Cardiology Flashcards
What is the aetiology of angina?
- mostly atheroma
- rare causes include anaemia, aortic stenosis, small vessel disease
What is the pathophysiology of angina?
Atherosclerosis narrows the coronary arteries causing ischaemia which leads to pain
What are the risk factors of angina?
- smoking
- hypertension
- diabetes mellitus
- obesity
- sedentary lifestyle
- age
- hypercholesteraemia
- family history (and genetic)
What is the clinical presentation of angina?
- central chest tightness/ heaviness that may radiate, provoked by exertion, heavy meals of the cold (stops with rest/ GTN spray)
- dyspnoea, nausea, sweating, faintness
What are the differential diagnoses of angina?
- pericarditis/ myocarditis
- pulmonary embolism
- chest infection
- aortic dissection
How is angina diagnosed?
Exercise ECG
- often normal
- ST depression
- flat/ inverted T waves
- signs of a past MI
CT scan calcium scoring (more calcium = suggestive of angina)
How is angina managed?
- modify risk factors
- medications: aspirin, BB, CCB, nitrates (GTN spray)
- surgical: PCI, CABG
What is the aetiology of a STEMI?
Coronary artery disease
What is the pathophysiology of a STEMI?
- complete occlusion of a major coronary artery previously affected by atherosclerosis, causing full thickness damage of heart muscle
- coronary plaque rupture resulting in thrombosis formation which occludes a coronary artery
What are the risk factors of a STEMI?
- smoking
- hypertension
- diabetes
- obesity
What is the clinical presentation of a STEMI?
- chest pain
- SOBOE
- pallor
- diaphoresis (unusual degree of sweating)
- dizziness
What are the differential diagnoses of a STEMI?
- unstable angina
- NSTEMI
- aortic dissection
- pulmonary embolism
- pneumothorax
- pneumonia
- pericarditis
How is a STEMI diagnosed?
- ECG (ST elevation, tall T waves, then pathological Q wave some time after → may also present as left bundle branch block)
- cardiac biomarkers (troponin)
- glucose
- electrolytes, urea, creatinine
How is a STEMI managed?
- aspirin and P2Y12 inhibitors e.g. clopidogrel
- oxygen
- morphine
- GTN
- anticoagulation (unfractionated heparin)
- PCI/ CABG
What is the aetiology of an NSTEMI?
- non-occlusive thrombus
- coronary embolism
- myocarditis
- pulmonary embolism
- aortic stenosis
What is the pathophysiology of an NSTEMI?
- complete occlusion of a minor coronary artery or partial occlusion of a major coronary artery causes partial thickness damage of heart muscle
- oxygen demand of heart muscle can’t be met
What is the clinical presentation of an NSTEMI?
- chest pain
- SOBOE
- weakness
- diaphoresis
- recent PCI/ CABG
What are the differential diagnoses of an NSTEMI?
- aortic dissection
- pulmonary embolism
- peptic ulcer disease
- acute pericarditis
- oesophageal spasm
How is an NSTEMI diagnosed?
- ECG (ST depression, T wave inversion)
- GTN trial
- cardiac troponin
How is an NSTEMI managed?
- aspirin and P2Y12 inhibitors e.g. clopidogrel
- oxygen
- morphine
- GTN
- anticoagulation (unfractionated heparin)
- PCI/ CABG
What is the aetiology of IHD?
Atheromatous plaque leading to obstruction of coronary blood flow
What is the pathophysiology of IHD?
Imbalance between myocardial oxygen supply and demand
What are the risk factors of IHD?
- advancing age
- tobacco smoking
- hypertension
- elevated LDL cholesterol
- obesity
- diabetes
- family history
What is the clinical presentation of IHD?
- angina symptoms (chest pressure etc)
- jaw pain
- arm pain
- SOBOE
What are the differential diagnoses of IHD?
- aortic dissection
- pericarditis
- pulmonary embolism
- pneumothorax
- pneumonia
How is IHD diagnosed?
- resting ECG
- haemoglobin
- fasting lipid profile
- fasting blood glucose/ HbA1c
How is IHD managed?
- anti platelet therapy
- statins
- antihypertensives
- revascularisation
- GTN spray
What is the aetiology of heart failure?
IHD, hypertension, alcohol excess
Cardiomyopathy
- disease of heart muscles where the walls have become thickened, stiff or stretched
Valvular heart disease
- e.g. aortic stenosis, aortic and mitral regurgitation
Cor pulmonale
- abnormal enlargement of the right side of the heart as a result of disease of the lungs of the pulmonary blood vessels
Any factor that increases myocardial work
- e.g. anaemia, arrhythmias, hyperthyroidism, pregnancy, obesity
What is the pathophysiology of heart failure?
