Cardiology (3) Flashcards
Define varicose veins
Subcutaneous permanently dilated veins >3mm diameter when measured in standing position, usually in the superficial veins of the lower leg due to valve insufficiency
Summarise the aetiology of varicose veins
Venous valve incompetence allowing backflow of blood and pooling
Primary:
Due to genetic or developmental weakness in the vein wall
Results in increased elasticity, dilatation and valvular incompetence
Secondary: Due to venous outflow obstruction Pregnancy Pelvic malignancy Ovarian cysts Ascites Lymphadenopathy Retroperitoneal fibrosis Due to valve damage (e.g. after DVT) Due to high flow (e.g. arteriovenous fistula)
What are the risk factors of varicose veins?
Increasing age Female Pregnancy Family history Caucasian Obesity Standing for prolonged periods of time Crossing knees for prolonged periods of time
Summarise the epidemiology of varicose veins
COMMON Prevalence higher in industrialised and developed regions Prevalence = 10-15% in men Prevalence = 20-25% in women More common in women Prevalence increases with age
What are the presenting symptoms of varicose veins?
Enlarged, tortuous, visible veins in the lower leg
Pain
Pruritis
Fatigue
Heaviness
Patients may complain about the cosmetic appearance
Aching in the legs - worse towards the end of the day or after standing for long periods of time
Swelling
Bleeding
Infection
Ulceration
What are the signs on physical examination of varicose veins?
Inspect when STANDING
Swelling of legs
Enlarged tortuous visible veins in the legs
Hyperpigmentation/darkening of leg (haemosiderin deposition)
Venous stasis ulcers
May feel fascial defects along the veins
Cough impulse may be felt over the saphenofemoral junction
Tap Test - tapping over the saphenofemoral junction will lead to an impulse felt distally (this would not happen if the valves were competent)
Palpation of a thrill or auscultation of a bruit would suggest an AV fistula
Leg is elevated and the veins are emptied
Signs of venous insufficiency: Varicose eczema Haemosiderin staining Atrophie blanche Lipodermatosclerosis Oedema Ulceration
What are the appropriate investigations for varicose veins?
Duplex USS - assess for reversed flow, valve closure time (>0.5 seconds indicative of reflux), locates sites of incompetence or reflux and excludes DVT
What is the appropriate management for varicose veins?
Conservative: Elevate legs above heart regularly Compression stockings to prevent venous stasis Manual compression Exercise - improve skeletal muscle pump# Weight loss Reduce long periods of standing
Surgical: Saphenofemoral ligation Stripping of the long saphenous vein Avulsion of varicosities Vein transplant Vein repair Vein removal
What are the possible complications of varicose veins?
Chronic venous insufficiency Venous ulceration Haemorrhage of varicose veins Lipodermatosclerosis Haemosiderin deposition Eczema Superficial thrombophlebitis
Complications of Sclerotherapy :
Skin staining, local scarring
Complications of Surgery:
Haemorrhage, infection, recurrence, paraesthesia, peroneal nerve injury
What is the prognosis of varicose veins?
Slowly progressive
High recurrence
Define pulmonary hypertension
An increase in mean pulmonary arterial pressure >25mmHg which can be caused by a variety of other conditions and can lead to originally right ventricular hypertrophy, followed by right heart failure.
Summarise the aetiology of pulmonary hypertension
Idiopathic Chronic lung disease eg COPD Hypoxia Left heart failure Left heart valve failure Methotrexate leading to lung fibrosis Chronic thromboembolic events leading to clots constricting pulmonary vessels causing to increased resistance
Summarise the epidemiology of pulmonary hypertension
Idiopathic pulmonary hypertension is RARE
More common in severe respiratory and cardiac disease
What are the presenting symptoms of pulmonary hypertension?
Progressive dyspnoea Orthopnoea Fatigue Weakness Exertional dizziness and syncope Swelling of legs Angina and tachyarrhythmia
What are the signs on physical examination of pulmonary hypertension?
Hepatomegaly Raised JVP Peripheral oedema Dullness on percussion due to pulmonary oedema Right ventricular heave Loud pulmonary second heart sound Murmur - pulmonary regurgitation Tricuspid regurgitation
What are the appropriate investigations for pulmonary hypertension?
Echo - shows elevated pressure in pulmonary arteries and right ventricle
Right heart catheterisation - allows diagnostic measurement of pressure in pulmonary vessels
CXR – exclude other lung diseases
ECG – right ventricular hypertrophy and strain
Pulmonary function tests
LFTs – liver damage - portal hypertension
Lung biopsy – interstitial lung disease
Define ventricular tachycardia
A regular broad QRS complex tachycardia, characterised by heart beat greater than 100bpm which originates from a ventricular ectopic focus.
