Cardiovascular Flashcards
What is altherosclerosis?
A plaque blocking an artery - will form a thrombus is it ruptures
Risk factors for atherosclerosis?
Smoking, ageing, high serum cholesterol, obesity, hypertension, DM, family history
Where are atherosclerotic plaques usually located?
Peripheral and coronary arteries. Particularly form at locations with changes in flow, altered gene expression and wall thickness changes
What is the structure of an atherosclerotic plaque?
Lipid laden macrophages, necrotic core, connective tissue and fibrous cap
What inflammatory markers are found in plaque?
IL-2, IL-6, IL-8, IFN-gamma, TGF-beta, MCP-1 and C reactive protein
Treatment of coronary artery disease?
Stent implantation, aspirin, clopidogrel/ticagrelor, statins
What is angina?
Occurs due to a mismatch in the supply of oxygen and the demand of the myocardium
What may cause unstable angina?
Rupture/erosion of a coronary artery atherosclerotic plaque
S&S/Tests for unstable angina?
Chest pain at rest lasting for >20 mins, dysponea, sweating, nausea, anxiety.
ECG with ST depression, T wave inversion and normal troponin. Coronary angiography
Treatment for unstable angina?
Aspirin and P2Y12 inhibitor (such as Clopidogrel), Beta Blockers, Nitrates, Statins, AECis, PCI (with GPIIb/IIIa)/CABG
What causes an acute MI?
Thrombus formation in the coronary arteries due to atherosclerotic plaque rupture
What will the ECG show in MI?
NSTEMI = Non-Q wave infarction with ST depression/T wave inversion STEMI = Q wave infarction with ST elevation/tall tented T waves or new LBBB
S&S for MI
Unremitting severe chest pain occurs at rest and radiates to arms, neck, jaw and back, dysponea, vomiting, sweating, anxiety and elevated troponin
Treatment for MI?
Pre-hospital = Aspirin and GTN
Hosptial = Morphine, Oxygen, Nitrates, Aspirin/clopidogrel (MONA) then consider PCI/thrombolysis
Subsequent management = Beta-blockers, ACEis, Clopidogrel, Aspirin, Statins (BACAS)
What may cause stable angina?
Anaemia, polycythaemia, hypothermia, hypovolaemia = supply affected
Hypertension, hyperthyroidism, exercise, valvular heart disease = demand affected
What will a stress ECG show in unstable angina?
ST depression and T-wave inversion (inversion if ischaemia)
What is first line treatment of unstable angina?
Beta-blockers (atenolol or propanolol) OR CCBs (amlodopine, nifedipine). If intolerant SWITCH, if not controlled COMBINE.
Risk factors for ischaemic heart disease?
Increasing age, being male, smoking, obesity, hypertension, hyperlipidaemia, diabetes
What is heart failure?
The inability of the heart to deliver blood and therefore oxygen to the respiring tissues at a rate that is commensurate with the requirements of the metabolising tissues - depite normal or increased filling pressure.
Main S&S of LV HF?
Extertional/nocturnal dysponea, fatigue and displaced apex beat
Main S&S RV HF?
Peripheral oedema, raised JVP and hepatomegaly
What are the main symptoms of HF?
Dysponea when lying flat, fatigue and ankle oedema - Cardinal triad
Displaced apex beat, 3rd/4th heart sounds and cyanosis
Test for HF?
Increased NTproBNP (the higher this is the worse the HF) On CXR = Alveolar oedmea, B Kerley lines, Cardiomegaly, Dilated prominent upper lobes, Effusions (ABCDE)
What are the NYHA classes of heart failure?
I = No-limitation II = Slight limitation - symptoms on normal activity III = Marked limitation - symptoms on light activity IV = Inability to carry out any physical activity without discomfort - symptoms at rest
Treatment for HF?
Symptomatic relief = frusomide
1st line = ACEis AND Beta-blockets
2nd line = spironolactone
3rd line = digoxin
What is a Hypertrophic Cardiomyopathy?
An autosomal dominant condition leading to thickening of the heart muscle walls = small ventricles and a powerful heart which is less compliant in diastole. Causes disarray of cardiac myocytes = conduction issues. Causes fibrotic tissues to run through heart muscles = arrhythmias
S&S of Hypertrophic CM?
Angina, palpatations, dysponea, syncope, SADS
Treatment of Hypertrophic CM?
IV amioderone, verapamil/Beta-blockers, ICD
What is a Dilated Cardiomyopathy?
An autosomal dominat condition causing dilation of the hear chambers and thinning of the muscles = contractility problems
S&S of Dilated CM?
