Cardiology Flashcards
1
Q
Pathology of angina
A
o Restricted coronary blood flow
o Mismatch between O2 supply and demand –
diameter <75% for symptoms
2
Q
Causes of angina
A
o Almost always atheroma
o Rarely – anaemia, coronary artery spasm,
tachyarrhythmias
3
Q
Non-modifiable risk factors for angina and ACS
A
Gender, FH, age, personal history
4
Q
Modifiable risk factors for angina and ACS
A
Smoking, HTN, high cholesterol, sedentary lifestyle
5
Q
‘Controversial’ modifiable/non-modifiable risk factors for angina and ACS
A
Stress, type A personality, diabetes
6
Q
Signs and symptoms of angina
A
Chest pain:
o Heavy, central, tight, radiation to arms, jaw, neck
o Precipitated by exertion
o Relieved by rest/GTN spray
7
Q
Definition of stable angina
A
Angina induced by effort, relived by rest
8
Q
Definition of unstable angina
A
Angina with increasing frequency or severity, occurs on minimal exertion or at rest
9
Q
Definition of decubitus angina
A
Angina precipitated by lying flat (nocturnal)
10
Q
Definition of varient angina
A
Angina caused by coronary artery spasm
11
Q
Investigations for suspected angina
A
o ECG – usually normal, signs of IHD (ST elevation) o Echo and/or CXR o Bloods – FBC, U+E, TFTs lipids, HbA1C o Angiography o Exercise stress treadmill
12
Q
Management of angina
A
o Symptoms relief - GTN spray/sublingual tablets
o Betablockers and/or CCB
o Surgical – PCI, CABG
o Prevention - aspirin and statin
13
Q
Secondary prevention of CVD
A
o Qrisk calculated
o Lifestyle changes – diet, exercise, smoking
cessation
o Pharmacological – antihypertensives, statins,
diabetes treatment
o Surgical – PCI, CABG
14
Q
Definition of acute coronary syndromes (ACS)
A
Umbrella term, includes unstable angina and MI
15
Q
Symptoms of ACS
A
o Acute chest pain >20mins
o Nausea, sweatiness, dyspnoea, palpitations
o Can be silent in elderly and diabetic
16
Q
Signs of ACS
A
o Distress, anxiety, pallor, sweatiness
o Pulse and BP ↓/↑
o 4th heart sound and/or pansystolic murmur
o Signs of HF
17
Q
Investigations for suspected ACS
A
o ECG:
- STEMI – large T-waves, ST elevation -> T-
wave inversion and pathological Q-waves
- NSTEMI/unstable angina – ST depression, T-
wave inversion, or normal
o CXR – cardiomegaly, pulmonary oedema
o Bloods – FBC, U+E, lipids, troponin
18
Q
Differential diagnosis of suspected ACS
A
Stable angina, pericarditis, myocarditis, aortic dissection, PE, reflux, pneumothorax, musculoskeletal pain
19
Q
Management of ACS
A
o Acute attack - 300mg aspirin + call 999 -> pain relief,
anti-platelet, BB, anti-anginal
o Pharmacological:
- DUAL ANTIPLATELET THERAPY – aspirin +
clopidogrel
- Anticoagulant – heparin +/- fondaparinux
- General cardiac medication – BB -> ACEi -> CCB
o Surgical – patients not responding to drugs -> PCI
20
Q
Complications of ACS
A
HF, arrhythmias, pericarditis, systemic embolism, cardiac tamponade, mitral regurgitation
21
Q
Definition of heart failure
A
Cardiac output is inadequate for the body’s requirements
22
Q
Pathology of systolic failure
A
o Inability of ventricle to contract normally -> ↓cardiac output
o EF < 40%
23
Q
Causes of systolic failure
A
IHD, MI, cardiomyopathy
24
Q
Pathology of diastolic failure
A
o Inability of ventricle to relax normally -> ↑filling
pressure
o EF >50% (preserved EF)
25
Causes of diastolic failure
Tamponade, obesity, ventricular hypertrophy
26
Symptoms of left ventricular failure (LVF)
Dyspnoea, poor exercise tolerance, fatigue, nocturnal cough, wheeze, cold peripheries, weight loss
27
Causes of right ventricular failure (RVF)
LVF, pulmonary stenosis, lung disease