Summarise the aetiology of ventricular tachycardia
Idiopathic
Secondary to: Coronary heart disease Hypertension Cardiomyopathy Post-MI
Electrical impulses arise from a ventricular ectopic focus
Can be caused by infectious diseases such as Chagas’ disease.
Risk Factors:
Coronary heart disease
Structural heart disease
Electrolyte deficiencies (e.g. hypokalaemia, hypocalcaemia, hypomagnesaemia)
Use of stimulant drugs (e.g. caffeine, cocaine)
Summarise the epidemiology of ventricular tachycardia
Fairly common
It is one of the shockable rhythms that is seen in cardiac arrest patients
VT incidence peaks in the middle decades of life
Most common cause of sudden cardiac death
What are the presenting symptoms of ventricular tachycardia?
Symptoms of hypoperfusion of end organs due to decreased CO Dizziness Syncope Weakness Palpitations Fatigue Chest pain Dyspnoea
What are the signs on physical examination of ventricular tachycardia?
Depends on degree of haemodynamic instability: Tachycardia Hypotension Weak pulse Impaired consciousness Cannon A waves Respiratory distress Bibasal crackles Anxiety Agitation Lethargy Coma
What are the appropriate investigations of ventricular tachycardia?
ECG:
Broad QRS complex tachycardia - >120ms
Monomorphic (re-entrant tachy above scar tissue or focal) or polymorphic waves (focal)
Electrolytes:
Hypokalaemia and hypomagnesaemia are associated with torsades-de-pointes
Drug levels to check for digoxin toxicity
Troponin and creatine kinase MB - elevated in MI
What is the management of ventricular tachycardia?
Pulseless VT - follow advanced life support algorithm, DEFIBRILLATION (unsynchronised)
Unstable VT - reduced cardiac output:
Synchronised cardioversion
Correct electrolyte abnormalities or other reversible cause
Amiodarone – anti-arrhythmic medication
Stable VT: (no symptoms of haemodynamic compromise)
Correct electrolyte abnormalities
Amiodarone
2nd line if ineffective - Synchronised DC shock
Implantable Cardioverter Defibrillator (ICD) if:
Sustained VT causing syncope
Sustained VT with ejection fraction < 35%
Previous cardiac arrest due to VT or VF
MI complicated by non-sustained VT
Radiofrequency catheter ablation if structural heart disease
What are the possible complications of ventricular tachycardia?
ICD malfunction VF Sudden cardiac death ICD infection Congestive cardiac failure Cardiogenic shock
Summarise the prognosis of ventricular tachycardia
GOOD if treated RAPIDLY
Long-term prognosis depends on the underlying cause
Define peripheral vascular disease
A range of arterial syndromes caused by narrowing of vessels, resulting in reduced blood flow. This is most often due to atherosclerosis affecting the arteries of the leg.
Summarise the aetiology of peripheral vascular disease
The most common cause is ATHEROSCLEROSIS
Types of peripheral vascular disease:
Intermittent claudication - calf pain on exercise
Critical limb ischaemia - pain at rest: the MOST SEVERE manifestation of PVD
Acute limb ischaemia - a sudden decrease in arterial perfusion in a limb, due to thrombotic or embolic causes
Arterial ulcers
Gangrene
Risk factors: Hypertension Smoking Dyslipidaemia Diabetes Metabolic syndrome Age >60 years Obesity Physical inactivity
Summarise the epidemiology of peripheral vascular disease
Incidence increases with age
More common in men
What are the presenting symptoms of peripheral vascular disease?
INTERMITTENT CLAUDICATION:
Pain, tiredness, numbness of legs which is relieved by rest
Calf claudication = femoral disease
Buttock claudication = iliac disease
Critical limb ischaemia: Pain in legs at rest, worst when lying down Relieved by standing Ulcers Gangrene Night pain
Leriche Syndrome (aortoiliac occlusive disease):
Buttock claudication
Impotence
Absent/weak distal pulses
Progression from asymptomatic, intermittent claudication, rest pain, ulcers and gangrene
What are the signs on physical examination of peripheral vascular disease?
Hair loss Pallor Nail changes - loss, brittle, ridging Ulcers - dry, painful, punched out, non-healing Gangrene Dependent rubor - foot turns red when hanging down Elevation pallor Muscular atrophy
Acute ischaemic limb = 6Ps: Pallor Parasthesia Paralysis Pain Perishingly cold Pulseless
What are the appropriate investigations for peripheral vascular disease?
