Cardiovascular Flashcards
What is atherosclerosis?
- plaque build-up in the arteries
- main issue is when the plaque RUPTURES, leading to thrombus formation and ultimately death
What are 3 risk factors for atherosclerosis?
- age
- smoking
- high-serum cholesterol
- obesity
- diabetes
- hypertension
- family history
Where can atherosclerotic plaques be found?
- in peripheral and coronary arteries
What is the structure of an atherosclerotic plaque?
- lipid
- necrotic core
- connective tissue
- fibrous cap
What can cause inflammation in the arterial wall?
- LDLs - can accumulate
- endothelial dysfunction (response to injury hypothesis)
How do leukocytes recruit to vessel walls?
- They are captured and roll along the surface (mediated by selectins
- Adhere to surface
- Transmigration occurs
Describe fatty streaks of atherosclerosis
- earlest lesion
- appear v early age
- cannot cause much destruction
Describe intermediate lesions of atherosclerosis
- have foam cells, vascular smooth muscle cells and T-lymphocytes
Describe fibrous plaques of atherosclerosis
- impede the blood flow
- prone to rupture
- covered by fibrous cap and has necrotic debris
Which stage of atherosclerosis is a patient likely to start showing symptoms?
- Between 2 and 3
- between intermediate and advanced lesions
What happens with plaque rupture in atherosclerosis?
- the fibrous cap has to be resorted and redeposited
- the cap can become weak and rupture
- thrombus formation and vessel occlusion
What is the main treatment for atherosclerosis?
- Percutaneous coronary intervention (PCI)
- drug eluting stent
What are some limitations of PCI?
- Can lead to restenosis
How does a drug-eluting stent work?
- reduce the smooth muscle cell proliferation
- this reduces growth after placement of stent
What medication can be used in atherosclerosis?
- Aspirin
- Clopidogrel
- Statins
What are the contra-indications for aspirin and clopidogrel?
- Excessive bleeding
What is patent foramen ovale?
- Hole in the heart that did not close as it should have done after birth
- eventually produces arrhythmias, pulmonary hypertension and cardiac failure
How can we reduce disease incidence effectively?
- Modify risk facts for an individual and on a population basis
What are the unmodifiable risk factors in CHD?
- age
- sex
- ethnicity
- genetics
What are the psychosocial risk factors in CHD?
- behavioural patterns/traits
- depression/anxiety
- work
- social support
How is angina related to atherosclerosis?
- It is a symptom, which occurs as a consequence of resisted coronary blood flow
What are the modifiable risk factors for angina?
- smoking
- diabetes
- hypertension
- hypercholesterolaemia
- sedentary lifestyle
- stress
How would a patient with angina present?
- chest pain and discomfort
- heavy, central tight pain radiating to arms, jaw and neck
- worse on exertion
- relieved by rest/ GTN spray
- often normal on presentation
What conditions can show similar symptoms to angina?
- pericarditis
- pulmonary embolism
- chest infection
- dissection of the aorta
- GORD
What basic investigations would you perform on a patient with angina?
- 12 lead ECG = would show Q waves, T-wave inverson
- echo
- pre-test probability of CAD
What is the problem with a 12 lead ECG, echo and angina?
- Often normal - no direct markers are present
What are two examples of diagnostic investigations for angina?
- CT angiography
- invasive angiography
- exercise stress treadmill
- stress echo
- perfusion MRI
What are the diagnostic tests for angina looking for?
- Evidence of impaired blood flow
What is the treadmill test?
- induce ischaemia whilst walking
- looking for ST segment depression
- not used as regularly anymore
What is a CT angiogram?
- ideal for excluding CAD in younger, lower risk individuals
What is the best investigation for CAD and angina?
- Pre-test probability of CAD
- History most useful for angina
- choice depends on many factors
What is the primary management for CAD and angina?
- primary prevention
- 10 year risk is calculated
- diet, exercise, smoking cessation, etc.
What is the secondary management for CAD and angina?
