Cardiovascular Flashcards
1
Q
Ischaemic heart disease risk factors and management
A
- biggest killer in the UK, M>F
- age, smoking, HTN, high LDL:HDL ratio, diabetes, inactivity, obesity, Fhx, cocaine/meth
- ECG normal unless ACS is present
Mx
- lifestyle education
- antiplatelets - aspirin, clopidogrel
- statin
- antihypertensive - ACEi (ramipril), ARB (losartan), B blocker (metoprolol), Ca channel blocker (amlodipine), diuretics
- blood sugar control
- revascularisation therapy if severe - PCI/stenting, CABG
2
Q
Pathophysiology of IHD
A
- Fatty streak formation:
- epithelial dysfunction allows LDLs and
monocytes to enter the tunica intima
- monocytes become macrophages, which eat
the LDLs to become foam cells - Stable plaque formation:
- foam cells accumulate in the core
- VSMCs migrate and lay down a collagen rich
fibrous cap - Unstable plaque formation:
- T-cells produce MMPs, which degrade the extracellular matrix in the fibrous cap faster than the VSMCs can lay it down
- fibrous cap thinning
- lipid core grows and put pressure on the
now thin fibrous cap - Plaque rupture:
- releases lipid rich core into the lumen
- thrombus formation and occlusion
3
Q
Heart failure symptoms
A
Left sided - backlog in lungs
- SOB
- crackles
- wheeze
- tachypnoea
- orthopnoea (SOB lying down)
- paroxysmal nocturnal dyspnoea
- S3 gallop rhythm
- left ventricle dilatation/cardiomegaly
Right sided - backlog in periphery (usually caused by LHF)
- peripheral oedema
- hepatosplenomegaly
- ascites
- distended JVP
Congestive HF - all of the above
4
Q
Management of heart failure
A
- Diuretics for congestive symptoms and fluid
retention - If preserved ejection fraction: lifestyle + manage comorbidities
- If reduced ejection fraction / LV failure: ACEi (ramipril – beware of AKI) + beta blocker (metoprolol – beware of making severe heart failure worse due to negative inotropic effect & in airways disease)
/ ARB (candesartan) if ACEi intolerant
/ hydralazine and nitrate if ACEi and ARB intolerant - Specialist - digoxin or pacemaker
5
Q
Risk factors for heart failure and ejection fractions
A
- male, diabetes, dyslipidaemia, old age, previous MI, HTN, cocaine abuse, LV dysfunction, renal insufficiency, valve disease, FHx, AF, thyroid disorder, smoking, cor pulmonale (right heart fails due to problems in lungs)
- reduced ejection fraction (<50%) = systolic, ventricle dilated and can’t contract
- normal ejection fraction = diastolic, ventricle can’t relax
6
Q
Hypertension
A
Systolic >140 mmHg and/or;
Diastolic >90 mmHg
Key conditions ->
- cardiovascular disease
- cerebrovascular disease
- left ventricular hypertrophy
- hypertensive retinopathy
- nephropathy
- no signs and symptoms unless retinopathy if very long term
7
Q
Types and risk factors for hypertension
A
Primary HTN - no underlying cause
Secondary HTN - due to many vascular/renal/endocrine causes
RFs
- age >65, alcohol, lack of exercise, Fhx, obesity, metabolic syndrome, diabetes, black race, obstructive sleep apnoea
8
Q
Investigations and management of HTN
A
- ECG
- eGFR (to check renal function)
- fasting lipid profile (check LDL: HDL)
- urinalysis (check for proteinuria)
- Hb (check for anaemia/polycythaemia as a cause)
- TFTs (to check if thyroid is the cause)
- lifestyle modification
- ACEi (ramipril) or ARB (losartan) first line if <55 and non-black race
- Ca channel blocker (amlodipine) first line if >55 or black race
- second line, + CCB or ACEi or ARB (different class from original) or thiazide diuretic
- third line, all three (CCB, ACEi, ARB)
- fourth line, consider specialist advice. Confirm resistant HTN. Add spironolactone or alpha or beta blocker.
