Cardiovascular, Blood, Infectious diseases, HIV/AIDS, Diabetes, Red Flags Flashcards
What are the infective inflammatory conditions of the heart?
Endocarditis: Inflammation of heart valves due to infection by bacteria or fungi
Myocarditis: Inflammation of heart muscle due to many causes but most commonly viral attack
Pericarditis: Inflammation of pericardium due to many causes but commonly bacterial infection
What are the clinical signs and symptoms of myocarditis?
May develop along with cold/chest infection
Symptoms include fever, fatigue, chest pain, arrhythmias AND Joint pain and swelling (leg swelling common)
What are the clinical signs and symptoms of pericarditis?
Inner surfaces of pericardium become adhesive and can be auscultated as a rub
Oedema often results leading to fluid build up around heart (Tamponade)
Often associated with auto-immune conditions such as lupus AND rheumatoid arthritis
What are the pathophysiology and clinical signs and symptoms of endocarditis?
Vegetations (clumps of bacteria and cells) form on the heart valves – may cause valve destruction, regurgitation or obstruction.
Bacteria may gain entry from dental or medical procedure, respiratory infection, urinary tract infection or fracture
Signs and symptoms:
Fever/chills/ night sweats/excessive sweating
Fatigue & Shortness of breath with activity
Heart murmur
Joint pain/muscle aches and pains
Nail abnormalities (splinter hemorrhages under the nails)
Red, painless skin spots on the palms and soles (Janeway lesions)
Red, painful nodes in the pads of fingers/toes (Osler’s nodes)
Abnormal urine color & blood in the urine
Paleness
Swelling of feet, legs, abdomen
Weakness
Weight loss
What are arrhythmias?
If synchronization of cardiac muscle contraction is disrupted uncoordinated contraction known as fibrillation can result.
This may be a group of symptoms referred to as “palpitations”
Clinically these uncoordinated contractions are known as arrhythmias, a large and heterogeneous group of conditions in which there is abnormal electrical activity in the heart
Varied causes, classification by:
rate (normal, tachycardia, bradycardia)
mechanism (automaticity, re-entry, fibrillation)
site of origin (e.g., atrial or supraventricular)
What are the three types of arrhythmias?
Atrial fibrillation -very rapid, irregular twitching in the atrium, when the ventricular heart rate is not too fast
Atrial flutter - rapid but regular contractions in the atrium, when the ventricular heart rate is not too fast
Ventricular fibrillation - uncoordinated contraction of the cardiac muscle of the ventricles in the heart. As a result, the heart fails to adequately pump blood; hypoxia soon occurs, followed by unconsciousness within twenty to thirty seconds.
What are the signs and symptoms of arrhythmias?
Palpitations - described by patients as pounding, or fluttering sensations felt in the chest or neck
skipping beats - changes in the pattern of the pulse
Fainting, light-headedness, dizziness
Chest pain
Shortness of breath (dyspnoea)
Paleness
Sweating
Cardiac arrest
ALWAYS REMEMBER that the patient may not have symptoms!
What are the causes of arrhythmias?
Causes can be benign, such as: Caffeine, exercise or stress idiopathic or physiological hyperthyroidism drug side effect Causes can also be serious: Coronary artery disease Cardiomyopathy Complete heart block Aneurysm Valvular disease Immediate referral is indicated in prolonged palpitations, family Hx of sudden death of cardiac origin, or existing cardiac pathology
What is heart failure?
Congestive heart failure (CHF), congestive cardiac failure (CCF) or just heart failure, is a condition that can result from any structural or functional cardiac disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood through the body
Heart muscle disease
Ischaemic heart disease, cardiomyopathy
Restricted filling
Constrictive pericarditis, tamponade, restrictive cardiomyopathy
Inadequate heart rate
Heart block, post infarction, β-blockers
Effect of drugs that alter the force of contraction (inotropes) – Ca channel blockers
Chronic excessive after load - aortic valve stenosis or hypertension
What is left sided heart failure?
The left side of the heart pumps blood from the lungs to the organs
L side failure/congestion of the pulmonary vasculature (veins) and symptoms that reflect this AND reduced supply of blood to the tissues
Dyspnoea, possibly at rest; tachypnoea
Easy fatigueability
Orthopnea - increasing breathlessness on reclining, often measured in the number of pillows required to lie comfortably
Paroxysmal nocturnal dyspnea - a night time attack of severe breathlessness, usually several hours after going to sleep
Poor circulation to the body leads to dizziness, confusion and diaphoresis and cool extremities at rest; cyanosis
What is right sided heart failure?
