cardiovascular Flashcards
1
Q
where can thrombosis occur?
A
- arterial circulation: high pressure: platelet rich
- venous circulation: low pressure fibrin rich
- Coronary circulation
- Cerebral circularion
- Peripheral circulation
- Other territories
2
Q
what causes Arterial thrombosis?
A
Atherosclerosis
Inflammation
Infection
Trauma
Tumours
3
Q
what are Arterial thrombosis Presentations?
A
Myocardial infarction
CVA - stroke
Peripheral vascular disease
Others
4
Q
what is Leriche Syndrome?
A
occlusion in the distal aorta or proximal common iliac artery
traid of:
Thigh/buttock claudication
Absent femoral pulses
Male impotence
claudation mean pain due to lack of oxygen
5
Q
what is Buerger’s Test?
A
assesses for peripheral vascular disease
- legs lifted for 1-2 mins - pallor observed
- sitting with legs hanging - blue then dark red due to vasodilation
healthy response is remaining pink colour
6
Q
what are Arterial coronary thrombosis treatments?
A
- aspirin/antiplatelets
- LMWH or Fondaparinux or UFH
- Thrombolytic therapy: streptokinase tissue plasminogen activator
- Reperfusion – Catheter directed treatments and stents
7
Q
what is Prinzmetal’s angina?
A
- transient episodes of coronary artery spasm
- occurs at rest/sleep
- calcium channel blockers
8
Q
what are the treatments for Arterial cerebral thrombosis (stroke)?
A
- Aspirin, other anti-platelets, Thrombolysis - eg for stroke
- Catheter directed treatments (eg blasting thrombus), Reperfusion
9
Q
what are treatments of thrombosis in other arterial sites of the body?
A
- Antiplatelets
- statins
10
Q
what are venous thrombosis signs/symptoms?
A
non -specific
- can be calf pain, chest pain, breathlessness
11
Q
what is a blood test for venous thrombosis?
A
D-dimer - not specific
- used to show theres no thrombus
12
Q
how is a venous thrombus usually diagnosed?
A
imaging eg MRI
13
Q
what is virchows triad?
A
factors that contribute to the development of thrombosis:
- blood flow - immobilisation - eg - long flights, surgury
- endothelium injury - trauma, infection
- blood constituents - genetic or conditions that lead to Hypercoagulability
14
Q
what are the treatments for venous thrombosis?
A
Heparin or LMWH
Warfarin
DOAC - anticoagulants
15
Q
what are preventions for venous thrombosis?
A
- Mechanical or chemical thromboprophylaxsis - stockings
- early mobilisation and good hydration
16
Q
how is heparin given?
A
IV, continusly given, closely monitered
17
Q
how is Low molecular weight heparin given?
A
Once daily, weight-adjusted dose given subcutaneously
18
Q
what factors synthesis does warfarin prevent?
A
2, 7, 9, 10
(Antagonist of vitamin K)
19
Q
what do New Oral Anticoagulant Drugs NOAC / DOAC act on?
A
factor 2 & 10
20
Q
when is aspirin prescribed?
A
arterial thrombosis
- Inhibits thromboxane formation
21
Q
how does clopidogrel act as an antiplatelet?
A
inhibits ADP induced platelet aggregation by irreversibly binding to the p2y12 receptors
22
Q
what are signs/symptoms of DVT?
A
Symptoms: leg pain, swelling
Signs: tenderness, swelling, warmth, discolouration
23
Q
what are signs/symptoms of pulmonary embolism and what can cause it?
A
- symptoms - breathlessness, pleuritic chest pain, syncope
- Signs: tachycardia, tachypnoea, pleural rub,
Signs of DVT - complication of DVT
24
Q
what is a complications of pulmonary embolism?
A
Chronic thromboembolic pulmonary hypertension (CTEPH
- from fibrous tissue blocking vasculature
25
what is Pulmonary Embolism Differential diagnosis?
acute coronary syndrome
pneumonia
HF
Pneumothorax
musculoskeletal
pericarditis
26
how is pulmonary embolism treated?
- Supportive treatment - eg O2
- Anticoagulants: LMW Heparin & Oral warfarin, DOAC/NOAC
- Treat underlying cause
- embolectomy if severe
27
what are outcomes of atherosclerosis?
- ulceration
- thrombosis - acute ischemia
- growth - chronic ischemia
- necrosis - aneurysm development
28
what is acute/chronic lower limb ischaemia?
acute - 6Ps - acute-embolus (normally in heart - clots moves to peripheral circulation)
- includes acute on chronic ishaemia
chronic - rest pain, tissue loss
29
investigations of peripheral vascular disease
- physical examination - eg ulcers, hair loss, pallor
- Ankle-brachial pressure index (ABPI)
- Duplex ultrasound – shows the speed and volume of blood flow
- Angiography (CT or MRI)
- hand held doppler - weak pulse
30
management of limb ischaemia/caudation
caudation:
- lifestyle changes/exercise
- mediaction - Atorvastatin,Clopidogre
- bypass/stenting
ischaemia:
- Endovascular angioplasty and stenting
- Endarterectomy
- Endovascular thrombectomy/thrombolysis using catheter
- bypass surgery
31
what are 6Ps in limb ischaemia?
pain, pulselessness, pallor, poikilothermia, paresthesias, and paralysis
32
when is bypass surgery used in peripheral vascular disease?