9
Q
Aortic stenosis
A
Aortic stenosis
- DAD symptoms - dyspnoea, angina, dizziness/syncope
- slow rising pulse, crescendo-decrescendo ejection systolic murmur
- late symptoms left heart failure
- caused by calcification, congenital bicuspid, or rheumatic fever
- COMMON in the elderly
- balloon valvuloplasty to treat, or TAVI, or valve replacement
10
Q
Mitral regurgitation
A
- initially symptomless
- pansystolic murmur, maybe arrhythmias
- late symptoms of left heart failure
- caused by infective endocarditis, rheumatic fever, MI, connective tissue disease
11
Q
Aortic regurgitation
A
- initially no symptoms
- collapsing pulse, diastolic murmur
- late symptoms left heart failure
- caused by bicuspid valve, rheumatic disease, endocarditis, connective tissue disease
- valve replacement to treat
12
Q
Mitral stenosis
A
- dyspnoea, orthopnoea (due to increased pulmonary pressure)
- opening snap auscultation, diastolic murmur, raised JVP
- late symptoms left heart failure
- very rare
- valve replacement to treat
13
Q
Hyperlipidaemia
A
= hypercholesterolaemia / hypertriglyceridaemia
- see xanthelasma, tendon xanthoma, eruptive xanthoma, corneal arcus (and obesity)
- familial causes, or obesity, diabetes, hypothyroid
Ix - fasting lipid profile - thyroid function tests Mx - lifestyle modification - statins (cholesterol) - fish oils (triglycerides) - lomitapide / mipomersen if familial hypercholesterolaemia
14
Q
Acute pericarditis
A
- acute onset, severe sharp retrosternal pain radiating to neck / shoulders / back
- sitting forward and leaning forward improves pain
- hear pericardial friction rub on auscultation
- diffuse saddle ST elevation on ECG
- pericardial effusion found on echocardiogram
RFs
- recent viral infection
- MI, heart surgery, trauma, radiation, malignancy, RA, SLE, drugs
15
Q
Pericardial effusion
A
> 50ml of pericardial fluid
- only symptomatic if associated pericarditis, tamponade or compression of surrounding structures
- commonest in 30-40yrs
- ECG shows low voltage sinus readings, varying amplitudes of QRS complexes
- echo to visualise fluid (MRI if negative but still high suspicion)
- pericardiocentesis to treat (subxiphoid pericardiostomy if long term)
16
Q
Cardiac tamponade
A
- if pericardial effusion so large that increase in pressure -> compression and haemodynamic compromise
- decreased CO - hypotension, raised JVP, muffled heart sounds
- treat with emergency pericardiocentesis
- CXR, ECG, echo
17
Q
Constrictive pericarditis
A
- from abnormal scarring of pericardium causing impaired diastolic filling
- symptoms of RHF (oedema, nausea, ascites)
- caused by idiopathic, surgery, tuberculosis, recurrent pericarditis
- ECG, BNP, CXR, ECG, CT/MRI
- treat with low sodium diet, diuretics, pericardectomy
18
Q
Unstable angina
A
ACS where absence of biochemical evidence of damage to myocardium (enzymes not elevated, normal (ish) ECG)
- unstable not stable angina as pain occurs at rest and lasts >10 mins
- due to coronary artery disease, or can be if high myocardial oxygen requirements, hypotension or reduced O2 delivery
19
Q
Management of ACS
A
MONAC - Morphine - Oxygen - Nitrates - Aspirin - Clopidogrel \+ Fondaparinux antithrombotic whilst in hospital if NSTEMI
Always dual therapy for >1 year
- if also AF, get 6mo triple therapy and 6mo dual (3rd is warfarin or DOAC)
+ lifetstyle advice, statin, ?ACEi/B blocker
20
Q
NSTEMI
A
ACS where partial or near-complete occlusion of coronary artery
- also due to coronary artery spasm / cocaine use
- see ST depression, T wave inversion on ECG
- Troponin elevation (in 4-6hrs for 1 week)
- CK-MB elevation (shorter half life, so good for re-infarction)
May need PCI, must get coronary angiography within a week
21
Q
STEMI
A
ACS where complete occlusion of coronary artery leading to ischaemia and MI
- classically due to ruptured atherosclerotic plaque
- see ST elevation in 2 or more leads
- Troponin and CK-MB elevation
- needs PCI in 90 mins (if not available, then use alteplase thrombolysis)
22
Q
ECG territories
A
I, aVL, V5, V6 - circumflex (lateral)
II, III, aVF - RCA (inferior)
V1-V4 - LAD (anterior/septal)
23
Q
Systolic vs diastolic heart failure
A
Systolic = inability of ventricle to contract, so reduced CO. Low ejection fraction (<40%). Caused by IHD, MI, cardiomyopathy
Diastolic = inability of ventricle to relax and fill, so raised filling pressures. Ejection fraction normal or raised. Caused by ventricular hypertrophy, constrictive pericarditis, tamponade, restrictive cardiomyopathy, obesity.