The right side of the heart pumps blood returned from the tissues to the lungs to exchange CO2 for O2.
R side failure: congestion of peripheral tissues
This may lead to:
increased jugular venous pressure
peripheral edema or anasarca and nocturia (frequent nighttime urination when the fluid from the legs is returned to the bloodstream).
in more severe cases, ascites (fluid accumulation in the abdominal cavity) and hepatomegaly (painful enlargement of the liver) may develop
Right-side failure – cor pulmonale is due to chronic pulmonary hypertension – oedema secondary to pulmonary disease, pulmonary vascular disorders
What are signs of heart failure?
General signs indicating heart failure are a laterally displaced apex beat (as the heart is enlarged) and a gallop rhythm
Heart murmurs may indicate the presence of valvular heart disease, either as a cause (e.g. aortic stenosis) or as a result (e.g. mitral regurgitation) of the heart failure.
What is valve disease caused by?
Disease, e.g., calcification, RA, SLE
Congenital deformity
Infection e.g., rheumatic fever
What are the 3 types of valve deformity classifications?
3 types of valve deformity classifications
Stenosis - narrowing
Insufficiency – doesn’t close properly
Prolapse
What are the two main problems in heart and valve failure?
Valves that don’t shut properly, causing regurgitation of blood back across the valve in the wrong direction (for example, from the aorta back into the heart)
Valves that won’t open properly, known as stenosis of the valve, which means blood flow through the valve is limited. For example a condition known as called mitral valve prolapse, or floppy valve syndrome.
One of the cusps on the valve flips back the wrong way, making a characteristic clicking sound and a murmur. It’s now thought that as many as two per cent of adults have this syndrome and is considered a variation of normal and not a disease at all.
What is mitral valve failure?
10% of population have a variation in the connective tissue of the mitral valve leaflets that predisposes to prolapse
This protrusion of the leaflet can be heard as a click during ventricular systole
A murmur, produced when blood regurgitates back through the valve may also be present – effectively pressurises the pulmonary circuit
Frequently associated with an ANS imbalance, called dysautonomia
Thus linked with other conditions like Fibromyalgia
Symptoms of fatigue, shortness of breath, palpitations, chest pain, mild depression, anxiety, panic attacks and also, Migraine
What is hole in the heart?
About 1 in 100 people have a congenital heart defect
Defects include septal defects, shunts between the great vessels and congential stenosis of pulmonary, aortic or tricuspid valves
Usually require surgical correction
Undiagnosed they form the most common cause of sudden death during sport
Often can place the heart under long term stress, triggering other problems and adaptations
An atrial septal defect (ASD) is a hole in the heart between the upper chambers (atria). The hole increases the amount of blood that flows through the lungs. The condition is present at birth (congenital heart defect). Small atrial septal defects might be found by chance and never cause a concern.
What is hypertrophic cardiomyopathy?
Sudden Death Syndrome - unexpected and unexplained death occurring in apparently healthy young people e.g., while on rugby field or football field (Fabrice Muamba)
diagnosis by family history of sudden death
muscle becomes excessively thick and the fibres are arranged haphazardly making the heart vulnerable to some dangerous and potentially fatal heart rhythms (ventricular fibrillation / ventricular tachycardia).
In 25% there is left ventricle outlet obstruction from asymmetrical septal hypertrophy
Autosomal dominant inheritance
What is coronary artery disease?
The heart pumps blood to itself first directly at the junction of the aorta
The resting heart extracts 75% of the oxygen so the only way to increase supply is to increase flow
This is achieved by adenosine that is released as the oxygen content of the blood falls and adrenaline and noradrenalin
All of these factors dilate the coronary arteries
reduced pumping occurs if the oxygen supply is restricted (although myoglobin does provide a limited source of oxygen)
CAD is a condition in which plaque builds up inside the coronary arteries, causing a narrowing of the lumen.
Increased likelihood that blood clots (thrombus formation) will form in arteries, partially or completely blocking blood flow
Thrombus can break free forming an Embolus
What are signs and symptoms of coronary artery disease?