- physiological compensatory changes are initiated when the heart begins to fail to try and maintain cardiac output and peripheral effusion to negate the effects of HF
- as HF progresses, the mechanisms are overwhelmed and become pathophysiological (= decompensation)
- mechanisms = venous return (preload), outflow resistance, sympathetic system activation, RAAS
What are the risk factors of heart failure?
- > 65y
- African descent
- men (due to lack of protective effect of oestrogen)
- obesity
- people who have had a previous MI
What is the clinical presentation of heart failure?
- SOB, FATIGUE, ANKLE SWELLING
- dyspnoea, especially when lying down
- raised jugular venous pressure
- cyanosis
- hypotension
- peripheral/ pulmonary oedema
- ascite
LEFT-SIDED = SOBOE
RIGHT-SIDED = OEDEMA
How is heart failure diagnosed?
Blood tests:
- brain natriuretic peptide, FBCs, U&E, liver biochemistry
CXR:
- alveolar oedema
- cardiomyopathy
- dilated upper lobe vessels of lungs
- pleural effusion
ECG:
- shows underlying causes e.g. ischaemia, left ventricular hypertrophy
Echocardiography:
- assess cardiac chamber dimension, look for regional wall motion abnormalities, valvular disease and cardiomyopathies
If ECG and BNP are both normal, HF is unlikely
How is heart failure managed?
lifestyle changes, diuretics, surgeries, other drugs
Lifestyle changes:
- avoid large meals
- lose weight
- stop smoking
- exercise
- vaccinations
Diuretics:
- usually symptomatic relief (promote sodium and water loss so reduce ventricular filling pressure therefore reducing congestion)
- loop or thiazide diuretics
- aldosterone antagonists
Surgeries:
- mitral valve repair
- aortic/ mitral valve replacement
- heart transplant in young people
- ACEi, BB, digoxin, inotropes
- cardiac revascularisation and resynchronisation
What is the aetiology of primary hypertension?
- auto-regulation disturbance
- excess sodium intake
- renal sodium retention
- dysregulation of RAAS
- increased peripheral resistance
- endothelial dysfunction
What are the risk factors of primary hypertension?
- genetic susceptibility
- obesity
- high sodium
- low exercise
- low fruit and veg
- retinopathy
What is the clinical presentation of primary hypertension?
- headache
- visual changes
- SOBOE
- chest pain
- motor or sensory deficit
What are the differential diagnoses of primary hypertension?
- chronic kidney disease
- renal artery stenosis
- aortic coarctation
- obstructive sleep apnoea
- hyper/hypothyroidism
How is primary hypertension diagnosed?
- ECG (may show left ventricular hypertrophy)
- eGFR
- lipid panel
- urinalysis
How is primary hypertension managed?
- lifestyle modification
- antihypertensive therapy (ACEi, ARB, CCB, BB, diuretics)
What is the aetiology of secondary hypertension?
- often renal disease or pregnancy (CKD is most common cause)
- endocrine causes (Cushing’s, Conn’s…)
- coarctation of the aorta
- drug therapy (some prescription drugs like corticosteroids and the contraceptive pill, alcohol, ecstasy, cocaine)
What is the pathophysiology of secondary hypertension?
- vascular changes (hypertension accelerates atherosclerosis)
- heart (major risk factor for IHD)
- nervous system (intracerebral haemorrhage is a frequent cause of death in 2o hypertension)
- kidneys (can be the cause or the result of renal disease)
- malignant hypertension (markedly raised diastolic BP and progressive renal disease)
What are the risk factors of secondary hypertension?
- increasing age
- race (more common in black people)
- family history
- overweight and obese
- little exercise
- smoking
- too much salt
- alcohol
- diabetes
- stress
What is the clinical presentation of secondary hypertension?
- often asymptomatic
- found on screening
How is secondary hypertension diagnosed?
- look for end-organ damage e.g. LV hypertrophy, retinopathy and proteinuria
- urinalysis and albumin:creatinine ratio
- blood tests: serum creatinine, eGFR, glucose
- fundoscopy/ ophthamoscopy for retinal haemorrhage
- ECG and echo for LV hypertrophy
- 24h ambulatory BP monitoring
How is secondary hypertension managed?
- treatment goal is 140/90mmHg
- change diet: high consumption of fruits and veg, low fat, reduce salt and alcohol intake
- regular physical exercise
- lose weight
- stop smoking
ACD pathway:
A = ACEi
C = CCB
D = diuretic (thiazide or loop)
<55y = A → A+C or A+D → A+C+D → further diuretics, AB or BB
>55y or black of any age = C or D → A+C or A+D → A+C+D → further diuretics, AB or BB
