Cardiology Flashcards
asthlersoscleoriss
athlerosclerosis
fatty deposits in artery walls that harden and form plaques
affects medium and large arteries
chronic inflammation and acitvation of the immune ssytem casue athelroscleorriss
casuing depostiion of lipids in arterial walls and then devleop fibrous athermoatous plaques
the plaques can casue:
stiffening of walls=> ht, strain on heart as increased resistance
plaque rupture=> thrombosis=>block distal artery casuing ischmeia eg. ACS
stenosis=> decreased blood flow eg. angina
end resutls of athlerosclerosis
angina
MI
stroke
TIA
unstbale angina
peripheral vascualr disease
chronic mesenteric ischemia
risk factors of cardiovascualr disease
non modifiable:
increased age
male
fam hx
modifiable:
obesity
stress
alcohol
smoking
poor diet
low exercise
poor sleep
medical co morbiditits:
diabetes
ht
CKD
inflammation conditions- RA
atypical antipsycotic meds
preventions of cardiovascualr disease
optomise modifiable factors;
loose weight
stop smoking
stop alcholol
optomise medical co morbidiits
primary prevention- never had any cvd:
QRISK 3 score
if over 10% risk of having MI/stroke in 10 yrs then start them on a statin- atorvastatin 20mg at night
if had t1dm/ ckd for 10yrs or more then start on statin no matter their score
secondary prevention= patients developed MI, angina, TIA, stroke, peripheral vascualr disease :
4As
aspirin (and another antiplatlelt for 12 months - clopidogrel)
atenolol- or other beta blocker = titrate to max dose
atorvastatin 80mg
ACEi- titrated to max dose
checks for statins
check lipids after 3 months startijg
increase dose so aim to have 40% reduction in non HDL cholesterol- before increase dose though make sure they are adhering to their meds
do LFTs 3 months ater starting then 12 months- then no more
can casue rise in ALT and AST in first few weeks
stop if the rise is more than 3x the upper limit of normal
se for statins
muscle pain= myopathy- if pt muscle pain/weakness then check creatine kinase levels
T2DM
harmoerrhagic stroke- rare
constipation, diarrhoea
tendon damage
hepatits - feel flu like
pancreatitis - stomach pain
cardiovascualr disease
angina
MI
storke
coranry artery disease
due to athlerosclerosis
stable angina
insifficent blood supply not able to match the demand for it but relived on rest/ GTN spray
casues of stable angina
athleroscleorirs!!- late sign cus enoh so that its occluding some of the artery
vasosapsm
embolsim
ascending arotic dissection thats exaserbated by tachycardia, coranry arteritits eg. can get in SLE
presentation of stable angina
chest pain thats triggered on exertion/stress- anything that increases demand of heart
pain can be constricing, tight, dull, heavy
pain can radiate to arm/jaw
sob
dizzy
nausea
no pain can occur if neuopathy- b12 deficiency/diabetes
suspect pt stable anging qu to ask
rf for cvd- had before, diet, exercise, smoking, fam hist of heart/ atherlosclerosis
onset
trigger- doing at time
reliving factors- sitting
dizzy
nausea
sob
pain ofc
duration
how did you feel before- feel it coming on
how did feel after
loose consiousneess?
investigations for stable angina
diagnosist = ct coroanry angiogrpahy- involves contrast
physcial examination- heart sounds, bmi
fbc- anemia?
