cardiovascular Flashcards
3 types of cardiac ischaemia
STEMI - complete blockage of coronary artery
NSTEMI - supply and demand mismatch
unstable angina - supply and demand mismatch (ischaemia not infarction)
signs of chest pain caused by ischaemia
worse with exertion
doesn’t change with body positioning
not relieved with rest
radiates to
- epigastrium
- left shoulder/arm
- neck
- lower jaw
what is orthopnea
shortness of breath that occurs while lying flat and is relieved by sitting or standing
diaphoresis
abnormally excessive sweating
treatment for ACS
MONA
- morphine
- O2
- nitrate
- high dose aspirin
high dose statin
beta blocker eg metroprolol
first line of action when someone arrives with chest pain
- ECG
- history + physical
- if show signs of ischaemia eg chest discomfort., pressure, tightness, burning, syncope, dyspnea, diaphoresis, nausea/vomiting
–> measure troponin
signs of cardiogenic shock
pale skin
tachycardia
hypotension
cool extremities
diaphoresis
signs of acute heart failure
jugular venous distension
crackles on lung auscultation
new S3 gallop
murmur
orthopnea
edema
if a man with stable angina presents with change in baseline gain, new onset pain at rest, what is a likely diagnosis
ACS
how may women or older patients with stable angina present with ACS
dyspnea instead of new onset chest pain
signs of ongoing ischaemia >12 hours after symptom onset in ACS
refractory chest pain
haemodynamic instability
ventricular arrythmias
dynamic ECG changes
stable angina vs ACS
stable angina:
- during exertion, blood flow demand to heart increases, but narrowed coronary arteries cannot meet this increased demand leading to myocardial ischaemia and pain
ACS
- sudden plaque rupture and clot formation in the narrowed coronary arteries –> can cause partial or full occlusion
treatment for STEMI
- medical therapy: DAPT + anticoagulants
if <12 hrs since symptom start
- PCI
or
- fibrinolytic
if >12 hrs since symptom start
- assess for ongoing ischaemia
- PCI
or
- medical therapy
how to differentiate between NSTEMI and unstable angin
measure troponin
treatment for NSTEMI
- DAPT
- anticoagulants
+
- ongoing ischaemia –> PCI or CABG (multiple vessels / left main coronary artery affected)
- no ongoing ischameia –> medial therapy
what is never indicated for NSTEMI and unstable angina
fibrinolysis
unstable angina treatment
early risk stratification
- high risk –> DAPT + anticoagulant
+ PCI / CABG - low risk –> non invasive stress testing
what is fondaparineux
anticoagulant
what is tricagelor
antiplatelet
What are the signs and symptoms of ACS?
Signs: distress, anxiety, pallor, sweatiness, low grade fever, signs of heart failure (raised JVP, basal crepitations, 3rd heart sound)
Symptoms: acute central crushing chest pain lasting >20 minutes, nausea, sweating, dyspnoea, palpitations
What is a silent ACS and what patients does this occur in
ACS without the chest pain. May have syncope, pulmonary oedema, epigastric pain, bomiting, post op hypotension, oliguria, diabetic hyperglycaemia
Seen in the elderly and diabetics often
How are each of the three acute coronary syndromes diagnosed based on their investigation findings?
Triad of symptoms, ECG changes and hs-TnI levels
All will have cardiac sounding chest pain
STEMI:
ST elevation (>1mm in limb leads and 2mm in chest leads) or new LBBB
hs-TNI >100ng/L
CK often raised over 400
NSTEMI
ST depression, T-wave inversion or normal
hs-TnI>100ng/L
Unstable Angina
ST depression, T wave inversion or normal
hs-TnI is normal
what are type 2 myocardial infarctions
myocardial infarctions due to cardiac hypoperfusion for other reasons (e.g. severe sepsis, hypotension, hypovolaemia or coronary artery spasm)
what type of infarct causes a stemi vs nstemi
stemi - transmural infarct
nstemi - subendocardial infarct
what 3 substances can be measured in the blood to test for myocardial infarct, and which one can be used to measure reinfarction
Troponin I, Troponin T, CK-MB
CK-MB can be used to measure reinfarction as it returns to normal after 48 hours, but troponin levels remain high for days after the initial infarct
a patient presents with central pleuritic chest pain worse on inspiration, pain worse lying flat but relieved by sitting forward, and a fever
what’s the most likely diagnosis
pericarditis
what is a pericardial friction rub and what is it pathognomonic of
high pitched scratching noise, best heard over left sternal border during expiration
signs of pericarditis
- pericardial friction rub
- Beck’s triad (raised JVP, muffled heart sound, hypotension) –> bc pericarditis can cause pericardial effusion and cardiac tamponade
difference between pericarditis and GORD pain
pericarditic pain is often described as sharp
GORD discomfort may be described as a burning sensation that is worse with certain foods and bending over
difference between pericarditis and ACS pain
pericarditic chest pain is often described as sharp, pleuritic in nature, and relieved on sitting forward. In ACS, the chest pain is often described as a squeezing pressure that is not positional
difference between MSK and pericarditis pain
MSK pain is reproducible with palpation or certain movements.
