (if small and asymptomatic)
- Surgery
What is the main complication of VSD?
Eisenmenger’s syndrome
What are 6 complications of VSD?
- Aortic regurgitation
- Infundibular stenosis
- Infective endocarditis
- Subacute bacterial endocarditis
- Pulmonary hypertension
- Cardiac failure
What is atrioventricular septal defect?
Hole in the centre of the heart, involving the ventricular septum, atrial septum and tricuspid valves
Describe the epidemiology of AVSD
- 2/10,000 live births
- Strong association with Down’s syndrome
Describe the pathophysiology of AVSD
One big malformed AV valve instead of two separate AV valves
Describe a partial AVSD
- Can present in late adulthood
- Presents like a small VSD/ASD
- May be left alone if there is no right heart dilatation
Describe a complete AVSD
- Breathless as neonate
- Poor weight gain/feeding
- Torrential pulmonary blood flow
- Needs repair or pulmonary artery band in infancy
What is Tetralogy of Fallot?
Combination of four congenital heart defects - pulmonary infundibular stenosis, overriding aorta, ventricular septal defect, right ventricular hypertrophy
Describe the epidemiology of Tetralogy of Fallot
- Most common of the complex cardiac abnormalities
- 10% all of congenital heart defects
- 1/100 live births
- 15% have associated genetic abnormality (22q11 deletion)
Describe the pathophysiology of Tetralogy of Fallot
- Pulmonary infundibular stenosis, overriding aorta, ventricular septal defect and right ventricular hypertrophy
- Stenosis of RV outflow
- Higher pressure in RV than LV
- Deoxygenated blood moves from RV to LV
- Deoxygenated blood travels around body (patient becomes blue)
What are 4 signs of Tetralogy of Fallot?
- Pulmonary stenosis
- Cyanosis
- Systolic murmur
- Increased haemoglobin concentration
What are 2 investigations for patients with Tetralogy of Fallot?
- Echocardiogram - shows anatomy and degree of stenosis
- CXR - boot shaped heart
What is the treatment for patients with Tetralogy of Fallot?
Surgical repair in early life
What are 2 complications of Tetralogy of Fallot?
- Usually death before adult life
- Right heart failure
What is coarctation of aorta?
Narrowing of the aorta (at the site of insertion of the ductus arteriosus)
Describe the epidemiology of coarctation of aorta
5% of all congenital abnormalities
Describe the pathophysiology of coarctation of aorta
- Narrower aorta increases afterload on LV
- Collateral circulation forms to increase flow to the lower part of the body
- Intercostal arteries become dilated and tortuous
What are 4 signs of coarctation of aorta?
- Right arm/upper limb hypertension
- Lower pressure in vessels distal to coarctation
- Bruits (buzzes) over the scapulae and back from collateral vessels
- Murmur
What are symptoms for coarctation of aorta?
Often asymptomatic
What are the investigations for patients with coarctation of aorta?
- CT/MRI
- CXR - shows rib notching
What is the treatment for coarctation of aorta?
Surgical or percutaneous repair
- Coarctation angioplasty
- Subclavian flap repair
- End to end repair
What are 7 complications of coarctation of aorta?
- Hypertension
- Re-coarctation requiring repeat intervention
- Aneurysm formation at the site of repair
- Rupture of a dissecting aneurysm
- Congestive heart failure
- Intracerebral haemorrhage
- Bacterial endocarditis
What is bicuspid aortic valve?
Aortic valve with only two cusps instead of three
Describe the epidemiology of bicuspid aortic valve
1-2% of the general population
Describe the pathophysiology of bicuspid aortic valve
Abnormal degradation of aortic valve over time
What is a sign of bicuspid aortic valve?
Undetected at birth (works fine)
1. Exercise exacerbates complications
What are 2 investigations for patients with bicuspid aortic valve?
- Echocardiogram
- MRI
What is the treatment for bicuspid aortic valve?
Valve replacement (once complications develop)
What are 4 complications of bicuspid aortic valve?
- Aortic regurgitation
- Infective endocarditis
- Subacute bacterial endocarditis
- Aortic dissection/dilation
What is patent ductus arteriosus?
Failure of ductus arteriosus to close
Describe the epidemiology of patent ductus arteriosus
- 0.02% of live births
- More common in prem babies
Describe the pathophysiology of patent ductus arteriosus
- Abnormal shunt of blood from aorta to pulmonary artery
- Increased pulmonary arterial flow
- Right sided heart strain (right ventricular hypertrophy)
- Lack of oxygenated blood to the body results in left sided heart strain (left ventricular hypertrophy)
What are 2 signs and symptoms of a small patent ductus arteriosus?
Usually asymptomatic
1. Continuous ‘machinery’ murmur
2. Loudest at second heart sound
What are 6 signs and symptoms of a large patent ductus arteriosus?
