Cardiology Flashcards
1
Q
what is atherosclerosis
A
- degenerative
- fibrous and lipid rich plaque with variable inflammation, calcification and a tendency to thrombosis
2
Q
risk factors for atherosclerosis
A
Age Tobacco smoking High serum cholesterol Obesity Diabetes Hypertension Family history
3
Q
distribution of atherosclerosis
A
- peripheral and coronary arteries
- focal distribution along length
- changes in blood flow/ turbulence cause artery to develop neointima (new growth)
4
Q
what does a complex atherosclerotic plaque consist of
A
Lipid
Necrotic core
Connective tissue
Fibrous cap
5
Q
what are the main cells involved in atherogenesis
A
endothelium, macrophages, smooth muscle cells and platelets
6
Q
mechanism of development of an atherosclerotic plaque
A
- fatty streaks (<10y, lipid laden macrophage and T cells in intimal layer)
- intermediate lesions (smooth muscle, Tcells, platelets in vessel wall)
- fibrous plaques ( impedes flow, can rupture, more foam cells)
- plaque rupture (fibrous cap has to be resorbed and redeposited, shift in balance will cause rupture)
7
Q
what makes a complicated plaque
A
calcification, mural thrombus, vulnerable plaque
8
Q
what causes atherosclerosis to develop
A
- endothelial dysfunction and injury = lipid accumulation
- local cellular proliferation and lipid oxidisation
- mural thrombi, vessel healing and cycle repeats
9
Q
adaptation of atherosclerotic plaques
A
- plaque becomes>50% of lumen so vessel can’t compensate by remodelling
- narrowing drives cell turnover in plaque
- new matrix
- may progress to unstable plaque
10
Q
clinical manifestations of atherosclerosis
A
- Coronary arteries – chest pain/ pressure (angina)
- Brain arteries – transient ischaemic attack (TIA)
- Peripheral arteries – peripheral artery disease
- Renal arteries – high blood pressure or kidney failure
11
Q
management of atherosclerosis
A
- PCI (percutaneous coronary intervention), stop restenosis by using drug eluting stents (anti-proliferative and inhibits healing)
- aspirin
- clopidogrel/ ticagrelor (inhibits P2Y12 ADP receptor on platelets)
- statins (reduce cholesterol synthesis)
12
Q
investigations for heart disease - CXR
A
- snapshot of heart in little detail
- enlarged heart = congestive heart failure
- Signs of pulmonary oedema = decompensated heart failure
- globular heart = pericardial effusion
- Metal wires and valves show up
13
Q
investigations for heart disease - echocardiography
A
- US can give real time images of moving heart
- used at rest, during exercise or after use of pharmacological stressor
14
Q
investigations for heart disease - cardiac CT
A
- detailed
- CT angiography = contrast used = view coronary arteries = single breath hold and low radiation dose
15
Q
investigations for heart disease - cardiac MR
A
- radiation free
- first choice to look at diseases directly affecting myocardium
- pacemakers are safe with MR
16
Q
investigations for heart disease - nuclear imaging
A
- at rest or stress test
- assesses whether myocardium distal to blockage is viable ( hypoperfusion is reversed at rest)
17
Q
if an impulse travels towards an electrode in an ECG which way will it deflect
A
- upwards deflection
18
Q
what does each section/ wave show in an ECG
A
- P wave – atrial depolarisation
- PR interval – atrial depolarisation and delay in AV junction
- QRS – ventricular depolarisation
- T wave – ventricular repolarisation
19
Q
standard calibration of an ECG
A
25mm/s
0.1mV/mm
20
Q
common p-wave abnormalities
A
- Right atrial enlargement – tall >2.5mm – P pulmonale
- Left atrial enlargement – notched (M-shaped) – P mitrale
- long PR interval = first degree heart block
21
Q
common QRS complex abnormalities
A
-Depth of the S wave should not excess 30mm
-Pathological Q wave:
>2mm deep and >1mm wide
>25% amplitude of the subsequent R wave
22
Q
what does abnormalities in the QRS axis suggest
A
- ventricular enlargement or conduction blocks
23
Q
common abnormalities of the ST segment
A
ST segment is usually flat (isoelectric), elevation or depression of ST segment by 1mm or more can be pathological
24
Q
abnormalities in T wave
A
- Should be at least 1/8 but less than 2/3 of the amplitude of R
- Abnormal T waves are symmetrical, tall, peaked, biphasic or inverted
- T wave amplitude rarely exceeds 10mm
25
abnormalities in QT interval
- decreases when HR increases
| - should be 0.35 - 0.45 seconds
26
abnormalities in U waves
- small, round, symmetrical and positive in lead II, with amplitude <2mm (regular)
- U wave should be same direction as T wave
27
what can cause ST elevation
Normal variant, acute MI, Prinzmetal’s angina, acute pericarditis, left ventricular aneurysm
28
what can cause ST depression
Normal variant, digitoxin toxicity, ischaemic, angina, NSTEMI, acute posterior MI
29
what may myocardial infarction look like on ECG
- T wave may become peaked and ST segments may begin to rise
| - Within 24h, the T wave inverts. ST elevation rarely persists, unless a left ventricular aneurysm develops
30
what may a pulmonary embolism look like on ECG
sinus tachycardia, RBBB, right ventricular strain pattern
31
what is hypertension
- Chronic elevation of blood pressure in the arteries.