28
Symptoms of RVF
Peripheral oedema, ascites, anorexia, facial engorgement, epistaxis (nose bleeds)
29
Definition of congestive cardiac failure (CCF)
Both LVF and RVF
30
Definition of acute HF
New-onset acute or decompensation of chronic HF characterized by pulmonary/peripheral oedema with or without signs of peripheral hypoperfusion
31
Definition of chronic HF
HF that develops or progresses slowly, venous congestion is common but arterial pressure is well maintained until very late
32
Definition of low-output HF
CO is reduced and fails to increase normally with exertion
33
Causes of low-output HF
o Excessive preload – mitral regurgitation or fluid
overload
o Pump failure – systolic and/or diastolic HF,
decreased heart rate (betablockers, heart block,
post MI)
o Chronic excessive afterload – aortic stenosis, HTN
34
Causes of high output HF (rare)
Anaemia, pregnancy, hyperthyroidism
35
Signs of HF
* Cyanosis
* Low BP
* Narrow pulse pressure displaced apex
* RV heave (PH)
* Signs of valve diseases
36
New York Classification of HF
• I – no undue dyspnoea from ordinary activity
• II – comfortable at rest, dyspnoea during ordinary
activities
• III – less than ordinary activity causes dyspnoea,
limiting
• IV – dyspnoea at rest, all activity causes discomfort
37
Investigations for suspected HF
• ECG - Evidence of ischaemia, MI or ventricular
hypertrophy, rarely normal in HF
• Echo – may indicate cause and can confirm
presence or absence of LV dysfunction
• Bloods – test for BNP
38
Management of HF
* ACE-I - ramipril - 1st line, standard
* BB's - propanalol - 1st line, standard
* Spironolactone
* Digoxin
* Nitrates – arterial and venous dilators
39
Spirolactone pathology and therefore SE's
Aldosterone agonist -> renal failure and hyperkalaemia
40
ACE-i commonest SE
Cough -> switch to ARB
41
How should BB's be used
“start low and go slow”
42
Why are diuretics used in HF?
Relieve oedema and dyspnoea
43
Which patient group are ACE-i's not as effective in?
Black patients
44
Why and how is digoxin used to manage HF?
On top of standard therapy (ACE-i and BB), helps symptoms
45
Complications of HF
* Renal dysfunction
* Rhythm disturbances
* Systemic thromboembolism
* Hepatic dysfunction
* Neurological + Psychological complications
46
Definition of hypertension (HTN)
Chronic high blood pressure (>140/90mmHg)
47
What is white coat HTN?
Elevated clinical pressure but normal ABPM (day average <135/85)
48
What is malignant/accelerated phase HTN?
Rapid BP rise -> vascular damage, requires urgent treatment
49
Cause of primary HTN
Unknown
50
Causes of secondary HTN
o Renal disease
o Endocrine disease – Cushing’s, Conn’s,
acromegaly, hyperparathyroidism
o Others – coarctation, pregnancy, liquorice, drugs
(steroids)
51
Symptoms of HTN
• Usually asymptomatic
• Underling cause; renal failure, weak pulses
• End-organ damage; LVH, retinopathy and
proteinuria
52
Investigations to diagnose HTN
o ABPM or home BP monitoring
| o BP >135/85mmHg
53
Investigations to look for end organ damage in HTN
ECG or echo, urine analysis
54
Tachycardia definition
Heart rate >100bpm
55
Bradycardia definition
Heart rate <60bpm
56
Definition of atrial fibrillation
Irregularly irregular rhythm at 300-600bpm due to the AV node responding intermittently
57
Causes of AF
HTN, IHD, Rheumatic HD, mitral valve disease, pneumonia, hyperthyroidism, caffeine, alcohol
58
Why does AF increase stroke risk (x5)?
Atrial activity chaotic and mechanically ineffective -> blood stagnates in atria -> thrombus formation and risk of embolism
59
Why does AF lead to HF?