u and e- prior to startijg acei
lft- prior to starting statins
lipid profile
thyroid function
hba1c and fasting glucose- diabetes
managment of stable angina
ramp
refer to specialst
advise of managemnt and dx
medical managment- immediate + long term + 2 prevention
procsdures/surgical
medical:
immediate = GTN sprey when needed. if not gone after 5 mins use again. if after 2nd time pain not gone then ring 999
long term relief = betablocker- bisoprolol 5mg OD
or
CCB- amlodipine 5mg OD
if not controlled then can use both
other options for long term relieft that arnt first line:
long acting nitrates- isosoribide mononitrate
ivabradine
nicorandil
ranolazine
2ndry prevention:
aspirin 75mg OD
atorvastatin 80mg OD
acei
already on the beta blocker for the long term symtoom relive
procedural:
PCI with coronary angioplsaty - use acces via femoral/brachial artery so look for scars
or
CABG - slower recovery and more risk than pci
pt on statins and got muscle pains/ weakness
check creatine kinase as se can casue myopathy
pt is ill after pci from an mi
can have pappilary muscle rupture in mi so can casue murmur
Rupture of the papillary muscle due to a myocardial infarction → acute mitral regurgitation → widespread systolic murmur, hypotension, pulmonary oedema
why can an mi casue a murmur
Rupture of the papillary muscle due to a myocardial infarction → acute mitral regurgitation → widespread systolic murmur, hypotension, pulmonary oedema
cardiac tamponade ecg
electrical alternans
QRS morphology and amplitude changes as it swings in the pericardial fluid
cardiac tamponade presentation
becks triad- hypotension, rasied jvp, soft heart sounds
also esp if hx of chest trauma
pericarditis managment
first line- naproxen
ACS what in this category
unstable angina
NSTEMI
STEMI
= usally a result of a thrimbus from an athlerosclerotic plaque blocking a coronary a => normally made up of platelets hence antiplatelet meds treat
unstbale angina= no tissue damage. blocks off some of it at random times
STEMI = no blood at all. tissue death immediate and get changes to ecg as electrical activity changed
NSTEMI = some damage but not enough to affect electrical activity of heart in such a huge way
RCA supply and leads
r atrium
r ventricle
inferior aspect l venticle
psoterior septum
INFERIOR
II, III, aVF
II, III, aVF
affected
RCA- inferior aspect heart
LAD supply and leads
anterior apect heart
V1-V4
anteior L ventricle
anterior septum
circumflex artery supply and leads
lateral
I, aVL, V5-V6
l atrium
posterior aspect L ventricle
LCAsupply and leads
branches into circumflex and lad
anteriolaterlal
I, aVL, v3-v6
presentation of ACS
central constricting chest pain assocaite with:
nasuea and vomiting
dizzzy
palpitations
feeling impending doom
clammy and sweating
SO
ppain radiate to jaw/arm
CONTINUE AT REST FOR 20 MINS
if improve on rest then consider stable angina
silent MI - diabeteics may not have same sy ptoms- may not have the cp
investigations acs
ECG!
troponin- serial 0,6,12 hrs- rise
echo after to see functional damage
CT coroanry angiogram
CXR- asses for pulmonary odema and other cuases cp
examination
FBC- anemia
LFT
U E
thyroid funciton
lipid profile
HbA1c and fasting glucose
diagnosis of ACS
inital - ECG
if ST elevation/ new LBBB = STEMI
if no st eelveation or new LBBB then do tropnins levels
in raised troponin+/ other ECG changes (st depression, t wave inversion, pathological Qwave) = NSTEMI
if no raised troponin and normal ecg then unstbale angina - or consider other causes eg. MSK
ECG changes for STEMI
ST elevation in specific region
or
new LBBB
can haave raised tropnin too
ECG changes for NSTEMI
ST wave depression in spefic area
deep t wave inversion
patholigcal Q eaves- deep infarct and late sign
+/ raised troponin
ECG changes unstabel angina
non
normal troponin
= no tissue damage of heart occurs
when can torponin levels be raised
STEMI/NSTEMI - may not be. also rises 0,6,12 hrs
PE
sepsis
chronic heart failure
myocarditits
aortic dissection
=troponins are proteins found in cardiac muscle. rasied troponin doesnt mean ACS= they are non- specific
managemnt of ACS
mona
morphine
oxygen if less than 94%
nitrates- gtn be careful if low bp as vasodilator
aspirin- stat dose 300mg
managment acute stemi
300mg aspirin stat dose
then
if within 12 hrs of onset:
primary pCI: if available within 2 hrs of onset
thrombolysis: if PCI is no availbale within 2 hrs onset