(graft of vein)
after stents fail
- better patency and limb salvage rates
33
what are the treatment options for aortic aneurysm?
- endovascular - stents - require more follow ups etc.
- open surgery - no further follow ups or treatments - prefered option for long-term outcomes
34
what are the symptoms of aortic aneurysm?
-normally asymptomatic until severe
- Pain in the chest, abdomen, or back
- Hoarseness or difficulty swallowing (TAA)
- Shortness of breath
- Pulsating sensation in the abdomen
- (pre)Syncope
- Signs of shock (in cases of a ruptured aneurysm)
35
what is the most common aortic aneurysm?
abdominal
thoracic
36
what are treatments for venous disease
- lifestyle
- compression
- sclerotherapy- injection causing vein to shrink
- endo-venous
37
what is Cor pulmonale?
- pulmonary heart disease
- **right side** of the heart becomes enlarged/strained due to pulmonary hypertension
- eg due to pulmonary embolism/fibrosis, COPD, Interstitial lung diseases, sleep apnea
38
What are pulmonary embolism investigations?
- PE Wells score over 4=likely
- D-dimer - +ve - measure blood clots
- CT Pulmonary Angiography (CTPA) - gold
- echo/ecg
- xray - rules out pneumonia etc.
- blood gases - t1 resp failure, decreased o2 and co2
39
what are risk factors for Pulmonary embolism?
- DVT.
- Recent surgery.
- Significant immobility.
- Active cancer.
- pregnancy/postpartum
- recent MI
- increasing age
- smoking, obesity, contraceptives
40
what is massive pulmonary embolism?
haemodynamic instability
- HYPOTENSION, cyanosis, severe dyspnoea, right heart strain/ failure
- rare
- clot is bigger and more severe symptoms
41
what can atherosclerosis cause?
heart attack, stroke etc.
- due to plaque rupture leading to thrombus formation, partial/complete arterial blockage leading to a heart attack
42
where are atherosclerotic plaques mainly found?
within peripheral and coronary arteries
43
what do atherosclerotic plaques consist of?
Lipid/ fatty streak
Necrotic core
Connective tissue
Fibrous “cap”
44
what is the first step in atherosclerosis progression?
fatty streaks
- aggregations of **lipid–laden** **macrophages** and **T lymphocytes** within the **intimal layer** of the vessel wall
45
what is the second step in atherosclerosis progression?
intermediate lesions:
layers of:
- foam cells
-Vascular smooth muscle cells
- T lymphocytes
- Adhesion and aggregation of platelets to vessel wall
- Isolated pools of extracellular lipid
46
what is the third step in atherosclerosis progression?
fibrous plaques/advanced lesions
- impede blood flow, may rupture
- covered by dense fibrous cap
47
what is the fourth step in atherosclerosis progression?
plaque rupture
- due to Fibrous cap not being resorbed and redeposited - eg due to inflammation cap weakens
- thrombus/clot formation and vessel occlusion
48
what is the fifth step in atherosclerosis progression?
plaque erosion
- can cause coronary thrombosis
49
what is the difference between plaque ruption and plaque erosion?
ruptured - large lipid core and inflammatory cells
erosion - small lipid core, disrupted endothelium, more fibrous tissue and a larger lumen
50
what is the treatment for coronary heart disease?
- Percutaneous Coronary Intervention PCI
(widens blocked arteries)
(especially in STEMI)
51
What is the difference between STEMI and NSTEMI?
STEMI - complete blockage of coronary artery, more urgent
NSTEMI - partial blockage (ST-depression, T-wave inversion)
52
what is aspirin an irreversible inhibitor of?
platelet cyclo-oxygenase
53
what do statins inhibit?
HMG CoA reductase - reducing cholesterol synthesis
54
what kind of drugs can be used if statins are ineffective or not tolerated?
drugs that target PCSK9
55
what are acute coronary syndromes?
spectrum of conditions which include myocardial infarction with or without ST-segment-elevation, and unstable angina.
56
what is unstable angina an how is it diagnosed?
Clinical classification includes:
*Cardiac chest pain at rest
*Cardiac chest pain with crescendo pattern
*New onset angina
Diagnosis: history
ECG
troponin
57
what is the difference in symptoms between unstable/stable angina?
unstable - at rest, longer, more frequent
stable - with exercise/exertion, shorter, predictable
58
why is unstable angina more serious then stable angina?
unstable - ruptured/ unstable coronary artery plaques, can lead to heart attack
stable - narrowed but stable coronary artery plaques, usually no blockage
59
what other way may MI be classified?
Q-wave or non Q wave
60
what are risk factors of MI?
age
diabetes
renal failure
left ventricular systolic dysfunction
61
what signs/symptoms show MI?
cardiac chest pain - unremitting, severe but may be mild, occurs at rest
associated with sweating, breathlessness, nausea and vomiting
62
what is initial management of MI?
- aspirin 300mg immediately
- pain relief - opiates/nitrates
- o2 if hypoxic
- aspirin +/- platelet P2Y12 inhibitor
- consider beta-blockers
- Consider urgent coronary angiography e.g. if
troponin elevated or unstable angina refractory
to medical therapy
63
what is type 1 myocardial infarction?
Myocardial infarction due to atherothrombosis
64
what causes most acute cardiac syndromes
Rupture of an atherosclerotic plaque and
consequent arterial thrombosis
65
what are some causes of type 2 MI?