24
Q
Left vs Right ventricular failure
A
Left
- dyspnoea
- poor exercise tolerance
- fatigue
- orthopnoea
- PND
- nocturnal cough (pink frothy sputum)
- wheeze
- nocturia
- cool peripheries
- weight loss
Right
- peripheral oedema
- ascites
- nausea
- anorexia
- facial engorgement
- epistaxis
25
Acute heart failure
Sudden onset of reduced CO, tissue hypoperfusion, increased pulmonary pressure, tissue congestion
- triggered by ACS, acute arrhythmia, aortic dissection, acute myocarditis, cardiac tamponade
- or due to decompensation of chronic CHF from eg infection, hypertensive crisis, thyrotoxic crisis, phaeochromocytoma, anaemia, renal failure, valve disease, volume overload
Ix
- ECG - arrhythmia, ST and T changes
- CXR - cardiomegaly, pulmonary congestion, valvular calcification
- BNP - >500
- echo
- cardiac enzymes
26
Management of chronic heart failure
- lifestyle (smoking, salt, alcohol, weight loss)
- treat cause and exacerbating factors
- annual flu vaccine / pneumococcal annually
- diuretics (loop, + K sparing (spiro), + thiazide?)
- ACEi
- B-blocker
- digoxin
- vasodilators
27
AV heart block
1st degree
- fixed prolongation of PR interval
2nd degree, Mobtiz 1
- progressive prolongation of PR interval, then eventual loss of AV conduction for 1 beat
2nd degree, Mobitz 2
- fixed, unchanging PR intervals with occasional missed beat
3rd degree
- complete persistent loss of AV conduction
- if symptomatic or type 2-3, need to discontinue AV blocking medication, permanent pacemaker, cardiac resynchronisation therapy
28
Atrial fibrillation
= type of SVT
- important cause of stroke
- absent P waves and irregularly irregular QRS complexes
Ix
- ECG
- thyroid problem (hyper)
- echo (cardiac problems causing)
CHA2DS2 VAS score
- anticoagulate if score >2 (warfarin / DOAC)
- always antiplatelet aspirin
- B blocker
- anti-arrhythmic agent
- consider cardioversion
29
Paroxysmal supraventricular tachycardia
- type of SVT, occurs out of the blue then sinus rhythm in between
- often asymptomatic, but can get sporadic periods of palpitations, lightheadedness, SOB, chest pain, then resolution
- see tachycardia and narrow QRS on ECG
- F>M, age <45
- caffeine, nicotine, stress can precipitate
Mx
- conservative - vagal manoeuvre, carotid sinus massage, diving reflex
- medical - adenosine, B blocker
- surgical - catheter ablation, cardioversion
30
Atrial flutter
- sawtooth ECG
- unstable, typically descends into atrial fibrillation
- tachycardia, palpitations, SOB, dizziness, chest pain
- more common >80, HTN, CAD, diabetes
- high chance of clotting so need anticoagulation
31
Wolff-Parkinson-White syndrome
- congenital accessory pathway between atria and ventricles
- on ECG see characteristic delta wave (slurred upstroke in wide QRS complex) and short PR interval
- predisposes to AF, some risk of sudden cardiac death
Mx
- watchful waiting
- medications - amiodarone, avoid AV blockers
- catheter ablation
32
Hypertensive crisis
= malignant hypertension, where rapid rise of bp (usually >210/130) causing acute end organ damage
- encephalopathy, retinopathy, cardiac sx, renal failure
- caused by essential HTN or renal disease (or pre-eclampsia)
- needs urgent treatment
Ix
- FBC with smear - microangiopathic haemolytic anaemia
- raised creatinine
- ECG
- CXR
- head CT
33
Infective endocarditis
- symptoms of infection + murmurs, haematuria, splenomegaly, cerebral emboli, osler's nodes, janeway lesions, splinter haemorrhages, roth spots
