cardiovascular Flashcards
causes of MI
erosion or rupture of fibrous cap of coronary artery atheromatous plaque
subsequent formation of platelet rich cot and vasoconstriction produced by platelet release of serotonin a nd thromboxane A
types of MI and their causes
STEMI = complete blockage of coronary artery
NSTEMI +unstable angina
= partial/intermittent blockage to artery
ST depression and T inversion
risk factors for MI
age male fmaily history (first degree <50yo) hyperlipidaemia cigarette moking hypertension metabolic factors/diabetes diet/exercise psychological factors elevated CRP alcohol coagulation factors
presentation of MI
central crushing chest pain
radiating to arms, shoulder , neck
no longer than 15min
new onset or deterioration of stable angina
Nausea and vomiting, sweating, breathlessness, haemodynamic instbility, collapse, arrhythmia, new onset heart failure
signs on examination of MI
no physical signs unless complications develop
patient = pale, sweaty, grey
investigations of MI
ECG
bloods - cardiac markers (troponin, creatine kinase), FBC, creatinine, electrolytes glucose, lipids
signs of MI on ECG
STEMI - ST elevation within hours, followed by T wave flattening or inversion
NSTEMI - ST depression and T inversion
treament of MI
GTN spray + IV morphine antiemetic such as metoclopramide oxygen if needed insulin if hypo aspirin nad second antiplatelet
when to do reperfusion therapy in STEMI
if present within 12hrs of onset
types of coronary reperfusion
PCI (percutaneous coronary intervention) or fibrinolysis
CABG (coronary aryery bypass graft)
dependent on time after symptom onset - PCI if <12hrs
secondary prevention of MI
lifestyle changes ACE inhibitor beta blocker dual antiplatelet therapy statin
who gets angina?
55-64 yo
8% men, 3% women
Men>Women
causes of angina
insufficient blood supply to the heart muscle
due to coronary artery disease - atherosclerosis narrows lumen. symptoms when oxygen demand increases
can also be caused by valve disease, hypertrophic obstructive cardiomyopathy or hypertensive heart disease
risk facors fo ischaemic heart disease/angina
age male familyhistory hyperlipidaemia cigarrette smoking hypertension diabetes diet and exercise psychosocial factors elevated CRO high alcohol intake high level of coagulationfactors
presentation of angin
stable - consticting discomfort in front of chest spreadig to neck, shoulders, jaw or arms
precipitated by phsycial exertion
releived by rest or GTH within 5 mins
what pain features make angina more unlikely?
continuous or prolonged pain unrelated to activity brought on by breathing associated with dizziness palpitations tingling difficulty swallowing
signs on exmaination of angina
examine CAD risk via history and BMI
investigations for angina
ECG - look for changes consistent with CAD that may indicade ischaemia or prev infarct
normal ECG does not confirm or exclude angina
ECG consistent with CAD that may indicate ischaemia or prev infarct
pathological Q waves
left bundle branch block
st-segment and T wave abnromalities
treatment of angina
GTN before activies that may bring on and when stop
long term prevention:
- beta blcoker or calcium channel blocker as first line
- if cant - long acting nitrate, nicorandil, ivabradine,
secondary prevention of Cardiovasccular event s - management of CVS risk factors, psychological support, drug treatment, atherosclerotic disease treamtent (low dose aspirin, statin, ACEi)
AF, men or women?