what treatment is done for pericarditis pts who develop pericardial effusion d cardiac tamponade
pericardiocentesis - a procedure done to remove fluid that has built up in the sac around the heart (pericardium)
PR segment depression
+ multilead ST elevation
+ aVR ST depression
are characteristic of…
acute pericarditis
which investigations to do to distinguish between pericarditis and MI
- the pain is different - not affected by position in MI/ACS, worse lying down in pericarditis
- echocardiogram - ooking for the absence of regional wall motion abnormalities
- angiogram - checks for affected coronary arteries suggesting MI
what is the most common causative agent of acute IE
staph aureus
what is the most common causative agent of IE due to drug use
staph aureus
what is the most common causative agent of IE less than 2 month post valve surgery
staph epidermis
what is the most common causative agent of subacute IE following dental procedures
strep viridans
which causative agent predisposes to IE and colorectal cancer
strep bovis
strep vs staph shape
staph = clusters
strep = chain
which valve is most likely affected by IE due to IV drug use
tricuspid
clinical features of IE
SOB lying down (heart failure)
weakness
fatigue
weight loss
fever/chills
night sweats
tachycardia
headache
anorexia
janeway lesions
oslers nodes
splinter haemorrhages
Roth spots
clubbing
new heart murmur
what valve pathology are pink cheeks associated with
mitral stenosis - pink cheeks = “mitral facies”
what does a slow rising pulse indicate
aortic stenosis
what output type of heart failure does hypertension cause
low output heart failure (bc the hypertension causes excessive after load)
what would be the first line management in a patient with heart failure and pEF, fluid overload and hypertension
lifestyle advice
low dose diuretic eg furosemide
ACE inhibitor / ARB
which condition are BB’s eg bisoprolol contraindicated in
asthma
symptom management for acute HF
furosemide
sit upright
morphine
oxygen
what is sacubitril/valsartan and what HF is it indicated in
a new ACE inhibitor/ARB combination drug
indicated in pts with reduced EF
what normally presents with haemoptysis, sharp and pleuritic chest pain
pulmonary embolism
what condition is Prominent central pulmonary artery (Fleischner sign) seen in
pulmonary embolism
what condition is Water-bottle-shaped enlarged cardiac silhouette seen in
pericarditis
which heart failure does displaced apex beat indicate and why
left sided heart failure
due to left ventricular hypertrophy
where is BNP secreted from
cardiac ventricles
how does diastolic heart failure affect ejection fraction
EF is usually preserved
what kind of patients does HOCM present in
younger pts with breathlessness, particularly on exertion, palpitations and syncope
what kind of heart failure does HOCM cause
diastolic HF
what kind of heart failure does cardiac tamponade cause
diastolic HF
what kind of heart failure does ischaemic heart disease cause
systolic HF
why does spironolactone increase risk of hyperkalaemia?
