Cardiology Flashcards
What is bicuspid aortic valve?
Congenital heart condition where aortic valve has 2 instead of 3 leaflets
Bicuspid aortic valve - 2 Complications
Aortic stenosis (Narrowing aorta) Aortic regurgitation (Backflow blood from aorta to ventricle)
What activity would make the complications of bicuspid aortic valve appear faster?
Exercise
Bicuspid aortic valve - Treatment
Valve replacement
What is an ASD (Atrial septal defect) ?
Congenital heart condition which causes a left to right shunt (hole in heart)
Primum - presents earlier
Secundum - asymptomatic until adulthood
By age 40 what 2 issues can ASD lead to?
Heart failure
SOB
What can reverse shunt lead to in ASD?
Pulmonary hypertension - Cyanosis and organ damage
What is VSD (Ventricular septal defect) ?
Congenital heart defect which causes a left to right shunt (hole in heart)
No cyanosis
Size of holes in heart and their symptoms
Large holes - symptoms during infancy
Small holes - asymptomatic but increased risk of infective endocarditis
ASD//VSD - Treatment
Medically treated at first as may close naturally
Otherwise, surgery required
What is coarctation of the aorta?
Aorta is narrowed at the site of the ductus arteriosus
Coarctation of aorta - Complications (mild and severe)
Mild - Raised BP
Severe - Blocked aorta, heart failure, IE
Coarctation of aorta - Treatment
Surgery
Stent
What is cyanosis?
Blue-ish discolouration of skin etc, due to excessive concentration
What is the most common cyanotic cardiac disorder?
Tetralogy of fallot (TOF)
Tetralogy of fallot (TOF) - 4 features
VSD
Pulmonary stenosis
RV hypertrophy
Overriding aorta
Tetralogy of fallot (TOF) - Treatment
Surgery
ECG - PQRST
P wave - Atria depolarise
PR interval - Delay of AV node to allow ventricle filling
QRS complex - Ventricles depolarise
ST segment - Beginning of ventricle repolarisation
T wave - Ventricles repolarise
Myocardial ischaemia - 2 Causes
Reduced blood flow to heart muscle due to clot/atheroma
Reduced O2 carrying capacity (Anaemia) or availability (Hypoxia)
Ischemic heart disease - Risk factors
Modifiable - Smoking, obesity, exercise, diet
Clinical - Hypertension, diabetes
Non-modifiable - Age, genetics, gender (m>f)
Psychosocial - High stress jobs, low social interaction and support
Which tool predicts risk of cardiovascular disease in next 10 years?
QRISK2 score
Angina pectoris - Presentation
Chest pain on exertion but rapidly resolves with rest May radiate to arms, jaw and neck Dyspnoea Palpitations Syncope (fainting)
Angina pectoris - 4 Investigations (BECA)
ECG - ST depression, T wave inversion
Bloods - Anaemia
CXR - Heart size and pulmonary vessels
Angiogram - Luminal narrowing
Angina pectoris - Treatment
Lifestyle - Diet, exercise, stop smoking
Medical - Control hypertension and diabetes
Drugs - GTN spray (chest pain), B-blocker, aspirin, ACE-inhibitor, ivabradine (HR lowering)
PCTA - Stenting (ballooning) the narrowing
CABG is another option
Acute coronary syndrome (ACS) - Pathology
Plaque rupture leads to thrombosis and inflammation
Necrosis and myocyte death
Acute coronary syndrome (ACS) - ECG changes
STEMI (ST elevation MI) - ST elevation
NSTEMI (Non STEMI) - ST depression, T inversion
Ischaemia - ST depression, T wave flat
Q waves - indicate previous infarctions
Acute coronary syndrome (ACS) myocardial infarction (MI) localisation and affected artery
Anterior/septal MI - LAD Lateral - LCX Inferior - RCA/RCX Posterior - RCX Right ventricle/atrial - RCA
Acute coronary syndrome (ACS) - Investigations (EBC)
ECG (acute) - ST elevation
ECG (days) - T wave inversion, Q waves
Bloods - FBC, U&E
Cardiac enzymes - Raised troponin, CK (Creatine kinase), myoglobin
Which angina is stable?
Angina pectoris
Unstable angina - Investigations
FBC - Anaemia
Cardiac enzymes
ECG - ST depression
Coronary angiography
Myocardial infarction (MI) - Pathology
Plaque rupture leads to a clot which occludes a coronary artery causing myocardial cell death and inflammation
Myocardial infarction - Signs and symptoms
Signs - Pale, pansystolic murmur, peripheral oedema
Symptoms - Acute central chest pain radiating to jaw/shoulder, lasting over 20 mins, SOB, palpitations
Which tends to be more dangerous STEMI or NSTEMI?