- drug abuse
- pulmonary embolism
- anaemia
- haemorrhage
- thyrotoxicosis
- sepsis - causing o2 mismatch
(imbalance between supply and demand other than coronary artery disease)
66
what is Tako-Tsubo/stress-induced cardiomyopathy?
- due to extreme emotional distress
- cause **left ventricular systolic
dysfunction**, typically ballooning of the left
ventricular apex during systole
- reversible within couple weeks
67
what does troponin show?
markers for cardiac muscle injury
68
what are the 3 P2y12 inhibitors?
thienopyridines - clopidogrel & prasugrel (better prodrug) - irreversible
ticagrelor - reversible - more rapid offset
| used in antiplatelet therapy and in ACS
69
what are Adverse effects of P2Y12 inhibitors?
Bleeding e.g. epistaxis, GI bleeds, haematuria
Rash
GI disturbance
ticagrelor - Dyspnoea (shortness of breath), Ventricular pauses
70
what are features of GPIIb/IIIa antagonists?
- used in combination, only IV
- increase risk of major bleeding
- reduced use due to better antiplatelet therapy
- used in patients with delayed absorption of oral P2Y12 inhibitors
71
what do anticoagulants target?
formation/activity of thrombin
- Inhibit both fibrin formation and platelet activation
72
what are the main anticoagulants?
fondaparinux or heparin
73
what acute coronary syndrome is revascularisation used for?
NSTE
high risk unstable angina
74
what are some predisposing factors for ischaemic heart disease?
- age
- smoking
- family history
- diabetes
- high BP, high lipids
- kidney disease
- obesity
- physical inactivity
75
what are symptoms of ischaemic heart disease?
- chest pain
- breathlessness
- fluid retention
- palpitations
- Syncope or pre-syncope - fainting
76
what are some differential diagnosis of ischaemic heart disease?
Pericarditis/ myocarditis - inflammation
Pulmonary embolism/ pleurisy
Chest infection/ pleurisy
Dissection of the aorta
Gastro-oesophageal (reflux, spasm, ulceration)
Musculo-skeletal
Psychological
77
how is ischaemic heart disease treated?
lifestyle changes
asparin, Beta blockers, statins
78
what are the side effects of beta blockers?
tiredness, nightmares
erectile dysfunction
cold hands and feet
79
how do nitrates affect the heart?
vasodilation
- lower BP and afterload, in turn lowering venous return and preload
- reduce oxygen demand of the heart
80
how do Ca channel blockers affect the heart?
- lower BP, lower O2 demand
- Suppression of Abnormal Rhythms
- increase blood flow
81
what is an antiplatelet agents (aspirin) side effect?
gastric ulceration
82
how do ACE inhibitors (ramipril) effect the cardiovascular system?
- inhibit angiotensin 2 synthesis that cause vasoconstriction
- LOWER BP
83
what are chronic coronary syndromes?
chronic mismatch between supply and demand in myocardial oxygen conspumtion
84
what medication is given for chronic coronary syndromes?
aspirin
b blockers
nitrates
85
what psychosocial factors can effect coronary heart diease?
- anxiety/depression
- lack of social support
- work/family life - stress
- anger/hostility
-
86
how are pscychosocial factors related to CHD assesed and what is done about it?
- assessed by clinical interview or standardized questionnaires
- in cases with increased risk multimodal, behavioural intervention, integrating counselling
87
what is Coronary Prone Behaviour Pattern?
'type A' behaviour
- eg highly competitive, ambitious, aggressive
88
what happens to a muscle during depolarisation?
contraction
89
what is the standard calibration of an ECG?
25mm/s
0.1 mV/mm
90
what does the p wave in an ECG show?
atrial depolarisation
91
what does the QRS wave show in an ECG?
ventricular depolarisation
92
what does the T wave show in an ECG?
ventricular repolarisation
93
what does the PR interval show in and ECG?
- represents the time for electrical activity to move between the atria and the ventricles
- time between atria depolarisation and ventricular depolarisation
(between P and Q point)
94
what are the 12 leads in an ECG?
3 standard limb leads
3 augmented limb leads
6 precordial leads
95
what is a normal PR interval range?
120 to 300 ms
(3 to 5 little squares)
96
what should the width of a QRS complex be?
less than 110 ms ( 3 little squares)
97
what leads is the QRS complex are upright?
lead 1 and 2
98
the QRS and what wave tend to have the same general direction in the limb leads?
T wave
99
in lead aVR, what are all the waves?
negative
100
where does the R and S wave increase in size?
R wave - V1 to at least V4
S wave - V1 to at least V3, disappear in V6
101
what part of a normal ECG may a ST segment be elevated?
V1 and V2
starts isoelectric
102
where is the P wave upright in a normal ECG?
1, 2, V2 to V6
103
what part of the ECG is there no Q wave (or less than 0.04s)?
1, 2, V2 to V6
104
what part of a normal ECG must a T wave be upright?
1, 2, V2 to V6
105
what should a P wave look like in an ECG?
+ve in lead 1 and 2
-ve in lead aVR
<3 squares in duration, <2.5 squares in amplitude
commonly biphasic in lead V1
best seen in lead 2
106
in an ECG, what shows right atria enlargement?
pointed P wave, over 2.5mm
- P pulmonale
107
in an ECG, what shows left atrial enlargement?