It’s a potassium sparing diuretic, so decreases excretion of potassium in urine. Therefore serum potassium increases –> hyperkalaemia
if a pt is on an ACE inhibitor + beta blocker but can’t tolerate spironolactone, what do you give them
epleronone
if a pt is on an ACE inhibitor + beta blocker but can’t tolerate spironolactone and is afro-carribean, what do you give them
hydralazine
chest x ray findings for congestive heart failure
○ A: Alveolar oedema (with ‘batwing’ perihilar shadowing)
○ B: Kerley B lines (caused by interstitial oedema) ○ C: Cardiomegaly (cardiothoracic ratio >0.5) ○ D: upper lobe blood diversion ○ E: Pleural effusions (typically bilateral transudates)
F: Fluid in the horizontal fissure
what does Widespread saddle-shaped ST elevation on ECG indicate
acute pericarditis
what does Bilateral hilar lymphadenopathy on chest x-ray indicate
sarcoidosis
what does a fourth heart sound indicate and which wave on the ECG is it
indicates forceful atrial contraction against a stiff hypertrophic left ventricle
atrial contraction –> P wave
what is U wave on ECG associated with
hypokalaemia
hypercalcaemia
what is U wave on ECG associated with
hypothermia
what investigation is essential to confirm heart failure diagnosis
echocardiogram
what kind of heart failure is associated with orthopnoea
left sided heart failure
what do bibasal crepitations indicate
pulmonary oedema
what are the criteria for cardiac resynchronisation therapy
LBBB on ECG
LVEF < 30%
NYHA class 3/4
what is P pulmonale
P pulmonale (right atrial enlargement) is a big, tall, peaked P waves on ECG
what is the diagnosis of a pt with raised JVP, COPD, high Bp, pitting oedema in legs
Cor Pulmonale: right sided heart failure secondary to longstanding pulmonary arterial hypertension (in this case it’s as a result of the severe COPD causing the pulmonary arterial hypertension)
which axis deviation do you see on an ECG with cor pulmonale
right axis deviation
name the levels of the NYHA Classification (Severity of Cardiac Failure Symptoms)
○ Class I → no symptoms, no limitation
○ Class II → mild symptoms, slight limitation (comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea) ○ Class III → moderate symptoms, marked limitation of physical activity (comfortable at rest but less than ordinary activity results in symptoms)
Class IV → severe symptoms, unable to carry out any physical activity without discomfort (symptoms of heart failure are present even at rest with increased discomfort with any physical activity)
when is DC cardio version indicated
tachyarrhythmias (eg atrial fibrillation with fast ventricular response rate) with signs of confusion, heart failure, hypotension, confusion
does Digoxin improve mortality in heart failure
no
what counts as a reduced ejection fraction
A reduced LV ejection fraction is usually 40% or less
if a pt has HFpEF with ankle odema and no hypertension what is the first line treatment
Furosemide
(Lifestyle advice would be first line if pt didn’t have ankle oedema)
what is the treatment for HFpEF
- lifestyle advice
- low dose diuretic if have signs of fluid retention eg ankle oedema
- ACE inhibitor/ARB if hypertensive
if a pt is prescribed high dose diuretic eg furosemide for heart failure, what side effects may they experience
tinnitus
deafness
if a pt is prescribed spironolcatone for heart failure, what side effects may they experience
Gynacomastia
what counts as a jugular venous distension
JVP > 4cm
what are Coryzal symptoms
hallmark of URTIs that include nasal stuffiness, runny nose, sneezing, sore throat, and cough
what is a patient with alcoholic cirrhosis at risk of if they take diuretics
Diuretics can increase the risk of hypomagnesaemia in those with alcoholic cirrhosis - leading to arrhythmias
what are these findings associated with and in which pts: Regional wall motion abnormality, ejection fraction <55%
These findings are consistent with congestive cardiac failure caused by coronary artery disease.
This typically presents in older patients with risk factors for coronary artery disease (smoking, diabetes, hyperlipidaemia, hypertension, positive family history)
what are these findings associated with and in which pts: Apical ballooning of the left ventricle
These findings are consistent with Takotsubo cardiomyopathy. The condition typically occurs after extreme stress
Is more common in post-menopausal women. Symptoms may mimic a myocardial infarction (except angiography reveals patent coronary arteries)
what are these findings associated with and in which pts: Left ventricular dilation, ejection fraction <55%
These findings are consistent with dilated cardiomyopathy. Dilated cardiomyopathy is commonly caused by excess alcohol consumption or is idiopathic.