- WHO classification: >140/90mmHg.
- Malignant hypertension: >160/110mmHg (rapid rise causing fibrinoid necrosis of vessels)
- causes 50% of all vascular deaths
32
pathology of hypertension
- altered RAAS elevated BP, impaires sympathetic output, causes vasoconstriction
- normally balanced by atrial natriuretic factor
- hypertension alters vessel walls by increasing the wall thickness
33
causes of hypertension
- 90% primary with unknown aetiology
| - secondary hypertension
34
causes of secondary hypertension
- Endocrine disease = overproduction of aldosterone (Conn’s syndrome), Chronic vascular disease
- renal disease (most common) = intrinsic renal disease, renovascular disease
- drugs = NSAIDS, COC, corticosteroids, ciclosporin, cold cures, antidepressants, recreational
- lifestyle = obesity, high salt and alcohol
35
signs and symptoms of hypertension
- asymptomatic
- Malignant hypertension = Bilateral renal haemorrhages, Papilledema, Headache and visual disturbance
- look for causes and end organ damage
36
tests for hypertension
- 24 hour ambulatory BP monitoring
- fasting glucose, cholesterol
- ECG or echo (look for organ damage)
- special tests (renal US, 24h urinary meta-adrenaline, urinary free cortisol)
37
complications of hypertension
- cor pulmonale:
- Right ventricular hypertrophy and dilatation due to pulmonary hypertension
- Can also be caused by emboli, cystic fibrosis or chronic bronchitis
38
management of hypertension
- treatment goal <140/90 mmHg - reduce slowly
- lifestyle changes
- drugs
39
calcium antagonists
dihydropidines - inhibit the opening of voltage-gated calcium channels in vascular smooth muscle (decrease vasoconstriction)
40
ACE inhibitors
Ramipril and captopril – prevent generation of angiotensin II from angiotensin I.
41
angiotensin receptor blockers
aliskiren (inhibits renin) – block the action of angiotensin II at peripheral angiotensin II receptors
42
thiazide diuretic
Bendroflumethiazide – inhibit sodium reabsorption by the DCT, reducing the ECF volume
43
drug treatment of hypertension in patients <55 or with T2DM
1. ACEi (angiotensin blocker if not tolerated)
2. ACEi + CCB or thiazide diuretic
3. all 3
44
drug treatment of hypertension in patients >55 or of black African/Caribbean descent
1. CCB
2. CCB + ACEi (angiotensin blocker if black) or thiazide diuretic
3. all 3
45
what is angina pectoris
Recurrent transient episodes of chest pain due to myocardial ischaemia
46
what are the 4 types of angina
- Stable angina: induced by effort, relieved by rest.
- Unstable angina (crescendo): angina of increasing frequency or severity – occurs on minimal exertion or at rest. high risk of MI.
- Decubitus angina: precipitated by lying flat.
- Prinzmetal angina: caused by coronary artery spasm (rare)
47
pathology of angina
- myocardial ischaemia occurs when myocardial O2 demand outweighs supply
- artery stenosis increases resistance to flow
- myocardial ischaemia = pain
48
causes of angina
- Atheroma
| - Rarer = Anaemia, Coronary artery spas, Tachyarrhythmias
49
modifiable risk factors for angina
smoking, diabetes, hypertension, hypercholesterolaemia, sedentary lifestyle, stress
50
precipitants of angina
> affects supply = anaemia, hypoxemia, hypothermia, hypovolaemia, hypervolemia
> affects demand = hypertension, hyperthyroidism, valvular heart disease, tachyarrhythmia, cold weather
51
3 angina history features
1. Constricting/heavy discomfort to the chest, jaw, neck, shoulders or arms
2. Symptoms brought on by exertion
3. Symptoms relieved within 5min by rest or GTN spray
- 3/3 = typical angina, 2/3 atypical, 0/3 not anginal pain
52
symptoms of angina
```
Dyspnoea
Nausea
Sweatiness
Faintness
Crushing chest pain
```
53
investigations for angina
- ECG (often normal, Twave inversion, BBB)
- bloods = FBC, U&E, TFTs, lipids, HbA1c
- echo = normal or signs of previous infarcts
- CXR
- - stress echo, exercise stress treadmill, perfusion MRI
54
management of angina
- address exacerbating factors (anaemia, tachycardia, hyperthyroid)
- GTN (glyceryl trinitrate) spray
- ambulance if pain doesn't go 5mins after second dose
55
primary prevention of angina
- reduce risk of CAD and complications
| - risk factor modification
56
secondary prevention of angina
- lifestyle changes
- 75mg aspirin daily
- ACEi if diabetic
- PCI or surgery (CABG)
57
what is coronary artery bypass graft surgery (CABG)
- deals with complex disease
- open heart surgery
- risk of stroke/bleeding
- one-time treatment
- can't do if frail
58
what are acute coronary syndromes
- unstable angina, MI
| - pathology = plaque rupture, thrombosis, inflammation
59
what is myocardial infarction
- myocardial cell death, releasing troponin.
