Cardiology Flashcards
What are the two types of acute coronary syndrome?
Stable and unstable angina
What is the definition of angina?
A symptom, caused by inadequate oxygenation to the myocardium
What is the cause of angina?
formation of an atherosclerotic plaque leads to obstruction of a coronary artery meaning there is less blood flow to the heart causing inadequate oxidisation
What is the main difference between stable and unstable angina symptoms wise?
Unstable angina has increasing frequency and severity of symptoms that does not get better unrest or GTN
What are the symptoms of stable angina?
Chest pain or pressure lasting several minutes
symptoms provoked by exercise or racial stress
relieved by rest or GTN spray
what investigations might want to perform to someone who has stable angina?
resting ECG shows no changes
cardiac biomarkers (tropponins) should be normal
fasting lipid profile
fasting blood glucose
and HbA1c
CXR - HF, DD
FBC - look for underlying infection or anaemia which could cause similar symptoms, or exacerbate angina
If someone presents to any with chest pain what investigations are necessary?
order a full cardiac work up. FBC, - anaemia, underlying infection DD Cardiac troponins, (+cardiac isoforms CK-MB, Creatinine kinase ) CRP - DD ECG CXR
If you suspect another couse you can perform more imaging. A CXR could rule out pulmonary oedema. CTPA for PE
How do you treat stable angina?
Improving lifestyle
control hypertension
anti platelet therapy ( aspirin, second-line= clopidogrel)
How do you treat unstable angina?
Oxygen (if decompensating), nitrates, and morphine
anti platelet therapy (aspirin, clopidogren) + consider adding anticoagulants (LMWH, Warfrin)
statins
There are various different cardiac markers:
Troponin
creatinine MB, CK
which is the best to look at and why?
High sensitivity troponin are very sensitive.
More so than creatinines:
They only last about 1 day after MI whereas troponins last around 1 week.
CK is general and can be from basically any muscle breakdown and is a good marker if renal function is good. CK MB is specific to myocyte muscle breakdown
HS troponins are high sensitivity.
If someone presents to you with chest pain that occurred 1h ago has now gone and the troponin levels are low does that mean that they are in the clear?
no
HS troponin peak after 3 h
a patient who had chest pain an hour ago which is now resolved,
troponin came back negative
x-ray was clear,
no clear ECG changes
is keen to be discharged, is it safe to discharge?
No
do serial troponin until 3hrs have passed
do serial ECG’s
In a heart attack what to drugs can give the pain relief?
Morphine
GTN
Under new guidelines when should you start oxygen in a chest pain patient?
If saturation is under 94%
What is the management of a patient who has a confirmed heart attack?
M(O)NA
PCI
Anticoagulation
When is PCI indicated in a heart attack?
Within 12 hrs from onset of symptoms and within 120 mins from diagnosis
If PCI isn’t indicated what else can you give?
Fibrinolysis treatment:
Altepase
Tenecteplase
Streptokinase
What are contraindications to fibrinolysis?
Acute pancreatitis; aneurysm; aortic dissection; arteriovenous malformation; bacterial endocarditis;
Who performs a PCI?
Interventional cardiologist
What other drugs/Mx should be considered in the treatment of acute coronary syndrome?
(apart from PCI/ thrombolysis)
Anticoagulants:
- LMWH
- Clopidogrel
Bisoprolol
Glycoprotein 11B/11a inhibitor – not commonly used
What ECG leads show changes in an anterior infarct?
leads V3, V4
What leads do you find changes in a posterior infarct?
V7, V8, V9 – these are V5, V6 put more laterally in the axilla, you know to do this if you see reciprocal changes V1, V2, V3
What leads do you find changes in an inferior infarct?
leads II,III,aVF
What leads one to find changes in a septal infarct?
V1, V5
What can the consequences of an MI?
Death
VSD
ventricular aneurysm occurring 4 to 6 weeks post heart attack due to a weakened myocardium
What is heart failure?
Where cardiac output does not meet the demands of the body without increasing diastolic function
What are the three types of heart failure based on ejection fraction?
- heart failure with reduced ejection fraction (<49%)
- heart failure with midrange ejection fraction ( 40-49%)
- heart range with normal ejection fraction (>50%)
Is all heart failure congested heart failure?
Yes
A patient comes to you complaining of: dysnopea needing to use an extra pillow to help sleep SOB cough
what is the most likely diagnosis?
Congestive heart failure
What physical signs are present during congestive heart failure?
Tachycardia (>120bpm) distended neck veins+JVP s3 gallop hepatomegaly chest crackles
What investigations are used to diagnose congestive heart failure?
Chest x-ray
transthoracic echo
ECG
FBC - anaemia = poor prognosis
serum lipids
iron studies - ? iron overload cardiomyopathy
HbA1c
urea and electrolytes (including creatinine) - renal function, renal disease can cause HF and be caused by HF
TSH - can cause HF
What findings would you see on test x-ray for congestive heart failure?
Cardiomegaly
Pulmonary congestion (kerlay B lines)
pleural effusion
What ECG changes can you find with congestive heart failure?
Prolonged QRS (above 120)
What is the management of heart failure?
ACEi or ARB (if ACEi intolerant) B blockers Loop diuretics (frusemide) + other diuretics
digoxin can be used
if underlying cause treat that
How does hypertension cause heart failure?
High blood pressure causes the left ventricle to hypertrophy.
This is due to the pressure overload which occurs in the heart.
The heart chamber becomes smaller due to the hypertrophy, and there is less cardiac output.
Thus causing heart failure.
How do cardiac myopathies cause heart failure?
The heart muscle becomes enlarged, thick or rigid or in some cases scarred.
This abnormal heart muscle causes the heart to enlarge – cardiomyopathy. And also causes cardiac dysfunction.
The cardiac output is reduced either due to reduced space in the ventricles or because the heart loses contractility.
Thus causing heart failure
How does valvular disease cause heart failure?
The inappropriate function of the valve will cause heart failure because of either:
1. increased pressure
2. increase volume
3. both.
this will cause hypertrophy of the chamber.
The condition will deteriorate until there is insufficient cardiac output thus causing heart failure
How does ischaemic disease cause heart failure?
Ischaemic heart failure.
Thrombus detaches and migrates to vessels supplying the myocardium (coronary arteries)
this means myocardium isn’t oxygenated and cannot bleat effectively.
This will cause inadequate cardiac output and heart failure
What is pulmonary hypertension?
High blood pressure in the pulmonary arteries caused by precipitating lung disorder.
What is the pathology of pulmonary hypertension?
There is a precipitating lung disorder
there is hypoxaemia and vasoconstriction
increasing the resistance in pul. vessels.
this can lead to right-sided heart failure due to the right ventricles trying to overcome the high-pressure
What are the characteristic symptoms of pulmonary hypertension/cor pulmonale?
Fainting fatigue and shortness of breath distended neck veins and JVP hepatomegaly oedema
past medical history of chronic lung conditions
What investigation are necessary in order to diagnose cor pulmonale?
lung CT and echocardiogram
chest x-rays, CTPA, spirometry and lung function tests can all be useful in finding lung pathology
What is the management of pulmonary hypertension
Treating the underlying condition
treating the caused heart failure
oxygen therapy is usually required
What is the definition of a cardiomyopathy?
Inappropriate ventricular hypertrophy or dilatation caused by mechanical or electrical dysfunction
can be primary or secondary
What is a primary cardiomyopathy?