- Lifestyle changes
- Pharmacological - beta blockers and nitrates
- Interventional (PCI and surgery)
What is the pharmacological treatment for CAD and angina?
- beta-blockers (bisoprolol and atenolol)
- these reduce HR and contractility to reduce work of heart and oxygen demand
What are the side effects of beta blockers?
- tiredness, nightmares
- erectile dysfunction
- bradycardia
- cold hands and feet
What are contra-indications of beta blockers?
- severe bronchospasm (asthma)
- excess bradycardia
- severe heart block
How do nitrates work?
- primarily venodilators
- reduce preload on the heart
- reduce work on heart and oxygen demand
How do calcium channel antagonists work?
- reduce afterload on heart to reduce work of heart and oxygen demand
How does revascularisation work?
- To restore coronary artery and increase flow reserve
What are acute coronary syndromes?
- a spectrum of acute cardiac conditions
How does a myocardial infarction present?
- cardiac chest pain which is severe and unremitting
- occurs at rest
- associated with sweating, breathlessness, nausea and/or vomiting
What is the management of MI?
- call 999, give aspirin
- pain relief
- consider urgent coronary angiography
What are P2Y inhibitors (anti-platelet drugs)?
- Used in combination with aspirin as a management of ACS
- examples are clopidogrel and ticagrelor
What types of factors can affect the response to clopidogrel?
- dose
- age
- weight
- disease states e.g. diabetes
- drug-drug interactions
What are adverse side effects of clopidogrel and ticagrelor?
- bleeding
- rash
- GI disturbance
How would you diagnose deep vein thrombosis?
- symptoms and signs are non-specific
- symptoms are pain and swelling
- signs include tenderness, swelling, warmth and discolouration
How would you investigate DVT?
- D-dimer
- ultrasound compression test
What is the treatment for DVT?
- LMW heparin
- oral warfarin
- compression stocking
What are two examples of risk factors for DVT?
- surgery
- OC pill, pregnancy
- long haul flights (rare)
- inherited thrombophilia
How does pulmonary embolism present?
- chest pain and sob
- breathlessness, may have signs of DVT,
- no other diagnosis more likely
- likely to be tachycardic and have pleural rub
How would you investigate PE?
- x-ray usually normal
- ECG shows sinus tachy
- ABG - decreased O2 and CO2
How would you treat PE?
- LMW heparin
- oral warfarin
- DOAC
What is DOAC?
- used for treatment of AF and DVT/PE
- cannot be used in pregnancy
What is the clinical diagnosis for stage 1 and stage 2 hypertension?
- BP 140/90mmHg = stage 1
- BP 160/100mmHg = stage 2
What is the primary treatment for stage 1 hypertension?
- lifestyle modification
- then pharmacological medication
What are the different types of diuretics which can be given in hypertension?
- thiazides e.g. bendroflumethiazide
- loop diuretics e.g. furosemide
- potassium-sparing e.g. amiloride
- aldosterone antogonists
What are side-effects of diuretics?
- hypovolaemia
- hypotension
Name two beta-blockers
- bisoprolol
- propanolol
- atenolol
Name two calcium channel blockers
- amlodipine
- nifedipine
- verapamil
What are CCBs used in?
- hypertension
- angina
- tachycardia
What is another example of a type of anti-hypertensive medication?
- alpha-1 adrenoreceptor blockers
- prazosin, doxazosin
How is chronic stable angina defined (5)?
- anginal chest pain
- predictable
- exertional
- infrequent
- stable
How is unstable angina/NSTEMI defined (4)?
- unpredictable
- may be at rest
- frequent
- unstable
How is ST-elevation MI (STEMI) defined (4)?
- unpredictable
- rest pain
- persistent
- unstable
What is hypertrophic cardiomyopathy (HCM) caused by and what can it cause?
- sarcomeric protein gene mutations
- symptoms include angina, dyspnoea, palpitations or syncope
What is dilated cardiomyopathy (DCM)?