Signs & Symptoms
Angina
Referred pain
What is the mechanism?
Heart attack/myocardial infarction (MI)
blood flow to an area of heart muscle is completely blocked causing cell death, permanent impairment or death.
What would be the complications of a heart attack if the patient survives?
What are the two types of angina?
Angina
The main symptom of angina is a dull, heavy or tight pain in the chest that can sometimes spread to the left arm, neck, jaw or back. The pain is usually triggered by physical activity or stress and usually only lasts for a few minutes.
Two types occur;
Stable – where symptoms develop gradually over time and appear at times of stress/load. They quickly disappear especially with GTN spray
Unstable – Symptoms develop rapidly and persist, often resistant to GTN. A medical emergency
What is atherosclerosis?
Atherosclerosis (Atheroma)
Athera meaning porridge
the nodular accumulation of a soft, flaky, yellowish material at the center of large plaques
Disease of the large and medium sized arteries characterized by fibrosis, lipid deposition and chronic inflammatory response
Atheroma, when combined with hypertension can cause aneurisms, which can then burst, causing a bleed. This is a major cause of strokes.
Risk factors: smoking, obesity, dietary, hypertension, low socio-economic status
What is arteriosclerosis?
Arteriosclerosis
Arterio meaning artery
Age related changes to the muscular vessel wall
Loss of strength and elasticity (hardening of artery)
Evident after 40
Physiological changes in the intima, replacement of the muscle and elastin with collagen
Where does atherosclerosis usually occur?
Affects medium and large arteries especially of heart, brain and kidneys
Plaques often occur in:
areas of turbulent flow particularly in hypertension e.g., branch points
situations where there is a continuous inflammatory stress as a result of chemical abnormalities or some infections
Is the leading cause of death in the developed countries (2 x cancer)
How does an atheroma develop?
Development of an atheroma
Damage to the endothelium causes an inflammatory response
Monocytes and T cells are activated and move through the endothelium to the artery’s wall
Monocytes/MΦ collect fatty materials, mainly cholesterol and become foam cells
Smooth muscle cells move from the middle layer into the lining of the artery’s wall and proliferate.
Connective and elastic tissue materials also accumulate there, as may cell debris, cholesterol crystals, and calcium
This accumulation of fat-laden cells, smooth muscle cells, and other materials forms a patchy deposit called an atheroma or atherosclerotic plaque.
The plaque grows narrowing the vessel 🢡🠟 blood flow
Plaques may rupture initiating local clotting that may block the artery or the thrombus may break off and embolise
How is arteriosclerosis different than atheromas?
It is generalised and doesn’t come in localised plaques.
It affects both the tunica media and intima.
It is not due to fat.
It does not often cause ischaemia – there is only slight narrowing.
When it is due to hypertension it affects arterioles more than arteries and particularly damages the kidney.
What are aneurysms?
Defined as a pathologic dilatation of a segment of a blood vessel
May involve all three layers – ‘true’ or the two inner layers – ‘pseudoaneurysm’
Several types:
fusiform – affects whole circumference
saccular/‘berry’ – bubble-like outpouching – typically found in brain
dissecting – hemorrhage into tunica media separates the layers
What are signs and symptoms of aneurysms?
Tenderness or pain in the chest Back pain (Character?) Hoarseness & Cough Shortness of breath Pulsatile distension of abdomen Often asymptomatic until ruptured
What are the signs and symptoms of an abdominal aortic aneurysm?
Abdominal Aortic Aneurysm (AAA)
typically men, >50 years old; (50% of AAA’ers are hypertensive)
SOB on exertion
deep penetrating pain in the back or the side of the abdomen
steady gnawing pain in the abdomen that lasts for hours or days at a time
pulsatile mass in the abdomen
possibly detectable by palpation and/or bruits
claudication; coldness, numbness, or tingling in feet due to disturbed blood flow to LEx – possibly intermittent
if an AAA ruptures it is frequently FATAL. Symptoms can include sudden, severe pain in the lower abdomen and back; nausea and vomiting; clammy, sweaty skin; lightheadedness; and a rapid heart rate when standing up
internal bleeding from a ruptured AAA can cause physiological shock due to hypotension
Where is a common site of brain aneurysms?
