Cardiovascular Flashcards
What is the principle cause of heart attack, stroke and gangrene of extremities?
atherosclerosis
What is the best-known risk factor for coronary artery disease?
age
What are the risk factors for atherosclerosis?
age
tobacco smoking
high serum cholesterol
obesity
diabetes
hypertension
family history
Where is atherosclerosis found?
peripheral and coronary arteries
Name the coronary arteries
left anterior descending
right
circumflex
What does an atherosclerotic plaque consist of?
lipids
necrotic core
connective tissue
fibrous cap
What eventually happens to an atherosclerotic plaque?
either occlude the vessel resulting in restriction of blood flow (angina), or rupture leading to thrombus formation and death
What starts atherosclerosis formation?
response to injury hypothesis
injury to endothelial cells leads to inflammation
What are some negative outcomes of inflammation?
myocardial repercussion injury
atherosclerosis
ischaemic heart disease IHD
rheumatoid arthritis
asthma
inflammatory bowl disease
shock
excessive wound healing
At what age do you begin getting fatty streaks?
younger than 10 years old
What is PCI?
percutaneous coronary intervention (stent)
What are coronary stents used in patients today made up?
stainless steel
Which drugs are on stents? Why?
sirolimus
stops cell proliferation which prevents significant stenosis
What does aspirin do pharmacologically?
irreversible inhibitor of platelet cyclo-oxygenase (anti-platelet)
How does statins affect cholesterol?
reduces cholesterol synthesis
What is angina?
mismatch of oxygen supply and demand
What are the risk factors of IHD?
age
cigarette smoking
family history
male
diabetes mellitus
hyperlipidemia
hypertension
kidney disease
obesity
physical inactivity
stress
What is ischaemic heart disease (IHD)?
heart problems caused by narrowing of the arteries
What is Ohm’s Law in medicine?
ΔP = QR
P= pressure
Q= flow
R= resistance
What is crescendo angina?
worsened angina over a series of months
What is unstable angina?
experiencing angina at rest
What is Prinzmetal’s angina
a coronary spasm that is very rare
What is microvascular angina?
angina with apparently normal main coronary arteries that mostly affects females
What kind of family history would be relevant for IHD?
first degree relative under the age of 60 years old
What is the differential diagnosis for chest pain?
MYOCARDIAL ISCHAEMIA
peri/myo carditis
pulmonary embolism/ pleurisy
chest infection
gastro-oesophageal (reflux, spasm, ulceration)
musculo-skeletal
psychological
dissection of the aorta
What are the side effects of beta blockers?
tiredness
nightmare
bradycardia
erectile dysfunction
cold hands and feet
Who should you never prescribe beta blockers to?
patients with severe asthma
What effect do nitrates have on the vessels?
venodilators
What do you need to be very careful with when prescribe aspirin?
gastric ulceration
What is CABG surgery?
coronary artery bypass graft surgery
What is syncope?
fainting
How can intake of digoxin show on an ECG?
QT prolonging
How many leads does a standard ECG have?
12 leads:
3 bipolar leads
3 augmented unipolar limb leans
6 unipolar precordial (chest) leads
What is the annulus fibrosis?
isolating barrier between atria and ventricles
What are the layers of the pericardium?
2 layers:
visceral single cell layer
fibrous parietal layer
What is acute pericarditis?
inflammatory pericardial syndrome with or without pericardial effusion
What is pericardial effusion?
build up of too much fluid in the pericardium
What percentage of incidences of pericarditis is idiopathic?
80-90%
What is the leading cause of pericarditis in the UK?
viral infections
What is the most common non-infectious cause of pericarditis?
neoplasms
What is the most common non-infectious cause of pericarditis?
neoplasms
Describe pulsus paradoxus
when you breath in bp usually falls by <10mmHg but in moderate/ greater effusion the fall is >10mmHg. Due to greater drop in bp, cardiac output is reduced which reduces volume of peripheral pulse
What does acute STEMI mean?
acute ST elevation myocardial infarction (heart attack)
Why can it be difficult to distinguish between pericarditis and MI?
Both ECGs will have an ST elevation. In MI the elevation will be concave, in pericarditis the elevation will be saddle shaped.
What is cardiomyopathy?
primary heart muscle disease
What is HCM and what causes it?
hypertrophic cardiomyopathy
caused by sarcomeric protein gene mutations
How many people are affected by HCM?
1 in 500 people
What are the categories of cardiomyopathies?
hypertrophic
dilated
arrhythmogenic
What feature will you see in the histology of a heart with cardiomyopathy?
myofibrillar disarray
What is CPVT?
catecholaminergic polymorphic ventricular tachycardia
What is the major risk of atrial fibrillation?
stroke and/ or pulmonary embolism
What drugs are used to treat hypertension?