A condition confined to the heart muscle which can be genetic, mixed, acquired
What is a secondary cardiomyopathy?
Myocardial involvement occurring as part of the systemic or multiorgan disorder
What are the three common cardiomyopathies?
Idiopathic
myocarditis
alcoholic
What are genetic cardiomyopathy examples?
Duchenne’s muscular dystrophy
genetic haemochromatosis
What are infective cardiomyopathy examples?
Can be viral (coxackies!), bacterial (GAS) or parasytic
What are autoimmune cardiomyopathy examples?
SLE
giant cell vasculitis/ myocarditis
sarcoidosis
What are toxic cardiomyopathy examples?
Alcohol
cocaine
methamphetamines
iron overload
What nutritional deficiencies can cause cardiomyopathy?
ZInc
copper
thamaline
What drugs can cause cardiomyopathy?
Antipsychotics - clozapine olanzapine risperidone
chloroquine
What endocrine causes of cardiomyopathy?
Hypo and hyperthyroidism Cushing's Addison's pheochromocytoma acromegaly diabetes pre-partum
Which electrolyte abnormalities can cause cardiomyopathy?
Hypocalcaemia
hypophosphataemia
What investigations are used to diagnose cardiomyopathy?
what do they show?
Chest x-ray - and large top shadow
echocardiogram - ventricular dilation and reduced stroke volume with lower ejection fraction
ECG - non specific findings
Biopsy - underlying cause (infection, iron build up, antibodies)
What is the treatment of cardiomyopathy?
Treating any underlying cause
heart failure management
What is the pathophysiology of mitral regurgitation?
Blood leaks backwards into the left atrium when the ventricle contracts
this reduces cardiac output and increases the amount of blood remaining in the atrium
this causes there to be a delegation of the Chambers and increases left ventricular diastolic function
these changes are in order to try and maintain cardiac output
What causes for mitral regurgitation?
rheumatic fever
infective endocarditis
acute dilatation of the left ventricle from myocarditis or ischaemia (post MI)
What is the purpose of an echocardiogram?
Let’s at structural and valvular abnormalities
assesses pressure within the ventricles
looks at flow of blood
While investigations are required in mitral regurgitation?
ECG
echocardiogram
What is the management of mitral regurgitation
if they are asymptomatic and left ventricular injection function (LVEF) >60
= ACEi and B Blockers
if LVEF is <60
= surgery
if symptomatic and LVEF > 30
= surgery + ACEi and B Blockers + Diuretic
if symptomatic ND LVEF < 30
= same as with >30 but with additional surgical measures
What type of surgery is used in mitral regurgitation?
percutaneous mitral valve leaflet repair
What is the pathophysiology of mitral stenosis?
and event occurs/congenital
leading to the fusion of the leaflets of the valves.
This restricts blood flow increasing the left arterial pressure causing pulmonary congestion and increasing its blood pressure.
restricted orifices of the valve limit the filling of ventricle/
there is limited cardiac output
What investigations will you use for mitral stenosis?
Echocardiogram.
ECG.
chest x-ray
What would an echocardiogram show in mitral stenosis?
Hockey stick shaped mitral deformity
What Myerson ECG showed in mitral stenosis?
Rhythm disturbances such as atrial fibrillation
left atrial enlargement and right ventricular hypertrophy
what finding would you see on chest X ray for Mitral stenosis?
Mainly ordered as a baseline test
can show enlarged left atrium giving a double right heart border and a prominent pulmonary artery plus other signs of pulmonary congestion
What’s the treatment of mitral stenosis?
If asymptomatic do not treat.
a symptomatic treatment with diuretics and surgery
In what exceptions to an asymptomatic patient would you treat mitral stenosis?
If pregnant
if severe and asymptomatic
- there is either a small valve area or a large pressure gradient
What is the main cause of mitral stenosis?
Rheumatic fever
What causes mitral prolapse?
Unknown thought to have some genetic link
What investigation is indicated for mitral prolapse?
Echocardiogram - shows leaf prolapse
What is the management of mitral prolapse?
If asymptomatic:
- reassure
- start on aspirin or warfarin (second line)
if symptomatic:
- halter/ ambulatory monitoring indicates management plan
- aspirin or warfarin (second line) if halter positive also give beta-blockers
if severe asymptomatic or symptomatic:
- valve repair plus aspirin or warfarin (second line)
What other two types of aortic regurgitation?
Acute
Chronic
What is the pathophysiology of acute aortic regurgitation?
Blood passes back through they’ll take valve causing a sharp increase in end-diastolic pressure in the left ventricle
heart begins to compensate with an increased heart rate and contractility to keep up with the increased preload
at one point this will fail and stroke volume is maintained
acute aortic regurgitation’s medical emergency causes sharp increase in left arterial pressure, pulmonary oedema and cardiogenic shock
What is the pathophysiology of chronic aortic regurgitation?
there is regurgitation back into the left ventricle
increasing left ventricular volume and pressure
causing hypertrophy and dilation to maintain stroke volume and reduce the now raised and diastolic volume
however due to the compensatory methods developed in the chronic process the end-diastolic pressure is normal
what investigations are indicated in aortic regurgitation?
ECG
Echo +Dopper
x-ray
What ECG changes would show on aortic regurgitation?
S T wave changes
left axis deviation or conduction abnormalities
What is the management of acute aortic regurgitation?
IV Inotropes - dopamine
IV vasodilators - nitroprusside
urgent valve replacement
What is the management of mild chronic aortic regurgitation?
If mild and asymptomatic:
reassurance.
if mild and symptomatic:
see if there is an underlying cause and treat that.
What is the management of mild chronic aortic regurgitation?
if severe and asymptomatic with ejection fraction >50%:
assess whether or not it is the compensating with exercise tolerance test:
if they manage to exercise tolerance test starts on vasodilator therapy - nifedepine
if they are in fact decompensated assess for surgery.
if the ejection fraction is < 50% or symptomatic:
assess for surgery immediately.
is unsuitable for surgery use:
- vasodilators (nifedipine)
- ACE inhibitors
- transcaheter approach
what is the pathophysiology of aortic stenosis?
Calcification of the leaflets leads to abnormal blood flow across the valves
the turbulent flow damages the endothelium initiating an inflammatory response further calcifying the valves (like atherosclerosis).
this causes a pressure overload and hypertrophy of the left ventricle which compensates for a while but eventually will fail causing heart failure
How does rheumatic fever cause aortic stenosis?
There is an autoimmune inflammatory response triggered by streptococcal infection
from molecular mimicry
both the infection and the immune system to target the valvular endothelium causing damage and stenosis
What are risk factors to aortic stenosis?
Cardiovascular risk factors ( including diabetes)
majority caused by a congenital bicuspid valve- found commonly in co-optation of the water and Turners syndrome
rheumatic fever
What would an ECG show in aortic stenosis?
Left ventricular hypertrophy
absent Q waves
atrioventricular block
or bundle branch block
What investigations would you perform for aortic stenosis?
Echo and Doppler
ECG
consider an MRI and cardiac catheterisation (shows elevated pressure gradient)
What is the treatment for an unstable patient with aortic stenosis?
Vasodilator or beta-blockers or balloon valvuloplasty until patient is stable enough for surgery
What is the treatment for a stable but symtpmatic patient with aortic stenosis
If low risk:
aortic valve replacement
if they are intermediate risk management is saying that they might need a TAVR
is high risk they need an aortic valve replacement and a TAVR
any risk then needs long-term infective endocarditis prophylaxis and long-term anticoagulation
What is the treatment for a stable and asymptotic patient with aortic stenosis
The clinical follow-up and an echo every 1 to 2 years unless they are severe in which case surgery is needed
What is the pathophysiology of tricuspid stenosis?
