Cardiovascular/cardiology Flashcards
Angina:
- Aetiology
- Types and differentiating factors
- Investigations
- Management
Aetiology: Atherosclerosis (most common), anaemia, arrhythmia causing myocardial ischaemia
Types: Stable - Pain on exertion and relieved by rest/GT
N, Unstable - pain at rest, increasing frequency and severity, indicator for future MI
Investigations: ECG - Unusual to see changes but may have ST depression, T wave inversion
Exclude anaemia (FBC), diabetes (glucose), thyrotoxicosis
Management: Aspirin 75mg, beta-blocker (atenolol), nitrates (GTN spray, isosorbide mononitrate), CCB if beta-blockers are contraindicated. Refer if new onset, PMH of MI/CABG, uncontrolled by drugs, unstable angina
Define an acute coronary syndrome Risk factors S/S Investigations Treatment
ACS encompasses unstable angina, NSTEMI and STEMI. They are usually broken into ST elevation or LBBB types.
RF: Non-modifiable - Gender, age, FHx
Modifiable - Smoking, high cholesterol, sedentary lifestyle, HTN, DM, obesity, cocaine use
S/S: Central crushing chest pain >20mins (like a band around chest) that can radiate to the neck and shoulders. Dyspnoea, sweating, nausea. Distress, deranged HR and BP, fourth heart heart sound
Ix: ECG - ST elevation (STEMI), ST depression (NSTEMI), t wave inversion (cardiac ischaemia), tall tent T waves, LBBB
Cardiac enzymes - Troponin (T and I) levels increase 3-12 hours after onset and peak 24-48hrs, creatinine kinase (cardiac isoenzyme type), aspartate transaminase, LDH
Bloods - FBC, U/E, glucose, lipids
Tx - W/O ST elevation
MONA: morphine, oxygen, nitrates, aspirin
Oral beta-blocker (metoprolol) for tachycardia/HTN. If contraindicated then verapamil
Fondaparinux
IV nitrate for continuing pain
ST elevation
Morphine and aspirin (oxygen if <90%)
PCI (if available w/i 2 hrs)
Fibrinolysis - if unsuccessful then transfer for PCI
Mortality risk score for ACS?
GRACE score
Complications of MI?
Management?
Cardiac arrest - ABC + CPR
Unstable angina - treat along ACS guidelines and refer
Bradycardia - atropine, cardiac pacing
Tachyarrhythmias - Check potassium, hypoxia and acidosis. If compromised DC cardioversion. Rate control with digoxin ± beta-blocker
Pericarditis - NSAIDs
Right ventricular failure - Give inotropes
DVT/PE - enoxaparin
Mitral regurgitation - anticoagulants ± valve replacement
Define heart failure
Types + definitions + causes
Cardiac output is insufficient for the body’s requirements
HF-REF - pump failure (systolic) with ejection fraction <40%. Caused by IHD, MI, cardiomyopathy
HF-PEF - poor filling (diastolic) leading to EF >50% but low output. Caused by restrictive pericarditis, tamponade or cardiomyopathy
Low output HF - encompasses both the above and is by far the most commone
High output HF - increased peripheral demands meaning CO is insufficient, very rare (anaemia, pregnancy, hyperthyroidism)
S/S of heart failure? How do they differ with area of the heart affected?
Criteria for diagnosis of CCF?
Signs on CXR?
Ix?
Left sided - dyspnoea, poor exercise tolerance, cool peripheries, weight loss, PND, nocturnal cough (how many pillows)
Right sided - peripheral oedema, ascites, nausea, anorexia, pulsation in face and neck, epistaxis
Framingham criteria
ABCDE Alveolar oedema (bat's wings) Kerley B lines (interstitial oedema) Cardiomegaly Dilated upper lobe vessels Pleural effusion
ECG BNP (if both these two normal then HF unlikely ECHO FBC, U/E CXR
Management of HF?