M shaped/bifid P wave
- P mitrale
108
what shows WPW, wolff-parkinson-white syndrome in an ECG?
short PR interval
(and tachycardia)
109
what does a long PR interval show?
1st degree heart block
110
what is second degree heart block type 1 know as?
Mobitz type 1 AV block or Wenckebach phenomenon.
111
ecg finding on 2nd degree heart block type 1?
- increasing prolongation of PR interval
- occasional QRS dropped
112
what causes 2nd degree heart block type 1?
Increased vagal tone: often seen in athletes
Drugs: beta-blockers, calcium channel blockers, digoxin, amiodarone
Inferior myocardial infarction
Myocarditis
Cardiac surgery
113
what causes first degree heart block?
Enhanced vagal tone: often seen in athletes (non-pathological)
Post myocardial infarction
Lyme disease
Systemic lupus erythematosus
Congenital
Myocarditis
Electrolyte derangements
thyroid
drugs
114
what is management of first degree heart block?
- AV blocking drugs should be stopped
- normally asymptomatic so no intervention
- pacemaker is symptomatic
115
what symptoms in 2nd degree heart block type 1?
- Irregular pulse
- Bradycardia
- pre/syncope
116
ecg findings in Mobitz type 2 AV block
- regular normal PR
- intermittently dropped QRS complexes
117
treatment of 2nd degree heart block type 2
- underlying cause treated - pacemaker if untreatable
- cardiac monitoring - risk of progression to complete AV block
- Temporary pacing or isoprenaline if haemodynamically compromised due to bradycardia
118
what are features of 3rd degree heart block?
- complete failure of conduction
- P wave and QRS present but no association - working independantly
119
symptoms/signs of 3rd degree heart block
Palpitations
Pre-syncope/syncope
Confusion
Shortness of breath (due to heart failure)
Chest pain
Sudden cardiac death
bradycardia
irregular pulse
120
ecg of bundle branch block
- broad QRS
- RSR’ pattern in V1-V3
- Wide, slurred S wave in lateral leads: I, aVL, V5-V6
121
cause of AV/heart block
idiopathic - fibrosis and sclerosis of the conduction system
122
what are Narrow complex tachycardia?
narrow QRS
- atrial fib/flutter
- sinus Supraventricular tachycardia
- Supraventricular tachycardia
123
what are Broad Complex Tachycardia?
broad QRS
- atrial fib/flutter with bundle branch block
- ventricular tachycardia
- Polymorphic ventricular tachycardia eg torsades de pointes
124
how is torsades de pointes treated?
IV magnesium
125
what is the outcome of Torsades de pointes?
- return to sinus rhytham
- ventricular tachycardia - can lead to cardiac arrest
126
what causes prolonged QT interval?
- Long QT syndrome (an inherited condition)
- Medications eg antipsychotics, amiodarone
- Electrolyte imbalances - hypokalaemia, hypomagnesaemia and hypocalcaemia
127
what should the S wave be in a QRS complex?
depth shouldnt exceed 30 mm
128
what shows an abnormal T wave?
symetrical, tall, peaked, biphasic or inverted
129
in what lead is the QT interval measured?
lead aVl
130
how does QT interval change with heart rate?
heart rate increases = QT decreases
131
what should a QT interval be?
0.35-0.45s
132
how is the heart rate calculated using an ECG?
- counting number of big boxes between QRS complexes, then divide into 300
- count number of beats per page and times by 6 (one page of ECG shows 10 seconds of rhythm)
133
what can abnormalities in the QRS axis show?
ventricuar enlargement
conduction blocks
- normal is from-30 to +90
134
what is the difference between RBBB and LBBB?
RBBB - affects RV electrical conduction - terminal force of QRS is higher than baseline
LBBB - affects LV electrical conduction - terminal force of QRS is below baseline
135
what is acute pericarditis?
an inflammatory pericardial syndrome with or without effusion
136
where does pericardial effusion occur and what does the fluid consist of?
- pericardial sac
- Transudates (low protein content)
Exudates (associated with inflammation)
Blood
Pus
Gas - bacterial
137
what is Pericardial tamponade?
severe pericardial effusion - lots of fluid causing increased intra-pericardial pressure and lower CO
138
what causes transudative pericardial effusion
Increased venous pressure can reduce drainage from the pericardial cavity eg due to:
Congestive heart failure
Pulmonary hypertension
139
what causes exudative pericardial effusion
Inflammatory:
Infection eg tb
Autoimmune and inflammatory conditions SLE, RA
Injury to the pericardium (e.g., after myocardial infarction, surgery or trauma)
Uraemia (raised urea) secondary to renal impairment
Cancer
Medications
140
what are symptoms/signs of pericardial effusion
Chest pain
Shortness of breath
A feeling of fullness in the chest
Orthopnoea (shortness of breath on lying flat)
(hiccups, dysphagia, horse voice)
Hypotension
Raised JVP
141
how is pericardial effusion diagnosed?
- echo
- fluid analysis
142
how is pericardial effusion treated?
- drainage - surgical/Needle pericardiocentesis
- treatment of underlying cause eg NSAIDS, aspirin
143
what 2 of 4 criterias need to be made for a diagnosis of pericarditis?
- chest pain
- pericardial rubs
- ecg changes
- pericardial effusion
144
what causes pericarditis?