There is a produced orifice size causing reduced and turbulent blood flow during diastole to the right ventricle.
this causes are to be elevated right atrial pressure.
there is pulmonary congestion and reduced cardiac output with atrial enlargement and hypertrophied this can precipitate atrial fibrillation
How does rheumatic fever because tricuspid stenosis?
There is an antibody cross sensitivity between group a strep and the host tissue
and inflammatory response targeting mainly the leaflets causes fibrin deposition
this leads to fusion
and the chord tendinae are shortened
What are the causes of tricuspid stenosis?
Rheumatic fever/ rheumatic heart disease- as a late complication
rarely:
coronary heart disease and infective endocarditis and carcinoid syndrome heart disease
What investigations are necessary for tricuspid stenosis?
ECG chest x-ray echo Doppler liver function test full blood count blood cultures 24-hour excretion of urinary 5-HIAA (carcinoid)
What is the management of tricuspid stenosis if congenitally acquired?
Surgery and pre-op alprostadil
a post up anti platelet
What is the management of tricuspid stenosis in rheumatic fever?
Fluid and sodium restriction
loop diuretics
surgery if severe enough
What is the management of tricuspid stenosis in carcinoid heart disease?
Fluid and sodium restriction
loop diuretics
somatostatin analogues
valve replacement
How do somatostatin analogues work?
suppression of the secretions of the pituitary, pancreas, stomach, and gut; interference with growth factors; and direct antiproliferative effects on some tissues
What is tricuspid regurgitation?
Blood throwing back through the tricuspid valve causes elevation in right ventricular pressure
this causes right ventricular enlargement
eventually there is a reduced cardiac output
eventually also affects the atrium causing atrial distension and heart failure
What are the causes of tricuspid regurgitation?
Congenital
secondary causes are rheumatic fever, infective endocarditis and carcinoid
can also be caused by rheumatoid arthritis
How would you treat congenital tricuspid regurgitation?
Unless the surveyor and symptomatic manage heart failure symptoms, if severe symptomatic requires replacement
How would you manage secondary tricuspid regurgitation?
Treat any underlying cause and heart failure symptom management
if severe surgery
What is pulmonary stenosis?
The narrowing of the pulmonary valve causes an increase in right ventricular strain
Due to its congenital nature myocardium undergoes hyperplasia however if not congenital there is hypertrophy of the heart
eventually the pressure buildup will become severe and cause pulmonary congestion causing heart failure
What are the causes of pulmonary stenosis?
Congenital is most common: associated with noone’s and William’s
secondary causes are carcinoid, infective endocarditis, myocardial tumours
basically only one where rheumatic fever doesn’t affect the valve
What is the murmur associated with tricuspid regurgitation?
It is a high pitched, holosystolic murmur.
it is best heard at the left lower sternal border and it radiates to the right lower sternal border
What is the murmur associated with pulmonary stenosis?
midsystolic high-pitched crescendo-decrescendo murmur heard
best at the pulmonic listening post and radiating slightly toward the neck, (the murmur of pulmonic stenosis does not radiate as widely as that of aortic stenosis)
What would an ECG show for pulmonary stenosis
Right axis deviation with peaked P waves
What is the management of mild pulmonary stenosis?
Observation
What is the management of moderate pulmonary stenosis?
Surgery
What is the management of severe pulmonary stenosis?
Usually present at birth
give supplemental O2 with alprostadil and then surgery
What is pulmonary regurgitation
Helps equalise the pressure of the right ventricle and the pulmonary artery causing pulmonary congestion this can lead to pulmonary hypertension and heart failure
what the causes of pulmonary regurgitation?
congenital cases are rare to is usually in conjunction with another valve disease (occurs secondary to it) such as mitral stenosis, or infective endocarditis or rheumatic heart disease or in Marfan syndrome
What is the murmur of pulmonary regurgitation?
Pulmonic regurgitation produces a soft, high-pitched, early diastolic decrescendo murmur heard best at the pulmonic listening post (left upper sternal border)
What is infective endocarditis?
An episode of bacteraemia leading to the colonisation of an area of the heart causing vegetation
what is the pathophysiology of invective Endocarditis?
Underlying risk factors cause turbulent blood flow across the endothelium causing damage to it usually of the valvular surfaces of the heart.
Pay platelets and fibrin adhere to the underlying collagen of the endothelium taking a pro-thrombotic milau.
An episode of bacteraemia leads to the colonisation of the thrombus.
The colonisation causes further inflammatory response precipitating further fibrin and platelet buildup making a vegetation.
What are the causes of infective endocarditis?
Classically caused by Staphylococcus aureus
patient who has a prosthetic heart valve presents to you with fevers, chills, night sweats, myalgia, fever, weight loss and anorexia, weakness, arthralgia, headaches, shortness of breath
what are you concerned about?
Infective endocarditis
what are the risk factors for infective endocarditis?
Prior history of infective endocarditis
presence or prosthetic valve
post heart transplant patients
recent history of IV drug use
dental work
in hospital stay
catheters
How would you diagnose infective endocarditis?
You have to follow the Duke criteria in which he must have:
- two major criteria
- one major and three minor criteria
- five minor criteria
What are the major criteria for infective endocarditis?
An echo showing the vegetations or access
positive blood cultures
a new valvular regurgitation mamma
coxiella brunette inflection
What are the minor criteria for infective endocarditis?
Predisposing heart condition or IV drug use
a fever of 38°C or over
M belie to organs or brain haemorrhages
glomeruli nephritis, also notes, rust spots, rheumatoid factor
positive blood cultures that do not meet specific criteria
How would you manage bacterial endocarditis?
first ABCD approach
If a patient presents with decompensated heart failure diuretics and prompt surgery is needed
blood cultures echo and broad-spectrum antibiotics started
What is the antibiotic of choice used if staphylococcus is on blood culture?
Beta-lactam (vancomycin)
Methillin resistant ad trimethoprim and clindamycin
what is rheumatic fever?
An autoimmune disease resulting from infection from group a Streptococcus causing molecular mimicry.
What is the pathophysiology of rheumatic fever?
There is antibody attachment and basement membrane to the valve endothelium duty molecular mimicry.
There is up-regulation and adhesion of T cells.
These T cells then infiltrate and cause Neo- vascularisation and further recruitment of T cells damaging the endothelium.
How would you define primary rheumatic fever?
A patient without prior episodes of rheumatic fever and no evidence of rheumatic heart disease
How would you describe recurrent rheumatic fever?
A patient with documented rheumatic fever in the past but without evidence of established rheumatic heart sees
What is the Jones criteria?
The diagnostic criteria for rheumatic fever
What are the major criteria of the Jones criteria/ symptoms of rheumatic fever?
Pancarditis poly arthritis Sydenham Chorea subcutaneous nodules erythema marginatum (pink rings on the torso and inner surfaces of the limbs which come and go for as long as several months.)
What are the minor criteria of the Jones criteria/ symptoms of rheumatic fever?
Fever arthralgia prolonged PR interval increased ESR or CRP leucocytosis
What is required to diagnose rheumatic fever?
recent group A streptococcal infection with at least 2 major manifestations or 1 major plus 2 minor manifestations present.
or..
