Cardiovascular conditions 1 Flashcards
Arrhythmias and intrinsic conditions
1
Q
What is Atrial fibrillation/flutter?
A
Supraventricular tachyarrhythmias, characterised by uncoordinated atrial activity on the surface ECG with fibrillatory waves of varying shapes, amplitudes and timing associated with an irregularity irregulat ventricular response when atrioventricular conduction is intact
2
Q
What causes atrial fibrillation/flutter?
A
Cronary artery disease Heart failure Valvular disease Diabetes Thyroid disorders COPD Obstructive sleep apnoea advanced age
3
Q
What are the risk factors for atrial fibrillation/flutter?
A
Increasing age Diabetes mellitus Hypertension Congestive heart failure Valvular heart disease Coronary artery disease Other atrial arrhythmias Cardiac or thoracic surgery Hyperthyroidism Hypoxic pulmonary conditions Alcohol intoxication Obesity Smoking Inflammatory disorders
4
Q
What are the symptoms of Atrial fibrillation/flutter?
A
Palpitations Dizziness SOB Syncope Chest discomfort
5
Q
What are the signs of atrial fibrillation/flutter?
A
Irregular pulse rate Hypotension Elevated JVP Added heart sounds (Gallop rhythm in HF, pericardial rub in pericarditis) Rales (Present in HF) Evidence of stroke
6
Q
What investigations are done for Atrial fibrillation/flutter?
A
ECG (diagnostic - could be not detected)
TFTs (Raised)
FBC (Anaemia)
U&Es (Abnormal K+ can potentiate arrhythmias, especially if on digoxin)
TTE, do a TOE in those with an abnormality on TTE
7
Q
How do you manage Atrial fibrillaiton/flutter?
A
Control arrhythmia and thromboprophylaxis to prevent strokes
Treat underlying cause
Treatment associated with heart failure
Need lifestyle changes e.g. avoid precipitating factors
Rate/ rhythm control
Left atrial ablation if drugs cant control it
8
Q
What is used to maintain Rate in atrial fibrillaiton/flutter?
A
Standard Beta blocker or a rate-limiting CCB (ditliazem/verapamil)
Consider digoxin for those with paroxysmal AF if sedentary
Combo of: Beta-blocker, ditliazem, digoxin
DO NOT offer amiodarone for long-term rate control
9
Q
What drugs are used for rhythm control in atrial fibrillaiton/flutter?
A
Cardioversion if lasts longer than 48 hrs
Amiodarone for 4 weeks, before cardioverson and up to a year after
Long term:
Beta blocker
Dronedarone for maintenance of sinus rhythm after successul cardioversoin in people with paroxysmal or persistent AF
Amiodarone for those with left ventriuclar impairment or heart failure
10
Q
What scoring system is used to assess stroke risk in those with AF or at risk of arrhythmia?
A
CHA2DS2-VASc score
11
Q
What is the CHA2DS2-VASc score?
A
1 point for each: - Heart failure - Diabetes - Hypertension - Vascular disease - Aged >65 - Female 2 points for: - Prior TIA/Stroke/thromboembolism - >/= 75 years old Males: Score 1 or more - oral anticoagulation Females: Score of 2 or more - consider oral anticoagulation
12
Q
What anticoagulation is used in atrial fibrillation/flutter?
A
Apixaban (Prevent stroke and systemic embolism in people with non-valvular AF who have had a stroke or TIA)
Rivaroxaban (Congestive heart failure, HTN, 75+, DM, stroke or TIA)
13
Q
How would someone manage acute atrial fibrillaiton/flutter?
A
Emergency electrical cardioversion without delay if haemodynamic instability
If use cardioversion: offer flecainide or amiodarone with evidence of structural heart damage
If >48 hrs, delay cardioversion until on therapeutic anticoag for minmum 3 weeks
Do not offer magnesium or CCB for pharmacological cardioversion
Anticoagulation (heparin)
Other management options: Cryoablation or high intensity focused ultrasound ablation
14
Q
What are the complications of atrial fibrillation/flutter?