- Strep viridans most common
- always based on pre-existing heart defect allowing fibrin-platelet deposition on valve, then with transient bacteraemia get vegetation
- RFs from prosthetic valve, congenital heart disease, IVDU
- need specific abx, treat in hospital for at least 1mo
34
Congenital heart disease
- usually asymptomatic, but may get tachypnoea, tachycardia, poor feeding, poor weight gain
Left to right shunts
- eg VSD, ASD, AVSD, PDA
Right to left shunts
- eg TOF, transposition of great arteries
Obstructive lesions
- get echo, then surgery as newborn
35
Primary myocardial disease
Primary = underlying genetic disease
1. Hypertrophic cardiomyopathy - unexplained LVH
2. Dilated cardiomyopathy - unexplained ventricular dilation and contractility
3. Restrictive cardiomyopathy - infiltrative, non-infiltrative or storage diseases causing increase in ventricular wall stiffness
4. Arrhythmic cardiomyopathy
5. Unclassified
36
Secondary myocardial disease
```
- more common than primary
Due to
1. Hypertension/valvular disease
2. Ischaemia
3. Alcohol
4. Metabolic cardiomyopathy (diabetes)
5. Peripartum cardiomyopathy
6. Tachycardia
```
37
Thoracic aortic dissection
= separation in aortic wall intima
- acute tearing chest pain (anterior = ascending aorta, interscapular = descending aorta)
- RFs - HTN, atherosclerotic disease, connective tissue disorders eg Marfan's, bicuspid aortic valve, smoking, FHx
Ix
- hallmark BP differential between arms
- ECG - ST depression
- CXR - widened mediastinum
- cardiac enzymes -ve
- CT scan for intimal flap
- renal function tests
- cross match, G+S
Mx
- strong B blocker (labetalol)
- vasodilators
- opioids
- EVAR or open surgery
- antihypertensives
38
Thiazides
- diuretics, eg bendroflumethiazide, indapamide
- block Na/Cl cotransporter in the distal convuluted tubule
- used for heart failure, or HTN
SEs
- postural hypotension
- gout (uric acid competes for secretion)
- hypercalcaemia
- hyponatraemia
- hypokalaemia
So not hyperuric/calcaemic, not if hyponatraemic/kalaemia
- not in Addison's
39
Loop diuretics
eg furosemide
- inhibits Na/2Cl/K cotransporter in loop of Henle
- for heart failure or resistant HTN
- potent and fast acting
SEs (uncommon)
- dehydration
- hyponatraemia
- hypokalaemia
- hypocalcaemia
- ototoxicity
Not given in anuria, severe hypoNat/Kal
40
Potassium sparing diuretics
eg spironolactone
- aldosterone antagonists (so cause Na reduction, K retention and water loss)
- used alongside loop and thiazide diuretics to maintain potassium, only when hypokalaemia + HF or HTN
SEs
- hyperkalaemia (arrhythmias)
41
B blockers
- competitive antagonist of B-adrenergic receptors, so block adrenaline/NA effects
- decrease myocardial oxygen demand + decrease bp (smooth muscle relaxation, less heart contractility, reduce renin release)
- nonselective = propanolol, carvedilol
- B1 selective (heart) = atenolol, bisoprolol
- B2 selective (lungs)
- used in thyrotoxicosis, HTN, prophylaxis for variceal bleeding, angina, anxiety, MI prophylaxis, essential tremor, migraine prophylaxis, arrhythmias
SEs
- lethargy
- erectile dysfunction
- nightmares
- headache
- bronchospasm
42
Calcium channel blockers
eg nifedipine, amlodipine, verapamil, diltiazem
- block calcium channels to cause vasodilation and treat HTN
Nifedipine/amlodipine block L type - for HTN, angina prophylaxis, Raynaud's NOT angina!