Rheumatic chorea: can be diagnosed without the presence of other features (which is described as ‘lone chorea’) and without evidence of preceding streptococcal infection. It can occur up to 6 months after the initial infection.
or…
Chronic rheumatic heart disease: established mitral valve disease or mixed mitral/aortic valve disease, presenting for the first time (in the absence of any symptoms suggestive of acute rheumatic fever).
What is the management of rheumatic fever?
Benzylpenicillin intramuscularly plus treating any complications
How would you treat arthritis caused by rheumatic fever?
Salycylate therapy/NSAID
How would you treat HF caused by rheumatic fever?
Diuretic furosemide or spironolactone \+/- ace inhibitor \+/- glucocorticoids if there is pericardial effusion
How would you treat chorea caused by rheumatic fever?
Anticonvulsants such as carbamazepine or valproic acid
What is pericarditis?
Inflammation of the pericardium
Describe the pericardium?
A two layer fibrinous sack covering the hearts surface.
It has a micro villous surface secreting pericardial fluid and is a highly innovative structure (phrenic nerve)
What is the function of the pericardial?
To protect, restrict, determine cardiac filling, limit cardiac dilatation and balances the ventricles
What are the common causes of pericarditis?
90% are idiopathic recorded viral infections most common viruses are:
Coxsackie virus
mumps
EBV
Apart from viral causes what else can cause pericarditis?
Pathogenic: Pneumococcus meningococcus Ghonnococcus and chlamydia candida
systemic diseases: SLE rheumatoid arthritis sclerosis IBD
other:
three days post MRI, radiotherapy, and cardiac surgery
A patient presents with :
chest pain which is worse on inspiration
has had a low grade fever
and been feeling generally under the weather
examination:
you hear high-pitched and squeaky sound heard of the left sternal edge
what is the diagnosis?
Pericarditis
Can also present with R sided heart failure which indicates constructive pericarditis!!!
What investigations would you run for someone with pericarditis?
ECG pericardial fluid culture and blood culture inflammatory markers for blood count urea chest x-ray echocardiogram
What changes would you find on ECG for pericarditis?
ST segment elevation and PR depression
also serum proponent could be mildly elevated
Why might you perform a chest x-ray or echo for pericarditis?
To check if there is a pericardial effusion and assess severity it
pericardial effusion sound in 60% of cases
Do you admit someone suffering from pericarditis to hospital ?
Yes
if there’s any presentation suggesting an underlying aetiology
or
predictor of poor prognosis:
- fever
- subacute onset
- symptoms of large pericardial effusion and cardiac tamponade
- failure to respond to 7 days of NSAIDs
what is the first-line management of pericarditis?
If idiopathic or viral use NSAIDs plus gastric protection for seven days and colchicine for three months afterwards to prevent re-occurrence and exercise restriction
if bacterial then systemic antibiotics plus the basic therapy
if there is a symptomatic or purulent effusion or cardiac tamponade then perform pericardial centrepieces
what would be the second line management of pericarditis?
Idiopathic or viral ad corticosteroids instead of NSAID and PPI but the rest is the same
what are the nine underlying causes of hypertension?
disturbance of the auto regulation reflects causing an increase in vascular resistance to match cardiac output
excess sodium intake
renal sodium retention
this regulated our AAS
increased sympathetic drive
endothelial dysfunction
increase peripheral resistance
hyper insulinaemia
cell membrane transporter dysfunction
What is a presentation of hypertension?
Usually presents a symptomatically.
in more advanced undiagnosed cases you can get some symptoms:
- headaches
- visual changes (retinopathy)
- dysnopea (from congestive hf)
- chest pain
- sensory or motor deficit (cerebrovascular disease)
What are risk factors of hypertension?
Obesity inactive lifestyle alcohol use metabolic syndromes over 60 families Hx sleep apnoea
After the initial diagnosis of hypertension what investigations need to be performed and why?
ECG - checking for left-ventricular hypertrophy from cardiac failure
fasting metabolic panel and EGFR- renal disease
lipid panel
full blood count - anaemia can be complication
thyroid function test
what is the diagnostic criteria of hypertension?
he patient should be seated quietly for at least 5
Two or more measurements should be made on two or more occasions and the average recorded.
What values are pre-hypertension?
120-130/80-89
What values are hypertension stage I?
140-159/90-99
What values are hypertension stage II?
160+/100+
What values of a hypertensive crisis?
180+/110+
What is the treatment of an adult with hypertension who is younger than 55 or type II diabetic?
step 1: ACE inhibitor (or ARB)
step 2: add a calcium channel blocker or thiazide like diuretic
step 3: all three
step 4: add low-dose spironolactone or an alpha blocker or beta-blocker, resistant hypertension should be confirmed with ambulatory monitoring.
What is the treatment of an adult with hypertension who is over 55 or a black patient of African/Caribbean descent?
step 1: CCB
step 2: add an ACEi or thiazide like diuretic
step 3: all three
step 4: add low-dose spironolactone or an alpha blocker or beta-blocker, resistant hypertension should be confirmed with ambulatory monitoring.
What are treatment aims for hypertension?
To get the blood pressure below 140/90 unless they are over 80 or particularly frail then 150/90
In hypertension when would you want to measure both standing and sitting blood pressure?
Resistant hypertension
anyone with type II diabetes
anyone with symptoms of postural hypotension
anyone over 80
An example of an ace inhibitor?
Ramipril
What are side effects of ramipril/acei?
Dizziness headache hypotension cough rash angioedema
Give an example of an ARB?
candesartan
What are side effects of candesartan/arbs?
Abdominal pain back pain hypotension hyperkalaemia renal impairment
What are side effects of CCB’s?
Peripheral oedema flushing palpitations abdominal pain muscle cramps rash
Give an example of a CCB?
Amlodipine
Give an example of Thiazide like diuretic and where thiazide like diuretics work?
Hydrochlorothiazide
Distal convoluted tubule
what are side effects of Thiazide like diuretics?
Alkalosis hypokalaemia diarrhoea nausea postural hypotension
Gave an example of a beta-blocker?
metoprolol
Give side effects of metoprolol?
cough erectile dysfunction dry eye fatigue peripheral coldness constipation
When is nifedipine contraindicated absolutely?
Malignant hypertension - in the acute Mx
as causes BP to drop too suddenly and can cause MI
what is the pathophysiology of atherosclerosis?
- Through a variety of mechanisms there is endothelial damage (we are taking in arteries)
- this increases the permeability of cells
- LDL can now pass through the intimal layer triggering white blood cells to (monocytes) morph into macrophages
- the macrophages release free radicals which oxygenate the LDL
- oxygenated LDL further up regulates the white blood cell response causing more macrophages
- macrophages engulfed the oxidised LDL particles and form foam cells
- foam cells eventually die and propagate inflammation forming a fatty streak. the immune inflammatory response also causes smooth muscle proliferation and migration from the tunica media into the internal layer in response to cytokines
- smooth muscle cells form the plaques for breast capsule and endothelial layers then cover the plaque
- over time there is calcification of the plaque and crystallisation hardening the blood vessel
- now higher pressure and turbulent blood flow which passes onto the plaque damages the endothelium
- causing clots to form forming a thrombus which can detach and cause embolus.
what causes peripheral vascular disease
Atherosclerosis aortic co-arctation arterial embolism venous thrombosis temporal arteritis
What is peripheral vascular disease?
Peripheral vascular disease (PVD) is a slow and progressive circulation disorder.