- Left ventricular impulse
- Cardiomegaly
- Shortness of breath/breathlessness
- Failure to thrive/poor feeding
- Eisenmenger’s syndrome
- Differential cyanosis (clubbed/blue toes, normal fingers)
What are 2 investigations for patients with patent ductus arterious?
- Echocardiogram
- CXR (cardiomegaly if large)
What is the treatment for patent ductus arteriosus?
- Surgical/percutaneous closure
- Venous approach (sometimes requires an AV loop)
What is patent foramen ovale?
Failure of the foramen ovale to close in the weeks after birth
Describe the epidemiology of patent foramen ovale
1/4 people
Describe the pathophysiology of patent foramen ovale
Deoxygenated blood shunted from right atrium into left atrium
What are symptoms of patent foramen ovale?
Usually asymptomatic
What are 2 investigations in patients with patent foramen ovale?
- ECG
- Bubble test (watch a bubble go across the heart)
What is the treatment for patent foramen ovale?
- None usually
- Cardiac catheterization
What is a complication of patent foramen ovale?
- None usually
- Thromboembolic stroke (extremely rare)
What is pulmonary stenosis?
Narrowing of the outflow of the right ventricle
Describe the epidemiology of pulmonary stenosis
8-12% of all congenital heart defects
Describe the pathophysiology of pulmonary stenosis
- RV hypertrophy/failure
- Poor pulmonary blood flow
- Tricuspid regurgitation
What are 4 signs and symptoms of pulmonary stenosis?
- Well tolerated (mild/moderate)
- Murmur
- Shortness of breath
- Chest pain
What is the treatment for pulmonary stenosis?
- Balloon valvuloplasty
- Open valvotomy
- Shunt to bypass blockages
What is cardiomyopathy?
Deterioration of the myocardium’s ability to contract (mechanical and/or electrical dysfunction)
What are the 4 types of cardiomyopathy?
- Dilated (DCM)
- Hypertrophic (HCM)
- Arrhythmogenic (ACM)
- Restrictive (RCM)
What is dilated cardiomyopathy?
Dilatation of the left ventricle leading to thin muscle and poorly generated contractile force
Describe the epidemiology of DCM
- Most frequent cause of heart transplant
- 35/100,000
- Median age = 50
- More common in males
What are the 4 causes of DCM?
- Ischaemia
- Alcohol
- Thyroid disorder (thyrotoxicosis)
- Genetic (often caused by cytoskeletal gene mutations)
Describe the pathophysiology of DCM
- Enlargement/dilatation of LV chamber
- Disrupts heart’s ability to pump blood effectively
- Systolic dysfunction of left/both ventricles
What are 9 signs of DCM?
- Congestive heart failure
- Arrhythmia
- Thromboembolism
- Increased JVP
- Sudden death
- Pulmonary oedema
- Oedema
- Cardiomegaly
- 3rd/4th heart sounds
What are 3 symptoms of DCM?
Asymptomatic
1. Shortness of breath
2. Fatigue
3. Weakness
What are 3 investigations for patients with DCM?
- CXR - cardiomegaly and pulmonary oedema
- ECG - tachycardia
- Echocardiogram - dilated ventricles
What is the treatment for DCM?
- Treat the cause
- Bed rest
- Loop/thiazide diuretics for fluid overload
- ACE inhibitors
- Beta blockers
- Potentially an ICD (implantable cardioverter defibrillator)
What are 2 complications of DCM?
- Progressive heart failure
- Sudden cardiac death
What is hypertrophic cardiomyopathy?
Ventricular hypertrophy leading to the obstruction of the outflow tract
Describe the epidemiology of HCM
- Most common cause of sudden death in young people
- Most common genetic CVD
- 1/500
- More common in black men
What are the 2 causes of HCM?
- Genetic - autosomal dominant (sarcomeric protein gene mutations)
- 50% sporadic
Describe the pathophysiology of HCM
- Genetic mutation of sarcomere protein
- Left ventricular hypertrophy
- Impaired diastolic filling
- Reduced stroke volume/cardiac output
- Abnormal mitral valve
- Dynamic obstruction of left ventricular outflow tract
What are 5 signs of HCM?
- Late ejection systolic murmur (augmented by standing)
- Jerky carotid pulse (forceful apex beat)
- Left ventricular outflow tract obstruction (LVOTO)
- Alpha wave in JVP
- Sudden death
What are 5 symptoms of HCM?
Asymptomatic
1. Chest pain/angina
2. Dyspnoea/SOB
3. Palpitations
4. Dizziness
5. Syncope
What are 3 investigations for patients with HCM?
- ECG
- CXR - left atrial enlargement (especially with mitral regurgitation)
- Genetic analysis
What does an ECG look like in patients with HCM?
- T wave inversion
- Deep Q waves
- Left ventricular hypertrophy
What is the treatment for HCM?
