Cardiology Flashcards
What is heart failure?
The heart is unable to pump enough blood to meet the demands of the body
How do you calculate cardiac output?
HEART RATE x STROKE VOLUME = CARDIAC OUTPUT
What types of heart failure are there?
- Systolic
- Diastolic
What is meant by systolic heart failure?
Inability of the heart muscle to contract forcefully enough during systole
Reduced ejection fraction (< 40%)
What is meant by diastolic heart failure?
Inability of the heart muscle to fill with blood adequately during diastole
Normal ejection fraction
What are the causes of systolic heart failure?
- Ischaemic heart disease
- Cardiomyocyte damage/death due to ischaemia means heart muscle cannot contract as forcefully. - Long-standing hypertension:
- LV has to contract more forcefully against a higher pressure, which results in LV hypertrophy. LV hypertrophy increases number of cardiomyocytes (increasing oxygen demand) and squeezes the coronary arteries (reducing oxygen supply). Increased demand for oxygen and reduced supply means that the heart muscle cannot contract as forcefully. - Dilated cardiomyopathy:
- LV wall is thinner so cannot contract as forcefully. - Congenital heart disease, e.g. ASD, VSD
- This will cause a left to right shunt, which increases the blood volume in the RV. RV contracts more forcefully, causing RV hypertrophy and right-sided HF (explanation - see number 2)
What are the causes of diastolic heart failure?
- Long-standing hypertension:
- LV has to contract more forcefully against a higher pressure, which results in LV hypertrophy. LV hypertrophy means there is less space in chamber to fill with blood. - Aortic stenosis:
- LV has to contract more forcefully against a higher pressure, which results in LV hypertrophy. LV hypertrophy means there is less space in chamber to fill with blood. - Hypertrophic/restrictive cardiomyopathy:
- Hypertrophy cardiomyopathy causes LV hypertrophy. LV hypertrophy means there is less space in chamber to fill with blood.
- Restrictive cardiomyopathy = ventricular wall is stiffer and less compliant, so cannot stretch/allow ventricle to fill with blood adequately. - Congenital heart disease, e.g. ASD, VSD
- This will cause a left to right shunt, which increases the blood volume in the RV. RV contracts more forcefully, causing RV hypertrophy and right-sided HF as there is less space in the chamber to fill with blood.
What is the main complication of left-sided heart failure? What are the symptoms and signs of this complication?
Give some other signs of left-sided heart failure.
Pulmonary oedema:
- Symptoms: dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, fatigue
- Signs: crepitations
Other signs:
- Cardiomegaly (displaced apex beat)
- 3rd and 4th heart sounds
What is cor pulmonale?
Cor pulmonale is right-sided heart failure caused by chronic lung disease, e.g. COPD.
In chronic lung disease, there is hypoxaemia which results in pulmonary vasoconstriction. This vasoconstriction increases pulmonary BP. Increased pulmonary BP means that the RV must contract more forcefully against a higher pressure, which causes RV hypertrophy and right-sided heart failure (systolic and diastolic).
What is the main complication of right-sided heart failure?
What are the signs of this complication?
Systemic congestion/oedema:
- Jugular venous distension
- Ascites
- Hepatosplenomegaly
- Sacral/pedal oedema
Describe the investigation of heart failure
CXR: characteristic changes! A - alveolar oedema B - Kerley B lines C - cardiomegaly D - dilated, prominent upper lobe vessels E - pleural Effusion
Bloods:
- B type natriuretic peptide
- FBC (anaemia exacerbates HF), LFTs (check for damage due to hepatomegaly/cirrhosis), U&Es (as a baseline before starting pharmacological therapy)
ECG:
- May show underlying cause, e.g. ischaemia, LV hypertrophy
Echo:
- To assess ventricular systolic and diastolic function
Describe the pharmacological management of heart failure
ABCD:
A - ACE-i / ARB (if ACE-i is contraindicated)
B - Beta blocker
C - CCB
D - Diuretics (loop diuretic, aldosterone antagonist)
a) In clinic, what blood pressure reading is indicative of hypertension?