Narrowing, blockage, or spasms in a blood vessel can cause PVD.
PVD may affect any blood vessel outside of the heart including the arteries, veins, or lymphatic vessels.
What is the definition of claudication?
Inadequate blood flow during exercise causing fatigue discomfort or pain
trouble when walking
may have ulcers
muscular pain
What is the definition of critical limb ischaemia?
Compromise of blood flow to the extremity causing limb pain at rest
pain is muscular
patients often having also gangrene and ulcers which do not heal
trouble when walking
What is acute limb ischaemia ?
A sudden disease in which limb perfusion is decreased that threatens limbic viability causing the six Ps pain paralysis paraesthesia pulseless nurse parlour perishing with cold
What staging is used for peripheral vascular disease?
and what is each stage?
Fontaine staging
- asymptomatic
2a. mild claudication
2b. moderate to severe claudication - ischaemia rest pain
- ulceration or gangrene
What is the presentation of peripheral vascular disease?
Usually is asymptomatic
however may present with intermittent claudication symptoms
males may present with erectile dysfunction
symptoms are usually worse on one side and the other
What are some red flags in peripheral vascular disease?
Pain in larger muscles of the upper leg (indicates narrowing of the femoral artery)
diminished pulses or absent pulses (indicating acute limb ischaemia)
+ paralysis, paraesthesia, pallor, and perishing with cold
What is the first line test in peripheral vascular disease?
An ankle brachial index
or
toe brachial index
Describe the test ankle brachial index?
what result would be significant?
The ratio of the blood pressure at the ankle compared to the arm whilst resting done using a Blood pressure monitor
and ABI= 0.90 is positive
What follow-up tests might you want to do if a patient with peripheral vascular disease has an ABI of over 0.9?
A Doppler ultrasound
CT angiography or MR angiography
What is a screening process for peripheral vascular disease?
An ABI will be done for anyone at risk
the criteria are:
- 65 or over
- 50 to 64 with risk factors or family history
- under 50 with diabetes mellitus and one other risk factor
- known atherosclerotic disease in another vessel bad
What is the toe brachial index test and when is it used?
it is used when you suspect lower extremity PAD or
in patients with:
long-standing diabetes
or who are very elderly
due to the vessels in ankle not being compressible
What is the management of acute ischaemic event in peripheral vascular disease?
Assess whether or not the limits viable
if the limb is still viable= endovascular revascularisation and intra-arterial thrombolysis or surgical revascularisation
if the limb isn’t viable than amputation is required
in both cases a follow-up of:
- antiplatelet (aspirin or clopidogrel)
- analgesia
- anticoagulation (Heparin)
what is the ongoing management of peripheral vascular disease?
If not life limiting = antiplatelet therapy
if life limiting = antiplatelet therapy plus Cilostazol or Naftidrofuryl, used to help vasodilate
what is aortic dissection?
An intimal tear extending into the medial layer of the aortic wall
What is the pathophysiology of aortic dissection?
The intimal tear extends into the medial layer of the aortic wall
blood then passes through the media causing damage
this causes the deception to propagate down words (or upwards) through the medial layer creating a false lumen
What are the risk factors for aortic dissection?
- Hypertension
- atherosclerotic disease
- aortic aneurysm
- bicuspid aortic valve ( weakened aortic wall)
- co-optation of the aorta ( long-standing hypertension)
- marphans syndrome ( weakened aortic wall)
- Ehlers danlos syndrome ( weakened aortic wall)
- smoking
- family history
what is the presentation of aortic dissection?
Severe chest pain drugs were described as a ripping pain
acute onset
gradually extending pain
syncope
What signs might you find on aortic dissection?
A different blood pressure and left and right arm
a weakened pulse
diastolic murmur ‘crescendo’
hypotension
What is a first line investigation in aortic dissection?
CT angiography including abdomen and pelvis
What investigations might you want to perform to exclude differential diagnosis of aortic dissection?
ECG - MI
cardiac enzymes
chest x-ray - pulmonary causes
After performing a CT angiography in someone presenting with aortic dissection what other investigations would you want to do?
Type and cross for surgery
lactate levels indicating mild perfusion
full blood count to assess level haemorrhage
What is the management of an aortic dissection?
ABCDE approach until confirmed
once confirmed I the beta-blocker blockade keeping the heart rate below 60 bpm (labetalol)
give opioids
if blockade isn’t enough give vasodilator’s (nitroprusside or 2nd line diltazapam)
surgery
If you managed to treat an aortic dissection what is the ongoing management?
Managing hypertension using beta-blockers with or without ACE inhibitors
if both BB and ACEi not enough
then adding thiazide diuretics and/or calcium channel blockers
What other causes of an aortic aneurysm?
Diminished arterial wall integrity
atherosclerosis
What are the three types of AAA?
- Congenital
- infectious
- inflammation causing abnormal accumulation of macrophages and cytokines
What are congenital conditions which predispose to AAA?
Marfan’s syndrome
bicuspid valves
have accelerated medial degeneration - diminished arterial wall integrity
What is the most important risk factor in aortic aneurysm?
cigarette smoking
What is the presentation of an abdominal aneurysm?
Some patients may feel a palpable pulsating abdominal mass
most patients are symptomatic and it is found on accident
What is the first line test for abdominal aneurysm?
Abdominal ultrasound
When does an abdominal aneurysm becomes symptomatic?
what are the symptoms?
When it has ruptured or it is very large
pain and ripping sensation
low blood pressure symptoms
and signs of shock
or chest pain, SOB, low bp etc
What is the management of an asymptomatic aortic aneurysm?
If it is small=
surveillance and aggressive risk factor management
if it is large=
elective surgery with pre-op antibiotics and aspirin and ongoing hypertension management from diagnosis
What is the management of a symptomatic aortic aneurysm?
If it is ruptured=
ABCD, intubation with bag and mask central venous catheter arterial catheter and urinary catheter withholding fluids giving a target systolic blood pressure of 50 to 70 using IV beta-blockers then surgery
if it hasn’t ruptured=
surgery as soon as possible was pre-and post low-dose aspirin hypertension management as well as antibiotic therapy
what is shock?
Hypoperfusion on a cellular level or increased demand without adequate physical response.
hypo perfusion doesn’t allow for normal metabolic functions and triggers a systemic stress response
once the system is overwhelmed organ failure begins
What is the pathophysiology of shock?
- There is inadequate perfusion causing cell hypoxaemia and an energy deficit
- this causes lactic acid accumulation and a falling pH from anaerobic metabolism and also causes more anaerobic metabolism
- a fall in pHcauses metabolic acidosis which causes laser construction resulting in peripheral pooling of blood
- there is sound membrane dysfunction causing a release of digestive enzymes from intracellular lysosomes causing an influx of potassium influx of sodium and water
- this causes toxic substances to enter the circulation damaging the capillary endothelium
- this results in destruction dysfunction and cell death of multiorgan system
What are the different causes of shock?
Hypovolaemic
- diarrhoea and vomiting
- low albumin
- haemorrhage
Cardiogenic
- myocardial infarction
- arrhythmias
- substance misuse
Obstructive
- tension pneumothorax (causes an increase in inrathoracic pressure with is harder to pump against)
- cardiac tamponade (fills pericardium causing restriction on myocardium)
Anaphylactic
- causes vasodilation and an increase in leaky vessels causing decrease in albumin
Neurogenic
- disturbances of the sympathetic nervous system cause peripheral vasodilation
What is the initial investigations of shock?