- strpotokinase, tenecleplase, alteplase
managment of nstemi
BATMAN
Betablocker
Aspirin 300mg stat dose
ticagrelor 180mg stat dose (clopidogrel 300mg alternative)
moprhine
anticoagulant - LMWH- enoxaparin 1mg/kg twice dailiy 2-8 days
nitrates- gtn- relive coroanry artery spasm
GRACE score
if med/high risk of recurrence death then consider PCI within 4 days of admission
for all ACS secondary prevtion
6 As for ACS
Aspirin 75mg OD
Atenolol
another antiopaltelt for max 12 motnhs- clopidofrel/ticagrelor
atorvastatin 80mg OD
ACEi
aldosterone antagonist if heart failure - epelerone
also lifestyle changes- stop smoking, no alchol, healthy diet, exercise sloly
complications of ACS
septum tupture/ papillary muscle rupture- murmur
death
arythmia/ aneurysm
Dresslers syndrome
whats dresslers syndrome
also called post mycocardial infarction syndrome
usally within 2-3 weeks after MI
caused by localised immune system causing pericarditits
presentation:
pleuritc chest pain, low grade fever, pericardial rub on auscultiation
can casue pericardial effusion and rarely pericardial tamponade
dx of dresslers synfrome
recent mi
ECG= global ST elevation and T wave inversion
echo can show pericardial effusion
raised inlfam markers- CRP and ESR
managment of dresslers syndrome (pericarditits after MI)
NSAIDS-aspririn/ ibruprofen/ naproxen
more severe cases= prednisolone
may need pericardocentesis to remove fluid around ehart
whats acute LVF and pulmonary oedema
left ventricle is unable to adeqyatley pum blood out the heart and so get a backlog of blood into the pulmonary veins and lungs
the veins have lots p so become leaky and fluid leadks out and cant reabsirb fluid==> pulmonary oedema and have decreased gas cexchange
casues of acute LVF and pulmonary oedema
iatrogenic- agresive fluids in frail elderly pt with already impaired LV function
MI- damage ehart tissue so cant pump blood out as well
Arythmias
sepsis
presention of acute LVF and pulmonary oedema
rapid onset breathlessnes
exaserbated by lying down
improved on sitting up
cough with frothy white/pink sputum
increase rr
tachycardia
dec oxygen sats
look and feel unwell
T1 resp failure- low oxygen normal co2
3rd heart sound
bilateral basal crackles
hypotension in severe cases- cardiogenic shock
may also see s and s of underlying cause
eg.
chesp pain in ACS
faver in spesis
palpiatatins with arrythmua
may also have Rheart failire- raised JVP, periheral oedema of ankles, calves and sacrum
pt rapid onset sob
cough with frothy white/pink sputum
chest pain
nasusa
dizzy
clammy
tachycardia
bibasal crackles on ausculttion of lungs
left ventricular heart failure with pulmonary oedema due to MI
investifations for acute LVF and oulmonary odedma
if clinical presentation shows then initate rx bedre dx is confirmed
confrim dx= echo/BNP
ECG - ishcemia/ arrythmia
ABG
CXR- mau show cardiomegaly, upper lobe venous diversion (the backpressure casues the upper lobe veins to also be encorged with lbood even when standing= see increased prominence of diameter of upper lobe vessels in cxr), bilateral pleural effusions, fluid in interlobular fissures, kerley lines
bloods- infection, kidney function, BNP, troponin if suspect mi
Echo- ejection fraction above 50% mormla
whats normal ejection fraction
over 50%
cxr findings o acute LVF and pulmonary oedema
bilateral pleureal effusions
upper lobe venous diversion
kerley lines
cardiomegaly
fluid in interlobular fissures
when can bNP be rasied
BNP is senstiv ebut no specific= good for excluding LVF (stretching of the ventricles more than its range as blood cant leave it as heart overloaded.) but can be psotive and be due to other things
overloaded heart
PE
COPD
sepsis
tachycardia
renal impairment
managment of acute LVF and pulmonay oedema
pourSOD
pour away- stop- IV fluids
Sit up
Oxygen if needd - if unfer 95% - be careful if got copd
diuretics- IV furosemide 40mg stat
monitor fluid balace- measure fluid intake, measure urine output, u and e and daily body weight
if severe acute pulmonary oedema/ cardiogenic shock may:
iv opiates ans morphine vasodilate but not always
NIV- cpap
intubaion and ventilation
inotropes
- noradrenalin
strenghten force of cotraction of the heart - needs monitoring
chronic heart failure
impaired LVF results in chronic back pressure of bloodd
casues of chroninc heart failure
systolic heart failure- impaired lv contraction => alcoholism, myocardium, IHD, dilated cardiomyopathy