Treat cause (arrhythmia, valve disease) Avoid precipitants (NSAIDs, anaemia) Treatment: - Diuretics = furosemide/ bumetanide - ACEi/ARB - Beta-blockers = carvedilol (not at same time as ACEi/ARB) - Spironolactone - Digoxin - Hydralazine/ isosorbide mononitrate
What is the most common valvular heart disease? Causes? Presentation? Investigations? Treatment?
Aortic stenosis
Senile calcification (most common). Bicuspid aortic valve. Rheumatic fever.
Chest pain, exertional dyspnoea, syncope, features of heart failure.
Signs: Slow rising pulse with narrow pulse pressure, heaving, aortic thrill, EJECTION SYSTOLIC MURMUR
Ix: ECG = p-mitrale, LV hypertrophic changes (tall QRS in lateral leads, LBBB
CXR = LVH, calcified valve
ECHO = diagnostic modality - gradient >50mmHg and valve area <1cm
Tx: Valve replacement, TAVI
What are the causes of aortic regurgitation?
S/S?
Ix?
Tx?
Acute - infective endocarditis, ascending aortic dissection, trauma
Chronic - congenital, connective tissue disorders (Ehler-Danlos, Marfan’s), rheumatic fever, Takayasu’s arteritis, rheumatoid artheritis
Exertional dyspnoea, PND, orthopnoea. Palpitations, angina, syncope
Signs: Collapsing (water-hammer) pulse, wide pulse pressure, displaced hyperdynamic apex beat, HIGH PITCHED EARLY DIASTOLIC MURMUR. Corrigan’s - carotid pulsation. De Musset’s - head nodding. Quincke’s - nail bed pulsation
Ix: ECG - LVH
CXR - LVH, dilated ascending aorta, pulmonary oedema
ECHO - diagnostic
Tx - Reduce HTN = ACEi/ARB, CCB
ECHO - 6-12 monthly
Valve replacement before significant LV dysfunction
Causes of mitral stenosis? Presentation? Signs? Ix? Tx? Complications?
Rheumatic fever, congenital - v rare
Dyspnoea, fatigue, palpitations, chest pain, systemic emboli, haemoptysis - symptoms occur <2cm diameter
Malar flush, low volume pulse, LOUD S1 OPENING SNAP, RUMBLING MID-DIASTOLIC MURMUR (best heard on expiration in left lateral position)
Ix: ECG - AF, p-mitrale, RVH
CXR - left atrial enlargement, valvular calcification, pulmonary oedema
ECHO - diagnostic
Tx: rate control AF if present Anti-coagulate with warfarin Balloon valvuloplasty Open mitral valvotomy or replacement IE prophylaxis (Abx)
Pulmonary HTN, emboli, hoarse voice (pressing on recurrent laryngeal nerve)
Causes of mitral regurgitation?
S/S?
Ix?
Tx?
Function (LV dilatation), calcification (elderly), rheumatic fever, IE, mitral valve prolapse
Fatigue, dyspnoea, palpitations, IE
Signs: AF, displaced hyperdynamic apex beat, heave, SOFT S1 WITH SPLIT S2, PANSYSTOLIC MURMUR AT APEX RADIATING TO THE AXILLA
Ix: ECG - AF, p-mitrale, LVH
CXR - enlarged LA/LV, mitral valve calcification, pulmonary oedema
ECHO
Tx - Control rate and anticoagulate if in AF
Diuretics
Valve replacement for deteriorating symptoms
What is the most common valvular abnormality? Causes? S/S? Ix? Tx?
Mitral valve prolapse
ASD, PDA, cardiomyopathy, Turner’s, Marfan’s
Asymp or with chest pain and palpitations
Signs: Mid-systolic click or late systolic murmur
Ix: ECHO
ECG - inferior T wave inversion
Tx: Beta-blockers may help palpitations and chest pain
If develops to severe mitral regurgitation then surgery is indicated