ABCDE approach ABG to check for acidosis measure lactate measure glucose do a full blood count (Hb and WCC) blood cultures U+Es to check for renal hypo perfusion ECG
think Buffalo six
What is Buffalo six?
Blood cultures and septic screen - CXR, LP (inc. U+E) urine output - hourly fluid resuscitation Start empirical antibiotics measure lactate measure oxygen saturations
What is the initial management of hypovolaemic shock?
Give lots of fluids consider blood products
give a vasopressor’s and no inotropes
What is the initial management of septic or anaphylactic shock?
Give fluids and vasopressor’s consider giving inotropes
What is the initial management of cardiogenic shock?
Consider giving fluids
do not give vasopressor’s
give I know troops
also consider giving loop diuretics and GTN
What is an example of a vasopressor?
Adrenaline or noradrenaline
What is an example of an inotrope?
digoxin
what is an atrial septal defect
a congenital (usually ) small hole in the heart in the atrial septum causing a left-to-right shunt
What types of atrial septal defect are there?
by location: - premium - secundum (less commonly) - sinus venosis - unroofed
by size:
- small 3-6mm
- med 6-12 mm
- large 12 + mm
What are risk factors for developing an atrial septal defect?
Being female
maternal alcohol use
What is the presentation of an atrial septal defect?
Left-to-right shunt causes congestive heart failure failure to thrive arrhythmias and associated symptoms
usually they are asymptomatic
What murmur is associated with an atrial septal defect?
Systolic ejection murmur
What investigations are required to diagnose an atrial septal defect and what would they show?
Echocardiogram - showing defect
Doppler - showing blood flow
ECG may show tall P waves (RA enlargement) and large are waves (RV hypertrophy)
chest x-ray - may show cardiomegaly and increased pulmonary vascular margins
What is the management of an atrial septal defect?
if asymptomatic or small it may close on its own
if the defect does not close on its own by 2 to 4 y+ surgery
+ profylactic antibiotics are given 1h - 6m after surgery (for IE)
amoxicillin or clindamycin
What is a ventricular septal defect?
The most common congenital heart disease causing a hole in the heart in the ventricular septum
Causing a left-to-right shunt
What are risk factors of developing ventricular septal defects?
Down syndrome and maternal alcohol use
rarely can occur 2 to 5 days post MRI or after penetrating trauma
How are ventricular septal defects classified?
by size :
- small: 3- mm
- med: 3-6 mm
- large: 6+ mm
and resulting pulmonary vascular resistance: systemic resistance
How is pulmonary hypertension caused in ventricular septal defects in infants?
Pulmonary hypertension can be due to increased vascular resistance but in infancy it is mainly because of an increased blood flow to the lungs
in which area of the heart are ventricular septal defects most common?
perimembrane
can also be septum or muscle
What heart murmur is associated with ventricular septal defects?
pan systolic murmur that doesn’t worsen on inspiration Like in tricuspid regurgitation
In ventricular septal defects is a large murmur better than quiet murmur?
No a loud murmur is good as it indicates a small defect
What is the presentation of a ventricular septal defect
Usually asymptomatic
larger defects present with shortness of breath failure to thrive and recurrent chest infections
What investigations are used in ventricular septal defect and what do they show?
An Echo and Doppler shows heart defect and blood flow(high velocity jet)
if symptomatic the following can be present:
CXR shows cardiomegaly and increased vascular markings
ECG may show changes depending on level of severity they are different:
- LV enlargement
- LV + LA enlargement
- bi ventricular enlargement
what is management of a ventricular septal defect?
Small:
observation and antibiotic prophylaxis if undergoing any surgery
medium to large:
surgery at 3 to 6 months
large:
until there has been corrective closure medical therapy is also required to treat paediatric heart failure
What is the medical management of paediatric heart failure?
frusemide
frusemide + captopril or enalapril
frusemide + captopril or enalapril + digoxin
+ a high calorie diet
what is pericarditis?
inflammation of the pericardium
usually caused by viral infections
What are the common viral causes of pericarditis?
Coxsackie virus
Echo virus 8
mumps
EBV
What are bacterial causes of pericarditis?
Pneumococcus
meningococcus
Connie Caucus
chlamydia
What non-infectious causes are there of pericarditis?
SLE rheumatoid arthritis sclerosis IBD radiotherapy cardiac surgery 1 – 3 days after NI
What nerve innervates the pericardium?
Phrenic nerve
What are symptoms of pericarditis?
Pleuritic chest pain
fever – indicating effective cause
myalgia
On examination what sign may you find in pericarditis?
A high pitched squeaky sound heard at the left external edge this is pericardial rub
When might pericarditis cause right-sided heart failure?
Constrictive pericarditis
What investigations are required in pericarditis?
Any chest pain will require an ECG
pericardial fluid culture and blood culture will find infective causes
check your rear for renal failure which can cause pericarditis
chest x-ray/ echo
bloods for inflammatory markers
What signs would you find on an ECG In pericarditis?
ST elevation and PR depression
What might an x-ray or echo show in pericarditis?
Pericardial effusion showing a water bottle -shaped cardiac silhouette
What is the management of pericardial effusion?
for any cause gives NSAIDs PPI and exercise restriction
and 3 months colchicine
second line is the addition of corticosteroids unless it is a bacterial cause in which case do a pericardectomy
plus:
pericardioscentesis is required if:
symptomatic with purulent effusion and cardiac tapenade
systemic antibiotics required for infective cause
When would you admit hospital a patient with pericarditis?
A fever over 38° insidious or subacute onset large pericardial effusion cardiac tamponade failure to respond to 7 days of NSAIDs
consider admitting if they have one of the minor factors: pericarditis with myocarditis immunosuppressed traumatic cause oral anticoagulant therapy
What is the possible underlying mechanism for hypertension?
Disturbances of auto regulation reflects causing there to be a persistent increase in vascular resistance
access sodium intake
renal sodium retention
disregulated RAAS
increased sympathetic Drive
increased peripheral resistance
Endothelial dysfunction
hyperinsulinaemia
Cell membrane transporter dysfunction
what is the presentation of hypertension?
It is usually asymptomatic but will have some symptoms in more advanced cases:
headaches visual changes disnopea (congestive heart failure) chest pain sensory or motor deficit (from cerebrovascular disease)
What are the risk factors for hypertension?
Obesity sedentary lifestyle alcohol use metabolic syndromes black ancestry over 60 years old family history sleep apnoea
What investigations are required in hypertension?
Blood pressure cuff
- ECG
- fasting metabolic panel with EGFR (check renal damage and associated metabolic abnormalities)
- lipid profile and urinalysis (proteinuria and increased albumin suggests and organ damage)
- full blood count (anaemia is suggestive of a secondary causal complication)
- TSH
What is the management of hypertension in an adult who is under 55 years old or has Type II diabetes?
- ACE inhibitor (ARB if ACEi is CI)
- add CCB or thiazide like diuretic
- ACE inhibitor + CCB+ thiazide like diuretic
… if resistant
+ Spironolactone or beta-blocker and consult specialist
management of hypertension in adults who is over 55yrs of black ancestry?
- CCB
- add ACEi or ARB or thiazide like diuretic
- ACE inhibitor + CCB+ thiazide like diuretic
… if resistant
+ Spironolactone or beta-blocker and consult specialist
what are the ranges of blood pressure for:
- low blood pressure
- normal blood pressure
- pre-hypertension
- high blood pressure
- hypertension stage I
- high blood pressure hypertension stage II
- high blood pressure crisis
- <90
- 90-120
- 120-139
- 140-159
- 160 <
- 180 <
When do you need to measure both the standing and sitting blood pressure?