- full thickness necrosis
- Non-ST-elevation myocardial infarction (NSTEMI)
- ST-elevation myocardial infarction (STEMI)
60
modifiable risk factors for acute coronary syndromes
- smoking, diabetes, hypertension, hyperlipidaemia, sedentary lifestyle, cocaine use
61
diagnosis of acute coronary syndromes
- An increase in cardiac biomarkers (e.g. troponin)
- Symptoms of ischaemia
- ECG changes of new ischaemia
- Development of pathological Q waves
- New loss of myocardium
62
symptoms of acute coronary syndromes
- Acute central chest pain lasting >20min
- Nausea
- Sweatiness
- Dyspnoea
- Palpitations
- silent ACS = in elderly = syncope, pulmonary oedema, epigastric pain
63
signs of ACS
```
Distress
Anxiety
Pallor
Sweatiness
4th heart sound
Possibly signs of heart failure
Low grade fever
```
64
management of ACS
- GTN and opiates for chest pain
- modify risk factors
- cardioprotective meds = aspirin, clopidogrel, anticoagulants, beta blocker, ACEi, high dose statin
65
unstable angina
- severe acute myocardial ischaemia without necrosis
- at rest or minimal exertion
- no significant rise in troponin
66
different types of MI
- Subendocardial/ patchy infarction – involves the innermost layer and some middle parts of the myocardium, but not the epicardium. NSTEMI
- Transmural infarction – full thickness of the myocardium
67
initial management of STEMI
1. 12-lead ECG
2. IV access. Bloods for FBC, U&E, glucose, lipids, troponin
3. History
4. Aspirin 300mg and ticagrelor 180mg
5. Morphine 5-10mg IV +anti-emetic
6. STEMI on ECG = primary PCI
68
treatment of MI
- Aspirin – inhibits platelet function
- LMW heparin
- Thrombolytic therapy
69
what is cardiac failure
- heart can't pump enough = cardiac output is inadequate for the body’s requirements
- severe cardiac failure causes cardiogenic shock
70
what happens if the stretch capability of sarcomeres in the myocardium is exceeded
- cardiac contraction force diminishes
| - hypertrophic response triggered by angiotensin 2, ET-1, I-LGF1, TGF-beta
71
systolic failure
- inability of the ventricle to contract normally, resulting in low cardiac output.
- Ejection fraction <40%.
- Causes: IHD, MI, Cardiomyopathy
72
diastolic failure
- inability of the ventricle to relax and fill normally, causing increased filling pressures
- stiff heart
- Ventricular hypertrophy, Constrictive pericarditis, Tamponade , Restrictive cardiomyopathy, Obesity
73
L and R ventricular failure
- L = causes pulmonary congestion then overload of R side
| - R = venous hypertension and congestion (leg veins)
74
acute HF
new-onset acute or decompensation of chronic heart failure characterised by pulmonary and/or peripheral oedema with/without signs of peripheral hypoperfusion
75
chronic HF
develops or progresses slowly. Venous congestion is common but arterial pressure is well maintained until very late
76
diagnosis of HF
- symptoms of failure
| - FBC, U&E, CXR, ECG (cause), echo
77
signs of HF
```
Cyanosis
Decreased BP
Narrow pulse pressure
Displaced apex (LV dilatation)
Pulmonary hypertension
Pink frothy sputum
Signs of valve diseases
```
78
differential diagnoses for HF
```
COPD
Emphysema
Myocardial infarction
Pulmonary embolism
Pneumonia
```
79
management to acute HF - emergency
1. sit upright
2. high flow O2
3. treat arrhythmias
4. investigations
5. Diamorphine 1.25-5mg IV slowly
6. Furosemide 40-80mg IV slowly
7. GTN spray 2 SL puffs
8. If systolic BP 100mmHg, start a nitrate transfusion
80
management of chronic HF
- manage risk factors
- treat cause and exacerbating factors (anaemia, infection)
- flu vaccine
- pharmacological = diuretics, ACEi, beta-blocker (carvedilol), mineralocorticoid receptor antagonist (spironolactone), digoxin ( helps symptoms), vasodilators (hydralazine and isosorbide nitrate)
81
2 congenital valvular heart diseases
Congenital aortic stenosis
| Congenital bicuspid valve
82
2 acquired valvular heart diseases
Degenerative calcification
| Rheumatic heart disease
83
what is mitral regurgitation
- Backflow through the mitral valve during systole.