Circle of Willis
What is Reynaud’s phenomenon?
Raynaud’s disease is a common condition that affects the blood supply to certain parts of the body, usually the fingers and toes.
blood vessels go into a temporary spasm which blocks the flow of blood. This causes the affected area to change colour to white, then blue and then finally red as the blood flow returns.
Raynaud’s is usually triggered by cold temperatures or by anxiety or stress.
There are two types of Raynaud’s. :
primary: when the condition develops by itself (this is the most common type)
secondary: when it develops in association with another health condition
The causes of primary Raynaud’s are unclear. However 1 in 10 people with primary Raynaud’s will go on to develop a condition associated with secondary Raynaud’s such as lupus or RA.
What happens during a stroke?
When the supply of blood is interrupted the brain cells are damaged or killed
Sufferers may become numb, weak or paralysed on one side of the body. They may slur their speech and find it difficult to find words or understand speech. Some people lose their sight or have blurred vision, and others become confused or unsteady.
In virtually all cases a stroke attack does not present with a headache
What is peripheral artery disease?
Disease of the distal arteries and arterioles
Usually affects the iliac vessels or more distal
Almost always associated with CHD/CAD via atherosclerosis
May be chronic or acute
Risk factors;
smoking
diabetes
abnormal lipid profile; hyperlipidemia/cholesterolaemia
hypertension
hyperhomocysteinaemia
renal/heart disease (family history)
high levels of fibrinogen
age and gender; 7% middle-aged men; 4% women; 2/1000/yr at 30yrs; 6/1000/yr at 60; 7/1000/yr at 70yr
ethnicity; caucasians >indo-asians & afro-Caribbeans
Signs and symptoms of chronic peripheral artery disease?
intermittent claudication (limping) – brought on by exercise, often worse going uphill, affects calf more often than buttock/thighs
Cold extremities (usually LEx)
Changes to skin (dry) and nail quality, loss of hair (‘trophic changes’)
Pain, severe/unremitting (in foot) at rest that disturbs sleep – may be helped by dangling foot over edge
Ulcers/gangrene
Absent/weak/delayed pulses e.g., radiofemoral delay (uni-/bi-?)
Bruit at site of stenosis
Pallor on elevation
Signs and symptoms of acute peripheral artery disease?
Symptoms; the 5 P’s
pain pallor parasthesia paralysis perishly cold extremities
Signs
🡻 pulses
cold marbled/mottled skin
🡻 sensation and motor
may have compartment syndrome e.g., in calf
What are varicose veins?
The veins and/or their semilunar valves are stretched and less/ineffective in assisting venous return
May also form “spider veins” under the skin; hemorrhoids in rectum; oesophageal varicies in alcoholics
Varicose veins usually lead to phlebitis and subsequent thrombosis
What are features and risks of varicose veins?
Features
Poor appearance of the legs Pain: aching, throbbing, tingling, sharp Cramps, heaviness, tiredness of legs Restless” legs at night itching, dermatitis, hyperpigmentation, ulceration of the skin, bleeding, blood clots
Risks
Family history (80% M+F; 50% one; 20% neither)
Pregnancy
Sedentary lifestyle - less venous return by the muscular pump. Sitting cross-legged!
Exacerbated by standing for long periods, or other activities which allow the blood to pool due to inertia
Damage due to previous clotting episodes
Obesity
What is superficial thrombophlebitis?
Superficial Thrombophlebitis
Often a consequence of varicose veins
Vein wall becomes inflamed leading to thrombus formation
Painful, tender, cord-like structures, redness and swelling
Usually responds to NSAID’s
Embolism not a problem
What occurs in a DVT?
Unlike superficial thrombophlebitis the thrombus forms in the vein
Often in the calf, frequently following MI or in 50% of prostatectomy patients
Axillary DVT may occur following trauma
Often associated with pulmonary embolism but this is mainly from iliofemoral DVT
Clot usually initiates around valves of deep veins and is composed of RBC’s and fibrin
Is more likely to occur if blood flow is slow (e.g., in reflux
It propagates as a thrombus of platelets and fibrin and is more likely to embolise
What are the risk factors and signs & symptoms of DVT?