In anyone with :
type II diabetes
symptomatic of postural hypotension
anyone aged over 80
What is the target blood pressure?
Ideally as close to normal as possible aim for under 140/90 unless they are over 80 or particularly frail in which case aims for 150/90
what are examples of ACE inhibitors?
Lisinopril
enalapril
captopril
What are side effects of ACE inhibitors?
Cough headache dizziness and hypotension and drowsiness rash angioedema
What are examples of angiotensin two receptor antagonists A.k.a. ARB’s
candesartan
irbesartran
losartan
What are side effects of ARB’s?
Abdominal pain back pain diarrhoea hypotension hyperkalaemia renal impairment
What are some examples of a calcium channel blocker?
Amlodipine
filodipine
nifedipine
What are side effects of calcium channel blockers?
Muscle cramps peripheral oedema palpitations flashing abdominal pain rash
When is nifedipine absolutely contraindicated?
In the management of malignant hypertension in an acute case it causes BP to drop to suddenly and can cause myocardial ischaemia so another calcium channel blocker or other antihypertensive should be used
What are examples of thiazide like diuretics?
I hydrochloride
indapamide
clorthiadone
what are side effects ofThiazide like diuretics?
alkalosis - low Cl- diarrhoea hyperuricaemia nausea postural hypotension
what are some examples of beta-blockers used for cardiac purposes?
metoprolol
bisopralol
cardevilol
What are side effects of beta-blockers?
Cost erectile dysfunction dry eye fatigue peripheral coldness vascular disease constipation
Describe the stages of atherosclerosis?
- endothelial damage
- LDL moves into inntima and oxidises
- macrophages engulf oxygenated LDL
foam cells formed
- foam cells die and propagate inflammation
- process unregulated
fatty streak is formed
- smooth muscle cells form plaques fibrous capsule
- calcification and crystallisation occurs
What are the causes of peripheral vascular disease?
Atherosclerosis aortic co-arctation arterial embolism thrombosis temporal arteritis Buegers disease
What are symptoms of claudication?
Fatigue discomfort or pain in the affected limb due to inadequate blood flow during exercise
What are symptoms of critical limb ischaemia?
Limb pain at rest predisposition to ulcers or gangrene due to a compromise blood flow to extremities
What is acute limb ischaemia?
A sudden decrease in limb perfusion that threatens limb viability
what are symptoms of acute limb ischaemia?
The six p’s
pain paralysis paraesthesia pulse listeners pallor perishing with cold
what are risk factors for peripheral vascular disease?
Smoking
diabetes
hyperlipidaemia
cardiovascular history - family or personal
cerebrovascular history - family or personal
If patients with peripheral vascular disease also get pain in the larger muscles of the upper leg what does this indicate?
Narrowing of the deep femoral artery
True or false
patients with peripheral vascular disease may have erectile dysfunction?
true
True or false
peripheral vascular disease is commonly worse in one leg
true
What is crucial you do during your initial examination of a patient with peripheral vascular disease
Check all limb pulses
What is the first line investigation of peripheral vascular disease?
And ankle brachial index
What ABI result is positive for peripheral vascular disease?
less/ or equal to 0.9
A patient presents with symptoms of intermittent claudication that ABI comes back positive what next investigations could you perform?
- doppler US
- CT angio
- MR angio
Who is eligible for screening for peripheral vascular disease?
- Anyone over/ or the age of 65
- 50 to 64-year-olds with risk factors or a family history
- anyone younger than 50 with diabetes mellitus and one other risk factor
- anyone with known atherosclerotic disease in another vascular bed
What is the acute management of an acute ischaemic event in peripheral vascular disease?
- check limb viability
- if it is viable:
endovascular revascularisation + intra arterial thrombolysis OR surgical apprach - if it isn’t viable:
amputation - antiplatelets (clopidogrel or aspirin), analgesia, anticoagulation (heparin)
What is the ongoing management of claudication that is not lifestyle limiting?
antiplatelet therapy - Clopidogrel
What is the ongoing management of claudication that is lifestyle limiting?
Antiplatelet therapy – clopidogrel, symptom relief using cilosazol or naftidrofuryl +/- revasc
what is the ongoing management of chronic severe limb ischaemia?
Assessor revascularisation and give antiplatelet
some patients may benefit from spinal-cord stimulation or autologous bone marrow stem cell transplantation
What is aortic dissection?
And into multi extending to the medial layer of the aortic wall so the blood passes through the media due to degeneration caused by the blood pressure it’s essentially a false lumen
What are risk factors for aortic dissection?
Hypertension atherosclerotic aortic aneurysm bicuspid aortic valve co-optation of the aorta Marfan's syndrome Ehlers danlos syndrome smoking family history
what is the common presentation of aortic dissection?
An acute and severe chest pain that feels like ripping
different blood pressure in the left and right arm
pulse deficits or a weakened pulse
syncope and hypertension
What are the investigations you should do for suspected aortic dissection?
CT angiogram ASAP
ECG can be used to exclude other myocardial causes such as MRI
chest x-ray can be used to exclude pulmonary causes but may show a widened mediastinum
FBC, Lactate (malperfusion)
type and cross for surgery
what is your initial management for aortic dissection?
ABCD E – very important to give fluids noradrenaline and O2 until confirmed
once confirmed given IV beta-blocker blockade to get heart rate less than 60 bpm (labetalol or metoprolol)
opioids
if blockade is insufficient vasodilator (nitroprusside or 2ry dilaiazam)
surgery is required
What is the ongoing management for aortic dissection?
Manage hypertension using metoprolol +/- enalapril
+/- beta-blocker and ace inhibitor
+/- thiazide like diuretic +/- calcium channel blocker
What are the three types of AAA?
- Congenital: Marfan’s and bicuspid valves
- infectious: staphylococcus and salmonella
- inflammatory: abnormal accumulation of macrophages and cytokines
Risk factors of aortic aneurysms?
Cigarette smoking (most important)
family history
increased age
congenital disorders such as Marfan’s syndrome
What is the presentation of an abdominal aortic aneurysm?
A palpable pulsating abdominal mass but patients are usually asymptomatic and the aneurysm is found by accident
What is the diagnostic investigation of an aortic abdominal aneurysm?
Ultrasound scan
How would you manage an asymptomatic aortic abdominal aneurysm?
small:
surveillance and aggressive risk factor management
med/large:
elective surgery with pre-aspirin and hypertension management
How would you manage a symptomatic aortic abdominal aneurysm?
Has it ruptured?
yes: intubation central venous catheter arterial catheter urinary catheter withholding spirits target systolic BP is 50 to 70
surgery
no:
surgery as soon as possible
what is the definition of shock?
Inadequate oxygenation of organs to meet metabolic demand causing organ damage and failure
Describe the pathophysiology of shock?
inadequate perfusion causes cell hypoxaemia and an energy deficit
this causes lactic acid to accumulate and the pH to fall causing metabolic acidosis
- metabolic acidosis triggers vasoconstriction leading to the peripheral pooling of blood
cell membrane disfunction occurs causing:
sodium pump disfunction - efflux of potassium, influx of sodium and water
and digestive lysosome release
capillary endothelium is damaged
organ disfunction
how can you classify the causes of inadequate perfusion in shock?
fluids
cariogenic
distributive/ neurogenic
obstructive
What are fluid causes of shock?