diastolic heart failure- impaired lv relaxation
stiff LV -> amylodosis, sarcoidosis, hypertrophyic cardiomyopathy
ischemia heart disease
arrythmia- AF
valvular heart disease- aortic stenosis
hypertension- excessive overload
presentation of chronic heart failure
sob worsened on exertion
cough - frothy white/pink sputum
orthopnea- breathlessness lying flat, relived sit or stanidng - ask re pilllows at night
paroxysmal nocturnal dynsponea- wake up at night
peripheral oedema
investigations chronic ehart failure
NT-proBNP
then alsso ecg, ehco - look at ejection fractonover 50% normal
what levels of NT-proBNP suggest chronic heart fiaure
over 2000ng/l - refer speciaislt immediate 2ww
400-2000ng/l- specialst in 6 weeks
for these two then see specialst and do TOE to see heart
if under 400ng/l then prob not heart failure and look for other causes
managment of chronic heart fialure
specialsit- withi 6 weeks, or wothin 2 weeks if over 2000ng/l
surgical rx if severe aortic stenosis/ mitral regurg
see heart failure specialst nurse
yearly flu and pneumococcal vaccine
stop smoking
optomise co morbidities
exercise as tolerated
medical:
give loop diuretics for congestive symptoms and fluid retention - furosemide 40mg OD
then if preserved ejection fraction: manage co morbiditis
if reduced ejection fraction =
ACEi + Bblocker as tolerated titrate up to 10mg OD for both
(if acei not tolerated can give ARB)
if depsite ACEi + Bblocker symtpoms persist add aldosterine antagonist - spironolcation and eplereone
monitor u and e start and any dose change as diruetics, acei and aldosterone antagnoiss can casue electroylte disrubances.
mode of action ACE i intermes of how help chronic heart failure
se
reduce angiotnesin II
vaodialtion and decrease fluid retenion and decrease sns=> decrease preload and afterload
dry cough
postrual hypotension
increase potassium = hyperkalaemia
renal impairment
mode of action of beta blockers in terms of for chronic heart fialure
se
decrease workload of heart
triggers remodelling
se
postrual hypotnsion
dizzy
bradycardia
= possible syncope
heart rate on ecg how calculate
over 100= tachy
under 60 brady
regular can do 300/no big squares between r-r interval
if irregular- then number of complexes X 6
is the rate irregualry irregular- eg. AF
or is it regularly irregular- some form of pattern
once done rate of heart on ecg then look at axis of heart
what is left/right axis deviaition and whats normal
normal= lead II most positive defelction
left axis deviation- I and III leaving eachother
I moat positive delfection
II and III negative delfection
= conduction abnomality
right axis deviation- I and III towards eachother
I negative delfection
III most postiive deflection
- r ventricular hypertrophy
once looked at axis deviation then look at P waves what look for
present?
QRS after each?
duration, direction and shape
no p wave? is there saw tooth- flutter
chaotic baseline- fibrillation
flat- no atrial activity
once looked at p wave then look at what
PR interval
PR interval whats normal
normal 3-5 small squares
if more than5 small squares- more than 0.2 seconds then AV block
types of AV block
fisst degree heart block = prolonged fixed PR interval
second degree heart block type 1= mobitz type 1= progressvily longer PR interval until eventually QRS dropped
then this repeats = longer longer longer and then non
secind degree heart block type 2= mobitz 2=
fixed prolonged PR interval (like first degree) but then also QRS compleze is intermittently dropped and repeat cycle - if dropped afer every 3rd then 3:1 if dropped aftr every 4th p the 4:1
(first degree heart block and secind degree t2 are similar in that they both have a fixed prologned PR interval but in secind degree goes that bit further and qrs drops)
third degree heart block= compete heartblock
no electrical communication between atria and ventricles and so have p waves and QRS complex but no asscoaition between them
fixed prolonged PR interval
frist degree heart block
progressviely longer PR interval then QRS drops
secind degree heart block type 1
fixed prolonation PR interval and then QRS intermittently drops
second degree heart block t2= mobitz2
p waves there
qrs there
no assocaition with timings of the teo
thrid degree-complete heart block
cor pulmonale
r sided heart fialure due to resp disease
increase pressure and resitance in pulmonary arteries= pulmonary ht