HF symptoms, arrhythmia and embolism
What is Arrhythmogenic CM?
Myocytes die and are replaced with fat/fibrous tissues. The desmosomes are diseased so cells separate both physically and electrically - typically affects the RV
S&S of Arrhythmogenic CM?
Arrhythmias, oedema, dysponea, syncope, ventricular tachycardia, epsilon wave on ECG, Naxos disease
Treatment of Arrhythmogenic CM?
ICD, ACEi/beta-blockers, cardioversion
What is Primary Restrictive CM?
A group of diseases where amyloidosis causes the myocardium to become rigid, this restricts diastolic ventricular filling
S&S of Primary Restrictive CM?
Dysponea, exercise intoleracnce, palpatations, oedema and fatigue
Treatment of Dilated CM?
Diuretics and Beta-blockers
What is Brugada syndrome?
This causes disruption to the hearts normal rhythm - causes sudden death in the young.
What is tetralogy of fallot?
Ventricular septal defect, pulmonary stenosis, hypertrophy of RV, overriding aorta
S&S of tetralogy of fallot?
Cyanotic and squatting in toddlers, boot shaped heart
What is a ventricular septal defect?
An abnormal connection between the ventrciles - most close in childhood
S&S of ventricular septal defect?
Large = dyponea, poor feeding/failure to thrive, loud pansystolic murmur
What is an atrial septal defect?
An abnormal connection between the atria, often presents in adulthood
S&S of atrial septal defect?
Large = chest pain, palpatations and dysponea
What is an atrio-ventricular septal defect?
A whole in the very centre of the heart often seen in Down’s syndrome. The whole septum is involved leading to one large malformed valve
THIS REQUIRES URGENT REPAIR
What is Coarctation of the Aorta?
Narrowing of the aorta at the site of the ductus arteriosus (distal to the left subclavian artery)
S&S of coarctation of the aorta?
Severe = complete obstruction of blood flow leading to heart failure and collapse, REQUIRES URGENT REPAIR
Right arm hypertension and bruits over the scapulae/back
S&S of Patent Ductus Arteriosus?
Continuous machinery murmur, cyanosed and clubbed toes but normal fingers
What is associated with a bicuspid aortic valve?
Coarctation/dilation of the ascending aorta as the valve degenerates quicker than normal valves
Which heart defects cause systolic murmurs?
Aortic stenosis (on ejection) Mitral regurgitation (pansystolic blowing murmur)
Which heart defects cause diastolic murmurs?
Aortic regurgitation (early diastolic) Mitral stenosis (rumbling mid-diastolic murmur)
What is Eisenmenger’s syndrome?
High pressure in the pulmonary circulation damages the pulmonary vasculature creating resistance through the lungs. RV pressure will then increase and the shunt reverses leading to cyanosis, clubbing and syncope
S&S of aortic stenosis?
Syncope/dysponea, angina and HF.
Slow rising carotid pulse and crescendo-decrescendo ejection systolic murmur
CAN BE CAUSED BY A BICUSPID AROTIC VALVE
What is the general investigation/treatment for all valvular heart diseases
ECHO
Good dental hygiene (IE prophylaxis) and valve replacement
S&S of aortic regurgitiation?
Wide pulse pressure, decrescendo diastolic murmur, palpatations, angina and dysponea
What is the extra treatment of aortic regurgitation?
ACEis
S&S of mitral stenosis?
Dysponea, malar flush, low-pitched diastolic murmur/rumble. WILL SHOW AS AF ON ECG
What is the extra treatment of mitral stenosis?
Diuretics
S&S of mitral regurgitation?
Exercise intolerance/dysponea, fatigue, palpatations and pansystolic murmur
MAY BE CAUSED BY MITRAL VALVE RELAPSE OR AF
What may cause all valvular heart diseases?
Rheumatic heart disease (group A beta-haemolytic strep) and accquired calcification
What are the stages of hypertension?
Stage 1: >140/90mmHg or ABPM >135/85mmHg
Stage 2: >160/100mmHg or ABPM >155/95mmHg
Severe: Systolic >/= 180 and/or diastolic >/= 110
Essential vs secondary hypertension?
Essential = unknown cause/idiopathic Secondary = commonly caused by renal disease, pregnancy, coarctation of the aorta, endocrine issues (such as Cushing's) and drugs such as NSAIDs
Risk factors for hypertension?
Increasing age, race (being black), alcohol, diabetes, obesity, stress, excess salt
S&S of hypertension?