- infections - viral (enterovirus etc.) or bacterial (Mycobacterium tuberculosis)
- autoimmune - sjogren syndrome, rheumatoid arthritis, scleroderma
- neoplastic - lung/breast cancer
- metabolic - uraemia, myxoedema
- trauma - direct/indirect injury
145
what are the symptoms/signs of pericarditis?
- chest pain: serve, sharp, rapid onset, left anterior chest or epigastrium, worse with inspiration and lying down
- low grade fever
- pericardial rub
146
what are the differential diagnosis for pericarditis?
- myocardial ischaemia/infarction
- pneumonia
- pulmonary embolus
- Gastro-oesophageal reflux
- shingles
- pancreatitis
147
what investigations are done for pericarditis?
- clinical examinations - pericaridal rub, tachycardia, fever, signs of effusion
- ECG Saddle-shaped ST-elevation, PR depression
- Bloods - inflammatory markers
- Echocardiogram
148
how is an ECG different in pericarditis?
- Saddle shaped st elevation
- PR depression
149
how is pericarditis managed?
- treat underlying condition eg viral/autoimmune
- Sedentary activity until resolution of symptoms and ECG/CRP
- NSAIDs: ibuprofen aspirin
- colchicine
- corticoseroids if contraindications for above
- pain-relief, antibiotics?
150
what do blood tests for pericarditis show?
- FBC - Modest increase in WCC, mild lympocytosis
- Troponin - Elevations suggest myopericarditis
- ESR & CRP
151
what is the most common cause of pericarditis?
viral pericarditis
152
what is Hypertrophic cardiomyopathy?
- autosomal genetic condition
- caused by sarcomere protein mutation
- LV wall thickenss
153
what signs/symptoms can HCM cause?
angina,
dyspnoea, palpitations,
dizzy spells
syncope
154
what is dilated cardiomyopathy
disease of heart muscle characterized by dilation and **enlargement of of one or both ventricles**, with impaired contractibility
- cytoskeleton gene mutation
155
what kind of symptoms does DCM present with?
heart failure symptoms
156
what is Arrhythmogenic cardiomyopathy?
- desmosome gene mutation condition
- heart muscle replaced with **scar/fatty cells**
- mostly affects **RV**
157
what are the main cardiac channelopathies?
long QT
short QT
Brugada
CPVT- Catecholaminergic polymorphic ventricular tachycardia
(can only be identified by ECG - no symptoms until an event occurs)
158
what is sudden arythmic death syndrome - SADS?
when a patient dies due to abnormal heart/arrhythmia but otherwise healthy
159
what is Familial hypercholesterolaemia ?
an inherited abnormality of cholesterol metabolism
- leads to serious premature coronary and other vascular disease
160
what is important to consider when precribing to a patient with long QT syndrome?
QT prolonging drugs - can kill patient
eg some antidepressants etc.
(and recreational drugs)
161
what are some examples of Aortovascular syndromes?
Marfan - fibrillin mutation
Loeys-Dietz
vascular Ehler Danlos (EDS)
162
what system do BP drugs target?
RAAS
sympathetic nervous system - noradrenaline
both increase/maintain BP
163
what groups of drugs decrease BP?
ACE inhibitors
ARB - angiotensin receptor blocker
calcium channel blockers
beta blockers
aldesterone antagonists
alpha blockers
renin inhibitors - rarely used
centrally acting drugs
164
what is the most common ACE inhibitor?
Ramipril
165
what are side effects of ACE inhibitor?
1. related to angiotensin 2
- hypotension
- acute renal failure
- hyperkalaemia
- teratogenic effects - baby
2. related to kinins
- cough
- rash
- anaphylactoid reactions
166
what are the types of calcium channel blocker?
1. dihydropyridines - eg amlodipine
- affects peripheral arterial vasodilators
2. verapamil - main effects on heart
3. diltiazem - cardiac and peripheral effects
167
what are adverse effects of CCB?
- Due to peripheral vasodilatation (mainly dihydropyridines)
Flushing
Headache
Oedema
Palpitations
- Due to negatively chronotropic effects (mainly verapamil/diltiazem)
Bradycardia
Atrioventricular block
- Due to negatively inotropic effects (mainly verapamil)
Worsening of cardiac failure
- Verapamil causes constipation
168
what are side effects of Beta blockers
Fatigue
Headache
Sleep disturbance/nightmares
Bradycardia
Hypotension
Cold peripheries
Erectile dysfunction
Worsening of: Asthma (may be severe) or COPD
PVD – Claudication or Raynaud’s
Heart failure – if given in standard dose or acutely
169
what are the classes of diuretics?
Thiazides and related drugs (distal tubule)
Loop diuretics (loop of Henle)
Potassium-sparing diuretics
Aldosterone antagonists
170
what are the adverse effects of diuretics?
hypovolaemia
hypotension
low serum potassium, sodium, magnesium,calcium
raised uric acid
impaired glucose tolerance
erectile dysfunction
171
what drugs are best used in pregnancy for hypertension?
methyldopa - centrally acting
172
what population has CCB most commonly prescribed for hypertension?
over 55
or afro-caribean any age
173
what groups of people are best prescribed ACE inhibitors/ARB?
diabetics
under 55
174
what are the types of heart failure?
Heart Failure with Reduced Ejection Fraction HFrEF - (systolic) (LVSD)
Heart failure with preserved ejection fraction HFPEF - (diastolic failure)
Acute heart failure / Chronic heart failure
(left sided most common)
175
what is the first line treatment for heart failure?
