Cardiology p2 Flashcards
What is congestive cardiac failure?
Structural/functional disorder affecting ability to function as a pump
Either caused by impaired left ventricular contraction (“systolic heart failure”) or left ventricular relaxation (“diastolic heart failure”). This impaired left ventricular function results in a chronic back-pressure of blood trying to flow into and through the left side of the heart
What is cardiac output made up of?
pre-load
afterload
myocardial contractility
What adaptations occur to the heart in CCF?
Decreased CO: activation of SNS and RAAS
RAAS leads to vasoconstriction and increased water and sodium retention. increases BP and cardiac work
SNS leads to myocyte apoptosis and necrosis
What are the causes of CCF commonly?
Ischaemic Heart Disease
Valvular Heart Disease (commonly aortic stenosis)
Hypertension
Arrhythmias (commonly atrial fibrillation)
What are the more rare causes of CCF?
congenital heart disease Cor pulmonale Alcohol/drugs AF Heart block
What is the most common cause of RHF?
LHF
What is the presentation of LHF?
fatigue
exertional dyspnoea
paroxysmal nocturnal dyspnoea
orthopnoea
What are the examination findings of LHF?
Cardiomegaly + displaced apex beat
3rd heart sound, gallop rhythm
bi-basal coarse crackles
What is the presentation of RHF?
breathless
fatigue
anorexia
swollen ankles
What are the signs of RHF?
Increased JVP Splenomegaly Pitting oedema Pleural effusion Cardiomegaly/gallop rhythm
What investigations would you do for CCF?
Bloods - FBC, U+E, LFT, TFT, cardiac enzymes
BNP: normal excludes heart failure
CXR: cardiomegaly and pulmonary oedema
ECG: ischaemia, HTN or arrhythmia
Ejection fraction <45% is diagnostic
What further investigations can be done for CCF?
Cardiac MRI, cardiac catheter (measure pressure) or functional testing
What is the NYHA classification?
I - disease present, no undue dyspnoea from normal activity
II - dyspnoea present, on ordinary activities
III - less than ordinary activity causes dyspnoea which is limiting
IV - dyspnoea at rest, any activity causes discomfort
What is the management of LV failure?
Lifestyle:
vaccines
stop smoking
exercise as tolerated
Medical:
ABAL:
A:ACE inhibitor: Ramipril (titrated to 10mg o.d)
B: Beta blocker: bisoprolol titrated to 10mg o.d.)
A: Aldosterone receptor antagonist
L: Loop diuretic (furosemide 40mg) for symptoms
Third line: digoxin
What are the lifestyle measures for CCF?
Obesity control and diet (decrease salt and fluid intake)
stop smoking
physical activity
vaccination (pneumococcal vaccine)
Sex - don’t take viagra (causes hypotension)
What ACEis should be given for CCF?
ramipril, lisinopril
low dose and titrate up to 10mg once a day
don’t use with NSAIDs (renal damage)
What are the Side effects of ACEi?
Dry cough (give candesartan 32mg if this is the case)
Renal side effects so monitor U+Es
First dose hypotension - give at night
Which diuretics are used in CCF?
thiazides - bendroflumethiazide
Loop - furosemide
both can cause hypokalaemia
Spironolactone (potassium sparing)
What is digoxin?
+ve inotrope and -ve chronotrope SO increases force and decreases heart rate
Inhibits Na/K pump and leads to Na+ accumulation
contra-indicated in heart block and bradycardia
What are the causes of valvular heart disease?
Degenerative
Rheumatic fever
Congenital
Ischaemic
Describe how infection causes valvular heart disease?
Immune mediated (rheum) or direct: bacterial/functional endocarditis
result is:
collagen exposure and thrombus development
post-inflammatory scarring - functional impairment
Which side of the heart is more commonly affected in endocarditis?
LH - emboli can affect systemic organs
Mitral valve most commonly affected
What is the most common cause of chronic valve scarring?
Rheumatic fever
What is rheumatic fever caused by?
Group A B haemolytic streptococci
Antibody production to GAS cross reacts with cardiac antigens causing a self-limiting myocarditis
damage to valves - fibrosis so you get shrunken, fibrotic valves
What congenital causes of valvular disease are there?
Congenital bi-cuspid aortic valve - calcification –> aortic stenosis
How does ischaemic cause valvular heart disease?
Infarction –> papillary muscle dysfunction leads to mitral regurgitation
What are the causes of aortic stenosis?
Calcification of congenital bicuspid valve
rheumatic fever
Senile calcific degeneration
Describe the pathology of aortic stenosis
Progressive outflow obstruction leads to LV hypertrophy and angina
risk of sudden cardiac death due to arrhythmias
What are the symptoms of aortic stenosis?
syncope, angina and dyspnoea on exercise
What are the signs of aortic stenosis?
EJECTION systolic high pitched murmur (aortic region to carotid)
Pulse: small volume, slow rising
BP: narrow pulse pressure
crescendo-decrescendo murmur
What are the treatments for aortic stenosis?
Valve replacement
percutaneous valvuloplasty
What are the causes of mitral regurgitation?
idiopathic weakening of the valve with age
Ischaemic heart disease
Infective Endocarditis
Rheumatic Heart Disease
Connective tissue disorders such as Ehlers Danlos syndrome or Marfan syndrome
What are the symptoms of mitral regurg?