more in men
causes of AF
IHD hypetension valvar heart disease hyperthyroidism cardiac diseases non cardiac - drugs, infection, electrolyte issues, lung cancer, PE, thyrotoxicosis, DM
presentation of AF
irregular pulse
+ SOB, palpitations, chest discomfort, syncope or dizziness, reduced exercise tolerance, malaise or polyuria
complications of AF
stroke, TIA, heart failure
signs on examination of AF
irregularly irregular pulse
suspect paroxysmal AF if symptoms are episodic and last <48hr
investigations of AF
ECG - no P waves, chaotic baseline, irregular ventricular rate, ventricular compleses unless conduction defect
24 hr tape if paxosymal AF suspected
treatment of AF
when caused by acute precipitating event, treat underlying cause
rate control - reduce HR at rest and: beta blocker, calcium antagonist, sedentary people = digoxin
rhythm control: electrical DC cardioversion then beta blockers, catheter ablation techniques
define essential hypertension
BP > 140/90
major risk factor for stroke and heart disease
who gets essential hypertension
20-30% of pop
more common in africans and old ppl
risk factors for essential hypertension
non-modifiable - fmaily history, older age, ethnicity, gender, metabolic syndrome
modifiable - obesity, smoking, alcohol, stress, sodium/salt - diet, physical activity
causes of secodnary hypertension
congenital
acquired - renal disease, endocrine disease, pregnancy, drugs, white coat syndrome
presentation of essential hypertension
usually asymtpomatic
headache/visual disturbance
sweating, palpitations, headaches, episodic feeling of ‘about to die’
epistaxis, nocturia, SOB due to LVH or HF
stage 1 hypertension
140/90mmHg in surgeyr
135/85 at home
stage 2 hypertension
160/100mmHg in surgery
150/95 at home
stage 3 hypertension
> 180/129 in surgery
masked hypertensuon
lower on measuring in surgery than at home
white coat effect
> 20/10mmHg between clinic and ABPM/HBPM
malignant hypertension
> 200/130,mHg + end organ failure
short onset
urgent same day assessment
investigations for essential hypertension
look for organ damage - fundoscopy, ECG, blood tests, urinalysis, renal ultrasound, echo, fasting glucose, investigations for suspected secondary cuases
Q risk = provides risk of MI/stoke in next 10 years
management of essential hypertension
referral to specialist if:
- urgent treatment needed, malignant hyeprtension severe, suspected pahechromocytoma, impending complications
- possible underlying cause conns, onset worsening, resistnent, young age
- herapeutic probllems
- hypertension in pregnancy
lifestle changes
treatment goal of essential hypertension
reduce to 140/85 - slowly as rapid reduction cna be fatal esp in storke
reudce risk of complciations
treatmnet of essential hypertension <55 yo
ACE inhibitor (or ARB)
then,
ACEi + Ca antagonist or thiazide diuretic
then,
ACEi + Ca antagonist + thiazide diuretic
if Qrisk > 20, give statin
treatment of essential hypertension >55yo
Ca antagonist or thiazide diuretic
then,
ACEi +Ca antagonist or thiazide diuretic
then,
ACEi + Ca antagonist + thiazide diuretic
statin if Q risk >20
causes of DVT
provoked by risk facros
unprovoked - DVT w/o transient risk factor
risk factors of DVT
intrinsic - prev., cancer, age, overwight, male, heart fialure, severe infection, thombophilia, injury to vascular wall, varicose veins, soking
temporary - immobility, trauma, hormone treatment, pregnancy, dehydration
presentation of DVT
often asymptomatic
leg - warm, swollen, calf tenderness, superficial venous distension, changes to skin colour
investigations of DVT
d-dimer test if low clinical probability score - sensitive but not specific
venous compression ultrasonography for iliofemoral thrombosis
wells score
coagulation screen to exclude pre existing thormbotic tendancy
treatment of DVT
LMWH where feasible
warfarin start at same time
congestive heart failure
left and right sided heart failure
causes of heart failure
ischaemic heart disease
cardiomyopathy (dilated)
hypertension
many other causes
HF with reduced ejection fraction AKA systolic failrue
left ventricle loses ability to contract normally
heart cant pump with enough force to push enough blood into cirucaltion
HF with preserved ejection fraction AKA diastolic failure
left ventricle loses ability to relax normally - muscle has become stiff
the heart cannot properly fill with blood during the rest period between each beat
risk factors for HF
AF, diabetes, family hsitory of heart fialure or sudden cardiac death
presentation fo HF
breathlessness - on exertion, rest, kying flat, nocturnal cough, waking up from sleep
fluid rentention - ankle swleling, bloated, weight gain
fatigue
lightheadedness or history of syncope
signs of HF
tachycardic laterally discplaced apex beat heart murmurs 3rd and 4th heart sonds hypertension raised JVP enlarged liver tachypnoea, basal crepitatios, pleural effysions
dependent oedema
ascites
obesity
investgiations of HF
ECG
if no prev MI - naturitic peptide level
tests for aggravating facorrs and exclude other conditions - CXR, urine dipstick, lung function tests
blood tests - U+Es, eGFR, FBC, thyroid, LTs, HbA1c, fasting lipids
treatment of HF with reduced ejection fraction
heart fialure with reduced ejection fraction:
- loop diuretic
- ACEi and Bblocker
- antiplatelet or statin?
