Cardiovascular Flashcards
Outline the basic approach in examining a cardiology patient?
- ABCDE (Airways, Breathing, Curculation, Disability, Exposure)
- Detailed history and exam
- (key) character of pain
- onset, duration, radiation, positional
- Exacerbating/relieving factors, associated symptoms - Past medical history inc. specific risk factors
- Drug use (particularly if young)
- Baseline observations (o2 stats, HR, RR, temp)
What investigations can be done in investigating a cardiology patient?
- ECG (electrocardiogram)
- CXR (chest x-ray)
- Blood test: FBC; U&E; 12-h troponin (v.useful); BNP (indicative of HF); D-dimer (PE)
- Echocardiogram
- Coronary angiogram
- CT coronary angiogram
- Nuclear perfusion test
How would a patient with a PE present?
Patient presents with:
- sudden onset pain
- pleuritic (worse on inspiration)
- ocassionally haemoptysis or collapse
- dyspnoea
What are the risk factors of a PE?
Virchow’s triad (vessel wall, coagulability, blood stasis):
- surgery
- being immobile
- thrombophilia
- pregnancy/post-partum
- previous PE
- active cancer
How would you investigate a PE?
- ABG would show lower O2 stats and peak O2
- CxR (usually normal)
- ECG may show sinus tachycardia, right axis deviation, and right bundle branch block. Rarely see S1Q3T3 pattern
- D-dimer to exclude PE if scores low pre-test
- VQ scan will show mismatch
How would you treat a PE?
- LMWH
- Thrombolytic
- Warfarin
How would a patient with a musculoskeletal pain present?
pain that is worsened when the chest is pressed on. Differentiated as that pain can be reproduced in all positions, while coronary pain tends to be positional in nature.
How would a patient with GORD present?
Location and character may mimic MI
However, will be worse at night, on eating and patient may have dysphagia too
How would a patient with an Aortic Dissection present?
- usually young person
- pain radiates from to jaw and left arm
- can present with soft early diastolic murmur in aortic are
- sudden tearing pain radiating to back
What is an Aortic Dissection, and its risk factors?
A false lumen created in the aorta between the tunica intima and media, blood spurts through it and can tear.. Risk factors include hypertension or connective tissue disease such as marfans’s syndrome, trauma (deceleration injury)
How would you investigate an Aortic Dissection
- CxR may show a widened mediatunum
- Echocardiogram
- CT is the gold standard
How is an aortic dissection managed?
- Revascularisation
- BP control with IV beta blockers and nitrates
- Surgery
What are the signs/symptoms of myocarditis and pericarditis?
- Chest pain, positional element (worse on lying flat)
- Proceeding flu-like symptoms
- Palpitations
What are the causes of myocarditis and pericarditis?
• Idiopathic
• Viral, bacterial
• Drugs, chemotherapy, phenytoin, penicillin
- Autoimmune
How would you investigate myocarditis and pericarditis?
- ECG would show saddle-shaped ST elevation
- Troponin, and bloods for viral serology
- Angiogram, echo, CMRI, myocardial biopsy (to determine cause)
How would you investigate an acute coronary syndrome?
- ECG to determine if STEMI or not. If not it may be NSTEMI or UAP (unstable angina)
- Blood test (troponin)
How would you manage an acute coronary syndrome?
- Manage all via ABCDE
- Give pain relief (Glyceryl Trinitrate or morphine with metoclipramide)
- If STEMI, patients can ideally go for PCI (pericutaenous cornonary intervention to remove clot and stent open artery) or thrombolysis
- If NSTEMI may also benefit from PCI
- Antiplatelets
- Beta-blockers
What characteristics are vital in categorising an arrhythmia?
- Tachycardia (>100bmp) or Bradycardia (120ms)
3. Irregularity or Regularity
How can an ECG be used to determine where the electrical disturbance arrises from in an arrhythmia?
If narrow QRS complex,it is supraventricular in nature. Either problem with SAN or AV node.
If wide QRS complex then problem with ventricles.
How do we determine if the arrythrmia is a AVRT or AVNRT
If narrow QRS and regular ECG
How are AVNRT or AVRT treated?
Adenosine should terminate the arrhythmia.
If AVNRT (A-V Nodal Reentrant Tchardia): give agents that block the AV node such as beta blockers or calcium channel blockers
If AVRT (A-V Reentrant Tchardia): Na+ channel blockers (Class I anti-a) or catheter albation to destroy extra pathway
How is atrial fibrillation treated?
If someone has gone into AF for less than 48h (acute), treat with:
- Electrical cardioversion if haemodynamically unstable
- Give amioderone if stable and probably have structural heart disease
- Give flecainide if stable and probably don’t have structural heart disease
After 48h or if not acute, then give B-blockers or digoxin (rate controlling - rhythm control is only for symptoms)
Also give anticoagulants (dabigatran) depending on CHA2DS2VASC score
How is atrial flutter diagnosed?