Atrial activity is chaotic and mechanically ineffective -> reduction in CO -> HF
60
Symptoms of AF
```
o Asymptomatic
o Chest pain
o Palpitations
o Dyspnoea
o Faintness
```
61
Signs of AF
o Irregularly irregular pulse,
| o 1st heart sound is of variable intensity
62
Investigations for suspected AF
o ECG - absent P waves and irregular QRS complexes
o Bloods - U&E, cardiac enzymes, thyroid function
tests
o Echo - look for structural abnormalities
63
Management of AF
o Rate control – BB/CCB’s -> digoxin -> amiodarone
Digoxin 2nd line
o DC cardioversion
o Anticoagulate – warfarin
64
Atrial flutter definition
Atrial rate = 300bpm, Ventricular rate = 150bpm
65
What does ECG show in atrial flutter?
Sawtooth flutter waves (F waves)
66
Management of atrial flutter
Like AF - radiofrequency catheter ablation as recurrence rates high
67
Definition of heart block
Block in AV node or bundle of His
68
Pathology/ECG of 1st degree heart block
PR interval prolonged and unchanging, no missed beats
69
Causes of heart block
Inferior MI, drugs (BB's, CBB's), cardiac surgery, trauma
70
Pathology/ECG of 2nd degree heart block (Mobitz I)
o Some atrial pulses fail to reach ventricles
o PR interval becomes longer and longer until a QRS is
missed, then pattern resets (Wenckebach
phenomenon)
71
Symptoms of heart block
Dizziness, syncope, chest pain, SOB, postural HTN
72
Pathology/ECG of 2nd degree heart block (Mobitz II)
o Some atrial impulses fail to reach ventricles
| o QRS’s regularly missed, may progress to complete heart block
73
Pathology/ECG of 3rd degree (complete) heart block
No impulses passed from atria to ventricles so P waves and QRS’s appear independently of each other
74
Management of heart block
Atrophine if symptomatic (IV if complete HB), pacemaker
75
Pathology of bundle branch block
RBB/LBB no longer conducts an impulse and the two ventricles do not receive an impulse simultaneously (first left then right)
76
Causes of RBBB
Normal variant, pulmonary embolism, cor pulmonale
77
Symptoms of bundle branch block
Asymptomatic
78
ECG in RBBB
M pattern in V1 and slurred S wave (W) in V5 - MaRRoW
79
Management of bundle branch block
Treat underlying cause, pacemaker
80
ECG in LBBB
W pattern in V1, M pattern in V6 - WiLLiaM
81
Causes of LBBB
IHD, LV hypertrophy, aortic valve disease
82
Causes of sinus tachycardia
Infection, pain, exercise, anxiety, dehydration, bleeding, drugs, fever, pregnancy
83
Management of sinus tachycardia
Do NOT cardiovert, treat cause, rate control with beta blockers
84
Definition of supraventricular tachycardia
Rapid heart rhythm originating at/above the AV node
85
Causes of supraventricular tachycardia
Drugs, alcohol, caffeine, anaemia, fever
86
Management of supraventricular tachycardia
1. Vagal manouveres
2. Adenosine
3. Verapamil
4. DC cardioversion
87
Definition and pathology of Wolff-Parkinson-White syndome
Congenital accessory pathway between atria and ventricles -> removes AVN delay -> ventricles contract early
88
WPW syndrome ECG
Short PR interval, wide QRS, delta wave
89
WPW syndrome management
Radiofrequency catheter ablation of accessory pathway
90
Causes of ventricular tachycardia
Congenital, drugs, MI, HOCM
91
Ventricular tachycardia ECG
Broad QRS, tachycardia
92
Management of VT/VF
Amiodarone, DC cardioversion
93
Symptoms of ventricular extrasystoles (ectopic)
Palpitations, thumbing sensation, heart “missing a beat”
94
ECG for ventricular extrasystoles (ectopic)
Broad QRS complexes, may be single or in patterns
95
Definition of long QT syndromes (LQTS)
Channelopathies that result in prolonged repolarisation phases -> predisposition to ventricular arrhythmias
96
Definition of aortic aneurysm
Aortic diameter >3cm
97
Epidemiology of aortic aneurysm
o Male:female > 3:1
| o Less common in diabetics
98
Which population group is invited for aortic aneurysm screening in the UK?
