Cardiovascular Flashcards by Ellie C

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

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Examinations in hypertension

Obs (BP, pulse)
Cardio
Fundoscopy

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Sings and symptoms of hypertension

Headaches +/- blurred vision
Acute LVH
Acute renal failure/worsening CKD
Haemorrhagic stroke
Hypertensive encephalopathy 
Microangiopathic haemolytic anaemia

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Define gestational hypertension

Elevated BP >20wks gestation without proteinuria

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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)

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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

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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

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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

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Hypertension drugs

ACE inhibitors (ramipril)

Calcium channel blockers

Thiazide like diuretics

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Indications for statins prescription

Established CVS 10yr risk 10%
10yr history of DM
DM + renal disease
Raised LDL
DM aged 40-75

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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

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Signs and symptoms of heart failure

Symptoms:
Breathlessness, ankle swelling, fatigue

Signs:
Elevated JVP, pulmonary crackles, peripheral oedema

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Pathophysiology of heart failure

Injury:
HTN, ischaemia, valve disease

Pump dysfunction:
Pressure overload (hypertrophy), volume overload (dilation of heart), RAAS activation and fluid overload

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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

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Classifications of heart failure

L vs R

Systolic vs diastolic

Low vs high output

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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