Ankle brachial pressure index - systolic ankle/systolic arm <0.91
Toe-brachial index <0.6
Doppler ultrasound - FIRST LINE - shows site and degree of stenosis
CT/MR arteriography
Conventional arteriography - gold standard for vascular imaging
DO NOT APPLY PRESSURE BAND - will worsen ischaemia
Define ventricular fibrillation
Uncoordinated muscle fibre contraction in the ventricles, resulting in an irregular broad-complex tachycardia that can cause cardiac arrest and sudden cardiac death and zero cardiac output.
Ventricular fibrillation is a medical emergency and will result in death within minutes if it is not rapidly identified and managed appropriately.
Summarise the aetiology of ventricular fibrillation
The ventricular fibres contract randomly causing complete failure of ventricular function
Most cases occur in patients with underlying heart disease
Causes:
Ischaemic Heart Disease/Coronary artery disease (most common)
Idiopathic (progression from idiopathic ventricular tachycardia)
Cardiomyopathy (hypertrophic, arrhythmogenic right ventricular)
Long QT Syndrome
Tissue heterogeneity
Ischaemia
Electrolyte disturbance - hypo or hyperkalaemia
Drugs - methamphetamines, cocaine
Scarring of heart causing anatomical reentrant
Summarise the epidemiology of ventricular fibrillation
The MOST COMMON arrhythmia identified in cardiac arrest patients
Incidence of VF parallels the incidence of ischaemic heart disease
What are the presenting symptoms of ventricular fibrillation?
Collapse, fainting and loss of consciousness are most common presentations
Preceding symptoms: Chest pain Nausea Vomiting Palpitations Dizziness SOB
History of associated conditions: Coronary artery disease Cardiomyopathy Valvular heart disease Long QT syndrome Wolff-Parkinson-White syndrome Brugada syndrome
What are the signs on physical examination of ventricular fibrillation?
Tachycardia Hypotension Weak pulses Presyncope Syncope Airway compromise Diminished responsiveness Dyspnoea
What are the appropriate investigations for ventricular fibrillation?
ECG:
No clear P, Q, R, S or T waves
Rate 150-500bpm
Chaotic irregular deflections of varying amplitude
Cardiac enzymes (e.g. troponins) - check for recent ischaemic event
Electrolytes - derangement can cause arrhythmias, including VF
Drug levels and toxicology screen - anti-arrhythmics and cocaine can cause arrhythmia
TFTs - hyperthyroidism can cause tachyarrhythmias
Coronary angiography - if patient survives VF, to check the integrity of coronary arteries
What is the management of ventricular fibrillation?
Urgent defibrillation and CPR
Cardioversion
ICD implantation if VF is due to irreversible cause
Patients who survive need full assessment of left ventricular function, myocardial perfusion and electrophysiological stability
Empirical beta-blockers
Some patients may be treated with radiofrequency ablation (RFA)
What are the possible complications of ventricular fibrillation?
Ischaemic brain injury due to loss of cardiac output Myocardial injury Post-defibrillation arrhythmias Aspiration pneumonia Skin burns Death
Summarise the prognosis of ventricular fibrillation
Depends on the time between onset of VF and medical intervention
Early defibrillation is essential (ideally within 4-6 mins)
Anoxic encephalopathy is a major outcome of VF
Define supraventricular tachycardia
A narrow-complex tachycardia with absent p waves which has a supraventricular origin.
AF is a type of SVT
Typically involves AVNRT and AVRT - regular narrow complex, paroxysmal SVT
Describe the aetiology of supraventricular tachycardia
AVRT - accessory pathway forms between atria and ventricles, allowing electrical impulse to pass back up from the ventricle to the atria, causing a re-entry circuit. Common type of this is Wolff-Parkinson-White syndrome with Bundle of Kent
AVNRT - accessory pathway is in or around the AV node (localised re-entry circuit)
Risk factors: Nicotine Alcohol Caffeine Previous MI Digoxin toxicity
Summarise the epidemiology of supraventricular tachycardia
Twice as common in females
More common in younger patients
What are the presenting symptoms of supraventricular tachycardia?
Paroxysmal
Abrupt onset and termination of symptoms
Dyspnoea Dizziness Chest pain Syncope Pre-syncope Fatigue Palpitations
What are the signs on physical examination of supraventricular tachycardia?