All males at age 65
99
Risk factors for aortic aneurysm
HTN, male, smoking, family history
100
Cause/pathology of aortic aneurysm
Degeneration of elastic lamellae and smooth muscle loss, genetic component
101
Signs and symptoms of unruptured aortic aneurysm
o Often none
o May cause abdominal/back pain
o Often discovered incidentally on abdominal
examination
102
Signs and symptoms of ruptured aortic aneurysm
```
o Intermittent or continuous abdominal pain (radiates
to back or groin)
o Collapse
o Expansile abdominal mass
o Shock
```
103
Management of unruptured aortic aneurysm
o Elective surgery - >5.5cm or expanding at >1cm/yr, or
symptomatic
o Stenting – allows major surgery to be avoided
104
Management of ruptured aortic aneurysm
o ECG
o Straight to theatre (CT only if patient stable)
o Prophylactic antibiotics
o Surgery – aorta clamped above leak and Dacron
graft inserted
105
Pathophysiology of aortic dissection
o Tear in aortic intima -> high pressure blood into
| aortic wall -> false lumen
106
What is the difference between type A and type B aortic dissection?
Type A = ascending aorta involved
| Type B = ascending aorta not involved
107
Risk factors for aortic dissection
Atherosclerosis, high BP, cocaine, aortic aneurysm, smoking
108
Signs and symptoms of aortic dissection
o Initial tear – sudden severe chest pain, pulse loss ->
diastolic murmur
o Later symptoms – aortic branch occlusion =
hemi/paraplegia, anuria
109
Investigations for suspected aortic dissection
ECG (ischaemia/MI), USS and MRI (site and severity)
110
Management of aortic dissection
Stenting -> surgery if dissection is progressing
111
Complications of aortic dissection
Aortic rupture, cardiac tamponade = syncope and hypotension
112
Pathology of peripheral arterial disease (PAD)
Atherosclerosis -> stenosis of peripheral arteries
113
RF's for PAD
* Smoking
* HTN
* Hypercholesterolaemia
114
Symptoms of PAD
asymptomatic -> exercise claudication (intermittent) -> critical ischaemia (pain, pulseless, pale, paralysed, pins and needles, perishingly cold)
115
Signs of PAD
Absent femoral/popliteal/foot pulse, ulcers/gangrene, cold white
116
Investigations for suspected PAD
* ECG – CHD evidence
| * Doppler ultrasonography confirms diagnosis
117
Management of PAD
* Antiplatelet – clopidogrel
* Modify risk factors
* Surgery (angioplasty vs reconstruction)
* Amputation
118
Causes of pericarditis
```
o Viral - HIV
o Bacterial – TB, rheumatic fever
o Autoimmune – SLE
o Drugs – chemo
o Trauma
o Cancer mets
```
119
Symptoms of pericarditis
```
o Chest pain – sever, sharp, rapid onset, radiates to
arms, relieved sitting
o Dyspnoea
o Cough
o Hiccups (phrenic)
```
120
What is the normal area of the aortic valve?
3-4cm2
121
At approximately what point do aortic valve stenosis symptoms begin?
Symptoms occur when valve area is 1/4th of normal
122
Causes of aortic stenosis
o Congenital
o Bicuspid valve
o Degenerative calcification (common),
o Rheumatic heart disease
123
What is the pathophysiology of symptomatic aortic stenosis?
pressure gradient develops between LV and aorta -> increased afterload -> LV function declines
124
Why is aortic stenosis not always symptomatic?
LV function initially maintained by compensatory pressure hypertrophy
125
Symptoms of aortic stenosis
o Syncope on exertion
o Angina
o Dyspnoea (especially on exertion)
o Sudden death
126
Signs of aortic stenosis
o Slow rising carotid pulse and decreased pulse
amplitude
o Absent 2nd heart sound
o Ejection systolic murmur
127
Investigations for suspected aortic stenosis
Echocardiography
128
Management of aortic stenosis
```
o Fastidious dental hygiene/care – IE prophylaxis
o Surgical replacement or TAVI
o Indications for intervention:
- symptomatic patient
- decreasing EF
- undergoing CABG with AS
```
129
Definition of mitral regurgitation
Backflow of blood from LV to LA during systole
130
Causes of mitral regurgitation
o Myxomatous degeneration (MVP)
o Ischaemic MR
o Rheumatic heart disease
o Infective endocarditis
131
Pathophysiology of mitral regurgitation
Pure volume overload -> LA and LV hypertrophy -> progressive HF and PAH
132
What are the compensatory mechanisms in mitral regurgitation?