ACE inhibitors
beta blockers
176
when is Sacubitril – neprilysin inhibitor used?
in heart failue in addition to other treatment eg beta-blockers
177
what are the effects of nitrates on the cardiovacsular system?
Arterial and venous **dilators**
Reduction of preload and afterload
**Lower BP**
- eg for ischaemic heart disease
- eg GTN spray
178
what is the first line treatment for chronic stable angina?
beta blockers
calcum channel blockers
179
what medication is used for acute coronary syndrome?
diamorphine for pain
anti-platelets
antithrombin
aspirin
beta bloackers
statins
therapy for treatment eg ACE inhibitors
180
what is the Vaughan Williams classification
for antiarrhythmic drugs?
Class I: **Sodium channel blockers** -
Ia - disopyramide, quinidine, procainamide
Ib - lidocaine, mexilitene
Ic - flecainide, propafenone
Class II: **Beta adrenceptor antagonists** - propranolol, nadolol, carvedilol (non-selective)
bisoprolol, metoprolol (β1-selective)
Class III: **Prolong the action potential** - amiodarone, sotalol
Class IV: **Calcium channel blockers** - verapamil, diltiazem
181
what are features of digoxin?
- Cardiac glycoside, **antiarrhythmic drug**
- Inhibit Na/K pump
- causes bradycardia and slows down conduction
- narrow theraputic range
182
what are the uses and side effects of amiodarone?
antiarrhythmic medication
side effects:
- QT prolongation
- liver dysfunction
- hypo/hyperthyroidism
- sun sensitivity
- corneal microdeposits
- optic neuropathy
- multiple drug interactions - eg warfarin
- very large volume of distribution
183
what are the types of aortic stenosis?
- supravalvular
- subvalvular
- valvular
184
when do symptoms of aortic stenosis occur?
when valve area is 1/4 of normal area (normal is 3-4cm2)
185
what are the causes of aortic stenosis?
- congenital: congenital aortic stenosis/bicuspid valve
- acquired: calcification, rheumatic heart disease
186
what are the 3 presentations of aortic stenosis?
syncope - fainting/loss of conciousness
angina
dyspnoea - difficulty breathing
187
what are the physical signs of aortic stenosis?
- Slow rising carotid pulse & decreased pulse amplitude
- Heart sounds- soft or absent second heart sound, S4 gallop due to LVH
- Ejection **systolic murmur- crescendo-decrescendo** character.
188
what investigations are done to diagnose aortic stenosis?
echocardiogram
- Left ventricular size and function: LVH, Dilation, and EF
- Doppler derived gradient and valve area (AVA) - under 1cm2 is severe
189
what is the management of aortic stenosis?
- Aortic Valve Replacement (if symptomatic):
Surgical
TAVI – Transcatheter Aortic Valve Implantation
- if asymptomatic then surveillance
- NO vasodilators in servere AS
- consider prophylaxis in dentals due to infection risk
190
what is mitral regurgitation?
backflow of blood from the LV to the LA during systole
(mildly seen in 80% of pop)
191
what are the causes of mitral regurgitation?
- Myxomatous degeneration (MVP)
- Ischemic MR
- Rheumatic heart disease
- Infective Endocarditis
192
what is the Compensatory Mechanism for mitral regurgitation?
Left atrial enlargement, LVH and increased contractility
- Progressive LV volume overload leads to dilatation and progressive HF
193
what are the signs/symptoms of mitral regurgitation?
- pansystolic murmur at the apex radiating to the axilla, In chronic MR, the intensity of the murmur does correlate with the severity
- Exertion Dyspnoea: ( exercise intolerance)
- heart failure
194
what are the investigations for mital regurgitation?
- ECG - May show, LA enlargement, atrial fibrillation and LV hypertrophy with severe MR
- CXR: LA enlargement, central pulmonary artery enlargement
- ECHO: Estimation of LA, LV size and function. Valve structure assessment
195
what is the management for mitral regurgitation?
- medications - b-blockers, anticoagulation, nitrate/diuretics for acute MR
- serial echo
- IE prophylaxis - for prosthetic valves/dental procedures
- surgery IF any symptoms at rest or exercise, or EF below 65% etc.
196
what is aortic regurgitation?
Leakage of blood into LV during diastole due to ineffective coaptation of the aortic cusps
197
what causes aortic regurgitation?
Bicuspid aortic valve
Rheumatic
Infective endocarditis
198
what is the Compensatory Mechanisms for aortic regurgitation?
LV dilation, LVH. Progressive dilation leads to heart failure
199
what are the ausculations of aortic regurgitation?
- **Diastolic blowing murmur** at the left sternal border
- **Austin flint murmur** (apex): Regurgitant jet impinges on anterior MVL causing it to vibrate
- **Systolic ejection murmur**: due to increased flow across the aortic valve
200
what are the signs/symptoms of aortic regurgitation?
- Wide pulse pressure
- Hyperdynamic and displaced apical impulse
- syspnoea
- palpitations
201
what are investigations for aortic regurgitation?
- chest xray - enlarged cardiac silhouette and aortic root enlargement
- ECHO: Evaluation of the AV and aortic root with measurements of LV dimensions and function
202
what is the management of aortic regurgitation?