STEMI>NSTEMI
STEMI - Acute management
1) 12-lead ECG
2) Oxygen
3) Establish IV access
4) Aspirin
5) Morphine and anti-emetic
6) B-blocker and ACE-inhibitor
7) Refer for PCI (Stent) or thrombolysis ASAP
STEMI - Chronic management (ABAS)
Aspirin B-blocker (Verapamil) ACE-inhibitor Statin (lower cholesterol) Address modifiable risk factors (exercise)
Name 2 life-threatening ventricular arrhythmias
Ventricular tachycardia
Ventricular fibrillation
Differential diagnosis of chest pain
Cardiac - ACS
Resp - PE, pneumonia
MSK - Rib fracture/chest trauma
GI - GORD
Peripheral arterial disease - Signs and symptoms
Signs - Absent pulses, ulcers
Symptoms - Cramping pain in calves, thighs and buttocks relieved by rest
Peripheral arterial disease - 6 Ps of limb ischaemia
Pain Pallor (pale) Pulselessness Paraesthesis (pins and needles sensation) Paralysis Perishing cold
Peripheral arterial disease - Investigations
Colour duplex US (ultrasound) - Blood vessels flow
CT angiography - Stenoses/vessel quality
Blood tests - Raised CK due to muscle damage
Peripheral arterial disease - Management
Risk factor modification - stop smoking, diet (lower fat/chol), exercise
Medication - Anti-platelet (Clopidogrel)
PTA (stent) /surgery - correct stenosis
Critical limb ischemia - Symptoms (6Ps)
Pain Pallor (pale) Pulselessness Paraesthesis (pins and needles sensation) Paralysis Perishing cold
Critical limb ischemia - Causes
Thrombosis
Emboli
Trauma
Graft occlusion
Critical limb ischemia - Management
Surgical embolectomy
Local thrombolysis with t-PA
If not revascularised within 6 hrs then amputation last resort
What is heart failure?
Symptomatic condition where breathlessness, fluid retention and fatigue are associated with a cardiac abnormality that reduces cardiac output
Heart failure - 2 Types
Systolic - Failure to contract (IHD, MI)
Diastolic - Inability to relax (Hypertension, cardiac tamponade, constrictive pericarditis)
Heart failure - 2 Types of output
Low output HF - Decreased cardiac output which fails to increase with exertion (due to pump failure)
High output HF - Anaemia, pregnancy, hyperthyroidism
Heart failure - 3 Compensatory changes to increase preload/afterload
Sympathetic stimulation (peripheral vasoconstriction) RAAS (salt/water retention, vasoconstriction) Cardiac changes (Myocyte hypertrophy)
Heart failure - 4 Mechanisms
1) Increased preload
2) Increased afterload
3) Salt and water retention
4) Myocardial remodelling
Left-sided HF - Signs and symptoms
Signs - Cardiomegaly, reduced BP, tachycardia, heart murmur, 3rd/4th heart sounds
Symptoms - Dyspnoea, fatigue, nocturnal cough (pink, frothy sputum)
Right-sided HF - Causes
Left ventricular failure (LVF)
Pulmonary stenosis
Lung disease
Right-sided HF - Signs and symptoms
Signs - Raised JVP (jugular venous pressure), hepatomegaly, pitting oedema, weight gain (fluid), ascites (fluid in abdomen)
Symptoms - Peripheral oedema, ascites, nausea, anorexia
Heart failure - Investigations
Bloods - FBC, U&E, LFT Cardiac enzymes - Creatinine kinase (CK), troponin CXR ECG Echo (TTE)
Heart failure - Management
Lifestyle - SED (Quit smoking, exercise, diet) Loop diuretics ACEi B-blockers Aldosterone antagonists
Heart failure - Treatment
Acute - Oxygen, GTN, diamorphine, furosemide (IV where poss)
Chronic - Ramipril (ACEi), atenolol (B-blocker), amlodipine (vasodilator), furosemide (loop diuretic)
Cardiac dysrhythmias - 2 Types
Bradycardia - <60bpm
Tachycardia - >100bpm
What is sinus tachycardia?
> 100bpm
Physiological response to exercise/excitement
Causes of sinus tachycardia?
Heart failure
Anaemia
Acute PE
Hypovolaemia (decreased blood/fluid in body)
Sinus tachycardia - Management
Beta-blocker (Atenolol)
What is a supraventricular tachycardia?
Tachycardia which arises from the atrium or atrioventricular junction
Supraventricular tachycardia - 4 Types
Atrial fibrillation
Atrial flutter
AV nodal re-entry tachycardia (AVNRT
AV reciprocating tachycardia (AVRT)
Which is the most common arrhythmia?