b) Which follow up investigation should be carried out to confirm the diagnosis of hypertension? How are the results of this investigation interpreted?
c) What other investigations should be performed once hypertension has been diagnosed?
a) BP > 140/90 mmHg is INDICATIVE of hypertension
b) Follow up investigation: ABPM (ambulatory blood pressure monitoring) or HBPM (home blood pressure monitoring)
A diagnosis of hypertension is made in patients with:
- A clinic BP reading of > 140/90 mmHg AND
- A HBPM/ABPM reading of > 135/85 mmHg
c) Checking for end-organ damage:
- Urine analysis, e.g. checking kidney function
- Fundoscopy, e.g. checking for hypertensive retinopathy
- ECG, e.g. checking for LV hypertrophy
It is also important to do a QRISK2 assessment
What are the causes of hypertension?
Primary (essential) hypertension
Secondary hypertension
Give some risk factors for developing primary (essential) hypertension
- Smoking
- Obesity
- Sedentary lifestyle
- Diet high in salt
- High alcohol intake
- High demand, low control jobs (stress)
- Genetics
- Age
Give some causes of secondary hypertension
- Renal disease, e.g. CKD
- Endocrine conditions, e.g. acromegaly, Conn’s syndrome
- Pregnancy
Describe the conservative management of hypertension
- Smoking cessation
- Weight control
- Encourage exercise
- Reduce salt/alcohol intake
Describe the pharmacological management of hypertension
Over 55 years old / Afro-Caribbean?
If answer is NO…
- A
- A + C
- A + C + D
- A+ B + C + D
if answer is YES…
- C
- A + C
- A + C + D
- A + B+ C + D
Key: A = ACE-i / ARB (if ACEi is contraindicated) B = beta blocker C = calcium channel blocker D = thiazide diuretic
Give 2 examples of an ACE inhibitor
Ramipril
Lisinopril
Give 2 examples of an ARB
Losartan
Candesartan
Give 3 examples of beta blockers
Atenolol
Bisoprolol
Propanolol
Give 2 examples of calcium channel blockers
Amlodipine
Nifedipine
Give an example of a loop diuretic
Furosemide
Give an example of a thiazide-like diuretic
Bendroflumethiazide
Give an example of an aldosterone antagonist
Spironolactone
What are the symptoms of stable angina?
CHEST PAIN
- Central, crushing, retrosternal chest pain
- Exacerbated by exercise
- Relived by rest
- Pain may radiate to left arm, neck or jaw
Other symptoms:
- Dyspnoea
- Palpitations
- Sweating
- Nausea
Describe the investigation of stable angina
ECG:
- Usually normal
- May show ST depression/T wave inversion
CXR:
Checking heart size and pulmonary vessels
CT angiography is diagnostic - coronary artery stenosis
Describe the conservative management of stable angina
- Smoking cessation
- Weight loss
- Exercise
- Monitor diet
Describe the pharmacological management of stable angina
Symptomatic relief for angina attacks:
- GTN spray
Preventing angina attacks:
- Beta blocker or CCB
Secondary prevention of CVD (4 A’s):
- Aspirin (and clopidogrel)
- Atorvastatin (statin)
- ACE inhibitor
- Atenolol (beta blocker) - if not already on one
Describe the interventional management of angina
- PCI (percutaneous coronary intervention)
- CABG (coronary artery bypass graft)
What is meant by the term ‘acute coronary syndromes’?
Umbrella term:
- Unstable angina
- STEMI
- NSTEMI
What is unstable angina?
Chest pain occurring on minimal exertion/at rest
Give an example of a rare type of angina and describe its pathology
Prinzmetal’s angina - transient ischaemia caused by coronary artery spasm
What is the difference between a STEMI and an NSTEMI? Describe their pathophysiology.