Narrow QRS and regular rhythm. Doesn’t respond to adenosine
What drugs are used to treat tachyarrhymias in the long term?
For the tachyarrhythmias, you also want to give rate control drugs such:
• Beta-blockers (best at rate control)
• Rate limiting calcium channel blockers
• Digoxin
Controlling rhythm rather than rate has no evidence of reducing morbidity. Only benefit of restoring rhythm is reducing symptoms.
Rhythm is controlled by amioderone
Describe the two types of valvular disease
- Stenosis is when the valve is too narrow and usually thickened and possible calcified. It does not let much blood through when it is supposed to be open.
- Regurgitation is when the valve is leaky and lets blood flow backwards causing insufficiency.
How can you hear an aortic stenosis?
left side = expiration
ejection systolic murmur
How can you hear a mitral regurgitation?
left side = expiration
pan-systolic murmur
How can you hear a aortic regurgitation?
left side = expiration
decrescendo early diastolic murmur
How can you hear a mitral stenosis?
left side = expiration
mid diastolic murmur
What do patients with aortic stenosis present with? + on examination
- Breathlessness
- Chest pain
- Blackout/syncope
- Tired
- Palpitations
(first three are red flag)
On examination you may notice a slow rising pulse (as blood does not flow forcefully through valve, and instead does so slowly), narrow pulse pressure, ejection systolic murmur, soft or absent second heart sound, displaced or having apex beat, signs of heart failure/pulmonary oedema.
How is an aortic stenosis investigated?
- An ECG may be normal, or may have a very tall QRS complex (sign of left ventricular hypertrophy, a sign of aortic stenosis).
- Should also get blood tests to look for anaemia (another cause of breathlessness). New biomarker such as BNP (brain naturetic peptide) is helpful.
- Echocardiography can be used to see the valve. This can be transthoracic or transoesophageal echo. It also allows us to measure the velocity through the valve using the Bernoulli principle, or the aortic valve area. Knowing the area and pressure can help us establish whether there is significant narrowing of the valve.
How can you classify a stenosis?
Using data from thousands of patients, we can categorise people into mild, moderate or severe stenosis. The greater the stenosis, the greater the velocity of the blood, due to the narrower area. The flow is measured using an echocardiogram.
What does aortic regurgitations present with?
They present with:
• Breathlessness
• Palpitations
• Symptoms of heart failure
On examination, what would you notice with aortic regurgitation?
- collapsing pulse
- wide pulse pressures
- diastolic murmer
- signs of heart failure
Causes of aortic stenosis?
- calcification
- infective endocarditis
- bicuspid valve
What are the common causes of AF?
MAJORITY:
- Ischaemic Heart Disease
- Hypertensive Heart Disease
- Valvular Heart Disease
- Endocrine: hyperthyroidism, hyperparathyroidism
- Electrolyte disturbances: K+, Mg, Ca
- Infection: pneumonia, UTI
- Drugs: alcohol, caffiene
What are the types of AF?
- paroxysmal (1y)
What are the symptoms of mitral valve regurgitation? and
- Breathelessness
- Fatigue
- Palpitations
- Embolic events
- Haemoptysis
Why are valve diseases affecting the right side of the heart are much less common.
due to reduced intra-ventricular pressures. They are heard better on inspiration.
What are the risk factors for infective endocarditis?
- prosthetic valves
- aortic or mitral valve disease
- previous rheumatic fever
- patent ductus arterioles
- communication between the right and left side of the heart through “shunts”
- previous endocarditis
How does a patient with infective endocarditis present?
fever, malaise, fatigue, anorexia, weight loss and a new onset murmur.
What are the signs and symptoms of infective endocarditis
- Fever
- Roth spots in the retina
- Osler’s nodes
- Murmur which is new or different
- Janeway lesions
- Anaemia
- Nail (splinter) haemorrhages
- Emboli
How is IE diagnosed?
IE is diagnosed by using Duke’s criteria, which includes blood culture and echocardiogram results to show vegetations and microbial involvement. Minor criteria include symptoms such as fever and new onset murmur.
How do you treat IE?
- Treatment is often a combination of antibiotics including IV high dose antibiotic therapy including benzylpenicillin, but varies depending on the organism involved and its sensitivities. Other antibiotics used include vancomycin, ceftriaxone, gentamicin and flucloxacillin.
- In certain situations, damage to the valve is so great that urgent surgical valve replacement and vegetation debridement is the main option
How would you asses a suspected ischaemic heart disease?
- Clinical history and physical examinations + CVD risk.
What are the risk factors for ischeamic heart disease?
- high cholesterol
- smoking
- family history
- obesity
- sedentary lifestyle
What are the limitations of history taking and physical examination in diagnosing ischaemic heart disease?