what are these findings associated with: Asymmetric septal hypertrophy, diastolic dysfunction
Hypertrophic ostructive cardiomyopathy (HOCM). HOCM typically causes diastolic dysfunction due to impaired relaxation of the thickened left ventricle during diastole. This results in impaired filling of the left ventricle
what is pulsus paradoxus and what conditions is it associated with
abnormally large decrease in bp during inspiration
associated with
- constrictive pericarditis
- cardiac tamponade
- pericardial effusion
what is pulsus alternans and what conditions is it associated with
alternating strong and weak pulses
associated with severe left heart failure
what type of heart failure is prolonged capillary time associated with
left heart failure
what is left heart failure commonly caused by in central/South America
Chaga’s disease
what are the 2 output states of heart failure
Low output state - low cardiac output
High output state - normal cardiac output, higher metabolic needs (anaemia, Beri-beri “thiamine deficiency”, hyperthyroidism, pregnancy)
what are the 2 types o left heart failure and their common causes
systolic LHF (HErEF <40%, unable to pump)
ischaemic heart disease,
dilated cardiomyopathy,
myocarditis,
arrhythmias
infiltration (haemochromatosis, sarcoidosis)
Diastolic (HFpEF >50%, heart can’t relax and properly fill with blood)
hypertrophic obstructive cardiomyopathy,
restrictive cardiomyopathy,
constrictive pericarditis,
cardiac tamponade
uncontrolled chronic HTN
what is RHF secondary to
left heart failure (congestive heart failure),
Infarction,
Pulmonary hypertension,
Tricuspid regurgitation
clinical features of LHF
(fluid accumulation in lungs = pulmonary symptoms)
dyspnoea,
orthopnoea,
paroxysmal nocturnal dyspnoea,
fatigue,
wheeze,
bibasal crackles,
cough,
pink frothy sputum (as a result of pulmonary oedema)
S3 gallop rhythm is an early sign of left ventricular failure
pulsus alternans
Clinical features of RHF
(fluid accumulates in peripheries = swollen signs)
swollen ankles (peripheral oedema),
increased weight,
reduced exercise tolerance,
raised JVP,
hepatomegaly (pulsatile liver edge on palpation),
Ascites
First line investigations for heart failure presentation
- BNP - if raised (above 400) then do echo
- echocardiogram (definitive)
heart failure symptom management
sit up
IV furosemide
o2
morphine
treatment for HFrEF with HTN
- ACEi + BB
no ACEi –> ARB
no ACEi/ARB –> Hydralazine - spironolactone + epleronone
arfo/carribbean –> hydralazine + nitrate - Ivabradine (only if sinus rhythm and HR >75)
- cardiac resynchronisation
treatment for HRpEF
- lifestyle advice
- if fluid overload –> furosemide
- if HTN –> ACE inhibitor/ARB
investigations of stable angina for ischaemic heart disease
- CT coronary angiogram
- MRI fir regional wall abnormalities / cardiac stress testing / ecg + troponin
what is the 1st line imaging for stable angina
CT coronary angiogram
what are pathological Q waves and what do they indicate
negative deflection before R wave
indicates previous infarct
treatment for stable angina / ischaemic heart disease
anti platelet (aspirin 75g /clopidogrel) + statin 20g
+ GTN spray (for the angina attacks when they come on)
+ (1st line ) BB (bisoprolol/atenolol) OR non dihydropyridine rate limiting CCB (verapamil/diltiazem)
or (2nd line) BB AND dihydropryidine CCB
or (3rd line) BB AND dihydropyridine CCB AND nitrate
GTN spray side effects
headaches, flushing, dizziness
what is the first line treatment for asthmatic pt with ischaemic heart disease
- rate limiting CCB eg verapamil / diltiazem
(BBs are contraindicated in asthma) - rate limiting CCB + nitrate
which CCBs cannot be used alongside BBs
Verapamil/diltiazem can’t be used alongside beta blocker → causes severe bradycardia and heart block
treatment for ischaemic heart disease can’t be managed medically
PCI, CABG
what is the aspirin dose for stable angina
75 g
what is the aspirin dose for acute CV events eg MI/stroke
300g
difference between angina and pleuritic chest pain
Angina: central crushing pain
Pleuritic pain: sharp, worse on inspiration, accompanied by features related to underlying cause: productive cough, fevers, VTE, hot swollen calf
what are the non dihydropryidine rate limiting CCBs
verapamil
diltiazem
which CCBS CANNOT be used with BB
non dihydropyridine CCBS (veramapil / diltiazem)
the combination will cause bradycardia and AV block
which condition is dual anti platelet therapy indicated in
ACS
what to look for when thinking about giving ivabradine
make sure the HR is not less than 70, as ivabradine slows down the heart
what are the 4 classes of stable angina
class 1: occurs with strenuous physical activity
class 2: slight limitation on physical activity
class 3: marked limitation on physical activity
class 4: occurs with any physical activity and may even occur at rest –> unstable angina
how would Spontaneous coronary artery dissection (SCAD) present and in which pts
constant sharp left sided chest pain with radiation
often in young, female, pregnant pts
what is takotsubos cardiomyopathy / broken heart syndrome
temporary akinesia of the left ventricle
in response to an intense emotional or physical experience
A 67-year-old man with ischaemic heart disease is on verapamil. The addition of which medication would carry a risk of heart block?