STEMI: is complete occlusion of a MAJOR coronary artery by a thrombus, causing full thickness damage of the heart muscle
NSTEMI: is complete occlusion of a MINOR coronary artery or partial occlusion of a MAJOR coronary artery, causing partial-thickness damage to the heart muscle
Describe the common pathology of all ACS
- Rupture of fibrous cap of atheroma
- Platelet aggregation, adhesion and local thrombus formation
- Distal thrombus embolisation in coronary artery
Describe the symptoms of ACS
CHEST PAIN:
- Central, crushing, retrosternal chest pain
- Pain may radiate to left arm, jaw or neck
- Pain not relieved by GTN spray/rest
Other symptoms:
- Dyspnoea
- Palpitations
- Sweating
- Nausea
Describe the initial investigations/management of a patient presenting to A+E with suspected ACS
Initial Ix:
- Bloods: Troponin T (to be measured again 12 hours after onset of symptoms)
- ECG
Initial management: MOAN
- Morphine
- Oxygen
- Aspirin 300 mg and clopidogrel
- Nitrates - GTN spray
How would the results of the initial investigations allow you to differentiate between STEMI/NSTEMI/unstable angina?
STEMI: ECG shows persistent ST elevation and troponin will show a significant RISE or FALL after 12 hours
NSTEMI: ECG may be normal or may show some ST depression/T wave inversion, and troponin T will show either a significant RISE or FALL after 12 hours
Unstable angina: ECG may be normal or may show some ST depression/T wave inversion, but troponin T levels will be NORMAL
Following the initial management for a patient presenting with a suspected ACS, describe the definitive management if ECG shows features associated with STEMI.
If patient has presented within 90 MINUTES of onset of symptoms: reperfusion therapy (percutaneous coronary intervention - PCI)
If patient has presented more than 90 minutes after the onset of symptoms: thrombolysis (IV alteplase)
Describe the pharmacological and interventional management of a NSTEMI/unstable angina
Pharmacological - 4A’s (secondary prevention of CVD):
- Aspirin (and clopidogrel)
- Atorvastatin (statin)
- ACE inhibitor/ARB
- Atenolol (beta blocker)
Interventional:
- PCI or CABG
What is meant by coarctation of the aorta?
Narrowing of the aorta at the site of the ductus arteriosus
What are the signs of coarctation of the aorta?
- Systolic murmur
- BP in right arm > left arm
- Radiofemoral delay
Describe the management of coarctation of the aorta
Interventional:
- Stent
- Surgical repair
What are the characteristic features of Tetralogy of Fallow?
4 characteristic features:
- VSD
- Pulmonary stenosis
- RV hypertrophy
- Overriding aorta
What are the signs of Tetralogy of Fallow?
- Squatting
- Failure to thrive
- Clubbing
What is ASD? What does ASD cause?
- Atrial septal defect (hole in the atrial septum)
- ASD causes left to right shunt
What is VSD? What does VSD cause?
- Ventricular septal defect (hole in ventricular septum
- VSD causes left to right shunt
ASD is associated with which syndrome?
Eisenmenger’s syndrome:
- Left to right shunt is reversed due to development of pulmonary hypertension
- This causes cyanosis and organ damage
What is peripheral arterial disease?
Atherosclerosis resulting in ischaemia of the leg muscles
What are the symptoms/signs of peripheral arterial disease?
Symptoms:
- Cramping pain in leg muscles/buttocks
- Pain is relieved by rest
Signs:
- Cold, pale, hairless skin on legs
- Absent peripheral pulses and reduced ABPI
- Arterial ulcers
- Postural colour change (Buerger’s test)
What is the diagnostic investigation for peripheral arterial disease?
CT angiography
Describe the conservative, pharmacological and interventional management of peripheral arterial disease
Conservative:
- Smoking cessation
- Weight control
- Exercise
- Modify diet
Pharmacological:
- Clopidogrel
Interventional:
- Angioplasty
- Artery bypass graft
What is pericarditis?
Inflammation of the pericardium
What are the causes of pericarditis?