Left atrial enlargement, LVH and increased contractility
133
Signs and symptoms of mitral regurgitation
o Soft S1 and pansystolic murmur at
the apex radiating to the axilla
o Exertion dyspnoea
o HF
134
Investigations for suspected mitral regurgitation
```
o ECG – LA enlargement, AF and LV hypertrophy if
severe
o CXR – LA enlargement
o Echo – valve
structure assessment
```
135
Management of MR
```
o IE prophylaxis
o Vasodilators - ACEI
o If w/AF - warfarin and BB
o Serial echocardiograms
o Surgical treatment if symptomatic
```
136
Definition of aortic regurgitation
Leakage of blood into LV during diastole due to ineffective coaptation of aortic cusps
137
Causes of aortic regurgitation
o Bicuspid aortic valve
o Rheumatic fever
o Infective endocarditis
138
Pathophysiology of aortic regurgitation
Combined pressure and volume overload -> progressive LV dilation -> HF
139
Compensatory mechanisms in aortic regurgitation
LV dilation, LVH
140
Signs of aortic regurgitation
o Wide pulse pressure
o Hyperdynamic and displaced apical impulse
o Diastolic blowing murmur, systolic ejection murmur
141
Symptoms of aortic regurgitation
o Dyspnoea
o Fatigue
o Chest pain
142
Investigations for suspected aortic regurgitation
o CXR – enlarged cardiac silhouette and aortic root
| o Echo - evaluation of the AV
143
Management of aortic regurgitation
o IE prophylaxis
o Vasodilators - ACEI
o Serial echocardiograms
o Surgical treatment if symptomatic
144
What is the normal area of the mitral valve?
4-6cm2
145
What is the most common cause of mitral valve stenosis?
Rheumatic heart disease
146
Definition of shock
• Circulatory failure resulting in inadequate organ
perfusion
• Low BP, systolic < 90mmHg
147
Basic mechansism of septic shock
Infection with any organism -> acute vasodilation from inflammatory cytokines
148
Basic mechanism of anaphylactic shock
Type-1 IgE-mediated hypersensitivity, release of histamine
149
Causes of neurogenic shock
Spinal cord injury, epidural or spinal anaesthesia
150
Causes of hypovolaemic shock
Bleeding, trauma, ruptured aortic aneurysm, GI bleed
151
Signs and symptoms of septic shock
o Temperature >38⁰C or <36⁰
o Tachycardia >90bpm
o Resps >20/min
o WBC very high or very low
152
Management of septic shock
o ABC – airways, breathing, circulation
| o Blood cultures before antibiotics
153
Definition of cardiomyopathy
Deterioration of myocardium’s ability to contract, without any heart disease involvement
154
What is dilated cardiomyopathy?
A dilated, flabby heart of unknown cause
155
What is dilated cardiomyopathy associated with?
Alcohol, HTN, chemotherapy, haemochromatosis, viral infections, autoimmune, congenital
156
Symptoms of dilated cardiomyopathy
Fatigue, dyspnoea, pulmonary oedema, RVF, emboli, AF, VT
157
Signs of dilated cardiomyopathy
Tachycardia, hypotension, displaced and diffuse apex, mitral or tricuspid regurg, oedema, ascites
158
Investigations for suspected cardiomyopathy
o Bloods – BNP
o ECG – tachycardia, abnormal
o CXR – cardiomegaly, pulmonary oedema
o Echo – dilation and low EF
159
Management of dilated cardiomyopathy
o Bed rest
o BB’s, ACE-i, anticoagulants
o Biventricular pacing
o Transplant
160
What is hypertrophic cardiomyopathy?