BBs
a pt is recently diagnosed with stable angina and reversible ischaemia - indicating coronary artery disease
what is the management
GTN spray + BB OR CCB
what investigation is required if clinical assessment reveals non anginas chest pain but a resting ECG shows changes in ST or Q waves
CT coronary angiography
what is an indication for a CABG
multi vessel coronary artery disease with poor response to medical therapy
when does CABG have a survival advantage over PCI
in pts who are
- over 65
- diabetic
- have complex 3 vessel disease
what are the clinical signs off cardiac tamponade
raised JVP
muffled heart sounds
hypotension
what ECG change does pericarditis involve
widespread ST elevation
A 23 year old man with a past medical history of cocaine abuse presents to the ED with sudden, central tearing chest pain. On examination, his vitals are: RR 24, SpO2 97% RA, BP 190/100 mmHg, HR 120 bpm, T 36.9 degrees Celsius. A CT thorax showed a widened mediastinum.
What is the next best step in management?
labetolol
High arched palate and lens dislocation indicate which condition
marfans syndrome
when would you do a TTE instead of a CT angiogram for suspected aortic dissection
when the pt is unstable and proximal dissection is suspected
difference between pain presentation of acute pancreatitis vs aortic dissection
aortic dissection - sudden onset, tearing, central chest pain which radiates to the back
acute pancreatitis - epigastric pain which radiates to back but is relieved by sitting forwards, is also associated iwth vomiting
what is Takayasu’s arteritis and in which patients does it normally present, and what is the main sign
vasculitis of the major arteries in the body
presents in young women
main sign is absent arm pulses
how to differentiate Takayusu’s arteritis and aortic dissection
both can have absent arm pulses
aortic dissection presents with chest pain but takayusu’s arteritis does not
what does the presence of a radio-radial delay indicate
Type A aortic dissection
what does expansile pulsatile mass in the abdomen indicate
ruptured aortic aneurysm
what does the presence of a radio-femoral delay indicate
Type B aortic dissection
a pt with blood pressure 190/117mmHg has sharp central tearing pain radiating to the back and a history of marinas syndrome.
what is the initial management
IV labetolol
(the pt is very hypertensive so bp needs to be controlled so it doesn’t worsen the dissection)
THEN surgical aortic repair
when is giving a red cell transfusion indicated
pt has Hb level < 70 g/L
or pt has ACS and Hb level < 80 g/L
what are the types of aortic dissection under Stanford classification
type A - involving ascending aorta
type B - involving descending aorta
what are the types of aortic dissection under Debakey’s classification
Type I - involving ascending + descending aorta
Type II - involving ascending aorta
Type III - involving descending aorta
what are the clinical signs of aortic dissection
central tearing chest pain which radiates to the back
absent or weak pulses in arms
radio-radial delay - type A
radio-femoral delay - type B
aortic regurgitation (early diastolic murmur)
severe aortic regurgitation (mid diastolic murmur/Austin flint murmur)
hypertension
focal neurological deficits eg Horner’s syndrome
first line investigations for aortic dissection
CT angiogram chest/abdo/pelvis
or Transoesophageal echocardiography if pt is to unstable to get CT
what ECG show ion aortic dissection
widened mediastinum
treatment for type A vs B aortic dissection
A - surgical repair, open or endovascular (but IV labetolol as initial management before surgery if pt is very hypertensive)
B - IV labetolol
71 yr old man, no past medial history, bp 155/95. first line management?
amlodipine
pt has bp 210/142 and has a headache. initial management?
IV labetolol
(headache raises suspicion of end organ damage, if didn’t have headache would give oral treatment instead)
pt has a high bp of 145/95 despite being on ACEi, what’s the next step
add CCB
(if monotherapy doesn’t work, add another medication)
what is doxazosin
an alpha blocker used for hypertension
what does S4 heart sound indicate
reduced ventricular compliance due to ventricular hypertrophy
a pt has high bp, high sodium and low potassium, what is a possible diagnosis
conn’s syndrome
What are the criteria for hypertension referral for same day specialist assessment
Clinical bp of 180/120 mmHg with
- retinal haemorrhage or papillodoema
Or
- life threatening symptoms eg confusion, chest pain, AKI, heart failure
If someone is allergic to ACEi and is on a CB but it’s not working what do you add
Thiazide like diuretic
(Some ppl allergic to ACEi are also allergic to ARB)
An Afro Carribean with HTN and T2DM is on ramipril but it’s not working. What do you add
CCB
(Can’t be on ACEi and ARB at the same time)
If a patient with Turner’s syndrome has radio-radial delay what is the likely diagnosis
Coarctation of the aorta proximal to the left subclavian artery