Haemorrhage
low albumin
Burns
diabetic ketoacidosis
What are the distributive/ neurogenic causes of shock?
Failure of vasoregulation causing hypo perfusion
sepsis
anaphylactic
brainstem or spinal injury
What cardiogenic causes of shock?
Heart failure
MI
arrhythmias
toxic substances
rapid access rise in blood pressure
nonadherence insult fluid balance or medication
infection (infective endocarditis pneumonia sepsis)
acute mechanical causes such as myocardial rupture and chest trauma
What important investigations are needed in sepsis?
ABG – check for acidosis
lactate – indicates hypoperfusion and pre-terminal events
glucose - is this because of hypoglycaemia such as DKA
FBC - check for blood loss and check for infection markers
U+E – is a matter of hypo perfusion
coagulation studies – coagulopathy is associated with mortality
blood cultures and swabs as well as a chest x-ray may be needed
Describe the first line management of sepsis?
is an ABCDE approach
A) Support their way and intubate if necessary (if GCS is less than eight)
B) aim for 94 to 98% oxygen or 88 to 92% oxygen if they are entitled to respiratory failure do not over oxygenate this increases mortality
C) give circulatory support
D) check their GCS
E) check body temperature and either warm or cool as appropriate
What are indications for invasive ventilation in sepsis/ any ABCDE approach?
between CPAP and BiPAP which is better?
Pneumothorax confusion and agitation severe hypoxaemia recent facial or upper respiratory trauma vomiting copious respiratory secretions
give CPAP ideally
In hypovolaemic shock what circulatory support is appropriate?
Lots of fluids IV
some vasopressors may be useful (adrenaline)
In septic or anaphylactic shock what circulatory support is appropriate?
Give fluids and vasopressor’s consider inotropes (digoxin)
In cardiogenic shock what circulatory support is appropriate?
Consider fluids and give inotropes
What is the most common arrhythmia?
Atrial fibrillation
What are the causes of atrial fibrillation?
Pulmonary embolism ischaemia respiratory disease atrial enlargement thyroid disease ethanol sleep ageing
What other characteristic ECG findings of atrial fibrillation?
Absence of P waves with irregularly irregular beats and very narrow QRS complexes
How would you class atrial fibrillation?
Based on duration:
first episode
recurrent ? (more than two episodes)
paroxysmal ? (less than seven days)
persistent (more than seven days)
long-standing persistent (more than one year)
permanent (more than one year with unsuccessful rhythm control or not attempted because to elderly)
What risk is associated with atrial fibrillation how do you measure this risk?
thromboembolism
assess anticoagulation need using CHADS-VAC
How do you manage atrial fibrillation?
Rate or rhythm control to try and get back into sinus rhythm
drugs ie amiodarone
DC cardioversion
ablation therapy
What is atrial flutter?
The regular narrow complex tachycardia caused by a re-entry circuit
What of the classic easy defining of atrial flutter?
sawtooth flutter P waves at around 300 bpm
what characteristic ECG findings are therefore 1st° heart block?
Fixed prolonged PR interval greater than 200 ms
What is the alternative name for 2nd° heart block type I?
Mobitz type 1 - wechneback phenomenon
What is the classic ECG findings 2nd° heart block for type I?
Progressively prolonged PR interval until the atrial impulse is not conducted and the QRS complex is dropped
What is the classic ECG findings 2nd° heart block for type II?
Consistent PR interval duration with intermittently dropped QRS complexes usually in a repeating cycle such as 2:1, 3:1
what is the classic ECG finding For third-degree heart block?
Completely disorganised P waves and QRS complexes
What is third-degree heart block?
Complete failure of the conduction system between the atria and ventricles
How do you manage atrial flutter?
Rate control using the jocks in beta-blockers and calcium channel blockers
rhythm control using DC cardio version and ablation
+ anticoagulants if needed
what are premature atrial complexes?
Extra beats originating from the SAN
What are premature junctional complexes?
Extra beats occurring from the AV node causing a negative P wave on ECG
what is paroxysmal supra ventricular tachycardia?
Caused by separate re-entry circuits which cause a sudden onset which is initiated by premature beat and which stop abruptly but may re-occur
What are the two types of paroxysmal supra ventricular tachycardia?
AV nodal re-entry tachycardia
Atrioventricular re-entry tachycardia
How can you manage a AVNRT?
Vagal manoeuvres and AB blocking drugs (beta-blockers, ccb)
what is an example of AVRT?
Wolff Parkinson White syndrome
What is a characteristic finding of a Wolff Parkinson White syndrome on ECG?
Delta wave
irregular rythma
short pr <120ms
slurring of QRS complex prolonging to >100ms
what is the risk of Wolff Parkinson White syndrome?
ventricular fibrillation
The rapid accessory pathway can often bypass AV node causing the heart rate to reach 200 bpm
What are junctional escape beats?
When the AV node becomes a backup pacemaker (40-60bpm) if the heart rate is slow enough or the essay and fails
What is an accelerated junctional rhythm?
when the AVN fires at 60 to 99 bpmOccurring when there is ischaemic inflammation drugs and some electrolyte disturbances
What is non-paroxysmal junctional tachy arrhythmia?
an accelerated junctional cardio
What are premature ventricular complexes?
Commonest ventricular arrhythmia caused by ectopic pulses from the ventricular myocardium
who typically has premature ventricular complexes?
healthy individuals but can indicate an underlying heart sees they are also associated with amlodipine antidepressants the jocks in and recreational drugs
What is aberrant ventricular conduction?
The temporary alteration of the QRS complex under normal conditions
what are ventricular or Ido-ventricular benign sustained arrhythmias?
Occurs when the lower pacemaker takes over
usually caused by third-degree AV block or drug induced AV block
can be caused by sinus arrest Sino atrial node block or hyperkalaemia
What drugs can cause AV block?
Beta-blockers
calcium channel blockers
digoxin
What are pan systolic benign sustained arrhythmias?
Occur when an ectopic focus fires independently from the basic rhythm causing a parallel beat and are usually caused by coronary artery disease
What are the characteristic ECG findings of ventricular tachycardia?
A regular broad QRS complex with a rate over 100 bpm occurring with more/equal to 3pcvs
What other three types of morphologic classification of ventricular tachycardia?
monomorphic
polymorphic
v rare = torsade de pointes
What typically causes ventricular tachycardia ?
A re-entry circuit
underlying heart disease
electrolyte disturbances - mainly potassium
drug toxicity with TCA or antiarrhythmic’s
What is the management of ventricular tachycardia?
The patient is often haemodynamically unstable after ABCD they require urgent treatment by DC cardioversion definitive treatment is ablation
what underlying Heart conditions can cause ventricular tachycardia?
Long QT syndrome is
regardless in Rome
hypertrophic cardiomyopathy or die related cardiomyopathy
coronary artery disease
What is ventricular fibrillation?
Disorganised and chaotic heart with them but there is ineffective action of ventricles and can cause cardiac arrest it is usually fatal if not treated
what is a precursor to ventricular fibrillation?
Ventricular tachycardia
what are the characteristic findings of ventricular fibrillation?
Chaotic irregular deflections of varying amplitude.
No identifiable P waves, QRS complexes, or T waves.
Rate 150 to 500 per minute.
What is the management of ventricular fibrillation?
Immediate CPR and different relation ideally biphasic