- Amiodarone (to reduce risk of arrhythmias and sudden death)
- Calcium channel blockers and beta blockers for pain
- ICD (to reduce risk of sudden death)
- Septal myectomy (severe)
What is a complication of HCM?
Sudden death
What is arrhythmogenic cardiomyopathy?
Inherited heart muscle disorder involving loss of myocytes and fibro fatty replacement of right ventricular myocardium
Describe the epidemiology of ACM
- 1/2,000
- Italy/Greece
- More common in males
- Genetic predisposition in 30-50% of cases (autosomal dominant)
What are 3 causes of ACM?
- Unknown
- Response to apoptosis, inflammation or genetics (desmosome gene mutations)
- Naxos disease (due to autosomal recessive condition)
Describe the pathophysiology of ACM
- Genetic mutation of desmosomes
- Fibro fatty replacement of RV myocytes
- Impaired ability of the RV muscle due to loss of myocytes
What are 4 signs of ACM?
1/2 patients have a normal examination
1. Sudden death
2. Arrhythmia
3. RV changes/failure
4. Biventricular pump failure (mimics DCM)
What are 2 symptoms of ACM?
- Palpitations
- Syncope/pre syncope
What are 3 investigations for patients with ACM?
- RV angiography (to evaluate RV function)
- MRI
- Echocardiogram
What does an MRI look like in patients with ACM?
- RV enlargement
- Fatty infiltration
- Fibrosis
- Wall motion abnormalities
What does an echocardiogram look like in patients with ACM?
- RV wall abnormalities
- RV dysfunction
What is the treatment for ACM?
- Standard heart failure medication
- Beta blockers (if asymptomatic)
- ICD (if high risk)
- Heart transplant (if refractory treatment)
What are complications of ACM?
- Progressive disease
- Mortality rate = 1-3%
What is restrictive cardiomyopathy?
Failure of ventricles to contract properly due to the replacement of normal heart muscle with scar tissue causing rigid ventricles - heart failure with normal systolic function
Describe the epidemiology of RCM
- 1/1000-5000
- 5% of all cardiomyopathies
- Elderly
- Tropical Africa
- Not familial
What are 5 causes of RCM?
- Amyloidosis
- Sarcoidosis
- Idiopathic
- End myocardial fibrosis
- Infiltrative myocardial disease
Describe the pathophysiology of RCM
- Increased myocardial stiffness in ventricular cavities with normal size and systolic function
- Impaired ventricle filling
- Ventricles become incompliant (fill predominantly in early diastole)
- Bi-atrial enlargement
What are 5 signs of RCM?
- Increased JVP (elevated on inspiration)
- Congestive heart failure
- Oedema/pulmonary oedema
- 3rd/4th heart sounds
- Murmur
What are 2 symptoms of RCM?
- Dyspnoea/SOB
- Fatigue
What are 3 investigations for patients with RCM?
- Echocardiogram - thickened ventricular walls, valves and atrial septum
- MRI (to distinguish between cardiomyopathies)
- Cardiac catheterisation
What is the treatment for RCM?
- Standard heart failure medication
- ICD (if high risk)
- Transplant
What are complications of RCM?
- Heart failure
- Sudden death
- Poor prognosis
What is an arrhythmia?
An abnormality in cardiac rhythm
What is tachycardia?
Fast heart rate >100bpm
What is sinus tachycardia?
- > 100bpm
- Physiological response to exercise and excitement (also occurs in anaemia, fever, heart failure, thyrotoxicosis, acute PE, hypovolaemia, atropine)
- Treatment = correction of cause and beta blockers
What is atrial tachycardia?
- > 150bpm
- Abnormal P waves
- Normal QRS complexes
What would an ECG look like in patients with ventricular tachycardia?
- No P waves
- Regular, wide QRS complexes
- No T waves
What is supraventricular tachycardia?
- Arises from the atrium or AV junction
- Atrial fibrillation, atrial flutter, AVRT, AVNRT
- P waves may not be visible
- Pre-excitation on resting ECG
- Short PR interval
What is ventricular tachycardia?
- Arises from the ventricles
What is atrial fibrillation?
An irregularly irregular heart rhythm
Describe the epidemiology of AF
- Most common sustained arrhythmia
- 5-10% of patients >65
- More common in males
What are 6 causes of AF?
- Idiopathic
- Heart failure
- Valvular heart disease (particularly mitral valve stenosis)
- Cardiac surgery
- Cardiomyopathy
- Rheumatic heart disease
What are 6 risk factors for AF?
- Over 60
- Diabetes
- Hypertension
- CAD
- Previous MI
- Structural heart disease
What is CHA2DS2-VASc?
Used to calculate stroke risk for patients with AF
What does CHA2DS2-VASc stand for?
- Congestive heart failure
- Hypertension
- Age >75
- Diabetes
- Stroke/TIA
- Vascular disease
- Age 65-74
- Sex (female)
What is ORBIT?
Used in patients with AF to assess the risk of major bleeding with anticoagulation