- does not always complain of typical symptoms
- e,g heartburn or indegention
What are the non-invasive diagnostic tolls in diagnosing ischaemic heart disease?
- 12-lead ECG
- exercise ECG
- stress cardiac imaging
- coronary calcium and CT angiography
What are the invasive diagnostic tolls in diagnosing ischaemic heart disease?
- Coronary angiography (gold standard)
- Intravascular ultrasound
- fraction flow reserve measurements
- optic coherence tomography
How do you manage Ichaemic Heart Disease?
- Statins to treat cholesterol
- Antihypertensives
- Aspiroin
- If patient is symptomatic, anti-angine drugs can be sued such as beta-blockers, calcium antagonists, nitrates, and nicorandil.
- if atherosclerosis is extensive then percutaneous procedures or coronary artery bypass.
Define heart failure
Inability of the heart to keep up with the demands on it, and in particular, inability to provide oxygenated blood to the organs that require it.
What are the common causes of heart failure?
- ischaemic heart disease
- cardiomyopathies
- hypertension
- valve disease
- drugs (e.g chemotherapy)
- thyrotoxicosis/anaemia
What are the history features of HF?
FACES:
- Fatigue
- Activities limited
- Chest congestion
- Edema
- Orthropnoea (shortness of breath on lying flat)
- Paroxysmal nocturnal dyspnoea
What are the examination features of HF?
Inspection: Raised jugular venous pressure, Ascites
Palpitation: Tachycardia pulse in congestive HF, pitting oedema, hepatomegaly in right sided heart failure
Percussion: pleural effusions, ascites and hepatomegaly
Auscultation: S3 gallop
How would you investigate HF?
- ECG: Q and T inversions are signs of previous ischaemia. ECG may also see left ventricular hypertrophy
- CxR shows cardiomegaly, upper lobe diverse and possible plural effusions
- Echocardiogram to see valve function
- BNP is secreted by ventricles
- Bloods to check for anaemia, thryroxicosis.
- Angiogram evaluates flow through the coronary arteries and is usually in diagnostic IHD.
- CMR
How do you treat HF?
To improve symptoms: loop diuretics and digoxin
To improve prognosis: ACEi, beta-blockers, aldosterone antagonists, implantable cardioverter defib.
Lifestyle: Stop smoking, excersise, low sodium diet, fluid restriction, protect against infection.
Why is it important to diagnose AF?
- death rate is doubled
- stroke risk increased; stroke severity is increased
- frequent hospitilisations from AF
- quality of life can be reduced + anxiety of
- left-ventricular function
How do you diagnose a sinus rhythm?
- ventricular rhythm is regular (gaps between the QRS complexes are the same)
- P waves are followed by QRS complexes
How do you diagnose AF?
- irregularly irregular rhythm (gaps between the QRS complexes are different)
- absent p waves
- there are fibrillations or ‘f’ waves
- there is difficulty in the diagnosis in patients with paroxysmal AF
What are the common causes of AF?
MAJORITY:
- Ischaemic Heart Disease
- Hypertensive Heart Disease
- Valvular Heart Disease
- Endocrine: hyperthyroidism, hyperparathyroidism
- Electrolyte disturbances: K+, Mg, Ca
- Infection: pneumonia, UTI,
What are the types of AF?
- paroxysmal (1y)
What investigations would you conduct to determine the underlying cause of AF?
• Blood tests:
- FBC, U&Es (in particular K, Mg)
- Thyroid function tests, liver function tests
- Coagulation screen
- CRP (infections)
• MSU: midstream specimen of urine, to diagnose infection
• CXR: cardiomegaly, pulmonary oedema, valve calcification
• Echocardiogram: LV systolic function, LV hypertrophy, valve disease, congenital heart disease
• Ischaemic heart disease: exercise ECG, cardiac CT angiogram, stress echo, stress MRI, myocardial perfusion scan
• 24h Holter: assess heart rate control or achievement of sinus rhythm
Explain the ECG waveform
p = atrial depolarisation/ contraction of the atria qrs = ventricular contraction t = repolarisation of ventricles
What is the system in reading the ECG?
- check details
- rate
- rhythm
- axis
- p wave
- pr interval
- qrs complex
- qt interval
- st segment
- t wave
How should an ECG be calibrated?
X axis: 25 mm/s
Y axis 10mm/s
What is the normal cardiac axis?
-30 to +90
How can you notice cardiac deviation in the ECG?
- left deviation is when the lead I and II QRS are ‘leaving eachother’
- right deviation is when the lead I and II QRS are ‘reaching eachother’
What is the Chest X-Ray used for?
- patients that present with cardiovascular or pulmonary problems
- check position and function of lines
- pre-operative assessment
- follow-up to check resolution pneumothoraces and check not missed a malginancy with pneumonia
- surveilance of active TB, occupational lung disease