Atrial fibrillation
Atrial fibrillation - 2 Causes
Any condition causing raised atrial pressure (Heart failure, hypertension)
Atrial fibrillation - Pathophysiology
1) Atrial over-activation
2) Only a proportion of these impulses are conducted to ventricles due to refractory period of AVN
3) HR increased - Tachycardia
Atrial fibrillation - Symptoms
Palpitations
Fatigue
Heart failure
Atrial fibrillation - Management
B-blocker - Atenolol (rate control)
Electrical DC cardioversion (rhythm control)
Warfarin (anti-coag)
Atrial fibrillation - ECG pattern
Irregular
F waves (sawtooth flutter waves)
No clear P waves
QRS is rapid and irregular
Which tool is used to calculate stroke risk in atrial fibrillation (AF) ?
CHADS2VASc score
What is atrial flutter often associated with?
Atrial fibrillation
Atrial flutter - ECG pattern
F waves (sawtooth flutter waves)
What is the HR in sinus bradycardia?
HR - <60bpm
Bradycardia - Causes
Extrinsic - B-blocker, digoxin, hypothyroidism, hypothermia, raised intracranial pressure
Intrinsic - Acute ischaemia, SAN infarction
Bradycardia - Treatment
Atropine (increase HR)
Temporary pacing
Heart block - 2 Types
AV block (AVN/bundle of his blocked) Lower conduction system block (RBBB/LBBB - Right/Left bundle branch block)
Heart block - Causes
Cardiomyopathy
Fibrosis of conducting tissues
Coronary artery disease
What is 1st degree heart block?
Delayed AV conduction (PR interval prolonged)
1st Degree heart block - Causes
Myocarditis
Hypokalaemia
1st Degree heart block - Treatment
Asymptomatic so no treatment
2nd Degree heart block - 2 Types
Mobitz type 1
Mobitz type 2
2nd Degree heart block mobitz type 1 - ECG pattern
Progressive PR interval prolongation until P wave fails to conduct and QRS drops
Cycle repeats
2nd Degree heart block mobitz type 1 - Symptoms
Light headedness
Dizziness
Syncope (temporary drop in BP leading to fainting)
2nd Degree heart block mobitz type 2 - ECG pattern
PR interval same
QRS drops
2nd Degree heart block mobitz type 2 - Symptoms
Chest pain
SOB
Postural hypotension
What is 3rd degree heart block?
Complete heart block
All atrial activity fails to conduct to ventricles (no association between atrial and ventricular activity)
3rd Degree heart block - ECG pattern
P waves and QRS complex are independent
3rd Degree heart block - Causes
Coronary heart disease
Infection
Hypertension
3rd Degree heart block - Management
IV atropine (acute) Pacemaker insertion
Bundle branch block - 2 Types
RBBB (Right bundle branch block)
LBBB (Left bundle branch block)
Bundle branch block - Causes
RBBB - PE, IHD
LBBB - IHD, aortic valve disease
Valvular disease - 4 Types
Aortic stenosis
Aortic regurgitation
Mitral stenosis
Mitral regurgitation
Aortic stenosis - 3 Types
Supravalvular
Subvalvular
Valvular
Aortic stenosis - Causes
Congenital bicuspid valve
Degenerative calcification
Rheumatic heart disease
Aortic stenosis - Symptoms (SAHD)
Syncope (exertional)
Angina
Heart failure
Dyspnoea
Aortic stenosis - Investigations
ECG
Echocardiography (diagnostic)
CXR - LVH (left ventricular hypertrophy), calcified aortic valve
Aortic stenosis - Management
General - Dental hygiene/care
Surgical - Valve replacement
What is mitral regurgitation?
Backflow of blood from LV>LA during systole
Mitral regurgitation - Causes
IE
Mitral valve prolapse
Mitral regurgitation - Pathophysiology
Volume overload leads to dilation Compensatory mechanisms (left atrial enlargement, LVH and increased contractility)
Mitral regurgitation - Symptoms
Dyspnoea (exertive)
Palpitations
Fatigue
Mitral regurgitation - Investigations
Echocardiogram
CXR - Enlarged LA/LV
ECG
Mitral regurgitation - Treatment
ACEi (vasodilator) B-blocker (AF rate control) Anti-coag - AF/flutter Diuretics Valve replacement
What is aortic regurgitation?
Blood leakage into LV during diastole due to ineffective coaptation of aortic cusps
Aortic regurgitation - Causes
IE
Bicuspid aortic valve
Aortic regurgitation - Pathophysiology
Combined pressure and volume overload leads to LV dilation, and so LVH too
Aortic regurgitation -Symptoms
Dyspnoea (exertional)
Aortic regurgitation - Investigation
Echocardiogram
ECG
CXR - Cardiomegaly
Aortic regurgitation - Management
ACEi
Valve replacement
What is mitral stenosis?
