Cardiovascular Flashcards
Ischaemic heart disease risk factors and management
- 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
Pathophysiology of IHD
- 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
Heart failure symptoms
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
Management of heart failure
- 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
Risk factors for heart failure and ejection fractions
- 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
Hypertension
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
Types and risk factors for hypertension
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
Investigations and management of HTN
- 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.
Aortic stenosis
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
Mitral regurgitation
- initially symptomless
- pansystolic murmur, maybe arrhythmias
- late symptoms of left heart failure
- caused by infective endocarditis, rheumatic fever, MI, connective tissue disease
Aortic regurgitation
- 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
Mitral stenosis
- 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
Hyperlipidaemia
= 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
Acute pericarditis
- 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
Pericardial effusion
> 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)
Cardiac tamponade
- 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
Constrictive pericarditis
- 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
Unstable angina
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
Management of ACS
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
NSTEMI
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
STEMI
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)
ECG territories
I, aVL, V5, V6 - circumflex (lateral)
II, III, aVF - RCA (inferior)
V1-V4 - LAD (anterior/septal)
Systolic vs diastolic heart failure
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.