A
Acute stroke
Myocardial infarction
Congestive Heart failure
15
Q
What is cardiac arrest?
A
Sudden cardiac arrest is a sudden state of circulatory failure due to a loss of cardiac systolic function.
16
Q
What are the 4 cardiac rhythm disturbances?
A
Ventricular fibrillation
Pulseless ventricular tachycardia (Torsades de pointes is a sub-group of polymorphic VT)
Pulseless electrical activity
Asystole
17
Q
What causes cardiac arrest?
A
Ischaemic heart disease, cardiovascular disease, cardiomyopathy/dysrhythmia
VT, VF most commonly IHD and acute MI
Most common cause of PEA = Myocardial ischaemia/infarction, hypovolaemia, hypoxia and PE
18
Q
What are the Risk factors for cardiac arrest?
A
Coronary artery disease Left ventricular dysfunction Hypertrophic cardiomyopathy Arrhythmogenic left ventricular dysfunction Long QT syndrome Meds that prolong QT interval Acute medical or surgical emergency Illicit substances Brugada syndrome Valvular heart disease Smoking History of eating disorders
19
Q
What is Brugada syndrome?
A
A rare, dangerous condition affecting potassium and sodium cell entry in cardiac cells - causing very fast heart beats
20
Q
What are the signs and symptoms of Cardiac arrest?
A
Unresponsive patients
Absence of normal breathing
Absence of circulation
Disturbed rhythm disturbance
21
Q
What investigations are done for cardiac arrest?
A
Continuous cardiac monitoring FBC (Low Hct in haemorrhage) Serum electrolytes (Hyper/hypokalaemia) ABG Cardiac biomarkers (positive/elevated) Echo (valvular abnormalities)
22
Q
What are the reversible causes of cardiac arrest?
A
4H's and 4T's Hypoxia (Give oxygen) Hypovolaemia (Correct with IV fluids) Hypothermia (Consider in those drowning) Hyperkalaemia Tension pneumothorax Tamponade Toxins Thromboembolism
23
Q
How do you manage cardiac arrest?
A
If responsive: Call ambulance If unresponsive: ABCD and call ambulance A: Airway - head tilt, chin lift B: Breathing - Look for chest movements C: Circulation (30:2) D: Defibrillation!
Further considerations:
- Amiodarone (150mg followed by infusion of 900mg, lidocaine if no amiodarone)
- Consider Ca2+ in case of PEA (hyperkalaemia, hypocalcaemia, OD on CCBs or magnesium)
- Consider magnesium sulphate
- Bicarbonate, 50mmol in arrests with hyperkalaemia or tricyclic antidepressants
Transfer to ITU for monitoring of breathing, circulation and ventilation
24
Q
What are the complications of Cardiac arrest?
A
Death - highly likley Rib and sternal fractures Anoxic brain injury Ischaemic liver injury Renal acute tubular necrosis Recurrent cardiac arrest
25
What is Heart block?
It is a cardiac electrical disorder defines as impaired (delayed or absent) conduction from the atria to the ventricles
26
What are the classifications of heart block?
```
First degree
Second degree (Mobitz I and Mobitz II)
Third degree (complete) block
```
27
What causes heart block?
Fibrosis and calcification of the conduction system, CAD and medication such as:
AV-nodal blocking agents (beta blockers, CCBs, digitalis, adenosine), Anti-arrhythmics (sotalol and amiodarone)
Others include: Vagal tone, cardiomyopathy, calcification from valvular calcification
28
What are the Risk factors for heart block?
```
Age-related degenerative changes
Increased vagal tone
AV-nodal blocking agents
Chronic stable CAD
Acute coronary syndrome
Chronic heart failure
Hypertension
Cardiomyopathy
Left ventricular hypertrophy
Recent cardiac surgery
Myocarditis
Sarcoidosis
Infective endocarditis
Blunt cardiac injury
```
29
What are the symptoms of heart block?