Obstruction of LV inflow that prevents sufficient filling during diastole
Mitral stenosis - Causes
IE
Rheumatic heart disease
Mitral calcification
Congenital
Mitral stenosis - Signs and symptoms
Signs - Malar flush (cheeks), Shallow pulse
Symptoms - Dyspnoea, fatigue, palpitations, chest pain
Mitral stenosis - Investigations
Echocardiogram
CXR - LA enlargement
ECG - AF
Mitral stenosis - Management
Rate control for AF (B-blocker)
Anti-coag (Warfarin)
Diuretics
Valvotomy
What is shock?
Circulatory failure resulting in inadequate organ perfusion
Low BP - Systolic <90mmHg
Shock - 4 Types (SHAN)
Septic - Infection (acute vasodilation from inflammatory cytokines)
Anaphylactic - Type-1 IgE-mediated hypersensitivity (histamine released)
Neurogenic - Spinal cord injury/anaesthesia, epidural
Hypovolaemic - Bleeding, trauma, ruptured aortic aneurysm, GI bleed
Septic shock/Systemic inflammatory response syndrome (SIRS) - 4 Features
Extremes of body temp (hot/cold) - Over 38/under 36 degrees
Tachycardia
Increased resp rate
Increased WBC
Septic shock - Management
ABC - Airways, breathing, circulation
Blood cultures then antibiotics
Hypertension - Risk factors
Obesity/unhealthy diet Lack of physical activity Afro-carib Male>female Old age Family history
Hypertension - Investigation
Check BP
If over 140/90 start BP monitoring
If over 180/110 start anti-hypertensive drugs
End-organ damage - Test
Urine analysis (kidney)
ECG/echo - LVH
History - MI/stroke
Fundoscopy - Hypertensive retinopathy
Hypertension - Causes
Renal (CKD), endocrine disease, aortic coarctation, pregnancy
Hypertension - Lifestyle changes
Stop smoking Low-fat/salt diet Reduce alcohol Increase exercise Reduce weight if obese
Hypertension - Treatment
ACEi
B-blocker
Diuretics
Sodium nitroprusside (SNP) - BP lowering
Hypertension - Signs and symptoms
Signs - Severe HTN - 200/130mmHg, bilateral retinal haemorrhages, papillooedema
Symptoms - Headache, visual disturbance
Hypertension - Complications
Acute kidney injury
Heart failure
Encephalopathy (brain damage)
What is pericarditis?
Inflammation of the pericardium
Pericarditis - Causes
Idiopathic (any condition which arises spontaneously with unknown cause)
Viral infection
Autoimmune
Dressler syndrome (inflammation of pericardium after MI)
Acute pericarditis - Symptoms
Central pain, worse on inspiration/lying flat, relieved by sitting forward
Acute pericarditis - Investigations
Stethescope auscultation (scratching sound - pericardial friction rub)
ECG - ST elevation, PR depression
Cardiac enzymes - Increased troponin
Acute pericarditis - Treatment
Aspirin (NSAID)
PPI (gastric protection)
Acute pericarditis - Complications
Chronic constrictive pericarditis (fibrosis) - Remove by surgical excision Pericardial effusion (fluid accumulation) - Pericardiocentesis (drainage of pericardial fluid)
Beck’s triad - 3 Features
Falling BP
Rising JVP
Muffled heart sounds
Aneurysm - 2 Types
True aneurysm - Affects all 3 layers of vessel (intima, media, adventitia)
False aneurysm - Collection of blood under adventitia only
Aneurysm - Causes (CAT)
Connective tissue disorders (Mafan’s)
Atheroma
Trauma
Abdominal aortic aneurysm (AAA) - Investigation
Aortic ultrasound (screening) CT angiography (suspected rupture - assessing for surgery)
Abdominal aortic aneurysm (AAA) - Signs and symptoms
Signs - Expansile abdo mass/pulsatile
Symptoms - Abdo/back pain
Abdominal aortic aneurysm (AAA) - Treatment
Surgery
What is aortic dissection?
Tear of intima
Blood then flows into aortic media and splits it
Leads to occlusion of aortic branches
Aortic dissection - Symptoms
Sudden tearing chest pain, radiating to back
Aortic dissection - 2 Types
Type A - Involves ascending aorta
Type B - Doesn’t involve ascending aorta
Aortic dissection - Treatment
Surgery for both types
Antihypertensive drugs for type B also
Aortic dissection - Investigation
CT
MRI