- Idiopathic
- Infective (usually viral)
- Autoimmune
- Post-MI (Dressler syndrome)
What are the symptoms and signs of pericarditis?
Symptoms:
Chest pain
- Worse on lying flat/inspiration
- Relieved by sitting forward
Signs:
- Pericardial rub
Describe the investigation of pericarditis
ECG:
- Concave (saddle-shaped) ST elevation in ALL LEADS
- PR depression
Describe the pharmacological management of pericarditis
- NSAIDs
- Colchicine
- Treat underlying cause, e.g. steroids if autoimmune
What is an aneurysm?
Enlargement of a section of an artery due to weakening of the wall
What are the causes of aneurysm?
- Atheroma (most common)
- Trauma
- Connective tissue disorders, e.g. Marfan’s, Ehlers-Danlos
Give an example of a type of clinically important aneurysm
AAA -Abdominal Aortic Aneurysm
What are the symptoms and signs of an abdominal aortic aneurysm?
Symptoms:
- Often asymptomatic
- May have a bit of abdominal/back pain
Signs:
- Pulsatile aorta on abdo examination suggests AAA
- Expansile aorta on abdo examination suggests ruptured AAA
Describe the investigation of AAA
Screening:
- Aortic ultrasound
Diagnostic:
- CT angiography
Describe the management of AAA
Surgery
What is an aortic dissection? Describe its pathophysiology
- Tear in the intima of the aorta
- Blood fows into media and splits it
- This leads to occlusion of the branches of the aorta
Describe the symptoms of aortic dissection
Sudden tearing chest pain radiating to back
Describe the investigation of aortic dissection
CT/MRI chest
Describe the management of aortic dissection
Type A (involving ascending aorta) = surgery
Type B (not involving ascending aorta) = surgery/antihypertensive drugs
Give the definitions in terms of BPM for tachycardia and bradycardia
Tachycardia > 100 bpm
Bradycardia < 60 bpm
Describe the pharmacological management of tachycardia
Beta blockers
What is the definition of sinus tachycardia?
Raised heart rate (over 100 bpm) that occurs due to overfiring of the sinoatrial node
What is the definition of supraventricular tachycardia? Give some types of supraventricular tachycardia
Raised heart rate (over 100 bpm) arising from atria/atrioventricular junction
- Atrial fibrillation
- Atrial flutter
- AVNRT (atrioventricular nodal re-entry tachycardia)
- AVRT (atrioventricular reciprocating tachycardia)
Give some causes of atrial fibrillation
- Heart failure
- Thyrotoxicosis
- Hypertension
Describe the pathophysiology of atrial fibrillation
- SAN fires 300-600/min
- Only a proportion of these are conducted to the ventricles due to refractory period of AVN
- Results in heart rate of 120-180 bpm and pulse that is ‘irregularly irregular’
Describe the investigation of AF
ECG:
- ‘irregularly irregular’
- F waves
- No clear P waves
- Rapid/irregular QRS
Describe the pharmacological management of AF
To control HR:
- Beta-blockers
- OR CCB
- OR digoxin
To control heart rhythm:
- Amiodarone
- Electrical DC cardioversion (pacemaker)
Anticoagulation:
- Warfarin
What is the name of the test used to calculate risk of stroke in AF patients
CHADS2VASc score
Give some causes of bradycardia
- Hypothyroidism
- Iatrogenic, e.g. digoxin
- Hypothermia
- Acute ischaemia, infarction of SAN
Describe the pharmacological treatment for bradycardia
Atropine
What is heart block?
Heart block is a type of cardiac arrhythmia where the heart beats irregularly and at a slower pace than normal
What is atrial fibrillation?
AF is a type of cardiac arrhythmia where the heart beats irregularly and at a faster pace than normal
What are the types of heart block?
Block in AVN/bundle of His = AV block
- There are three types of AV heart block (first degree, second degree and third degree)
Block in lower conduction system = LBBB/RBBB
Give some causes of heart block
- Cardiomyopathy
- Congenital heart defects
- Coronary artery disease
- Fibrosis of conducting tissues (occurs in elderly)
What is first degree heart block?
