Cardiology Flashcards
What is heart failure?
A syndrome where cardiac output is not sufficient to meet the body’s requirements
What is systolic failure? What causes it (top 3)
Inability of the ventricle to contract normally, reduced CO, ejection fraction typically <40%
Causes: IHD, MI, cardiomyopathy (hypertension)
What is diastolic failure? What causes it (5)
Inability of the ventricle to relax and fill normally, increased filling pressure. Typical ejection fraction >50%.
Causes include ventricular hypertrophy, constrictive pericarditis, tamponade, restrictive cardiomyopathy, obesity
What are the symptoms of left ventricular failure?
Dyspnoea, poor exercise tolerance, fatigue, orthopnea, PND, nocturnal cough (+/- pink frothy sputum), wheeze, nocturia, cold peripheries, weigh loss.
What are the symptoms of right heart failure ?
Peripheral oedema, ascites, nausea, anorexia, facial engorgement, epistaxis
NY classification of heart failure
I: no undue breath,Essenes
II: Breathlessness during ADLs, not limiting
III: breathlessness during ADLs, limiting
IV: breathlessness at rest
Chest x-ray findings in heart failure (5)
Alveolar Oedema (bat wing appearance)
kerley B lines (interstitial oedema, also known as septal lines)
Cardiomegally (>50% cardiothoracic ratio)
Dilated prominent upper lobe vessels (diversion due to oedema)
Effusions (blunted costophrenic angle and cardiac border)
How should you investigate suspected heart failure?
BNP and ECG. If either abnormal echocardiogram. If abnormal ever to cardiology.
Management of heart failure (not specific drugs, 5 things)
1) treat cause e.g. valvular heart disease, arrhythmia.
2)treat exacerbating factors e.g. anaemia,infection
3 )lifestyle modification e.g smoking cessation, alcohol reduction, reduced salt diet, healthy eating, weight loss.
4)avoid exacerbating factors e.g. NSAIDS and negative inotropes e,g, verapamil
5) annual flu vaccine and one off pneumococcal vaccine
Pharmacological management of heart failure. (3 core things + 2 to add on)
Reduce workload of heart.
1) diuretics - furosemide or bumetanide
2) ACEi or ARB
3) beta blocker e.g. bisoprolol. Start low and go slow.
4) spironolactone if renal function allows and potassium >3.4 or arrhythmia or digoxin therapy. Use if other diuretics not achieving adequate symptom control or if LVSD in post MI patients
5) digoxin considered in all who have LVSD who are still symptomatic with above management.
Palliative care considerations for heart failure patients (5)
1) treat and prevent comorbid conditions e.g. flu vaccine
2) good nutrition, allow alcohol
3) involve GP - discuss prognosis
4) treat symptoms - consider opiates for pain and dyspnoea
5) be realistic about prognosis
Hypertension management (not drugs)
If >135/85 in clinic, monitor, lifestyle advice
If >140/90 in clinic, home recordings
If at home >135/85 then stage 1 hypertension.
No comorbid disease or over 80- monitor
Comorbid disease and under 80- drug treatment
If in clinic >150/95 drug treatment
Pharmacological management of hypertension
A=ACEi
C= CA2+ blocker
D= thiazide diuretic
if <55yrs or diabetic = A
if >=55yrs or Afro-Caribbean =C
Then A and C
Then A and C and D
Then consider adding spironolactone or increasing D, if not tolerated add an alpha or beta blocker
If doesn’t tolerate ACEi use ARB
What is the cardiac output of an average male at rest
5L/min
Leads I and aVL on an ECG refer to which territory and which artery is likely to supply this area?
Septal or lateral - circumflex artery
Leads II, III and aVF on an ECG refer to which territory and which artery is likely to supply this area?
Inferior - RCA or Circumflex
Leads V1 to V4 on an ECG refer to which territory and which artery is likely to supply this area?
Anteroseptal - LAD
Leads V1 to V6 (+/- aVL) on an ECG refer to which territory and which artery is likely to supply this area?