- vasodilators
- serial echos to monitor
- surgical - TAVI in exceptional cases
203
what is mitral stenosis?
Obstruction of LV inflow that prevents proper filling during diastole
204
what are the causes of mitral stenosis?
- Rheumatic carditis is the predominant cause
- infective endocarditis
- mitral annular calcification
205
what are the signs/symptoms of mitral stenosis?
- Progressive Dyspnea
- Right heart failure symptoms
- mitral facies (rosey cheeks) due to vasoconstriction due to low cardiac output
- prominent "a" wave in jugular venous pulsations
206
what are the heart sounds in mitral stenosis?
- diastolic murmur
- Loud Opening S1 snap
207
how does mitral stenosis effect the heart?
- pulmonary hypertension
- RV hypertrophy
- LA dilation
- LA enlargement and fibrillation
208
what are the investigations for mitral stenosis?
- ECG: may show atrial fibrillation and LA enlargement
- CXR: LA enlargement and pulmonary congestion. Occasionally calcified MV
- ECHO: The GOLD STANDARD for diagnosis. Asses mitral valve mobility, gradient and mitral valve area
209
what is the management of mitral stenosis?
- serial echo
- medication eg b-blockers, diuretics
- percutaneous mitral balloon valvotomy.
- IE prophylaxis
- Mitral valve replacement - symptomatic with class3/4 symptoms
210
what is stage 1 & 2 and severe hypertension?
stage 1 BP over 140/90 (HBPM over 135/85)
stage 2 BP over 160/100 (HBPM over 150/95)
severe BP over 180, or over 110
211
when are antihypertensive drugs offered?
- if under 80yrs stage 1 and target organ damage/CVD/renal disease/diabetes/CVD risk over 20%
- or stage 2 any age
212
what is ABPM?
ambulatory blood pressure monitoring over 24hours
- used to diagnose hypertension if clinical BP is 140/90
213
what should BP targets be?
under 140/90 for under 80yrs
under 150/90 for over 80yrs
214
what are some congenital heart defects?
Ventricular septal defect
Atrial septal defect
Atrio-ventricular septal defects
Patent ductus arteriosus
Coarctation of the Aorta
Bicuspid aortic valve and aortopathy
Pulmonary stenosis
Tetralogy of Fallot
215
what are some clinical signs of a ventricular septal defect?
- tachycardia
- big heart on chest xray
- increased Resp rate
- small breahless skinny baby
216
what syndrome can a ventricular septal defect cause?
Eisenmengers syndrome
217
what are some clinical signs of an atrial septal heart defect?
- pulmonary flow murmur
- Fixed split second heart sound
- big pulmonary arteries, big heart on chest xray
- may have increased chest infections and right heart dilation
218
what people may often have atrio-ventricular septal defects?
downs syndrome
219
what are some clinical signs of AVSD?
- breathless neonate
- poor weight gain/feeding
- Presents like a small VSD / ASD
220
what are some clinical signs of Patent Ductus Arteriosus?
- Continuous ‘machinery’ murmur
- If large, big heart, breathless
- Eisenmenger’s syndrome
221
what are clinical signs of coarctation of aorta
- Right arm hypertension
- Bruits (buzzes) over the scapulae and back from collateral vessels
- Murmur
222
what is tertalogy of fallot?
congenital heart defect
- ventricular septal defect
- pulmonary stenosis
- hypertrophy of RV
- overriding aorta
223
what is the most common congenital heart defect?
ventricular septal defect
224
what is infective endocarditis?
Infection of heart valve/s or other endocardial lined structures within the heart (such as septal defects, pacemaker leads, surgical patches, etc).
225
who most commonly gets endocarditis?
the elderly (in an ageing population)
i.v. drug abusers
congenital heart disease/ autoimmune disease
Anyone with prosthetic heart valves
226
what is the 2 major criteria of infective endocarditis?
- Pathogen grown from blood cultures
- evidence of endocarditis on echo, or new valve leak, regurgitation
227
what is the 5 minor criteria of infective endocarditis?
- Predisposing factors
- Fever over 38
- embolism evidence - janeway lesions
- Immune phenomena - oslers/roths
- Equivocal blood cultures
228
what is the modified dukes criteria to diagnose endocarditis?
One major plus three minor criteria
Five minor criteria
229
what are the 4 peripheral signs of endocarditis?
- roth spots - on eye fundoscopy
- osler nodes - on digits
- janeway lesions - on palms/soles
- splinter hemorrhages - on nails
230
investigations of endocarditis
blood culture - Staphylococcus aureus, strep/enterococcus
echo (TOE) - Vegetations seen
231
what is the treatment of infective endocarditis?
- antibiotics/antimicrobials
- surgery to remove the infectious material and/or repair the damage
232
on an ECG, what shows left/right atrial enlargement?
right - tall p wave
left - Broad notched ‘Bifid' P wave
233
when is the PR interval prolonged?
in disorders of AV node and specialised conducting tissue
234
what is the most common reason for a broad QRS?
Ventricular conduction delay / bundle branch block
Pre-excitation
- eg damage from heart attack
235
when is a QRS complex small?
Obese patient
Pericardial effusion
Infiltrative cardiac disease
236
what is the QRS in Left ventricular hypertrophy?
tall
237
what does QT interval represent?
ventricular depolarisation and repolarisation
238
what part of the ECG is important to look at in ischaemia?