- Acute – back up into the lungs
- Chronic – dilation as it has had time to adjust
- volume overload
- compensated by LA enlargement, LVH and increased contractility
84
causes of mitral valve regurgitation
```
Rheumatic fever
Infective endocarditis
Mitral valve prolapse
Ruptured chordae tendinea
Papillary muscle dysfunction
Cardiomyopathy
```
85
signs and symptoms of mitral regurgitation
- Dyspnoea (exertion), Pulmonary oedema, Fatigue, Palpitations
- AF, pansystolic murmur, large LV
86
tests for mitral regurgitation
- ECG = AF, Pmitrale, LA enlargement and LV hypertrophy
- CXR = mitral valve calcification
- echo
87
management of mitral regurgitation
- Beta blocker if fast rate
- anticoagulant
- vasodilators - CCB (hydralazine)
- diuretics improve symptoms
- replace/ repair valve
88
what is mitral valve prolapse
- most common valvular abnormality
- two valve flaps of the mitral valve do not close smoothly or evenly, but instead bulge upwards into the left atrium
- atypical chest pain, palpitations, and autonomic dysfunction symptoms
- Mid-systolic click and/or late systolic murmur
89
complications of mitral valve prolapse
Mitral Regurgitation (MR)
Cerebral emboli
Arrhythmias
Sudden death
90
tests for mitral valve prolapse
- echo = diagnostic
91
treatment of mitral valve prolapse
- beta blockers help palpitations and pain
| - surgery is severe
92
what is mitral stenosis
- Obstruction of LV inflow that prevents proper filling during diastole.
- Normal mitral valve area 4-6cm2. Symptoms at <2cm2.
- causes = rheumatic fever, congenital, endocarditis, malignant carcinoid
93
symptoms of mitral stenosis
- Pulmonary hypertension (dyspnoea, haemoptysis)
- Pressure from large left atrium on local structures causes hoarseness (recurrent laryngeal nerve)
- Dysphagia
- Bronchial obstruction
- Fatigue
- Palpitations
- Chest pain
94
signs of mitral stenosis
- Prominent ‘a’ wave in jugular venous pulsations
- right-sided heart failure
- Mitral facies – severe MS leads to vasoconstriction: pink patches on cheeks
- Malar flush on cheeks
- Low-volume pulse
- Low pitch rumbling at apex
95
management of mitral stenosis
- rate control
- warfarin, beta-blocker, CCB, digoxin, diuretics
- mitral balloon valvotomy
- mitral valve replacement
96
what is aortic stenosis
- aortic valve narrowing restricts flow from LV to aorta
- symptoms when area 1/4 of normal (3-4cm2)
- supravalvular, subvalvular, valvular
- increases afterload, initially compensated by LVH then function declines
- causes = calcification, congenital, rheumatic heart disease)
97
classic triad for presentation of aortic stenosis
Angina (Chest pain)
Syncope
Breathlessness
98
signs of aortic stenosis
- Slow rising carotid pulse with narrow pulse pressure
- Heaving, non-displaced apex beat
- Ejection systolic murmur – crescendo-decrescendo
99
investigations for aortic stenosis
- echo
- LVH, dilation, ejection fraction
- cardiac catheter
- pulsus parvus et tardus (weak and late pulse)
100
management of aortic stenosis
- NEEDS SURGERY
- valve replacement
- transcatheter aortic valve implantation
101
what is aortic sclerosis
Senile degeneration of the valve. There is an ejection systolic murmur; but no carotid radiation, and normal pulse and S2.
102
aortic regurgitation
- Leakage of blood into LV during diastole due to ineffective coaptation of the aortic cusps.
- Acute: infective endocarditis, ascending aortic dissection, chest trauma.
- Chronic: congenital, connective tissue disorders (Marfan’s syndrome), rheumatic fever, Takayasu arteritis, rheumatoid arthritis
- pressure and volume overload
103
presentation of aortic regurgitation
Breathlessness
Orthopnoea (breathless lying down)
Palpitations
Diastolic blowing murmur
104
management of aortic regurgitation
- vasodilators
- serial echos
- surgical
105
what is tricuspid regurgitation
- doesn't close tight enough, backwards flow into RA
- causes = rheumatic fever, endocarditis, carcinoid syndrome
- fatigue, hepatic pain, ascites, oedema
106
signs of tricuspid regurgitation
Pansystolic murmur
Pulsatile hepatomegaly
Jaundice
107
management of tricuspid regurgitation
- diuretics
- treat underlying cause
- valve repair/ replacement
108
what is tricuspid stenosis
- narrowing , restricts blood flow from RA to L
- causes= rheumatic fever, congenital, endocarditis
- fatigue, ascites, oedema
109
signs of tricuspid stenosis
- opening snap, early diastolic murmur
| - AF
110
treatment of tricuspid stenosis
- diuretics
| - surgical repair
111
what is pulmonary stenosis
- obstructs flow from RV to pulmonary artery
- valve leaflets are thickened and fused together along their separation lines
- causes = congenital (Turners), rheumatic fever, carcinoid syndrome
- dyspnoea, fatigue, oedema, ascites
112
signs of pulmonary stenosis
Dysmorphic facies
Ejection click
Ejection systolic murmur
- prominent pulmonary arteries (post-stenotic dilation)
113
treatment for pulmonary stenosis
- pulmonary valvuloplasty or valvotomy
114
what is rheumatic fever
Pharyngeal infection with Lancefield group Aβ-haemolytic streptococci triggers rheumatic fever 2-4weeks later
115
pathology of RF
- An antibody to the carbohydrate cell wall of the streptococcus cross-reacts with valve tissue
- permanent damage to the heart valves
116
diagnosis of RF
- evidence of recent strep infection (Ab test or recent scarlet fever etc) + 2 major or 1 major, 2 minor
- major = carditis, arthritis, subcut nodules, erythema
- minor = fever, raised ESR/CRP, arthralgia
117
management of RF
- bed rest until CRP normal (2 weeks)
- benzylpenicillin
- analgesia for carditis/ arthritis
118
what is infective endocarditis
- Infection of the heart valve/s or other endocardial lined structures within the heart e.g. septal defects, surgical patches.