Incompetent mitral valve allows blood to leak back through during systolic contraction of the left ventricle
AF - palpitation
pulmonary HTN - SOB/orthopnoea
Fatigue
What are the signs of mitral regurg?
pan-systolic, high pitched “whistling” murmur due to high velocity blood flow through the leaky valve. The murmur radiates to left axilla. You may hear a third heart sound
laterally displaced apex beat + systolic thrill
LHF/RHF
What is the mx of mitral regurg?
treat heart failure
echo
surgery if deteriorate
What are the causes of aortic regurg?
post inflammatory scarring
infective endocarditis
age-related calcification
dilation of aortic root due to inflammatory disease
Connective tissue disorders such as Ehlers Danlos syndrome or Marfan syndrome
What are the symptoms of aortic regurg?
asymptomatic until acute left ventricular failure
angina pectoris and dyspnoea
What are the signs of aortic regurg?
early diastolic, soft murmur. It is also associated with a Corrigan’s pulse (bounding/collapsing pulse)
wide pulse pressure
signs of LVF
What are the signs of severe aortic regurg?
Quinke’s - pulsation in nail bed
DeMusset - nodding
Durozies - femoral murmur
pistol shot femoral (bang if auscultated)
What is the management of aortic regurg?
replace valve before significant LV dysfunction
What is the cause of mitral stenosis?
Rheumatic fever - post inflammatory scarring
Infective endocarditis
Describe the pathophysiology of mitral stenosis
LA can’t empty
pulmonary HTN
LA dilates and hypertrophies –> AF
Pulmonary HTN: RHF
What are the symptoms of MS?
pulmonary HTN: SOB and haemoptysis
RHF: fatigue, weakness, limb oedema
AF - palpitation
What are the signs of MS?
rumbling MID DIASTOLIC murmur Malar flush small volume pulse jugular vein distortion left parasternal heave
AF
What is the management of MS?
Treat AF
Diuretics
Surgery - balloon valvuloplasty + valvotomy
What is the cause of pulmonary / tricuspid disease?
due to post-inflammatory scarring
rheumatic heart disease
IVDU endocarditis
carcinoid syndrome
What are the symptoms of tricuspid disease?
symptoms of right heart failure
When is tricuspid stenosis heard?
MID DIASTOLIC murmur
When is tricuspid regurg heard?
Pan-systolic
When is pulmonary stenosis heard?
Ejection systolic
N.B in MCQ if you get a pan systolic murmur LOUDEST on inspiration - pulmonary stenosis
When is pulmonary regurg heard?
Diastolic murmur
How is the right heart catheterised?
Peripheral vein: FEMORAL
How is the left heart catheterised?
Peripheral ARTERY: femoral
What is the cause of eisenmenger’s syndrome?
Large L-R shunt causes an increase in pulmonary artery pressure
Increased pressure in RHS
RHS>LHS therefore blood flows L-R
What are the features of eisenmenger’s syndrome?
Cyanosis SOB Fatigue Chest pain Haemoptysis
What are the examination findings of Eisenmenger’s syndrome?
RV heave
Clubbing
Cyanosis
What re the cause of eisenmenger’s syndrome?
VSD
PDA
What is the management of Eisenmenger’s syndrome?
Heart lung transplant
What is infective endocarditis?
Infection of the endocardium of the heart
By staph aureus most commonly
Who is at risk of infective endocarditis?
Patients with a structural abnormality in their heart e..g value disease, replacements of congenital defects
Patients with normal hearts
How does Inf Endo occur in structural abnormality?
Normal GI/Skin commensal that enter blood trivially
Become enmeshed in platelet aggregates and lead to abnormal proliferation
How does inf endo occur in patients with structurally normal hearts?
acue
pathogenic organisms that directly invade valve:
IVDU after heart surgery or sepsis
What are the RF for infective endocarditis?
Previous IE, Rheumatic fever, prosthetic valves, congenital heart defect, IVDU and piercings
What is the presentation of infective endocarditis?
FEVER + NEW MURMUR micro-haematuria splenomegaly osler node splinter haemorrhage clubbing Roth spot - pale areas + haemorrhage on retina Janeway lesions
What Ix do you do for infective endocarditis?
Bloods - FBC, U+E, LFT, CRP, ESR
Blood cultures (3 sets)
Urinalysis ++ protein, microscopic haematuria
ECG
CXR
Transthoracic echo
What are the Major criteria on Dukes?
+ve blood culture
endocardial involvement on echo
What are the minor criteria on Dukes?
Predisposition
Fever >38
Vascular/Immunological phenomenon
Culture/echo not enough for major
what are the criteria for diagnosis of infective endocarditis?
2 x major
1 x major and 3 minor
What organisms cause infective endocarditis?
staph aureus
strep viridian’s (20%)
strep epidermis (most common post-surgery)
Describe the pathology of acute IE?
Bacterial proliferation in valve
necrosis of valve tissue
perforation of valve
acute cardiac failure
Describe the pathology of subacute IE?
infective organisms have decreased virulence
Gradual onset destruction of valves
Stimulation of thrombus formation - systemic embolizaion
What are the complication of IE?
systemic emboli pulmonary abscesses valvular incompetence CCF Glomerulonephritis
What is the management of IE?
Empirial - ben-pen, gentamicin and fluclux
IV for 4 weeks