ST segment
239
what are some reasons for T wave inversion?
Ischaemia/infarction
Myocardial strain (hypertrophy)
Myocardial disease (cardiomyopathy
240
what does a LBBB look like in an ECG?
QRS looks like a W in V1 and M in V6
- WiLLiam
241
what does a RBBB look like in and ECG?
QRS looks like M in V1 and W in V6
- MaRRow
242
what shows Ischaemia & Infarction in an ECG?
- T wave flattening inversion
- ST segment depression
- ST segment elevation
- Q waves – old infarction
243
what shows Hyperkalaemia in ECG?
Tall T waves, flattening of P waves, broadening of QRS… eventually ‘sine wave pattern’
244
what shows Hypokalaemia in an ECG?
Flattening of T wave, QT prolongation
245
what shows Hypercalcaemia in an ECG?
QT shortening
246
what shows Hyporcalcaemia in an ECG?
QT prolongation
247
what is the most common sustained arrhythmia?
AF
248
what can no P wave suggest?
supraventricular tachycardia
or AF
249
what is heart failure?
An inability of the heart to deliver blood (and O2) at a rate commensurate with the requirements of the metabolising tissues, despite normal or increased cardiac filling pressures
250
what most commonly causes heart failure?
myocardial dysfunction due to IHD, hypertension, excess alcohol
251
what are the main phenotypes for heart failure?
HF with reduced ejection fraction (HFrEF)
HF with preserved ejection fraction (HFpEF)
252
what are symptoms of right sided heart failure?
- peripheral edema, ascites
- hepatomegaly
- jugular venous distension (JVD) and raided pressure
- abdo discomfort
253
what are symptoms of left sided heart failure?
- dyspnea, orthopnea
- fatigue
- elevated JVP
- coughing/wheezing
254
what causes left sided heart failure?
- high BP
- alvular heart disease (aortic stenosis or mitral regurgitation)
- coronary artery disease
- MI
255
what causes right sided heart failure?
- often secondary to left sided
- pulmonary hypertension
- chronic lung diease eg COPD, pulmonary fibrosis
- right-sided valvular heart disease
256
what is definition for left vs right heart failure?
left - left ventricle fails to effectively pump oxygen-rich blood from the lungs to the rest of the body.
right - right ventricle fails to effectively pump blood to the lungs for oxygenation.
257
what are the symptoms of heart failure?
Breathlessness
Tiredness
Cold peripheries
Leg swelling
Increased weight
258
what are the signs of heart failure?
- Tachycardia
- Displaced apex beat (normally 5th intercostal space)
- Raised JVP (Jugular venous pressure)
- Added heart sounds and murmurs
- Hepatomegaly, especially if pulsatile and tender
- Peripheral and sacral oedema
- Ascites
259
what is the new york heart association cassification for heart failure?
Class I: No limitation (Asymptomatic)
Class II: Slight limitation (mild HF)
Class III: Marked limitation (Symptomatically moderate HF)
Class IV: Inability to carry out any physical activity without discomfort (symptomatically severe HF)
260
what causes acute decompensation (suddun worsening) of chronic heart failure?
- AMI - acute myocardial infarction
- Uncorrected BP
- Obesity
- Superimp. infection
- AF & arrhythmias
- Excess alcohol
- Endocrine (DM/T4..)
-ve inotropes (Ca/beta)
- NSAIDS
- Treatment and Na+ noncompliance.
- Lack of information given to patient about diet, medications, etc
261
what medications are used to treat heart failure?
- first line - ACE inhibitors and beta-blockers lisenced for HF
(angiotensin receptor blocker considered if ACE not tolerated)
- aldosterone antagonists
- mineralocorticoid receptor antagonist
- diuretics - relieve breathlessness and oedema
- loop diuretics
- thiazide only in mild fluid retention
- digoxin - for patients with sinus rhythm, for symptoms caused by acute exacerbations
- ivabradine - Blocker of the If current in the SA node - slows HR and treats angina
- NO Rate-limiting calcium-channel blockers for patients with reduced ejection fraction
262
why is IV-iron prescribed in heart failure?
- improves exercise tolerance
- may reduce the propensity for hospitalization of patients with HFrEF
263
should oxygen be given to patients with heart failure?
No
- only if sat below 90, or COPD
264
what causes Aortic dissection?
tear in aorta that propagates
- high BP
- trauma
- Connective Tissue Disorders eg Marfan syndrome, Ehlers-Danlos syndrome
265
symptoms of aortic dissection
- Sudden, Severe Chest and abdo Pain
- weakness, numbness, or paralysis in the limbs
- diff in BP between arms
- syncope
- hypertension, Hypotension as the dissection progresses
266
between what layers does aortic dissection happen?
intima and media
267
what is the Stanford system classification of aortic dissection?
Type A – affects the ascending aorta, before the brachiocephalic artery
Type B – affects the descending aorta, after the left subclavian artery
268
investigations for aortic dissection
- ecg/xray to exclude other
- CT angiogram (MRI more detail)
269
treatment for aortic dissection
- analgesia
- BP/HR control - beta-blockers
- surgery: A - open sugery, B - TEVAR catheter, grafts
270
complications of aortic dissection
- Myocardial infarction
- Stroke
- Paraplegia (motor or sensory impairment in the legs)
- Cardiac tamponade
- Aortic valve regurgitation
- Death