Risk factors
Varicose veins Obesity, stasis, especially inactivity (long flights/bed rest) Pregnancy Disorders of clotting & Thrombocythaemia MI Surgery
Signs & Symptoms
Pain in the calf with swelling & redness Engorged superficial veins Affected limb warmer Sometimes ankle oedema Iliofemoral DVT present with severe pain but few other signs!
What is erythropoiesis?
Erythropoiesis is stimulated by hypoxia (lack of oxygen) which stimulates the production of a hormone, erythropoietin.
Erythropoietin is a glycoprotein formed within the kidney. It is inactivated by the liver and excreted in the urine
Various other factors can affect the rate of erythropoiesis by influencing erythropoietin production.
Thyroid hormones, thyroid-stimulating hormone, adrenal cortical steroids, adrenocorticotrophic hormone, and human growth hormone (HGH) all promote erythropoietin formation and so enhance red blood cell formation (erythropoiesis
However, very high doses of steroid hormones seem to inhibit erythropoiesis.
What are the signs and symptoms of anaemia?
Fatigue Dyspnoea Palpitations Headache Tinnitus Anorexia Dyspepsia Bowel disturbance Angina (if CHD) Low [Hb] Abnormal MCV Abnormal TIBC Pallor Tachycardia Murmur Cardiac enlargement (Heart failure)
How is anaemia defined?
Anaemia is the commonest form of blood disorder.
It is defined as a lack of haemoglobin rather than a reduction in red blood cells
What are the three types of anaemia?
Hypochromic, normochromic, hyperchromic
What is the most common type of anaemia?
The most common form of anaemia (about 30% of the world population) is hypocytic hypochromic anaemia.
When is normocytic anaemia seen?
In the UK we often see normocytic anaemia where the erythrocytes are averaged sized but low in numbers within the formed blood.
Typically this will be as a result of;
Chronic Disease
Kidney Disease
Pregnancy
Bone Marrow Failure
How does macrocytic anaemia present?
The other commonly observed form of anaemia is macrocytic which can present;
Where large immature dysfunctional erythrocytes are present in bone marrow due to defective DNA synthesis (Megaloblastic)
Less common is Non-megaloblastic anaemia which is usually caused by alcohol abuse. DNA synthesis is not defective, and there are no megaloblastic changes in the bone marrow
What is megaloblastic anaemia?
Megaloblastic anemia is a condition in which the bone marrow produces unusually large, structurally abnormal, immature red blood cells (megaloblasts). Bone marrow, the soft spongy material found inside certain bones, produces the main blood cells of the body -red cells, white cells, and platelets.
What are the causes of anaemia?
Blood loss e.g. Trauma
Decreased production e.g. Iron deficiency
Increased destruction e.g. Sickle Cell
Sequestration e.g. Polycythaemia
What is pernicious anaemia?
Commonly caused by loss of gastric parietal cells, and subsequent inability to absorb vitamin B12. May also be linked to other reasons for malabsorbtion e.g. Crohn’s disease or inflammatory conditions of the small intestine.
Can also be due to dietary insufficiency – common in vegetarians and vegans
May be due to increased requirement, such as in pregnancy or where cancers may be widespread in tissue
Less commonly due to parasitic competitive upteake e.g fish tapeworm
What are signs and symptoms of sickle cell anaemia?
Episodes of pain during a sickle cell crisis are one of the most common symptoms
A sickle cell crisis is triggered when the abnormal blood cells block the small blood vessels that supply the body’s tissue.
As a child grows older, pain can affect any area of the body, although the most common areas are: ribs spine pelvis abdomen sternum (breastbone) long bones in the legs and arms
What is sequestration in anaemia?
Erythrocytes become entraped within organs or other tissue – commonly in an enlarged spleen (Felty’s Syndrome)
Splenomegaly results from the chronic inflammatory state.
The increased miles of sinusoids in this massive spleen leads to;
Shortened RBC life span (extravascular haemolysis)
Thromobytopaenia (easy of bruising) and
Leukopaenia, which leads to chronic bacterial infections
Often aggrivated by a dilutional anaemia due to increased plasma volume.
What is polycythaemia?
A range of disorders which have an increased number of circulating erythrocytes
The normal Hematocrit (packed cell volume – PCV) is 52% for males and 47% for females.
Two forms;
Relative Polycythaemia where there is a decrease in plasma volume Absolute Polycythaemia where there is an increase in erythrocyte numbers