the right ventricle is unable to effectively pump blood out the right side of the heart
back pressure of blood in the right atrium, vena cavca, systemic venous system
casues of cor pulmoanle
COPD!!!- most coomon
PE
CF
interstial lung disease
primary pulmoanry ht
left sided heart failure can cause it due to casuing pulmonary oedema and ht and then have increase afterload for right heart and then r ventricular failure
presentation cor pulmoanle
early- asymtpomatic
SOB- hard to tell as they also have resp disease- but if its worsening sob DEFO THINK OF COR PULMOANLE
SOBOE
hypoxia
cyanosis
syncope
hepatomegaly- back pressure in hepatic veins - pulsatile in tricuspid regurg
3rd heart sound
murmurs- tricuspid regurg pansystolic murmur
peripheral oedema
rasied JVP
chest pain
congestion of peripheral tissues:
oedema and ascited
gi congestion- weight loss and anorexia as poor absorbtion due to oedematous gut
liver congestion- impaired liver function- jaundice etc in late stagea
managment of cor pulmoanle
ecg- may show r ventricular hypertrophy
fbc- may have it due to polycythemia
abg
bnp
thoracic mri
main thing is treat symtoms and underlyin casue
give oxygen therapy and prognosis is poor
pt has copd
no fever
increasing sob
differnetilas
exaserbaion of copd
cor pulmonale
pt has copd
have increasing sob
peripheral oedema
hepatomegaly
cor pulmonale
casues of hypertension
essenetial ht- primary- no casue
secondary ht:
Renal disease- renal artery stenosis - esp consider if not repsonding to rx
obesity
pregnacy-pre eclampsia
endocrine- esp conns (hyperaldosteronsism) - check renin: aldosterone ratio- high aldosterone low renin
hypertension values satge 1 and 2
normal bp is under 120/80
if under 140/90 at clinic then check bp cevery 5 years
if 140/90-179/119 at clinic offfer Abulatory bp / home bo reading for few weeks throughout diff times of day and asses for cv risk and organ damage
stage 1=
clinic 140/90
home/ambulatory 135/85
stage 2=
clinic 160/100
home/abulatory 150/95
if under 40 and stage 2 consider specialst evaulation of secondary causes
180/120 or more then urgent specilsit if got compliactions or suspect phaeochromocytoma
complicatios ht
ishcemia heart diseasa
vascular dementia
aneurysm
CKD- hypertensive nephropathy
hypertensive retinopathy
cerebrovascualr accident - haemorrhage/stroke
peripheral arterial disease
aortic dissection
BP targets for pt on treatment
80 or over:
clinic less than 150/90
home/ambulatory= less than 145/85
under 80:
- under stage 1 so
clinic= under 140/90
home/ ambulatory= under 135/85
treatment for hypertension
life style advice for all- dec salt less 6g per day, regular exercise, stop smoking
anyone woth T2DM or under 55 = ACEi (or ARB)
if over 55 or black/african carribean = CCB
add in the opposite or thiazide like diuretic:
anyone woth T2DM or under 55= ACEi (ARB) + CCB or thiazide like diurtic
if over 55 or black african carribean = CCB + ACEi (ARB) or thiazide like diuretic
all three:
ACEi (ARB) +CCB + thiazide like diuretic
confrim resitant ht with home/ ambulatory bp, check postural hypotension and adherenace if is still ghihg then:
expert adivce
or
add low dose spirinolcatone if K 4.5mm/l or less
or
add alpha blocker/beta blocker if K more than 4.5mm/l
expert if BP unctorlled on 4 drugs
pt on ACEi + CCB + thiazide like diruetic and still ht
what do
look at potassoum levels
if 4.5 or less then give spironolactone
if more than 4.5mm/l postassium in blood then give alpha blcoker/beta blocker
what can ht drugs do to potassoim
thiazide like diuretics= hypokalaemia
ACEi + aldosterone antagonsists (spirinolactone) = hyperkalaemia
= monitor u and e if on ACEi or all diuretics
indapamide drug
thiazide like diruetic
ccb drus
amlodopine
verapamil
ACEi frug
ramipril
ARB drug
candesartan
S1
sound of atrioventricular valves closing as ventricles start contraction- systole
S2
sound of pulmonary and aortic valve shutting as heart start diastole- end of systole
S3
can be normal in youg
sound of fast filling ventricles as then chordae tendiane pulled
can be sign of heart failure as ventrcels and chordae are stiff and so limit is faster met
just after S2
what fills theventricles
diastole of ventrciles- very important - as get older this decreases
systole of atria
S4
sound before S1 always abnormal
what casues left atrial hypertrophy
mitral stenosis- atria having to push harder to get blood thorugh