Verapamil blocks voltage gated - for angina, HTN, arrhythmias NOT heart failure
Diltiazem is inbetween - for angina, HTN NOT heart failure
SEs
- flushes
- headache
- ankle oedema
43
ACE inhibitors and Angiotension receptor blockers
ACEi - ramipril, lisinopril
ARB - losartan, candersartan
- to block RAAS and so lower bp
- for HTN, heart failure, MI prophylaxis, CVS disease risk, nephropathy
SEs
- ACEi - dry cough, urticaria
- ARB - vertigo
44
Doxazosin
- alpha 1 blocker
- for HTN, and BPH
- as causes vasoconstriction of peripheries, and smooth muscle of prostate
(good for BPH in younger men, not older)
45
Nitrates
eg GTN, isosorbide mononitrate
- to cause vasodilation and increase blood flow, typically in angina/MI
```
SEs
- throbbing headache
- hypotension
- dizziness
(rapid tolerance)
```
46
Anti-arrhythmics
Singh Vaughan-Williams classification
I - Na channel blockade
Ia - moderate, increases AP duration and refractory period
Ib - weak, decreases AP duration and refractory period
Ic - strong, control, no affect on AP duration and refractory period
II - B blockers
III - K channel blockers eg amiodarone
IV - Ca channel blockers
Ic (flecanide) or III (sotalol) are good for AF
Always a risk of worsening arrhythmias
47
Low molecular weight heparin
eg dalteparin, enoxaparin, fondaparinux
- inhibits coagulation cascade (which makes thrombin)
- for low pressure venous scenarious
- used in PE, ACS, and mainly thromboprophylaxis peri-operatively, haemodialysis, pregnancy
- binds to antithrombin III (so inactivates FXa, stops production of fibrin)
- not if current/significant risk of bleeding
48
Clotting results
PT
- FVII (extrinsic pathway)
- FX, FV, FII, Fibrinogen (common pathway)
aPTT
- FVIII, FIX, FXI (intrinsic factors)
- FX, FV, FII, Fibrinogen (common pathway)
49
Aspirin
- anti-platelet (for arterial thromboses)
- COX1/2 inhibitor, to prevent platelet aggregation
- for secondary prevention of CVS disease, ACS, TIA, stroke, AF, after CABG, and for pain + pyrexia
- 75mg prevention dose, 300mg treatment
SEs
- increased risk peptic ulcers
50
Clopidogrel / ticagrelor
- anti-platelet (for arterial thromboses)
- ADP receptor antagonists, so less activation of platelets
- for secondary prevention of CVS disease, ACS, TIA, stroke, AF, after CABG, and for pain + pyrexia
SEs
- abdominal pain
Never for if active bleeding
51
Alteplase
- fibrinolytic (clot buster)
- recombinant tissue plasminogen activator (tPA) to break down plasminogen to plasmin
- for acute MI, PE, ischaemic stroke
- IV route
SEs
- bleeding
- hypotension
(+ beware embolic complications as clot breaks up)
52
Warfarin
Anti-coagulant, inhibiting coagulation cascade (which makes thrombin)
- good for venous system - for prophylaxis in AF, after prosthetic heart valve, DVT, PE, TIA
- inhibits vitK dependent synthesis of factors 2, 7, 9, 10 in the liver
- long half life, narrow therapeutic range, being replaced by DOACs
53
DOACs
eg dabigatran, rivaroxaban, apixaban
Anti-coagulants, inhibiting coagulation cascade (which makes thrombin)
- good for venous system - DVT + PE prophylaxis and treatment, stroke, post ACS
- rivaroXAban and apiXAban are factor Xa inhibitors
- dabigatran is direct thrombin inhibitor
- many SEs
54
Statins
- competitive inhibition of HMG-CoA reductase, so reduced liver cholesterol (so draws LDL out of the blood)
- for primary or secondary prevention of CVD
SEs
- muscle problems
- risk of diabetes
- deranged LFTs
- can't have grapefruit!
55
Anti-hypertensive therapy overview
1. if <55 or diabetic - ACEi (or ARB if intolerant)
1. if >55 or black - Ca channel blocker
2. ACEi/ARB + CaCB
3. ACEi/ARB + CaCB + D
4. ACEi/ARB + CaCB + D or alpha or beta blocker
ACEi - ramipril, lisinopril
ARB - losartan, candesartan
CCB - nifedipine, amlodipine, verapamil, diltiazem
D - bendroflumothiazide, spironolactone, amiloride
alpha-blocker - doxazosin
B blocker - propanolol, atenolol
56
Percutaneous coronary intervention
= cardiac catheterisation
- acute (eg STEMI) or elective (coronary artery disease)
- diagnostic ± therapeutic
Angioplasty + stent - balloon to open lumen and stent inserted
- need dual antiplatelet (aspirin + clopi) for at least 2 mo as risk of stent thrombosis
57
Pacemakers
Temporary
- if symptomatic bradycardia unresponsive to atropine
- after acute anterior MI + heart block 2-3
- maybe during GA, cardiac surgery, or in drug overdose
Permanent pacemaker (PPM)
- if complete AV block
- Mobitz II block
- persistent AV block after MI
- symptomatic bradycardia
- heart failure
- drug-resistant tachyarrhythmia
Will look weird on ECG!
58
Coronary artery bypass grafting
CABG
- in left main stem disease/multi vessel disease to improve survival
- in unresponsive angina or unsuccessful angioplasty to relieve symptoms
59
Valve replacement
Mechanical valves
- durable, but thromboembolism high risk
- lifelong anticoagulation (warfarin)
Xenografts
- porcine or from pericardium
- less durable (8-10 years) but don't need anticoagulation
Homografts
- cadaveric (not for young patients)