Asymptomatic,
Malignant hypertension = acute optic haemorrhage, papilloedema, renal vascular changes
Complications = LV hypertrophy, proteinuria, retinopathy, headache, nausea, vomiting and imptoence
Treatment of hypertension if under 55?
ACEis/ARBs -> add CCBs -> add bendroflumethiazide -> add furosemide
Treatment of hypertension in over 55s/Afro-Carribeans?
CCBs -> ACEis/ARBs AND CCBs -> add bendroflumethiazide -> add furosemide
ACEis are less effective in Afro-Carribeans so treat in combination with CCBs
Name the differnt types of shock?
Hypovolaemic = decreased blood volume Cardiogenic = heart not pumping Septic = organ damage due to widespread infection Alaphylactic = severe allergic reaction to an antigen (type 1) Neurogenic = spinal cord injury Anaemic = not enough capactiy to carry oxygen Cytotoxic = cells are poisoned
S&S of hypovolaemic shock?
Cold/pale/clammy/grey skin, drowsiness, confusion and increased sympathetic tone
S&S of cardiogenic shock?
Increased JVP, gallop rhythm, pulmonary oedema, HF signs
S&S of septic shock?
Nausea/vomiting, vasodilation, warm peripharies, pyrexia/rigours, bounding pulse
S&S of anaphylactic shock?
Profound vasodilation, warm peripheries, decreased BP, tachycardia, pulmonary oedema and bronchospam
Name the organs most at risk in shock?
Kidneys, lungs, heart and brain
Name some infective and non-infective causes of acute pericarditis?
Viral = enteroviruses and adeniviruses
Bacterial = mycobacterium TB
Fungal = histoplasma spp.
SLE, Rheumatoid Arthritis, trauma and secondary metastatic tumours.
S&S of pericarditis?
Severe pleuritic chest pain worse on lying flat/relieved by sitting forward, dysponea, pericardial friction rub, tachycardia and fever
What would an ECG show in acute pericarditis?
Saddle shaped ST elevation and PR depression
Treatment for pericarditis?
Restrict physical activity until symptoms improve, NSAIDs for 2 weeks and colchicine for 3 weeks
What is pericardial effusion and cardiac tamponade?
A collection of fluid within the pericardial sac which occurs due to acute pericarditis. If a large volume of fluid fills the ventricular space filling will be compromised leading to cardiac tamponade
S&S of pericardial effusion?
Soft and distant heart sounds, apex beat is obscured, raised JVP and dysponea
S&S of tamponade?
High pulse but low pulse pressure, riased JVP, Kussmaul’s sign, pulsus paradoxus and decreased cardiac output
What is Beck’s triad
Falling blood pressure, rising JVP and muffled heart sounds as the 3 main signs of cardiac tamponade
What is constrictive pericarditis?
When the pericardium becomes thick, fibrous and calcifeid as a result of pericarditis. This measn the pericardium becomes inelastic and so diastolic filling is restricted
What are the most common causes of infective endocarditis?
Strep. viridans (new cardiac murmur), Staph. aureus (VDU/DM), staph, epidermitis (metallic valves) and fungal infection
What are the types of infective endocarditis?
Left sided native, left sided prosthetic, right sided and device related
S&S of infective endocarditis?
Fever, new onset murmur, Osler’s nodes/Janeway lesions, splinter haemorrhages, Petechiae haemorrhages/Roth spots, emboli
Treatment for infective endocarditis?
Antimicrobials IV for 6 weeks, surgery and treat the complications
What is bradycardia?
A heart rate of less than 60bpm
What is tachycardia and what are the two types?
A heart rate of more than 100bpm.
Supraventricular = arises from the atrium/AV junction (narrow QRS and hidden P waves)
Ventricular = arised from the ventricles (broad QRS)
How does first degree heart block appear on ECG?
PR interval >200ms but 1:1 conduction (this is due to delayed AV conduction)
How does second degree heart block appear on ECG?
Not 1:1 conduction but still some relation.
Mobitz type I = progressive PR wave prolongation until P wave fails to conduct so QRS disappears
Mobitz type II = no progressive PR wave prolongation - QRS is lost predictably (in a ratio)
How does third degree heart block appear on ECG?
There is no association between atrial and ventricular contraction - P and QRS waves occur independantly.
S&S and treatment of thrid degree heart block?
Diziness and black outs - requires a permanent pacemaker
How can you tell between a right and a left bundle branch block?
Both are associated with wiced QRS complexs.
