Cardiology Flashcards
Define atherosclerosis
Combination of atheroma’s - fatty deposits - and sclerosis - hardening or stiffening - affecting medium to large arteries, caused by chronic inflammation leading to deposition of lipids and formation of plaques.
Risk factors for atherosclerosis
Age
FH
Male
Smoking
Alcohol
High sugar and fat diet low fruit and veg
Low exercise
Obesity
Poor sleep stress
Diabetes
HTN
CKD
Rheumatoid
Atypical antipsychotics
Complications of atherosclerosis
Angina
MI
TIA
Stroke
Peripheral vascular disease
Mesenteric ischaemia
Prevention of CVD
Diet, exercise and weight improvement
Stop smoking
Stop drinking
Tightly treat co-morbidities
Score the determine risk of stroke or MI in next 10 years
QRISK3 - if >10% risk, offer statin
Secondary prevention of CVD
AAAA
Aspirin
Atorvastatin
Atenolol
ACE inhibitor
Define stable angina
Narrowing of the coronary arteries such that during time of high demand, exercise, insufficient blood supply to the hear causing chest pain. Stable when symptoms are relieved by rest or GTN.
Investigations in stable angina
CT coronary angiogram - gold standard diagnostic
Physical examination
ECG
Bloods - FBC, UE, LFT, Lipid, Thyroid, HbA1c
Management of stable angina
RAMP
Refer to cardiology
Advise about diagnosis management and when to phone ambulance
Medical treatment
Procedural or surgical interventions
GTN - every 5 mins
Beta blockers, CCBs are first line
Long acting nitrites, ivabradine, nicorandil, ranolazine
2dry prevention - AAAA
Surgery - PCI, stents, balloon dilation, CABG
Define acute coronary syndrome
Term used to describe a range of conditions associated with sudden reduced blood flow to the hear.
Main types of ACS
Unstable angina
STEMI
NSTEMI
What is supplied by the Right Coronary artery
Inferior aspect
Right atrium
Right ventricle
Inferior aspect of left ventricle
Posterior aspect of septal area
What is supplied by the circumflex artery
Lateral aspect
Left atrium
Posterior aspect of the left ventricle
What is supplied by the Left anterior descending
Anterior aspect
Anterior aspect of the left ventricle
Anterior aspect of the septum
How to differentiated types of ACS
Chest pain = ECG
ST elevation - STEMI
No elevation = troponin
Raised trops +- other ECG changes - NSTEMI
Trops normal - unstable angina (or msk pain)
History of ACS
Central crushing chest pain
Nausea and vomiting
Sweating and clamminess
Feeling of impending doom
Shortness of breath
Palpitations
Pain radiates to jaw/arm
Symptoms continue at rest
Diabetic often have silent MIs - no pain
ECG changes in STEMI
ST segment elevation
New left bundle branch block
ECG changes in NSTEMI
ST depression
Deep T wave inversion
Pathological Q waves
Alternative causes for raised troponins
Chronic renal failure
Sepsis
Myocarditis
Aortic dissection
Pulmonary embolism
Investigations in ACS
Physical exam
ECG
Bloods - FBC, UE, LFT, Lipid, Thyroid, HbA1C
CXR
Echo - post event
CT coronary angiogram
Immediate management of ACS
MONA
Morphine
Oxygen (if low sats)
Aspirin 300mg
Nitrates - GTN
Management of STEMI
Primary PCI - if available within 2 hours
Thrombolysis - in PCI not available
Management of NSTEMI
BATMAN
Betablockers
Aspirin 300mg
Ticagrelor 180mg stat
Morphine
Anticoagulation - fodaparinux
Nitrates GTN
Complications of MI
Heart failure DREAD
Death
Rupture of heart septum or papillary muscles
Edema - heart failure
Arrhythmia + Aneurysm
Dressler’s Syndrome
Define Dressler’s syndrome
Also called post MI syndrome. Usually occurs 2-3 weeks post MI. Caused by local immune response and causes pericarditis. Pleuritic chest pain, low grade fever, pericardial rub , effusion./
Secondary prevention post MI
6 As
Aspirin - 75g OD
Another antiplatelet
Atorvastatin
ACE inhibitor
Atenolol
Aldosterone - if heart failue
Define left ventricular failure
The left ventricle is unable to adequately move blood throught the left side of the heart. Causes back pressure into the pulmonary system and they leak fluid causing pulmonary oedema.