- really bad infection that showers infectious material into bloodstream
119
types of IE
- Left sided native IE (mitral or aortic)
- Left sided prosthetic IE
- Right sided IE
- Device related IE (pacemakers/ defibrillators)
- Prosthetic
120
causes of IE
- abnormal valve (regurgitant or prosthetic valves are most likely to get infected)
- bacteria from haematogenous spread or onto heart during surgery
- had previous IE
121
what infections can cause IE
- s.aureus from skin via indwelling vascular lines or IV drug abuse
- S.viridans from oropharynx following tooth brushing or dentistry
- enterococci from instrumentation of the bowel or bladder
122
clinical presentation of IE
- Signs of systemic infection
- Embolisation
- Valve dysfunction – HF, arrhythmia
- Petechiae (skin lesions)
- Splinter haemorrhages (bruised nails)
- Osler’s nodes (small, tender, purple nodules on digits)
- Janeway lesions (non-tender lesions on the fingers, palm or sole)
123
Modified Duke criteria for diagnosis of IE
- 2 major (blood culture growth, endocarditis on echo, or new valve leak)
- 5 minor (Predisposing factors e.g. IV drug abuse, Fever, Vascular phenomena, Immune phenomena e.g. Osler’s nodes, Equivocal blood cultures)
- 2 major +3 minor or 1major +5minor
124
investigations for IE
- blood cultures, raised CRP
- CXR = cardiomegaly, pulmonary oedema
- CT = emboli
- ECG
- Echo = vegetations
125
treatment of IE
- IV antimicrobials for 6 weeks
- treat complications
- surgery to remove infected valves or prosthetics
126
what is congenital heart disease
general term for a range of birth defects that affect the normal way the heart works
- can be incompatible with ex-utero life
127
what is Eisenmenger syndrome
any untreated congenital cardiac defect with intracardiac communication that leads to pulmonary hypertension, cyanosis, reversal of flow
128
physiology of ventricular septal defects
- High pressure LV
- Low pressure RV
- Blood flows from high to low pressure chamber (so, not blue)
- Increased blood flow through the lungs
129
symptoms of ventricular septal defects
```
Severe heart failure in infancy
Very high pulmonary blood flow in infancy
Breathless
Poor feeding
Failure to thrive
```
130
signs of ventricular septal defects
- Small, breathless, skinny baby
- Tachycardia
- Big heart on chest X-ray and large pulmonary arteries
- Murmur varies in intensity
- Harsh pansystolic murmur heard at left sternal edge
131
complications of septal defects
Pulmonary hypertension
Eisenmenger’s complex
Heart failure from volume overload
132
Eisenmenger's syndrome in ventricular septum defects
1. pulmonary hypertension from L to R shunt
2. damages pulmonary vasculature
3. resistance to flow increases in lungs
4. RV pressure increases
5. shunt direction reverses
6. de-oxygenated blood enters systemic circulation
7. become cyanosed
133
treatment for ventricular septal defects
- may close spontaneously
| - surgical closure = shunt > 3:1
134
physiology of atrial septal defect
- Slightly higher pressure in the LA than the RA
- Shunt is left to right (therefore not blue)
- Increased flow into right heart and lungs
135
symptoms of atrial septal defect
- Significant increased flow through the right heart and lungs in childhood
- Right heart dilatation
- Shortness of breath on exertion
- Increased chest infections
- Chest pain
- Palpitations
136
investigations for atrial septal defect
- CXR = big pulmonary arteries and heart, small aortic knuckle
- ECG = RBBB with LAD or RAD
137
treatment for atrial septal defects
- may close spontaneously
| - close if symptomatic (transcatheter closure > surgical)
138
Atrio-ventricular septal defects