Tachycardia - 150-250bpm
AVNRT - normal except tachycardia
Wolff-Parkinson-White:
Tachycardia
Secondary cardiomyopathy (S3 gallop, RV heave, displaced apex beat)
What are the appropriate investigations for supraventricular tachycardia?
ECG:
Narrow complex tachycardia, absent p waves
Differentiating between AVNRT and AVRT – once the SVT has been terminated and normal rate and rhythm are re-established:
AVNRT – appears normal
AVRT – delta-waves (slurred upstroke of the QRS complex)
24 hr ECG monitoring - will be required in patients with paroxysmal palpitations
Cardiac Enzymes: Check for features of MI (especially if there is chest pain)
Electrolytes: can cause arrhythmia
TFTs: can cause arrhythmia
Digoxin Level: for patients on digoxin
Echocardiogram: check for structural heart disease
What is the appropriate management of supraventricular tachycardia?
Haemodynamically unstable = DC cardioversion
Haemodynamically stable = vagal manouvere and chemical cardioversion
AVNRT:
Vagal manouveres (blocks AV node) - carotid sinus massage, Valsalva manouvere (forced exhalation in acute attack
If unresponsive to vagal manouveres:
Adenosine
AVRT:
Acute: Same as AVNRT, avoid long acting AV nodal blockers e.g. digoxin, verapamil
Medical: Procainamide and Flecainide
Long term - radiofrequency ablation
What are the possible complications of supraventricular tachycardia?
Haemodynamic compromise Congestive heart failure Systemic embolism Cardiac tamponade DVT Syncope MI Tachycardia-induced angina
Summarise the prognosis of supraventricular tachycardia
Dependent on the presence of underlying structural heart disease
If structurally normal heart – GOOD PROGNOSIS
People with pre-excitation have a small risk of sudden death
Define Ischaemic Heart Disease
Characterised by decreased blood supply to the heart muscle resulting in chest pain (angina pectoris).
May present as stable angina or acute coronary syndrome.
ACS can be further subdivided into:
Unstable angina - chest pain at rest due to ischaemia but without cardiac injury
NSTEMI
STEMI - ST elevation with transmural infarction
Summarise the aetiology of Ischaemic Heart Disease
Angina pectoris occurs when myocardial oxygen demand exceeds oxygen supply, usually due to atherosclerosis
Rare causes of angina pectoris:
Coronary artery spasm (e.g. induced by cocaine), arteritis and emboli
Risk Factors: Male Diabetes mellitus Family history Hypertension Hyperlipidaemia Smoking
Summarise the epidemiology of Ischaemic Heart Disease
Common
More common in males
What are the presenting symptoms of Ischaemic Heart Disease?
Crushing central chest pain Pain radiates to jaw and down left arm Develops during exercise and relieved with rest - stable angina Nausea Sweating Fatigue Dyspnoea
What are the signs on physical examination of Ischaemic Heart Disease?
ACS: There may be NO CLINICAL SIGNS
Pale
Sweating
Restless
Low-grade pyrexia
Check both radial pulses to rule out aortic dissection
Arrhythmias, disturbances of BP and new heart murmurs
Signs of complications (e.g. acute heart failure, cardiogenic shock)
What are the appropriate investigations for Ischaemic Heart Disease?
Troponin - elevated if STEMI or NSTEMI
AST - raised 24 hours post-MI
LDH - raised 48 hours post-MI
ECG:
ST depression - NSTEMI
New onset LBBB - STEMI
ST elevation in leads V1-V4 - anterior - left anterior descending artery
ST elevation in leads II, III, aVF - inferior - right coronary artery
ST elevation in leads V5, V6, aVL, I - lateral - left circumflex artery
Posterior MI - ST depression V1-V3, tall R wave
Summarise the management of Ischaemic Heart Disease
Stable angina: Symptomatic - GTN spray Anti-anginals - beta blockers, CCB Risk factor control Aspirin 75mg/day
ACS management: Morphine Oxygen Anticoagulants - aspirin, clopidogrel Nitrates
Beta blockers
ACEi
Statins
Heparin
STEMI:
If <12 hours since symptom onset - urgent PCI
If >12 hours, coronary angiography followed by PCI if necessary
STEMI = aspirin, clopidogrel, PCI NSTEMI = aspirin, clopidogrel, LMWH
What are the possible complications of ischaemic heart disease?
Death Arrhythmia - VT Rupture Tamponade Heart failure Valve disease Aneurysm Dressler's syndrome Embolism Reinfarction