Common causes of left ventricular failure
Iatrogenic - aggressive fluids in frailty
Sepsis
MI
Arrhythmia
History of left ventricular failure
Shortness of breath - worse on lying.
Cough p frothy white/pink sputum
Clinical signs of left ventricular failure
High RR
Low O2
Tachycardia
3rd heart sound
Bilateral basal crackles
Hypotension
Peripheral oedema
Investigations in left ventricular failure
ECG
ABG
CXR
Bloods - BNP
Echo
CXR findings in heart failure
ABCDE
Alveolar oedema - bat wings
Kerley B lines - interstitial oedema
Cardiomegaly
Dilated prominent upper lobe vessels/Upper lobe Diversion
Effusion
Management of left ventricular failure
Pour sod
Pour away IV fluids - fluid balance
Sit up
Oxygen
Diuretics
History of chronic heart failure
Breathlessness worse on exertion
Cough - white pink frothy sputum
Orthopnoea - SOB on lying
Paroxysmal nocturnal dyspnoea
Peripheral oedema
Management of Chronic heart failure
ABAL
ACE inhibitor
Beta Blocker
Aldosterone - when controled with A or B
Loop diuretics - furosemide for symtom management
Define Cor pulmonale
Is right sided hear failure caused by respiratory disease, increased pressure in the pulmonary arteries results in right ventricle being unable to pump effectively causing back pressure.
Common causes of Cor Pulmonale
COPD
Pulmonary embolism
Interstitial lung disease
Cystic fibrosis
Primary pulmonary hypertension
History of Cor Pulmonale
Shortness of breath - also caused by respiratory condition
Peripheral oedema
Syncope
Chest pain
Clinical signs of Cor Pulmonale
Hypoxia
Cyanosis
Raised JVP
Peripheral oedema
Third heart sound
Murmur - pan-systolic in tricuspid regurg
Hepatomegaly - due to back pressure
Management of Cor Pulmonale
Treat underlying cause
Manage symptoms
Define hypertension
High blood pressure - 140/90 in clinic or 135/85 at home/ambulatory
Common causes of hypertension
ROPE
Renal disease - artery stenosis
Obesity
Pregnancy - pre-eclampsia
Endocrine - Conns (Hyperaldosteronism)
Complications of hypertension
Ischaemic heart disease
Cerebrovascular accident - stroke, haemorrhage
Hypertensive retinopathy
Hypertensive nephropathy
Heart failure
Stages of hyper tension
Stage 1 - >140/90 (135/85)
Stage 2 - >160/100 (150/96)
Stage 3 - >180/120
Management of hypertension
ABCD
ACE inhibitor
ARB
Beta blocker
Calcium channel blocker
Diuretics
ACEi first line then CCB
>55 CCB first or black
ACEi always in diabetics
Define heart murmur
Extra or unusual sounds heard when ascultating the heart. Caused by turbulent blood flow through the heart, or opening or closing of valves
What causes S1 Sound
Closing of the atrioventricular valves - tricuspid and mitral
Heard at the start of systolic contraction
What causes S2 sound
The closing of the semilunar valves - aortic and pulmonary
Heard once systolic contraction is complete
What causes S3 sound
Heard rapidly after S2 caused by rapid ventricular filling - chordae tendineae pull to full length - can be normal in ages 15-40
Indicates heart failure in older people.
What causes S4 sound
Heard directly before S1
Caused by turbulent flow from an atria contracting against a non-compliant ventricle.
