Cardiology 3 Flashcards
Define mitral regurgitation
Retrograde flow of blood from left ventricle to left atrium during systole
Summarise the epidemiology of mitral regurgitation
- Affect ~5% of adults
* Mitral valve prolapse is common in young female
Explain the aetiology/risk factors of mitral regurgitation
- Broadly speaking, it is caused by mitral valve damage or dysfunction, which, in turn could be caused by any of the following:
o Rheumatic heart disease (MOST COMMON)
o Infective endocarditis
o Mitral valve prolapse
o Papillary muscle rupture or dysfunction (secondary to IHD or cardiomyopathy)
o Chordal rupture and floppy mitral valve associated with connective tissue disease (e.g. Ehlers-Danlos syndrome, Marfan’s syndrome)
Recognise the presenting symptoms of mitral regurgitation
- Acute MR - may present with symptoms of left ventricular failure
- Chronic MR - may be asymptomatic or present with:
o Exertional dyspnoea
o Palpitations if in AF
o Fatigue
- Mitral Valve Prolapse - asymptomatic or atypical chest pain or palpitations
Recognise the signs of mitral regurgitation on physical examination
- Pulse may be irregularly irregular (if in AF)
- Laterally displaced apex beat with thrusting (due to left ventricular dilation)
- Pansystolic murmur
o Loudest at apex beat
o Radiating to the axilla
o Soft S1
o S3 may be heard due to rapid ventricular filling in early diastole
- Signs of left ventricular failure in acute mitral regurgitation
- Mitral Valve Prolapse
o Mid-systolic click
o Late systolic murmur
o The click moves towards S1 when standing and away when lying down
Identify appropriate investigations for mitral regurgitation
- ECG
o NORMAL
o May show AF or p mitrale (indicates left atrial hypertrophy)
- CXR
o ACUTE mitral regurgitation may produce signs of left ventricular failure
o CHRONIC mitral regurgitation shows:
- Left atrial enlargement
- Cardiomegaly (due to LV dilation)
- Mitral valve calcification (if rheumatic heart disease is the cause)
- Echocardiography
o Performed every 6-12 months in moderate-severe MR
o Allows assessment of LV ejection fraction and end-systolic dimension
Define mitral stenosis
Mitral valve narrowing causing obstruction to blood flow from the left atrium to the left ventricl
Summarise the epidemiology of mitral stenosis
Incidence is declining because rheumatic fever is becoming more and more rare
Explain the aetiology/risk factors for mitral stenosis
- MAIN CAUSE: Rheumatic Heart Disease (90% of cases)
- Rare causes of mitral stenosis:
o Congenital mitral stenosis
o SLE
o Rheumatoid arthritis
o Endocarditis
o Atrial myxoma
Recognise the presenting symptoms of mitral stenosis
- May be ASYMPTOMATIC
- Fatigue
- Shortness of breath on exertion
- Orthopnoea
- Palpitations (related to AF)
- Rare symptoms:
o Cough
o Haemoptysis
o Hoarseness caused by compression of left recurrent laryngeal nerve by an enlarged left atrium
Recognise the signs of mitral stenosis on physical examination
- Peripheral cyanosis
- Malar flush (image)
- Irregularly irregular pulse (if in AF)
- Apex beat undisplaced and tapping
- Parasternal heave (due to right ventricular hypertrophy secondary to pulmonary hypertension)
- Loud S1 with opening snap
- Mid-diastolic murmur
- Evidence of pulmonary oedema on lung auscultation (if decompensated
Identify appropriate investigations for mitral stenosis
- ECG
o May be NORMAL
o May see p mitrale (broad bifid p wave caused by left atrial hypertrophy)
o May see AF
o Evidence of right ventricular hypertrophy may be seen if there is severe pulmonary hypertension
- CXR
o Left atrial enlargement
o Cardiac enlargement
o Pulmonary congestion
o Mitral valve calcification (occurs in rheumatic cases)
- Echocardiography
o Assesses functional and structural impairments
o Transoesophageal echocardiogram (TOE) gives a better view
- Cardiac Catheterisation
o Measures severity of heart failure
Define myocarditis
Acute inflammation and necrosis of cardiac muscle (myocardium
Summarise the epidemiology of myocarditis
- Incidence is difficult to measure accurately
- Coxsackie B virus is most common in Europe and USA
- Chagas disease is most common in South Americ
Explain the aetiology/risk factors of myocarditis
- Usually IDIOPATHIC