ACE inhibitors
ARBs
Calcium channel blockers
Beta blockers
Aldosterone antagonist
Alpha blockers
Renin inhibitors
What do ACE inhibitors treat?
hypertension
heart failure
diabetic nephropathy
Give 4 examples of ACE inhibitors
ramipril
enalapril
perindopril
trandolapril
What are the main adverse effects of ACE inhibitors?
DUE TO REDUCED ANGIOTENSIN II FORMATION:
hypotension
acute renal failure
hyperkalaemia
teratogenic effects in pregnancy
RELATED TO INCREASED KININS:
cough
rash
anaphylactoid reactions
What does teratogenic mean?
refers to a substance that causes congenital disorders/ foetal abnormalities
What are anaphylactoid reactions?
immediate systemic reactions that mimic anaphylaxis but are not caused by IgE-mediated immune responses
What are Angiotensin II Receptor Blockers (ARBs) used to treat?
hypertension
diabetic nephropathy
heart failure (when ACEi contraindicated)
Name 3 ARBs
candesartan
losartan
valsartan
What are the main adverse effects of ARBs?
symptomatic hypotension
hyperkalaemia
potential renal dysfunction
rash
angio-oedema
Generally very well tolerated
What are Calcium Channel Blockers used to treat?
hypertension
IHD - angina
arrhythmia (tachycardia)
Name 3 common calcium channel blockers
amlodipine
nifedipine
felodipine
What are the groups of calcium channel blockers?
- Dihydropyridines: nifedipine, amlodipine, felodipine, lacidipine
preferentially affects vascular smooth muscle - Phenylalkylamines: verapamil
main effects on heart - Benzothiazepines: diltiazem
intermediate heart/ peripheral vascular effects
What are the adverse effects of CCBs?
DUE TO PERIPHERAL VASODILATION (mainly dihydropyridines):
flushing
headache
oedema
palpitations
DUE TO NEGATIVE CHRONOTROPIC EFFECTS:
bradycardia
atrioventricular block
DUE TO INOTROPIC EFFECTS:
worsening of cardiac failure
verapamil causes constipation
What are beta-adrenoceptor blockers used to treat?
IHD - angina
heart failure
arrhythmia
hypertension
Name 3 beta blockers.
propranolol
bisoprolol
atenolol
What is the difference between selective and non selective beta blockers?
non selective act on beta 1 and beta 2 receptors
selective act just on beta 1 receptors
however none are 100% selective
What are the adverse effects of beta blockers?
fatigue
headache
self disturbance/ nightmares
bradycardia
hypotension
cold peripheries
erectile dysfunction
Which kind of patients must never been prescribed beta blockers?
patients with asthma- can trigger a severe asthma attack, potentially fatal
What is bradycardia and tachycardia?
bradycardia: < 60bpm
tachycardia: > 100bpm
What is PVD?
peripheral vascular disease
Can you give beta blockers to patients in heart failure?
Yes- but you can’t give standard dose straight away, must start at low dose and rise slowly
What do diuretics treat?
hypertension
heart failure
What are the classes of diuretics?
- thiazides and related drugs (distal tubule)
- loop diuretics (loop of Henle)
- potassium-sparing diuretics
- aldosterone antagonists
Name 3 thiazide diuretics.
bendoflumethiazide
hydrochlorothiazide
chlorothiazide
Name 2 loop diuretics.
furosemide
bumetanide
Name 2 potassium-sparing diuretics.
spironolactone
eplerenone
What are the adverse effects of diuretics?
hypovolaemia
hypotension
low serum K+, Na+, Mg2+, Ca2+
raised uric acid (gout)
impaired glucose tolerance
erectile dysfunction
Name an alpha 1 adrenoreceptor blocker.
doxazosin
Name 2 centrally acting anti-hypertensives.
moxonidine
methyldopa
Name a direct renin inhibitor.
aliskiren
Why is methyldopa an important anti-hypertensive?
It can be used in pregnant women as it is not teratogenic, so women with preeclampsia (gestational high blood pressure) can be prescribed it
What is LVSD?
left ventricular systolic dysfunction
What is HFPEF?
heart failure with preserved ejection fraction (diastolic failure)
What is the most common cause of heart failure?
coronary artery disease
What is the first line treatment for heart failure?
ACE inhibitors and beta blockers
low dose and slow increase
What is heart failure?
when the heart is unable to pump blood around the body properly
What are ARNIs?
combination drug: aldosterone receptor antagonist and neprilysin inhibitor
What are nitrates used to treat?
IHD - angina
heart failure
Name 2 nitrate medications.
GTN spray/ infusion
isosorbide mononitrate
What are the types of coronary artery disease?
chronic stable angina
unstable angina/ acute coronary syndrome (NSTEMI)
ST elevation myocardial infarction (STEMI)
How do you treat chronic stable angina?