What are its symptoms?
How is it managed?
- Delayed AV conduction resulting in prolonged PR interval on ECG (>0.2 seconds)
- Asymptomatic
- Does not require treatment
What is second degree heart block?
What are its symptoms?
Electrical impulses SOMETIMES fail to be conducted to ventricles, so heart will skip beats
Types:
- Second degree type I (Mobitz I) = Electrical impulses fail to be conducted in a regular pattern, so heart skips beats in a regular pattern (the body can usually compensate for this, so won’t experience any symptoms)
- Second degree heart block type II (Mobitz II) = electrical impulses fail to be conducted in an irregular pattern, so heart skips betas in an irregular pattern (the body usually cannot compensate for this so will experience symptoms, e.g. dizziness, syncope)
What is third degree heart block?
What are its symptoms?
How is it diagnosed?
How is it managed?
All atrial activity fails to conduct to ventricles (no association between atrial and ventricular activity)
Symptoms: dizziness/syncope, dyspnoea, chest pain, fatigue, confusion
ECG: P waves and QRS complex are independent
Management: IV atropine, pacemaker
How to spot LBBB/RBBB on an ECG?
LBBB = ViLLhelM (V shape in V1, M shape in V6)
RBBB = MaRRooN (M shape in V1, N shape in V6)
Valvular disease - which ones do we need to know?
- Aortic stenosis
- Mitral stenosis
- Aortic regurgitation
- Mitral regurgitation
What are the symptoms of valvular disease?
- Dyspnoea
- Chest pain
- Fatigue
- Palpitations
What is aortic stenosis? When do symptoms start?
Obstruction of the outflow of blood from the left ventricle to the aorta during systole
Symptoms start when area of valve is 1/4th normal size
What are the signs of aortic stenosis?
- PULSE: pulsus tardus and pulsus parvus
- HEART SOUNDS: soft/absent S2
- MURMUR: ejection systolic murmur (crescendo-decrescendo pattern)
What is mitral stenosis?
Obstruction of the outflow from the left atrium to the left ventricle during diastole
What are the signs of mitral stenosis?
- PULSE: low volume pulse
- HEART SOUNDS: loud S1
- MURMUR: rumbling mid-diastolic murmur
What are the causes of valvular disease?
- Congenital defects, e.g. bicuspid aortic valve
- Degenerative calcification
- Rheumatic heart disease/infective endocarditis
What is aortic regurgitation?
Backflow of blood from the aorta into the left ventricle during diastole
What are the signs of aortic regurgitation?
- PULSE: collapsing pulse
- HEART SOUNDS: displaced hyperdynamic apex beat
- MURMUR: diastolic murmur
What is mitral regurgitation?
Backflow of blood from left ventricle into left atrium during systole
What are the signs of mitral regurgitation?
- HEART SOUNDS: displaced hyperdynamic apex beat
- MURMUR: pansystolic murmur
Describe the investigation of valvular disease
Echocardiography
ECG
CXR
Describe the interventional management of valvular disease
Valve replacement
What is shock?
Circulatory failure (significant hypotension) resulting in inadequate organ perfusion Characterised by systolic BP < 90 mmHg
Give some types of shock
Septic - infection resulting in acute vasodilation
Anaphylactic - IgE hypersensitivity reaction (histamine released)
Neurogenic - e.g. spinal cord injury
Hypovolaemic - acute blood loss
What are the complications of ACS?
DARTH VADER
D - death A - arrhythmia R - rupture of septum T - tamponade H - heart failure V - valve disease A - aneurysm of the ventricle D - Dressler's syndrome (pericarditis and pericardial effusion) E - embolism R - recurrence of ACS
What is the name of the criteria used to diagnose infective endocarditis?
Dukes criteria
Malar flush is a sign of…
The most common cause of this is…?
Mitral stenosis
Rheumatic fever