RBBB = M in V1, W in V6
LBBB = W in V1, M in V6
When do RBBB/LBBBs occur?
RBBB = occurs in health individuals and those with PE, RV hypertrophy, ischaemia or congenital heart diseases LBBB = associtated with underlying cardiac pathology e.g. ischaemic heart disease, LV hypertrophy and aortic valve disease
How does Wolff-Parkinson White Syndrome appear on ECG?
Short PR interval and wide QRS complex due to a congenital acessory conduction pathway
Treatment for Prolonged QT syndrome?
Arrhythmia prevention such as beta blockers and potassium supplements and arrhythmia termination (ICD)
What is atrial fibrillation? And what causes it
A chaotic persistent irregualry irregular atrial rhythhm with a HR of 120-180 bpm
Caused by HF/ischaemia, hypotension, pneumonia, PE or hyperthyroidism
S&S of Atrial FIbrillation?
Chest pain, palpatations, irregular pulse, dysponea and syncope
On ECG = absent P waves and irregular QRS wave
Treatment of AF?
Rate control = Beta-blockers or CCBs
Rhytmn control = cardioversion (electrical or amioderone)
Anticoagulation = LMWH until risk assed then if high risk Warfarin (INR 2-3)
What is an atrial flutter? How is it treated?
Occurs in those with CV disease/DM. Produces a saw tooth line on the ECG
Treat with anticoagulation and cardioversion as in AF
What is an Ectopic beat?
It is a disturbance in the beat and electrical conduction of the heart (may be atrial or ventricular)
What may cause sinus tachycardia?
Anaemia, anxiety, exercise, pain, sepsis and hypovolaemia etc.
S&S of stable angina?
Constricting central tight chest pain radiating to the jaw/neck, precipitated by exertion and relieved by GTN and rest
Treatment for stable angina?
Sympton relief = GTN
RF modification = aspirin and statins
Anti-anginal = Beta-blockers and/or CCBs
Interventional = PCI/CABG
After a patient has had a PCI what medications do they need?
Dual platelet therapy for 12 months (aspirin and clopidogrel)
What is the physiological difference between a STEMI and an NSTEMI?
STEMI = complete and sudden occlusion of the coronary artery NSTEMI = partial occlusion of the coronary artery
What are teh main cuases of heart failure?
IHD, hypertension an dilated CM
What are the ejection fractions seen in the different types of HF?
Reduced EF HF <40%
Mid-range EF HF 40-49%
Preserved EF HF >50%
What is cor pulmonale?
RV enlargement (may be due to RV HF) Presents are dysponea, syncope, fatigue, tachycardia, cyanosis and raised JVP
What is broad complex tachycardia? Give examples?
QRS >120ms, ventricular fibrilation and ventricular tachycardia
What is a narrow complex tachycarida? Give examples?
QRS <120ms, supraventricular tachycardias e.g. sinus tachycarida, AF and atrial flutter
How is stroke risk assed in AF patients?
CHA2DS2VASc = Congestive cardiac failure (1), Hypertension (1), Age (65-74 = 1, >75 = 2), Diabetes (1), Stroke/TIA (2), Vascular disease (1) Sex category (female = 1)
What is a ventricular flutter?
A chaotic rhythm with no pattern, requires urgent defibrillation and IV amioderone
How do you treat ventricular tachycardia?
Cardioversion (electrical or chemical)
What are the two types of aortic aneurysm?
True = all three layers are involved/dialted
False = blood collects between the media and adventitia (only the adventita will expand)
Both can rupture leading to sudden severe abdo pain, expanding abdo mass and rapid death
What is an aortic dissection, what are the types?
Tear in the intima leading to sudden severe tearing chest pain radiating to the back
A = in the ascending aorta (70%)
B = not in the ascending aorta
What is the classificsation for chronic peripheral vascular disease?
Fontaine classification: 1 = asymptomatic 2 = intermittent claudication (induced by exercise and relieved by rest) 3 = ischaemic pain at rest 4 = ulceration and gangrene
What is critical limb ischaemia?
A serious kind of PAD (ankle-brachial pressure index <0.5), pain of limb at rest, particularly at nigh - pain relieved by hanging the leg over the bed and shaking
What is first line treatment for peripheral arterial disease?
Clopidogrel
S&S of acute PVD?
Pulseless, Pale, Perisihingly cold, Parasthesisa, Paralysis and Pain in limb
Revascularise within 4-6 hours and give LMW Heparin
What are the sepsis interventions?
Blood cultures, Urine output levels, Fluids, Anitbiotics, Lactate levels, Oxygen