LV outflow tract (LVOT) obstruction from asymmetric septal hypertrophy
161
Epidemiology of hypertrophic cardiomyopathy
Leading cause of sudden cardiac death in the young – ask about family history of sudden death
162
What is the main cause of hypertrophic cardiomyopathy?
70% have mutations in genes encoding sarcomere proteins (50% are sporadic)
163
Symptoms of hypertrophic cardiomyopathy
Sudden death, angina, dyspnoea, palpitations, syncope
164
Signs of hypertrophic cardiomyopathy
Jerky pulse, double apex beat, harsh ejection systolic murmur
165
Investigations for suspected cardiomyopathy
o ECG – LVH, AF, ectopics
o Echo – asymmetric septal hypertrophy
o cMRI
o Exercise test to risk strategise
166
Management of cardiomyopathy
o BB for symptoms
o Amiodarone for arrhythmias
o Septal myomectomy surgery if severe
o Implantable defibrillator
167
Causes of restrictive cardiomyopathy
Idiopathic, haemochromatosis, sarcoidosis, endomyocardial fibrosis
168
Signs and symptoms of restrictive cardiomyopathy
Right heart failure with elevated JVP, like constrictive pericarditis, hepatomegaly, oedema, ascites
169
Management of restrictive cardiomyopathy
Treat cause (haemochromatosis, sarcoidosis, endomyocardial fibrosis)
170
What is arrhythmogenic right ventricular cardiomyopathy (ARVC)?
RV myocardium is replaced with fibro-fatty material
171
Symptoms of ARVC
Palpitations and syncope during exercise
172
What is the main ECG change seen in ARVC?
Epsilon wave
173
What are the causes of tetralogy of fallot?
Congenital, 22q11 deletion, Down’s syndrome
174
What are the four features of tetralogy of fallot?
1. Ventricular septal defect
2. Overriding aorta
3. Pulmonary stenosis
4. Right ventricular hypertrophy
175
Symptoms of tetralogy of fallot
Bluish skin, SOB, syncope, clubbing of fingers and toes
176
Signs of tetralogy of fallot
Cyanosis, harsh systolic ejection murmur, children may squat
177
What investigations should be done for a suspected structural heart defect?
o Echo
o ECG
o CXR
178
What might a CXR show in tetralogy of fallot?
Boot-shaped heart
179
Management of tetralogy of fallot
Complete surgical repair, monitor for pulmonary valve replacement
180
Pathology of a ventricular/atrial septal defect
o Opening in the interventricular/interatrial septum
| o LV pressure > RV -> blood flows from LV to RV
181
Signs and symptoms of a ventricular septal defect
```
o Increased respiratory rate
o Tachycardia
o Harsh pansystolic murmur
o Thrill
o Pulmonary hypertension
```
182
Management of a ventricular septal defect
PA band or complete repair in infancy, nothing if small
183
What is Eisenmengers syndrome?
Structural heart defect -> long-standing left-to-right cardiac shunt -> high pulmonary BP -> damages pulmonary vasculature -> increased resistance in lungs -> RV pressure increases -> shunt direction reverses -> patient becomes blue
184
Signs and symptoms of an atrial septal defect
```
o Pulmonary flow murmur
o Fixed split second heart sound
o SOB
o Palpitations
o Oedema
o Pulmonary hypertension
```
185
Management of atrial septal defect
Repair if right heart strain
186
What is coarctation of the aorta?
Narrowing of the aorta at the site of insertion of the ductus arteriosus
187
Signs of coarctation of the aorta
o Right arm HTN
o Bruits (buzzes) over scapulae
o Murmur (left scapula)
o Cold feet
188
Management of torsades de pointes
IV magnesium sulphate
189
What is the classification system for peripheral vascular disease (PVD)?
Fontaine
190
Give 5 signs of heart failure seen on a chest x-ray
```
ABCDE:
Alveolar oedema
kerley B lines
Cardiomegaly
Dilated prominant upper lobe vessels
pleural Effusion
```
191
Describe torsades de pointes on ECG
Broad complex tachycardia, irregular, increasing and decreasing amplitudes when in circuit (torsades de pointes)