- dilation of ventricles where walls are normal or thinner
- patients present with HF symptoms
- generally go to have transplants
What are inherited arrhythmias (channelopathy)?
- caused by ion channel protein gene mutations
- includes long and short QT and brugada
What are the common viral causes of pericarditis?
- enteroviruses
- herpesviruses
- adenoviruses
parvovirus B19
What are some non-infectious aetiologies of pericarditis?
- Sjogren syndrome
- rheumatoid arthritis
- scleroderma
- neoplastic - tumours
- myxoedema
What are some traumatic and iatrogenic reasons for pericarditis?
- direct injury (e.g. oesophageal performation)
- indirect injury (non-penetrating thoracic injury
- delayed onset - iatrogenic trauma e.g. PCI
What is the diagnosis for acute pericarditis?
- inflammatory syndrome with or without effusion
- Need 2/4 of: chest pain, friction rub, ECG changes and pericardial effusion
What type of chest pain would a patient present with if they had acute pericarditis?
- severe
- sharp and pleuritic
- rapid onset
- positional, less pressure of pericardium
- worse on coughing/deep inspiration
Other than chest pain, what are the symptoms of acute pericarditis?
- dyspnea
- cough
- systemic disturbance e.g. rash, joint pain
What past medical history can lead to pericarditis?
- cancer
- rheumatological diagnosis
- pneumonia
- cardiac procedure (PCI)
- MI
Name 3 differential diagnosis of pericarditis.
- pneumonia
- pleurisy
- PE
- MI
- Aortic dissection
- pancreatits
What are the examination and investigations of pericarditis?
- Examination - pericardial rub, sinus tachycardia, fever, Beck’s triad
- Investigations - ECG, bloods, echo
What is Beck’s triad?
- hypotension
- elevated jugular venous pressure (JVP)
- quiet heart sounds
How would pericarditis present on an ECG?
- diffuse ST segment elevation, ST segment not on isoelectric line
- No reciprocal ST depression
- saddle shaped
How would blood tests show pericarditis?
- increase in WCC
- increased troponin suggests myopericarditis
- CXR shows pneumonia common with bacterial causes
How do you manage a patient with pericarditis?
- sedentary activity until resolution of symptoms
- NSAID (ibuprofen or aspirin)
- colchicine (has nausea and diarrhoea as side effects)
What are two examples of heart failure?
- myocardial dysfunction
- hypertension
- alcohol excess
- cardiomyopathy
- valvular
What are the symptoms of heart disease (both specific and non-specific)
- SOB
- fatigue
- ankle swelling
- orthopnoea (SOB when flat)
- PND (SOB at night)
What signs would be present in a HF patient?
- peripheral oedema
- crackles and tachycardia are non-specific
- murmurs
- Raised JVP and displaced apex beat
How does the NYHA classify HF?
- Class 1 = no limitation
- Class 2 - slight limitation
- Class 3 - marked limitation
- Class 4 - inability to carry out physical activity without discomfort
What is the treatment for a HF patient with preserved left ventricular ejection fraction?
- give diuretics to deal with the congestion
- treat any CVD problem
What are some complications of HF?
- renal dysfunction
- rhythm disturbances
- systemic thromboembolism
- DVT and PE
What are the main treatments for HF?
- Diuretics (thiazides)
- ACEI
- aldosterone antagonism
- beta blockers
What is the 1st line treatment for HF?
- ACE inhibitors (ramipril or enalapril)
- Beta-blockers (isosorbide)
What is heart failure?
- The heart is not pumping blood around your body very efficiently
What is congenital heart disease?
- general term for a range of birth defects that affect the normal way the heart works
What is tetralogy of Fallot?
- stenosis of RV outflow
- RV is higher pressure than LV - so de-oxygenated blood passes to LV
What is the treatment for Tetralogy of Fallot?
- Surgical repair before age of 2
- most do very well
What are ventricular septal defects (VSD)?
- abnormal connection between two ventricles
- blood flows to RV, increased blood flow through lungs
- Associated with Eisenmenger syndrome
How would an infant patient with a large VSD present?