- ventricular septum, atrial septum, mitral and tricuspid valves
- AV valves become one big one
- complete defect = torrential pulmonary blood flow causing breathlessness as neonate, needs repair in infancy
- partial defect = can present in late adulthood, can be left alone if no heart dilation
139
patent ductus arteriosus
- ductus arteriosus fails to close after birth, leaving a vessel connecting the aorta and pulmonary artery
- Torrential flow from the aorta to the pulmonary arteries in infancy
- surgical closure under local anaesthetic
140
clinical signs of patent ductus arteriosus
- continuous murmur
- big heart, breathless
- Eisenmenger's syndrome = cyanosed
141
coarctation of the aorta
-Congenital narrowing of the descending aorta (usually occurs just distal to the origin of the left subclavian artery – the site of insertion of the ductus arteriosus)
142
what conditions are coarctation of the aorta associated with
- Turner's syndrome
| - bicuspid aortic valve
143
signs of coarctation of the aorta
```
Radiofemoral delay
Weak femoral pulse
High blood pressure
Cold feet
Scapular bruit
```
144
investigations for coarctation of the aorta
- CXR= rib notching as blood diverts down intercostal arteries to lower body (dilate and erode rib bone)
145
treatment for coarctation of the aorta
surgery
| balloon dilatation
146
tetralogy of Fallot
- congenital heart condition with 4 abnormalities
1. Ventricular septal defect (VSD)
2. Pulmonary stenosis
3. Right ventricular hypertrophy
4. The aorta overrides the VSD, accepting right heart blood
147
physiology of tetralogy of Fallot
- pulmonary stenosis = higher pressure in RV
- blood from RV to LV
- patients are blue
148
presentation of tetralogy of Fallot
- cyanotic
| - hypoxic spell = becomes restless and agitated
149
investigations for tetralogy of Fallot
- ECG: RV hypertrophy with RBBB.
- CXR may be normal or show a boot shaped heart (hallmark of TOF)
- Echo
150
management of tetralogy of Fallot
surgery before age 1 = closure of VSD and correction of pulmonary stenosis
151
what is cardiomyopathy
- primary heart muscle diseases
- often genetic
- all carry risk of arrhythmias
- heart doesn't pump as well
152
what is acute myocarditis
-Inflammation of the myocardium - often associated with pericardial inflammation
153
causes of acute myocarditis
- Idiopathic (unknown)
- Viral, bacterial, protozoan
- Spirochetes (Lyme disease/ syphilis)
- Drugs e.g. penicillin
- Toxins e.g. cocaine, lithium, alcohol, lead, arsenic
- Immunological e.g. heart transplant rejection
154
symptoms of acute myocarditis
ACS-like symptoms
Heart failure symptoms
Palpitations
Tachycardia
155
investigations for acute myocarditis
ECG: ST changes and T-wave inversion, atrial arrhythmias
Bloods: CRP, ESR and troponin may be raised
Echo: diastolic dysfunction
156
treatment for acute myocarditis
- supportive
- treat underlying cause
- treat arrhythmias and HF
157
what is dilated cardiomyopathy (DCM)
- dilated, flabby heart of unknown cause.
- Most autosomal dominant, but some recessive and X-linked. Mutations in several genes are recognised – dystrophin, troponin T
- pathology = poor contractile force leads to dilation of the heart with some interstitial tissue
- associated with alcohol, high BP, chemotherapeutics, viral infection, autoimmune
158
signs and symptoms of DCM
- fatigue, dyspnoea, pulmonary oedema, RVF, emboli
- high pulse, low BP, hepatomegaly, mitral/tricuspid regurgitation
- hyponatraemia indicated a poor prognosis
159
treatment of DCM
```
Bed rest
Diuretics
β-blockers
Anticoagulation
Transplantation
```
160
what is hypertrophic cardiomyopathy (HCM)
- LV outflow tract obstruction from asymmetrical septal hypertrophy.
