Cardiovascular Flashcards
What do we need to know about a patient with hypertension?
Any symptoms? Age Sex Ethnicity Family history Weight/BMI Diet (salt) Smoking Alcohol Exercise
Examinations in hypertension
Obs (BP, pulse)
Cardio
Fundoscopy
Sings and symptoms of hypertension
Headaches +/- blurred vision Acute LVH Acute renal failure/worsening CKD Haemorrhagic stroke Hypertensive encephalopathy Microangiopathic haemolytic anaemia
Define gestational hypertension
Elevated BP >20wks gestation without proteinuria
Causes of hypertension
95% essential
Genetics
Environment (stress, diet, intrauterine environment)
5% secondary causes (typically young pts) Chronic renal diseases Renin release Coarctation of aorta Endocrine diseases Raised intracranial pressure Toxaemia of pregnancy Drugs (steroids, COCP, NSAIDs, lithium, cocaine, amphetamines)
Pathophysiology of hypertension
Atherosclerosis:
Plaque formation, intimal lipid deposition and resultant inflammation
Arteriosclerosis:
Hardening of artery/arteriole
Hyaline arteriosclerosis:
SMC in media replaced by collagen and deposition of plasma proteins
Investigations for hypertension
BP Pulse Cardio exam Fundoscopy Home BP readings
Bloods:
U&Es, cholesterol, HbA1c, renin, aldosterone
Urine:
Dip, ACR, urinary free cortisol
ECG
Imaging:
Renal USS, MR aortogram
Retinal screening
Principles of hypertension management
Treat anyone with BP >150/100mmHg
Treat at risk with BP >140/90mmHg
At risk:
80yrs/CVS/DM/renal disease/20% QRISK2
Hypertension drugs
ACE inhibitors (ramipril)
Calcium channel blockers
Thiazide like diuretics
Indications for statins prescription
Established CVS 10yr risk 10% 10yr history of DM DM + renal disease Raised LDL DM aged 40-75
Define heart failure
Clinical syndrome characterised by typical symptoms that may be accompanied by signs
Caused by structural and/or functional cardiac abnormality
Resulting in reduced CO and/or elevated intracardiac pressures at rest or during stress
Signs and symptoms of heart failure
Symptoms:
Breathlessness, ankle swelling, fatigue
Signs:
Elevated JVP, pulmonary crackles, peripheral oedema
Pathophysiology of heart failure
Injury:
HTN, ischaemia, valve disease
Pump dysfunction: Pressure overload (hypertrophy), volume overload (dilation of heart), RAAS activation and fluid overload
NYA classification of heart failure
Class I:
No SOB with normal activity
Class II:
Slight limitation with normal activity (comfortable at rest but physical activity produces symptoms)
Class III:
Marked limitation of normal activity - comfortable at rest but any activity produces symptoms
Class IV:
SOB with minimal exertion or at rest
Classifications of heart failure
L vs R
Systolic vs diastolic
Low vs high output
Define systolic heart failure and its causes
HF with reduced EF
Failure of contraction and pumping action of the ventricle during systole
Ventricle dilated
EF reduced <40% (normally 50-70%)
Causes:
IHD, MI, cardiomyopathy
Define diastolic heart failure and its causes
HF normal EF
Failure of ventricle to relax and fill adequately due to increased wall stiffness
Seen in older pts, female with HTN.
Causes:
Age, HTN, constrictive pericarditis, tamponade, restrictive cardiomyopathy
Define low output heart failure and its causes
Decreased CO and failure to increase normally with exertion
Causes:
Pump failure, decreased HR, (chronic) excessive overload
Define high output heart failure and its causes
Normal or increased in face of increased needs, failure to occur when CO fails to meet these needs
Causes:
Anaemia, pregnancy, hyperthyroidism, Paget’s disease, AVM, beri-beri
Right heart failure (acute) presentation + causes
Presents with circulatory collapse, shock/instant death
Causes:
Massive PE or MI involving RV but sparing LV
Right heart failure (chronic) presentation + causes
Presents with peripheral oedema, raised JVP, hepatomegaly, ascites
Causes: Lung pathology (cor pulmonale), COPD, pulmonary fibrosis, recurrent small PEs, LHF, LR shunting causing hypertrophy
Define left heart failure
A syndrome which occurs when the pumping action of the heart is inadequate for the needs of the body
(Cardiac output unable to meet needs of body)
Left heart failure (acute) presentation + causes
Presents with acute pulmonary oedema
Causes:
Almost always complications of MI affecting LV
Extensive MI renders large volume of LV non-functional, rupture of mitral valve papillary muscle, development of arrhythmias
Left heart failure (chronic) presentation + causes
Presents with dyspnoea/orthopnoea/PND, poor exercise tolerance & fatigue, nocturnal cough +/- pink frothy sputum, wheeze (cardiac asthma), nocturia, cold peripheries, weight loss, muscle wasting, hemosiderin laden macrophages
Causes:
Almost always chronic LVF
LV damaged slowly over time by chronic IHD due to atherosclerosis, systemic HTN, valvular heart disease
What is the most common form of heart failure?