Suggests a stiff or hypertrophic ventricle
What vale condition cause hypertrophy
Stenosis - mitral and aortic
Heart works hard to push against stiff valve
What valve conditions cause dilation
Regurgitation
What murmur is heard in mitral stenosis
A low rumbling mid-diastolic murmur
Caused by low blood flow through stenosed valve during atrial contraction
What heart murmur is heard in mitral regurgitation
Pan-systolic high pitched murmur
Caused by blood leaking back into the atria during ventricular contraction
What is associated with mitral stenosis
Malar flush - back pressure into pulmonary system causing rise in CO2 and vasodilation
AF - left atria struggling to push through stenotic valve
What does a mitralregurgitation murmur radiate to
Left axila -
Cause of mitral regurgitation
Idiopathic -
ischaemic heart disease
Infective endocarditis
Rheumatic heart disease
Connective tissue disorders - ehlers danlos/marfans
What murmur is heard in aortic stenosis
Ejection systolic high pitched murmur
Crescendo-decrescendo character
Caused by turbulent blood flor across the valve during ventricular contraction
Where might an aortic stenosis murmur radiate to
Carotids
Other examination findings in aortic stenosis
Slow rising pulse
Narrow pulse pressure
Exertional syncope
Causes of aortic stenosis
Idiopathic
Rheumatic
What murmur is heard in aortic regurgitation
Early diastolic soft murmur
Caused by immediate back flow of blood through competent valve
What other clinicals signs of aortic regurgitation might be found
Collapsing pulse
Austin flint murmur - early diastolic rumbling murmur heard at the apex
Define atrial fibrilation
Contraction of the atria is uncoordinated, rapid and irregular due to disorganised electrical activity that overrides the normal activity of the sinoatrial node
Define atrial fibrillation
Contraction of the atria is uncoordinated, rapid and irregular due to disorganised electrical activity that overrides the normal activity of the sinoatrial node
History of atrial fibrillation
Asymptomatic
Palpitations
Shortness of breath
Syncope
Stroke,
What are the two differentials of irregularly irregular pulses
AF
Ventricular ectopic
Signs of AF on ECG
Absent P waves
Narrow QRS
Irregularly irregular ventricular rhythm
Common causes of AF
SMITH
Sepsis
Mitral valve pathology
Ischaemic heart disease
Thyrotoxicosis
Hypertension
Main principles of managing AF
Rate or Rhythm control
Anticoagulation
Why use rate control in AF
Atria are very inefficient
If atria contracting fast, they are even less efficient
Despite reducing rate you increase cardiac output by increasing atrial filling
When should you not use rate control to manage AF
First line unless:
Reversible cause
New onset
Causing heart failure
Remain symptomatic despite rate controll
Options for rate control in AF
Beta blocker - first line - atenolol 50mg
CCB - diltiazem - not in heart failure
Digoxin - sedentary people
What is the aim of rhythm control
Returning to sinus rhythm
Single cardioversion or long term medical rhythm control
When to use immediate cardioversion
AF present for <48 hours or severely haemodynamically unstable
When to use delayed cardioversion
If AF present for >48 hours and they are stable
How long should you be anticoagulated before delayed cardio version
At least 3 weeks - also rate control whilst waiting.
Options for cardioversion in AF
Pharmacological - flecanide, amiodarone
Electrical cardioversion
Long term - beta blockers, dronedarone, amiodarone
Scoring system to assess risk of stroke in AF
CHADSVASc (Orbit score for bleeding)
Define arrhythmia
Abnormal heart rhythms, they result from interruption to the normal electrical signals that coordinate the contraction of the heart
What are the shockable rhythms
Ventricular tachycardia
Ventricular fibrillation
What are the non-shockable rhythms
Pulseless electrical activity
Asystole
Management of Narrow complex tachycardia in stable patients
Atrial fibrilation - rate control with beta blocker or diltiazem
Atrial flutter - rate control with beta blocker
Supraventricular tachy cardia - treat with vagal manoeuvres and adenosine
Management of broard complex tachycardias in stable patients
Amiodarone
Define atrial flutter
Caused by a re-entrant rhythm in the atrium which stimulates the atria to contract rapidly
Management of atrial flutter
Rate/rhythm control - betablockers or cardioversion
Treat cause
Radiofrequency ablation of the re-entrant rhythm
Anticoagulation - CHADSVASC
Define supraventricular tachycardia
Cause by electrical signal re-entering the atria from the ventricles, causing a narrow complex tachycardia.
Define wolff-parkinson white syndrome
Extra electrical pathway that connects the atria and ventricles.
ECG changes in wolff-parkinson white syndrome
Delts wave - slurred upstroke on QRS
Short PR
Wide QRS
Define first degree heart block
Delayed atrioventricular conduction through the AV node
PR interval >0.2 (1 big square)
Define second degree heart block
Failure of atrial impulse to pass the AV node
Main types of second degree heart block
Mobitz Type 1 - Wenckebach’s phenomenon
Mobitz type 2
Define second degree heart block Mobitz type 1
Gradual lengthening of the PR interval until there is failure in conduction
Define second degree heart block Mobitz type 2
Intermittent failure to conduct atrial impulses
Usually in set ratio - 2:1, 3:1
Define third degree heart block
Complete heart block - no observable relationship between P waves and QRS complexes
Big risk of asystole
Management of hear block
Unstable mobitz type 2 or 3 - atropine
