Cardiology Flashcards
Definition of DVT
- Thrombosis formed within deep vein, usually leg. Can be proximal (involving the knee) or further distal isolated in the calf. It can involve the arms, mesentery and other areas.
Causes of DVT
- Common.
- Related to the stasis of blood flow and/or the increased coagulability of the blood.
- Patient’s can have many different risk factors and causes for DVT all contributing.
Risk factors of DVT
- Immobility, pregnancy, recent surgery, long haul flight, malignancy, use of OCP or HRT, smoking, obese, over 40 or PMH.
Pathology of DVT
- Sluggish blood flow through the vein with or without increased coagulability of the blood means that the body overcomes it’s natural anticoagulation activity and leads to thrombus formation. The thrombus continues to grow as it occludes the vein.
DD of DVT
Cellulitis, superficial thrombophlebitis
Presentation of DVT
- Unilateral pain, swelling and/or tenderness with or without fever in the limb.
- Pitting oedema
- Distension of collateral superficial viens.
Investigations of DVT
- Use of Wells score in patients - 2 or more = referral
- Serum D dimer
- Ultrasound D doppler for confirmation.
Management of DVT
- Prevention of PE.
- LMWH, warfarin, DOAC
- Compression stockings.
- Below knee - 6 weeks anti coag, above knee - 3 months anticoag
Complications of DVT
- PE, reoccurence
Prophylaxis of DVT
- LMWH in admitted patients who are bed bound.
- Post partum patients.
- Prophylaxis in patients with recurrent VTE events.
Definition of AF
- Common disturbance of heart rhythm, which can be episodic (Paroxysmal).
- Characterised by rapid irregularly irregular narrow QRS complex tachycardia with an absence of P waves..
Types of AF
- Paroxysmal (Episodic, resolves within 7 days).
- Persistent (Lasts longer than 7 days)
- Long standing (Lasts longer than 12 months).
- Permanent.
Causes of AF
- Congenital heart disease
- Abnormal heart valves
- High BP
- Coronary artery disease
RF of AF
- Age
- High BP
- Heart Disease
- Chronic conditions such as diabetes and thyroid issues.
- Alcohol user (especially binge drinkers)
- Family History
- Obesity
Pathophysiology of AF
- Normal heart: Impulses sent for SAN node across the atria to the AV node causing them to contract, there is a small pause before the signals are sent down the bundle of His into the Purkinje fibres to cause the ventricles to contract.
- AF heart: The signals in the atria are chaotic causing them to flutter/quiver, this bombards the AV node with multiple signals and causes the ventricles to constrict.
Presentation of AF
Heart palpitations, chest pain, fatigue, breathlessness, syncope and lightheadness.
Differentials of AF
- Atrial Flutter (Saw tooth appearance on ECG)
- Wolff Parkinson’s White Syndrome (Late teens/early 20’s).
- Atrial Tachycardia (Patient’s present with COPD)
Investigations of AF
ECG (Resting/Ambulatory)
Bloods (TFT’s, U&Es and FBC)
CXR
Management of AF
- Urgent admissions or referral if patient is acutely unwell.
- Assess patients for stroke risk using CHADSVASC2 , if the patient has a score of 2 or more, then consider anti coag.
- If patient considered for anti coag, weigh up bleeding risk using HAS BLED. Anti coag includes warfarin and DOACs (Rivaoxiban/apixiban).
- Beta blocker (Bisoprolol) andCCB can be used (Verapmil) for rate limiting to reduce heart rate at rest and exercise.
- Specialist care includes cardioversion, cardiac ablation and artificial pacemakers.
- ‘Pill in pocket’ approach for Paroxysmal AF = Beta blocker PRN.
Complications of AF
- Thrombus, stroke, dementia, MI, cardiac arrest.
Definition of Aortic Stenosis
- Represents an obstruction of blood flow through the aortic valve due to a pathological narrowing.
- Most common valvular disease.
- Progressive disease that has a long sub clinical period.
Causes of Aortic Stenosis
- 3 main causes: degeneration and calcification of a normal aortic valve (Elderly), calcification of a congenitally bicuspid aortic valve (Middle age) and rheumatic heart disease.
RF of Aortic Stenosis
Over 60, RHD, congenital bicuspid valve, radiotherapy, High levels of LDL and CKD.
Types of Aortic Stenosis
Supravalvular, subvalvular and valvular
Pathophysiology of Aortic Stenosis
- Increase pressure gradient between LV and AA due to increased afterload in the LV. Initially LV compensates through LV hypertrophy but eventually this becomes unsustainable due increased myocardium oxygen demand and therefore myocardium ischaemia.
Presentation of Aortic Stenosis
- Presentation once patients are moderate disease.
- 3 main symptoms include exertion syncope, angina and dyspnoea.
- Signs - carotid pulse = slow rising, apex beat = thrusting, harsh systolic ejection murmur heard at the right sternal angle and into the neck.
Investigations of Aortic Stenosis
- CXR = Normal heart size, potential prominence of the AA and possible valve calcification.
- ECG = LV Hypertrophy and strain = severe.
= Echo = Diagnostic - looks at valve size, gradient, flow, LV dilation and hypertrophy.
Differentials of Aortic Stenosis
- Aortic sclerosis, IHD and hypertrophic cardiomyopathy.
Management of Aortic Stenosis
- IE prophylaxis and attentive dental care.
- Valve replacement - open or transcatheter.
- Potential balloon valvotomy in children and teens.
Complications of Aortic Stenosis
- IE, infection, thrombus, stroke and cardiac arrest.
Definition of Mitral Stenosis
- Obstruction between LA to LV that leads to inadequate filling of the LV due to pathological narrowing.