- Viruses
o Coxsackie B
o EBV
o CMV
o Adenovirus
o Influenza
- Bacteria
o Post-streptococcal
o Tuberculosis
o Diphtheria
- Fungal
o Candidiasis
- Protozoal
o Trypanosomiasis (Chagas disease)
- Helminths
o Trichinosis
- Non-infective
o Systemic: SLE, sarcoidosis, polymyositis
o Hypersensitivity myocarditis: sulphonamides
- Drugs
o Chemotherapy agents (e.g. doxorubicin, streptomycin)
- Others
o Cocaine, heavy metals, radiation
Recognise the presenting symptoms of myocarditis
- Prodromal flu-like illness with:
o Fever
o Malaise
o Fatigue
o Lethargy
- Breathlessness (due to pericardial effusion/myocardial dysfunction)
- Palpitations
- Sharp chest pain (suggesting there is also pericarditis)
Recognise the signs of myocarditis on examination
- Signs of pericarditis
* Signs of complications (e.g. heart failure, arrhythmia)
Identify appropriate investigations for myocarditis
- Bloods
o FBC - raised WCC if infective cause
o U&E
o ESR/CRP - raised
o Cardiac enzymes - may be raised
o Tests to identify cause (e.g. viral/bacterial serology, ANA, TFT)
- ECG
o Non-specific T wave and ST changes
o PERICARDITIS: widespread saddle-shaped ST elevation
- CXR
o May be NORMAL
o May show cardiomegaly
- Pericardial Fluid Drainage
o Measure glucose, protein, cytology, culture and sensitivity
o Helps identify causative organism
- Echocardiography
o Assesses systolic/diastolic function
o Wall motion abnormalities
o Pericardial effusions
- Myocardial Biopsy
o Rarely required
Define pericarditis
Inflammation of the pericardium
o It may be acute, subacute or chronic
Summarise the epidemiology of pericarditis
- UNCOMMON
- < 1/100 hospital admissions
- More common in males
Explain the aetiology/risk factors of pericarditis
- IDIOPATHIC
- Infective
Most common causative organisms:
o Coxsackie B
o Echovirus
o Mumps
o Streptococci
o Fungi
o Staphylococci
o TB
- Connective tissue disease (e.g. sarcoidosis, SLE, scleroderma)
- Post-MI (within 24-72 hrs of MI - occurs in up to 20% of patients)
- Dressler’s Syndrome - pericarditis occurring weeks/months after acute MI
- Malignancy - lung, breast, lymphoma, leukaemia, melanoma
- Radiotherapy
- Thoracic surgery
- Drugs (e.g. hydralazine, isoniazid)
Recognise the presenting symptoms of pericarditis
- CHEST PAIN
o Sharp and central
o May radiate to the neck or shoulders
o Worse when coughing and deep inspiration (pleuritic pain)
o Relieved by sitting forward
- Dyspnoea
- Nausea
Recognise the signs of pericarditis on physical examination
- Fever
- Pericardial friction rub
o Heard best at lower left sternal edge, with patient leaning forward during expiration
- Heart sounds may be faint due to a pericardial effusion
- Cardiac Tamponade signs
o Beck’s Triad (signs associated with acute cardiac tamponade)
- Raised JVP
- Low Blood Pressure
- Muffled Heart Sounds
o Tachycardia
o Pulsus paradoxus
- Definition: an abnormally large decrease in SBP (> 10 mm Hg drop) and pulse wave amplitude during inspiration
- Constrictive Pericarditis signs
o Kussmaul’s sign
o Pulsus paradoxus
o Hepatomegaly
o Ascites
o Oedema
o Pericardial knock (due to rapid ventricular filling)
o AF
Identify appropriate investigations for pericarditis
- ECG - widespread saddle-shaped ST elevation
- Echocardiogram - assesses pericardial effusion and cardiac function
- Bloods
o FBC
o U&Es
o ESR/CRP
o Cardiac Enzymes (usually normal)
o Other investigations for cause: blood cultures, ASO titres, ANA, rheumatoid factor
- CXR
o Usually normal
o May be globular if there is a pericardial effusion
Generate a management plan for pericarditis
- Acute - cardiac tamponade is treated with emergency pericardiocentesis
- Medical
o Treat underlying cause
o NSAIDs for pain and fever relief
- Recurrent
o Low-dose steroids
o Immunosuppressants
o Colchicine
- Surgical
o Pericardiectomy is performed in cases of constrictive pericarditis
Identify the possible complications of pericarditis
- Pericardial effusion
- Cardiac tamponade
- Cardiac arrhythmias
Summarise the prognosis for patients with pericarditis
- Depends on the underlying cause
- Viral cases have a GOOD prognosis
- Malignant pericarditis has a POOR prognosis
Define peripheral vascular disease