- Caused by sarcomeric protein gene mutations – many recognised involving beta-myosin binding protein C, troponin T, titin
161
signs and symptoms of HCM
- Sudden death (troponin T)
- Cardiac hypertrophy and dysrhythmia (beta-myosin)
- Angina
- Dypsnoea
- Palpitations
- Dizziness
- Syncope
162
investigations for HCM
- echo = asymmetrical septal hypertrophy, small LV cavity, dilated LA
- ECG= Twave inversion, deep Q wave
163
management of HCM
- β-blockers for symptoms
- Amiodarone for arrhythmias
- Anticoagulate for systemic emboli
164
what is restrictive cardiomyopathy (RCM)
- Restrictive filling of the ventricles so insufficient pumping
- causes = idiopathic, amyloidosis, endomyocardial fibrosis
165
presentation of RCM
- Like constrictive pericarditis
- Features of RVF – hepatomegaly, oedema, ascites
- do echo and MRI
166
treatment of RCM
treat cause
167
what is arrhythmia right ventricular cardiomyopathy
- degenerative
- progressive dilation of the right ventricle with fibrosis, lymphoid infiltrate and fatty tissue replacement
- often caused by desmosome gene mutations
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what is a channelopathy
- Inherited arrhythmia caused by ion channel (K, Na, Ca) protein gene mutations
- include long QT, short QT, and Brugada syndrome
- structurally normal
- recurrent syncope
- QT prolonging drugs can kill these patients
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familial hypercholesterolaemia (FH)
- inherited abnormality of cholesterol metabolism (abnormal LDL protein)
- leads to coronary and other vascular disease
- aortic aneurysm or dissection
- AD
- genetic testing
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what is pericarditis
- inflammation of the pericardium
- infections are most common cause along with MI
- injury to the pericardium causes inflammation
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presentation of pericarditis
- central chest pain (worse lying flat, better sitting forward)
- if large may cause breathlessness
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acute pericarditis
- causes = viruses, bacteria, fungi, autoimmune, drugs, metabolic, others
- ECG shows concave (saddle-shaped) ST segment elevation and PR depression
- Blood tests: FBC, ESR, cardiac enzymes, tests related to aetiologies
- Cardiomegaly on CXR may indicate pericardial effusion
- CMR and CT may show localised inflammation
- may hear friction rub
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treatment of acute pericarditis
- NSAIDs or aspirin with gastric protection
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constrictive pericarditis
- heart is encased in a rigid pericardium
- dyspnoea, chest pain, nausea, bronchial breathing
- CXR = big globular heart
- ECG = low-voltage QRS complex
- echo = echo free zone around heart
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management of constrictive pericarditis
- treat cause
- pericardiocentesis
- send fluid for culture and cytology
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what are some cardiac causes of arrhythmias
ischaemic heart disease; structural changes e.g. left atrial dilatation secondary to mitral regurgitation; cardiomyopathy; pericarditis; myocarditis; aberrant conduction pathways
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what are some non-cardiac causes of arrhythmias
caffeine, smoking, alcohol, pneumonia, drugs, metabolic imbalance
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presentation of arrhythmias
```
Palpitations
Chest pain
Presyncope
Syncope
Hypotension
Pulmonary oedema
```
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investigations for arrhythmias
- FBC, U&E, glucose, Ca2+, Mg2+
- ECG: look for signs of IHD, AF, short PR interval, long QT interval, U waves
- 24h ECG monitoring
- Echo: look for structural heart disease e.g. mitral stenosis
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management of arrhythmias
- conservatively (eg. reduce alcohol)
- medical
- interventional (pacemakers, ablation, implantable cardioverter defibrillators)
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sinus tachycardia
- impulses initiated at high frequency
| - causes = infection, pain, exercise, anxiety, dehydration
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focal atrial tachycardia
- group of atrial cells act as a pacemaker, out-pacing the SAN.
- P-wave morphology is different to sinus.
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atrial flutter
electrical activity circles the atria 300 times per minute, giving a sawtooth baseline. The AVN passes some of these impulses on, resulting in ventricular rates that are factors of 300.
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junctional tachycardia
cells in the AVN become the pacemaker, giving narrow QRS complexes as impulses reach the ventricles through the normal routes; P waves may be inverted and late
185
bundle branch block
- delay or blockage along the pathway that impulses travel
186
ventricular tachycardia
- results from circuits similar to atrial flutter
| - QRS is broad with regularly increasing nd decreasing amplitudes (torsades de pointes)
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what is narrow complex tachycardia
- rate >100 bpm
- QRS <120ms (narrow because ventricles depolarised via the normal conduction pathway)
- can be regular or irregular
- treat underlying rhythm
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what is broad complex tachycardia
- >100bpm and QRS complexes >120ms.
- If no clear QRS complexes, is it VF or asystole
- differential diagnosis = ventricular tachycardia or fibrillation
- correct electrolyte problems
189
ventricular extrasystoles
palpitations, a thumping sensation, or their heart missing a beat. The pulse may feel irregular if there are frequent ectopics.
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what is atrial fibrillation
- chaotic, irregular atrial rhythm at 300-600bpm. The AVN responds intermittently, hence an irregular ventricular rhythm.
- The main risk is embolic stroke.
- chest pain, palps, dyspnoea, faintness
- irregularly irregular pulse
- signs of LVF
191
investigations for atrial fibrillation
- ECG: absent P waves, irregular rapid QRS complexes
- Blood tests: U&E, cardiac enzymes, thyroid function tests
- Echo: left atrial enlargement, mitral valve disease, poor LV function, other structural abnormalities
192
management of acute atrial fibrillation
- amiodarone
- is started >48h ago then bisoprolol
- correct electrolyte imbalances
193
management of chronic atrial fibrillation
- rate control = beta blocker or CCB
194
causes of atrial flutter
```
Obesity
Hypertension
Excess alcohol
COPD
Heart failure/ CHD
```
195
management of atrial flutter
Amiodarone – anti-arrhythmic drug
Beta blockers - Bisoprolol
LMW Heparin
Catheter ablation
196
first degree heart block
PR interval is prolonged and unchanging; no missed beats
197
second degree heart block
- Mobitz I – the PR interval becomes longer and longer until a QRS is missed = Wenckenbach phenomenon
- Mobitz II – QRSs are regularly missed = dangerous as may develop into complete heart block
- 3rd degree complete heart block: no impulses are passed from atria to ventricles so P waves and QRSs appear independently of each other. emergency, become bradycardia
198
management of heart block
IV atropine
| Permanent pacemaker
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what is Wolff-parkinson-white syndrome
- extra electrical pathway in the heart leading to periods of tachycardia
- congenital
- short PR interval, wide QRS complex
- prone to AF
200
what is an aortic aneurysm
- abnormal bulge that occurs in the wall of the aorta.