Anteriorlateral - LAD
What ECG change would make you suspicious of a posterior myocardial infarction? What should you do to confirm your suspicions?
ST depression in V1 to V3, there may also be reciprocal change in aVR
Repeat ECG with leads V7, V8 and V9 which are placed on the back, below the left scapula. You would expect to see moderate ST elevation in these leads.
Where does the ductus arteriosus run, what is it’s purpose and what does it become after birth?
Between the pulmonary artery and the aorta. Allows most of the semi-oxygenated blood to bypass the foetuses lungs which are fluid filled and therefore at high pressure.
It becomes the ligamentum arteriosus
What is the foremen ovale, and what does it become?
The foremen ovale is a hole in the interatrial septum providing a shunt for oxygenated blood between the right and left atrium, allowing it to bypass the non-functioning lungs.
After birth the foramen closes forming the fossa ovalis
What is the ductus venousus purpose and what does it become?
The ductus venous provides a shunt from the umbilical vein to the IVC, preventing the liver from using most of the the oxygenated blood from the placenta.
Becomes the ligamentum venosum, which separates the caudate lobe of the liver
Give two examples of acyanotic congenital heart defects
Atrial septal defect
Ventricular septal defect
Give two examples of cyanotic congenital heart defects
Tetralogy of fallot
Transposition of the great arteries
What defects are present in tetralogy of fallot?
Which direction is the shunt?
Ventricular septal defect
Overriding aorta
Pulmonary stenosis
Right ventricular hypertrophy
Produces right to left shunt, therefore some degree of cyanosis. Severity depends on level of pulmonary stenosis (and therefore amount of blood shunted)
What autonomic receptors are found in the heart?
Beta 1 adrenoreceptors - increase rate and contractility
M2 muscarinic ACh receptor - decrease rate
What is starling’s law?
The stroke volume of the heart increases if there is an increased volume of blood in the heart (i.e. a greater preload will result in greater contractility)
How do you calculate cardiac output?
CO= stroke volume * heart rate
What is preload?
The end diastolic pressure -the volume at which the ventricles are stretched the most.
What is afterload?
The tension within the left ventricle during systole -depends on arterial or pulmonary pressures
Describe Stable angina
- transient ischaemia which is relived when O2 demand decreases
- brief episodes of chest pain on breathlessness brought on by exertion or emotion and relieved by rest
- resting ECG normal, ST depression on stress test, troponin normal
Describe unstable angina
- ischaemia even at rest
- ST depression at rest
- no raised troponin as no necrosis
Describe an NSTEMI
ST depression or T wave changes pm ECG
Raised troponins
Some infarction but not full thickness
Describe STEMI
ST segment elevation on ECG with reciprocal changes
Troponins raised
Full thickeners infarction
When is troponin I most raised? How long will it remain raised? When would you look at creatinine kinase?
Troponin I reaches its peak level 24hours post infarction
It remains raised for approximately 1 week
CK may be used if there is a second episode of chest pain within 2 days of a confirmed MI
NYHA scale of dyspnoea in heart failure… go!
I - no symptoms or limitation
II - mild symptoms and slight limitation during ordinary activity
III - marked limitation on activity due to symptoms e.g. walking short distances. Only comfortable at rest.
IV - severe limitation, symptoms at rest, bed bound.
Causes of heart failure
Ischaemic heart disease Valvular disease Hypertension Arrhythmia Hypertrophic cardiomyopathy
What general advice would you give to someone with heart failure?
Regular, low level exercise, such as brisk walking
Have a low salt diet
STOP SMOKING
Education about the disease and it’s progression
Vaccination
Define cardiogenic shock
The inability of the heart to eject enough blood e.g. following myocardial infarction
What is a third heart sound and what can cause it?
Due to a stiff or dilated ventricle suddenly reaching its elastic potential which decelerates the incoming blood. “Lub…dub de”
Normal in under 30s and children
Causes include HF, MI, cardiomyopathy, hypertension