- breathless
- poor feeding (skinny)
- increased resp. rate
- tachycardia
- large heart
What is Eisenmengers Syndrome?
- high pressure pulmonary blood flow with damage to vasculature
- RV pressure increases and shunt direction reverses
- patient becomes blue
What are atrial septal defects (ASD)?
- abnormal connection between two atria
- causes increased circulation through the lungs
What are the clinical signs of an ASD patient?
- pulmonary flow murmur
- fixed split second heart sound
- big heart and pulmonary arteries
How would you treat an ASD?
- surgically
- percutaneous
What is an atrio-ventricular septal defect?
- hole in centre of heart
- can be complete or partial
- generally one large malformed valve
How would a patient with AVSD present?
- Generally have Down’s Syndrome
- breathless as neonate
- poor weight gain and feeding
- will need surgical repair
How would a patient with patent ductus arteriosus present?
- continuous murmur
- large, big heart, breathless
- will need to be closed within first few weeks of life
What is coarctation of the aorta?
- Narrowing of aorta at site of insertion of ductus arteriosus
How would a patient present with coarctation of aorta?
- right arm hypertension
- murmur
What is aortic stenosis?
It is the narrowing of the aortic valve opening
- Symptoms only occur once the valve is 1/4 of normal
What are the signs of aortic stenosis?
- syncope on exertion
- cannot keep BP high
- difficulty breathing
How would you investigate aortic stenosis?
- echo
What is the management of aortic stenosis?
- dental hygiene/care
- surgical replacement or TAVI
Why is medication not used in aortic stenosis?
- It is a mechanical problem
- vasodilators are CONTRAINDICATED in severe AS
What is TAVI?
- transcatheter aortic valve implantation
- used in aortic stenosis
What is mitral regurgitation?
- Backflow of blood from the LV to LA during systole
What are the signs and symptoms of mitral regurgitation?
- Exertion dyspnoea (exercise intolerance)
- displaced hyperdynamic apex beat
- heart failure
What investigations would you use for mitral regurgitation?
- ECG
- CXR
- echo
How would you manage mitral regurgitation?
- Vasodilators (ACEI)
- beta blockers for rate control
- diuretics for fluid overload
What is aortic regurgitation?
- Leakage of blood into LV during diastole
- due to ineffective aortic cusps
What are the symptoms of aortic regurgitation?
- Asymptomatic until 4/5th decade
- dypsnoea
- palpitations
How would you investigate aortic regurgitation?
- CXR
- echo
What is the management of aortic regurgitation?
- use vasodilators but only if patient is symptomatic
- serial echo to monitor
- surgical treatment
What is mitral stenosis?
- the obstruction of LV inflow that prevents proper filling
- always associated with rheumatic heart disease
What are the signs and symptoms of mitral stenosis?
- pulmonary hypertension
- signs of right-sided HF
- mitral facies (pink/purple patches on the cheeks)
How would you investigate mitral stenosis?
- ECG
- CXR (LA enlargement)
- echo - MOST USED
How do you manage mitral stenosis?
- echo for monitoring
- medical therapy does not prevent progression
- surgery - mitral balloon valvotomy
What is infective endocarditis?
- infection of heart valve or other structures e.g. septal defects
How does a patient get infective endocarditis?
- have an abnormal valve
- infectious material is introduced via surgery
- had IE previously
What are the symptoms of IE?
- depends on site
- systemic infection by fever and sweats
- embolisation via stroke, PE, kidney dysfunction, MI
- valve dysfunction with HF
Which microorganisms are consistent with IE?
- Streptococci viridans
- Staphylococcus aureus
How would you diagnose IE?
- ECG
- TTE (transthoracic echo)
- blood cultures
What is the treatment for IE?
- Antimicrobials (IV)
- treat complications - HF, embolisation, abscess drainage, surgery
What anti-biotics would you give for a patient with IE?
- For strep - penicillin or amoxicillin
- For staph - flucloxacillin with gentamicin