- anti platelet therapy- aspirin, clopidogrel
- lipid-lowering therapy- statins
- short acting nitrate- GTN spray for acute attack
- first line treatment: beta blockers or CCB
Name 4 statins.
simvastatin
atorvastatin
rosuvastatin
pravastatin
How do you treat acute coronary syndromes (NSTEMI and STEMI)
- pain relief: GTN spray and opiates (diamorphine)
- dual anti platelet therapy: aspirin plus tricagrelor/ prasugrel/ clopidogrel
- antithrombin therapy: fondaparinux
- consider glycoprotein IIb IIIa inhibitor for high risk cases: tirofiban
- background angina therapy: beta blocker, nitrate, CCB
- lipid lowering therapy: statins
- therapy for LVSD/ heart failure as required: ACEi, BB, aldosterone agonist
most patients will have invasive management of angioplasty or CABG
What is another name for diamorphine?
heroin
What are the classes of anti arrhythmic drugs?
sodium channel blockers
beta blockers
What are the classes of anti arrhythmic drugs?
sodium channel blockers
beta blockers
amiodarone (prolong action potential)
calcium channel blockers (verapamil and diltiazem only)
digoxin
List the main congenital heart defects.
Holes:
Ventricular septal defect
Atrial septal defect
Atrio-ventricular septal defect
Patent ductus arteriosus
Narrowings:
Coarctaction of the aorta
Bicuspid aortic valve and aortopathy
Pulmonary stenosis
Holes and Narrowings:
Tetralogy of fallot
Eisenmenger syndrome
Univentricular hearts
What percentage of patients with congenital heart defects have an intellectual disability?
10%
How many babies are born with tetralogy of fallot?
1 in 1000
What are the 4 features of tetralogy of fallot?
ventricular septal defect
pulmonary stenosis
hypertrophy of right ventricle
overriding aorta
How do newborns with tetralogy of fallot look?
patients are blue- these are called ‘fallot spells’
How is tetralogy of fallot treated?
complete surgical repair at 3-6 months (repair of VSD and incise pulmonary valve to increase size of pulmonary artery)
How does ToF affect patients that have undergone surgery?
often get pulmonary valve regurgitation later in life- 40% of ToF patients eventually need a pulmonary valve replacement
What is VSD?
ventricular septal defect
abnormal connection between the two ventricles
Are babies with VSD a normal colour?
yes- they are not blue as blood flows from high pressure chamber to low pressure chamber
How do you treat a small VSD?
leave it alone- as child grows the small hole will be less and less important
How does Eisenmengers syndrome present?
blue lips
clubbed blue fingers
What causes Eisenmengers syndrome?
Irregular blood flow in the heart and lungs causing pulmonary arterial hypertension. It is irreversible and causes early mortality.
How do you close an ASD?
surgically
percutaneous (key hole technique)
What is an ASD?
atrial septal defect
What is an AVSD?
atrio-ventricular septal defect
What condition is AVSD associated with?
trisomy 21 (Down’s syndrome)
What is an ASVD anatomically?
instead of 2 separate AV valves, there is one big malformed one
What is a patent ductus arteriosus?
connection between the pulmonary artery and aorta
How does a patent ductus arteriosus occur?
everyone has a ductus arteriosus that spasms and closes in the first few days of life, PDA occurs when this doesn’t happen
What is coarctation of the aorta?
narrowing of the aorta at the site of insertion of the ductus arteriosus
What are the ways to repair coarctation of the aorta?
subclavian flap repair
end to end repair
What is a bicuspid aortic valve?
a normal aortic valve has three cusps, but bicuspid AVs you only have two cusps
What the occurrence of bicuspid aortic valves?
very common: 1-2% of population
What is a BAV in cardiology?
bicuspid aortic valve
What is pulmonary stenosis?
narrowing of outflow of the right ventricle, can be valvular, sub-valver or supra-valvar
What is the pathway of electrical conduction in the heart?
SA node
atria
AV node
bundle of His
purkinje fibres
How do you find the heart rate from an ECG?
300/number of squares
What is a normal QRS axis?
-30 to +90 degree
What do the waves on an ECG mean?
P wave - atrial depolarisation
QRS complex - ventricular depolarisation
T wave - ventricular repolarisation
What is the PR interval?
atrial depolarisation and conduction from atria to ventricles
How does Wolf Parkinson’s White syndrome show on an ECG?
short PR interval
prolonged QRS complex
What does an abnormal ST segment indicate?
can be elevated in early repolarisation, peri/myocarditis, MI
What is a ‘normal heart rate’?
60-100 bpm
What are the causes of heart failure?
myocardial dysfunction
IHD
hypertension
alcohol excess
cardiomyopathy
valvular/ endocardial/ pericardial causes