- manage causes
- screen for depression and anxiety
- lifestyle improvements
treatment of HF with preserved ejection fraction
loop diuretic
consider antiplatelet and statin
lifestyle
screen for depression and anxiety
commonest valvular issue
mitral regurge
mitral regurge
pansystolic
apex + diaphragm + left side
radiates to axilla
mitral stenosis
mid diastolic murmur
apex
aortic stenosis
ejection systolic murmur
aortic area + radiate to carotids
aortic regurgitation
diastolic murmur
4 main valvular heart disease
mitral regurgitation
mitral stenosis
aortic stenosis
aortic regurgitation
what causes mitral regurgitation
MV prolapse - either congenital or rupture of chordae/papillary muscles
rheumatic disease
endocarditis
connective tissue disorder
what causes mitral stenosis
rheumatic heart disease
what causes aortic stenosis
calcific degeneration
bicuspid valve
rheumatic disease
what causes aortic regurgitation
rheumatoid endocarditis aortic dissection marfans + connective tissue disorders calcific degeneration trauma
signs of mitral regurge
acute - signs of congestive cardiac failure
chronic - exertional dyspnoea, orthopnoea
displaced apex beat, AF in 80%
signs of mitral stenosis
dyspnoea bronchitis haemoptysis AF left parasternal heave tapping apex beat
aortic stenosis triad
angina
syncope
dyspnoea
signs of aortic stenosis
angina, syncope, dyspnoea
sudden death
slow rising, low vol pulse
heaving apex beat
signs of aortic regurge
acute = endocarditis, signs of LVF chronic = asymptomatic
later - orthopnoea, fatigue, dyspnoea
collapsing water hammer pulse
investigations of valvular heart disease
CXR
transthoracic ECHO - diagnostic
ECG
diagnosis of mitral regurge
CXR cardiomegaly
transthoracic ECHO diagnostic
diagnosis of mitral stenosis
CXR shows enlarged LA
echo diagnostic
aortic stenosis diagnosis
ECG shows LV hypertrophy
echo diagnostic
aortic regurge diagnosis
CXR cardiomegaly
echo diagnostic
treatment of mitral regurge
surgery if acute or severe chronic
treatment of mitral stenosis
surgery if MC area <1cm (normal = 3-4)
treatment of aortic stenosis
surgery if symptomatic
treatment of aortic regurgitation
acute AR is a surgical emergency
chronic is operated on before ejection fraction <55% or LV dilates >5.5 cm
right ventricular failure AKA
cor pulmonale
systolic vs diastolic heart failure
systolic = cant pump hard enough during systole
diastolic = not enough bood fills during diastole
causes of right ventricular failure
pulmonary hypertension due to: damage to lung tissue, damage to pulmonary vessels, affecting spine or ribcage , or left heart dysfunction + failure
primary right sided heart failure due to right ventricular MI or pulmonary valve stenosis
symptoms of right ventricular failure
SOB fatigue fainting raised JVP hepatomegaly oedema
= all due to backup of blood
signs on examination of right ventricular failure
tachycardia laterally displaced apex beat raised JVP respiratory signs liver enlargement
investigations of right ventricular failure
ECHO
ECG
exclusion tests - CXR, urine dipstickm bloods, spirometry, eGFR, thyroid function, HbA1c etc
treatment of right ventricular failure
treat underlying lung condition - e.g. oxygen etc
confirmed heart failure with reduced ejection fraction: loop diuretic, ACEi, b blocker, consider antiplatelet or statin, manage causes, life style improvement, screen for depression and anxiety
confirmed heart failure with preserved ejection fraction: loop diuretic, antiplatelet/statin, lifestyle, anxiety and depression screen
causes of infective endocarditits
infections occur on valves:
- congenital or defected valves (usually on left side of heart, right side if IVDU)
- normal valves with virulent organisms
- prosthetic valves
- associated with VSD or persistent ductus arteriosis
strep viridans, enterooccci are common causes
symptoms and signs of infective endocarditis
systemic features of infection - malaise, fever, night sweats, weight loss, anaemia, splenomegaly
valve destruction - lead to heart failure or heart murmurs
vascular phenomena - abscesses in brain, spleen, kidney, embolisation to lung = infarct or pneumonia
immune complex deposition in blood vessels = vasculitits, petechial haemorrhage in skin, nails and retinae, oslers nodes, janeway lesins,
investigations of infective endocarditis
blood cultures ECHO serology CXR - septic emboli ECG to show MI anaemia with raised ESR and lecocytosis diagnosis - dukes criteria
treatment of infective endocarditis
empirical ABX until sensitivity performed
surgery to replace valves if severe heart failure, extensive damage or getting worse
who gets postural hypotension
elderly and polypharmacy
causes of postural hypotension
blood pressure lowering meds - beta blockers, ACEi, AIIRAs, diuretics, calcium channel blockers
define postural hypotension
drop in at least 20mmHg systolic and 10mmHg diastolic within 3 minutes of standing upright
presentation of postural hypotension
light headedness or syncope when standing up, e.g. going to toilet at night
treatment of postural hypotension
adjust medication doses