- Usually symptoms after the valve is less than 2cm2. Normal size = 4 - 6cm.
- Decease in prevalence and incidence.
Causes of Mitral Stenosis
Previous Rheumatic Heart Disease
Risk Factors of Mitral Stenosis
Female, infections of strepotoccoccal, SLE, amyloidosis, certain medications.
Pathophysiology of Mitral Stenosis
- Increased size of valve leaflets means obstruction between LA and LV. Leads to increased pressure in LA, ultimately cause LA hypertrophy, leading to pulmonary hypertension and eventually right sided heart failure.
Presentation of Mitral Stenosis
- Initial signs are externtional dyspnoea that becomes progressively worse, patients may have cough or haempotysis, it is a disease of plateauing phases.
- Signs include mitral facietis (flushed colour on tops of cheeks), tapping apex beat, low pulse volume and loud S1 sounds.
Investigations of Mitral Stenosis
- CXR (Left atrial hypertrophy/ pulmonary hypertension).
- ECG (AF or in normal sinus rhyhtm potential bifid P waves).
- Echo = diagnostic - assess severity and valve area.
Differentials of Mitral Stenosis
Left atrium tumour
Management of Mitral Stenosis
- If patient has mild then no mechanical interventions, just symptomatic control using beta blockers/digixoin, anti coag and diuretics.
- Valve replacement ultimately required - offered to all patients with HF at class 3 or more or those particularly symptomatic.
- Balloon valvectomy can be used to relieve symptoms.
Complications of Mitral Stenosis
- AF, stroke, bleeding for warfarin, IE.
Definition of Mitral Regurgitation
- Backflow of blood between LV and LA.
- 80% of people have mild MR.
Aetiology of Mitral Regurgitation
- Mitral valve prolapse.
- Rheumatic heart disease
Risk Factors of Mitral Regurgitation
- IE, history of cardiac trauma, MI, IHD, congenital heart disease, ventricular systolic dysfunction, hypertrophic cardiomyopathy.
Pathophysiology of Mitral Regurgitation
- Circulatory changes depend on speed of onset and severity.
- Overtime increase LA pressure compensated for by increased LA hypertrophy.
- Leads to pulmonary hypertension and right sided heart failure then CHF.
Presentation of Mitral Regurgitation
- Acute presentation as pulmonary oedema.
- Chronic presentation as progressive extertional dyspnoea, fatigue and lethargy.
- Eventually symptoms of right sided heart failure and CHF.
- Signs and symptoms include apex beat displaced, soft heart sounds and 3rd heart beat.
Investigations of Mitral Regurgitation
- CXR, ECG, Echo and doppler/colour flow doppler to assess severity.
Differentials of Mitral Regurgitation
- ACS, Mitral stenosis, atrial stenosis.
Management of Mitral Regurgitation
- Mild = no interventions, symptomatic treatment and re echo every 1 to 5 years.
- More severe symptoms include valve replacement.
- IE prophylaxis.
Complications of Mitral Regurgitation
- AF, pulmonary hypertension, recurrent regurgitation, prosthetic stenosis.
Definition of Atrial Regurgitation
- Leaking of blood into the LV during diastole due to ineffective coapulation of the aortic cusp.
Causes of Atrial Regurgitation
- Infective endocarditis or rheumatic fever complicating an already damaged valve.
- Occurs in patients in their 40’s or 50’s.
Risk Factors of Atrial Regurgitation
- Bicuspid aortic valve, rheumatic fever, IE, Marfan’s syndrome, systemic hypertension and older age.
Pathophysiology of Atrial Regurgitation
- Increased pressure in the LV, ultimately leeds to LV hypertrophy and then LV dilatation.
- Increased stroke volume leads to increased pulse.
- Eventually leading to LV HF and ultimately CHF.
Presentation of Atrial Regurgitation
- Asymptomatic for a long period of time.
- Dyspnoea, orthnopea and fatigue.
- Signs = collapsing pulse, displaced thrusting apex beat, and diastolic blowing murmur heard at the left sternal border.
Investigations of Atrial Regurgitation
- CXR = Enlarged heart size.
- ECG = LVH
- Echo with doppler = Severity and blood flow.
Differentials of Atrial Regurgitation
- Mitral regurgitation, mitral stenosis, atrial stenosis, pulmonary regurgitation.
Management of Atrial Regurgitation
- Mild symptoms treated with medication such as vasodilators, ACE inhibitors (Ramipril), diuretics (Fursoemide) etc.
- Valve replacement = patients with less than 50% EF or symptomatic when at rest.
- Consider IE prophylaxis.
Complications of Atrial Regurgitation
- IE, op mortality, arrhythmias, CHF, MI, sudden death.
Definition of Pulmonary Insufficiency
- Back flow of blood from the pulmonary arteries into the right ventricle.
- Rare and often symptomatic.
Causes of Pulmonary Insufficiency
- Congenital (Congenital heart defects)
- Acquired (Trauma, syphillis, left sided heart conditions, rheumatic heart disease)
Risk Factors of Pulmonary Insufficiency
- Left sided HF, rheumatic heart disease, RA, IE, permanent pacemaker.
Pathophysiology of Pulmonary Insufficiency
- Increased fluid build up in the RV, increase pressure causing RV dilatation leading to RV hypertrophy, eventually causing heart failure.
- Decrease stroke volume leading to decreased pulse.
- Leads to symptoms such as peripheral oedema, dyspnoea and fatigue.
Presentation of Pulmonary Insufficiency
- Dyspnoea, fatigue or palpitations.
- Some murmurs may be able to be heard and also differences in the internal jugular pulse.