- An artery with a dilatation >50% of its original diameter has an aneurysm
- true aneurysm = all layers of wall
- false aneurysm = collection of blood in outer layer only
201
causes of aortic aneurysm
```
Atheroma
Trauma
Infection
Connective tissue disorders
Inflammatory
```
202
common sites for aneurysm
Aorta (most common)
Iliac
Femoral
Popliteal arteries
203
clinical presentation of aortic aneurysm
- often asymptomatic (sometimes back pain) until ruptures (abdo pain, collapse, shock)
204
investigations for aortic aneurysm
X-ray
Echocardiogram
CT angiography
Ultrasound
205
management of aortic aneurysm
- check ups and monitoring
| - surgery (endovascular or open)
206
what is aortic dissection
- tear in aortic wall
- Blood can flow in between the layers of the blood vessel wall (dissection).
- This can lead to aortic rupture or decreased blood flow to organs.
- associated with aortic aneurysms.
207
risk factors for aortic dissection
- Ageing
- Atherosclerosis
- Blunt trauma to the chest
- High blood pressure
- Bicuspid aortic valve
- Coarctation (narrowing) of the aorta
208
clinical manifestations of aortic dissection
- Chest Pain – sharp, stabbing, tearing or ripping which radiates to the back
- Anxiety and feeling of doom
- Fainting or dizziness
- Heavy sweating (clammy skin)
- Nausea and vomiting
- Pale skin (pallor)
- Rapid, weak pulse
209
what is the gold standard test for diagnosing aortic dissection
- CT scan of chest
210
management of aortic dissection
- surgical repair
- lower BP ( beta blockers)
- pain relief
211
what is peripheral vascular disease
- Occurs due to atherosclerosis causing stenosis of arteries
| - restricts blood supply to leg muscles
212
symptoms of peripheral vascular disease
- Cramping pain in the calf, thigh, or buttock after walking for a given distance and relieved by rest
- Ulceration, gangrene and foot pain at rest
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signs of peripheral vascular disease
- Absent femoral, popliteal or foot pulses
- Cold, white legs
- Atrophic skin
- Punched out ulcers
- Buerger’s angle (angle that leg goes pale when raised off the couch)
214
investigations for peripheral vascular diseas
- FBC
- ECG
- Ankle-brachial pressure index (ABPI)
- Colour duplex USS
215
management of peripheral vascular disease
- risk factor modification
- supervised exercise programmes
- surgical reconstruction = bypass graft
- amputation
216
what is shock
Circulatory failure resulting in inadequate organ perfusion. Often defined by low BP – systolic <90mmHg, with evidence of tissue hypoperfusion
217
what is cardiogenic shock
a state of inadequate tissue perfusion primarily due to cardiac dysfunction
218
causes of cardiogenic shock
```
Myocardial infarction
Arrhythmias
Pulmonary embolus
Tension pneumothorax
Cardiac tamponade
Myocarditis
Aortic dissection
```
219
clinical manifestations of cardiogenic shock
```
Agitation
Pallor
Cool peripheries
Tachycardia
Slow capillary refill
Oliguria (abnormally small amounts of urine)
```
220
investigations for cardiogenic shock
- ECG
- CXR
- Echo
- Monitor –record ECG ever hour until diagnosis
221
management of cardiogenic shock
1. O2
2. Diamorphine 1.25-5mg IV for pain and anxiety
3. Investigations and close monitoring
4. Correct arrhythmias, U&E abnormalities, or acid-base disturbance
5. Optimize filling pressure
6. Look for and treat any reversible cause
222
what is cardiac tamponade
- Compression of the heart by an accumulation of fluid in the pericardial sac.
- Pericardial fluid collects -> intrapericardial pressure rises -> heart cannot fill -> pumping stops
223
what causes cardiac tamponade
```
Trauma
Lung/breast cancer
Pericarditis
MI
Bacteria
```
224
signs of cardiac tamponade
- low BP
- Muffled heart sounds (Beck’s triad)
- Echocardiography may be diagnostic
- CXR: globular heart
225
management of cardiac tamponade
- Pericardiocentesis – quick relief
- Give oxygen, monitor ECG, set up IV
- Surgery