Occurs due to atherosclerosis causing stenosis of arteries via a multifactorial process involving modifiable and non-modifiable risk factors
Explain the aetiology/risk factors of peripheral vascular disease
- Occurs due to ATHEROSCLEROSIS in peripheral arteries
- Types of PVD include:
o Intermittent claudication - calf pain on exercise
o Critical limb ischaemia - pain at rest
- NOTE: this is the MOST SEVERE manifestation of peripheral vascular disease
o Acute limb ischaemia - a sudden decrease in arterial perfusion in a limb, due to thrombotic or embolic causes
o Arterial ulcers
o Gangrene
- Risk Factors (same as the risk factors for any other atherosclerotic disease)
o Smoking
o Diabetes
o Hypertension
o Hyperlipidaemia
o Physical inactivity
o Obesity
Summarise the epidemiology of peripheral vascular disease
- 55-70 yrs = 4-12% affected
- 70+ yrs = 15-20% affected
- More common in MALES
- Incidence increases with AGE
Recognise the presenting symptoms of peripheral vascular disease
- Intermittent claudication - cramping pain in the calf, thigh or buttock after walking for a given distance (claudication distance) and relieved by rest
o Calf claudication = femoral disease
o Buttock claudication = iliac disease
- Features of Critical Limb Ischaemia
o Ulcers
o Gangrene
o Rest pain
o Night pain (relieved by dangling leg over the edge of the bed)
- Leriche Syndrome (aortoiliac occlusive disease)
o Buttock claudication
o Impotence
o Absent/weak distal pulses
- Fontaine Classification of Peripheral Vascular Disease
o Asymptomatic
o Intermittent Claudication
o Rest pain
o Ulceration/gangrene
Recognise the signs of peripheral vascular disease on physical examination
- Acute Limb Ischaemia - 6 Ps
o Pain
o Pale
o Pulseless
o Paralysis
o Paraesthesia
o Perishingly Cold
- Other symptoms:
o Atrophic skin
o Hairless
o Punched-out ulcers (often painful)
o Colour change when raising leg (to Buerger’s angle)
Identify appropriate investigations for peripheral vascular disease
- Full cardiovascular risk assessment
o Blood pressure
o FBC - anaemia will worsen ischaemia
o Fasting blood glucose
o Lipid levels
o ECG - check for pre-existing coronary artery disease
o Thrombophilia screen - for patients < 50 yrs
- Colour Duplex Ultrasound
o FIRST-line
o Shows site and degree of stenosis
- MRI/CT
o Assesses extent and location of stenoses
- ABPI (Ankle-Brachial Pressure Index)
o Marker of cardiovascular disease
o ABPI < 0.8 = do NOT apply a pressure bandage because this will worsen ischaemia
Define pulmonary hypertension
An increase in mean pulmonary arterial pressure which can be caused by or associated with a wide variety of other conditions.
Explain the aetiology/risk factors of pulmonary hypertension
Pulmonary hypertension has a variety of causes
o Idiopathic
o Problems with smaller branches of the pulmonary arteries
o Left ventricular failure
o Lung disease (e.g. COPD, interstitial lung disease)
o Thromboses/Emboli in the lungs
Summarise the epidemiology of pulmonary hypertension
- Idiopathic pulmonary hypertension is RARE
* More common in severe respiratory and cardiac disease
Recognise the presenting symptoms of pulmonary hypertension
- Progressive breathlessness
- Weakness/tiredness
- Exertional dizziness and syncope
- LATE STAGE - oedema and ascites
- Angina and tachyarrhythmia
Recognise the signs of pulmonary hypertension on physical examination
- Right ventricular heave
- Loud pulmonary second heart sound
- Murmur - pulmonary regurgitation
- Tricuspid regurgitation
- Raised JVP
- Peripheral oedema
- Ascites
Identify appropriate investigations for pulmonary hypertension
- CXR - exclude other lung diseases
- ECG - right ventricular hypertrophy and strain
- Pulmonar
- LFTs - liver damage –> portal hypertension
- Lung biopsy - interstitial lung disease
- Echocardiography - assess right ventricular function
- Right Heart Catheterisation - directly measure pulmonary pressure and confirm the diagnosis
Define supraventricular tachycardia (SVT)
A regular narrow-complex tachycardia (> 100 bpm) with no p waves and a supraventricular origin.
o AF technically counts as a type of SVT
o However, SVT generally refers to:
- Atrioventricular Nodal Re-entry Tachycardia (AVNRT)
- Atrioventricular Re-entry Tachycardia (AVRT)