Chronic left sided heart failure
Acute bi-ventricular (congestive) heart failure presentation
Severe pulmonary oedema
Chronic congestive heart failure patients may decompensate if heart is stressed - causing acute episodes
Chronic bi-ventricular (congestive) heart failure
CO insufficiency for body’s requirements
Congestive cardiac failure = L+R HF, symptoms of both, breathlessness and fluid retention
Risk factors for chronic bi-ventricular (congestive) heart failure
MI DM dyslipidaemia Age Male HTN LV dysfunction Cocaine/toxins Renal insufficiency Valvular heart disease Sleep apnoea Elevated homocysteine Elevated TNF-alpha IL-6, CRF & natriuretic peptides Decreased IGF-1 LVH Family history HF AF Thyroid disorders Low socioeconomic status Tobacco Excess alcohol & coffee Tachycardia Obesity Depression/stress Microalbuminuria Anaemia & large AV fistula
Complications of chronic bi-ventricular (congestive) heart failure
Pleural effusion Chronic renal insufficiency Anaemia Acute decompensation Acute renal failure Sudden cardiac death
Causes of acute bi-ventricular (congestive) heart failure
Concurrent illness MI and consequences Arrhythmias Uncontrolled HTN Valve disease Non-compliance with fluid restriction Diet or medication Anaemia Hyperthyroidism Excessive fluid/salt intake Medications causing fluid retention
Define ischaemic heart disease
Spectrum of heart disease which results from coronary artery atherosclerosis
Includes stable angina, ACS and sudden cardiac death
Modifiable risk factors for ischaemic heart disease
BP DM control RA Smoking Diet BMI Exercise LDL control HDL control TC/HDL cholesterol ratio
Unmodifiable risk factors for ischaemic heart disease
Family history
Sex
Age
Ethnicity
Pathophysiology of chronic ischaemic heart disease
Low grade chronic ischaemia -> Fine diffuse fibrosis -> Decreased contraction -> Compensates by hypertrophy of remaining myocytes -> Eventual decompensation
Signs and symptoms of stable angina
Induced by effort, relieved by rest SOB Pre-syncope Nausea & vomiting Non-pleuritic, positional, tender Central pain Tightness/heaviness Radiates to one or both arms Sweatiness, faintness Lasts <20 mins (typically 1-2) Relieved at rest / GTN
Causes of stable angina
Gradually enlarging atherosclerotic plaque in a coronary artery causing gradually progressive stenosis
Rare causes: Anaemia Tachyarrhythmias Hypertrophic obstructive cardiomyopathy Arteries/small vessel disease
Investigations for stable angina
ECG
ST depression
Flat/inverted T waves
Signs of past MI
CT coronary angiogram,
Coronary angiogram
Stress testing
Myocardial perfusion imaging
Exclude precipitating factors: Anaemia Diabetes Hyperlipidaemia Thyrotoxicosis Temporal arteries
Management of stable angina
Modify risk factors:
Lifestyle
Exercise
Weight loss
First line:
Beta blockers/Ca channel blockers
Monotherapy:
Add 2nd agent e.g. atenolol, dilitiazem or verapamil
All to receive aspirin, statin, nitrates
Surgical revascularisation - CABG
Stable angina triad of symptoms
Canadian Cardiovascular Society
3/3 typical angina,
2/3 atypical angina
1/3 non-angina - consider other diagnosis
Pain in retrosternal/neck/shoulders (T1-5 fibres)/jaw/arm
Provoked by exertion
Relieved by rest or GTN in 5 mins