1st degree - asymptomatic
Mobitz I - asymptomatic
Mobitz II and 3rd degree cause stokes-adams attacks (syncope caused by ventricular asystole)
- May cause: Dizziness, palpitations, chest pain and heart failure
30
What are the signs of heart block?
Often normal
Complete heart block: Slow large volum pulse, JVP shows cannon A waves
Reduced CO
31
What investigations are done for heart block?
```
ECG
Serum troponin (Raised)
Serum potassium (Very low or very high)
Serum calcium (very low or very high)
Serum pH (Very low or very high)
Serum digitalis (Normal to high)
```
32
What is seen on ECG for first degree heart block ?
Prolonged PR interval but prolonging is the same
33
What is seen on ECG for second degree heart block (Mobitz type I)?
Progressive prolonging PR until there is a P wave without a QRS
34
What is seen on ECG for second degree heart block (Mobitz type II)?
PR interval same but regular/intermittent lack of QRS
35
What is seen on ECG for third degree heart block?
Total dissociation of P wave and QRS complexes
| - QRS initiated in: Bundle of His (narrow complex) or More distally (Wide complex and slow rate)
36
How do you manage heart block?
```
1st degree or Mobitz I
Asymptomatic:
- Monitoring
Symptomatic:
1st: Discontinue Medications
2nd: Infrequently PPM or cardiac resynchronicsation therapy
```
Mobitz II or 3rd-degree
Asymptomatic:
- 1st: Condition specific management and discontinuation of AV node-blocking drugs
- 2nd: PPM or cardiac resynchronisation therapy +/- ICD placement
Symptomatic:
- 1st: Condition-specific management, discontinuation of AV nodal blocking drugs, and temporary
- 2nd: PPM or cardiac resynchronisation therapy +/- ICD placement
37
What are the complications of Heart block?
Pacemaker implantation sequelae
Asystole
Cardiac arrest
Heart failure
38
What is Supraventricular tachycardia?
SVT is any tachydysrhythmia arising from above the level of the bundle of His, usually the atria or AV node. These typically produce a narrow complex tachycardia.
There are 2 main types: Atrioventricular nodal re-entry tachycardia and Atrioventricular re-entry tachycardia
39
What causes AVNRT?
The most common type of SVT, due to a reentry that forms around the AV node, which conducts to the ventricles faster than normal conduction pathways
40
What is AVNRT?
Reentrant tachycardia with an anatomically defined circuit that consists of 2 distinct pathways
41
What causes AVRT?
Occurs when normal AV conduction is present as well as accessory pathways. Forming a re-entry between atria and ventricles
42
What are the risk factors for SVT?
```
Nicotine
Alcohol
Caffeine
Previous MI
Digoxin toxicity
```
43
What are the symptoms of SVT?
May have minimal symptoms or may present with syncope
Palpitations
Light-headedness
Polyuria (due to increased atrial pressure causing ANP release)
Abrupt onset and termination of symptoms
Other symptoms: Fatigue, chest discomfort, dyspnoea, syncope
44
What are the signs of SVT?
Normal except tachycaridia
45
What investigations are done for SVT?
ECG
24hr ECG monitoring required with paroxysmal palpitations
Cardiac enzymes (Check for MI)
Electrolytes (Can cause arrhythmias)
Digoxin level
Echocardiogram (check for structural disease)
46
What can be seen on ECG for AVNRT/AVRT?
Tachycardia
Narrow QRS
No P waves
Decreased PR interval
47
How can you tell the difference between AVNRT and AVRT?
Acutely you cannot tell the difference!
Once tachycardia has resolved, you can see delta waves on ECG in AVRT
48
What is the management of SVT?
Unstable:
DC cardioversion
Stable:
Vagal manouevres (valsalva, carotid massage)
If valsalva doesnt work:
- Adenosine 6mg bolus (increase to 12) [contraindicated in asthma, use verapamil insted]
- Wait 2 mins, no change adenosine 12mg
- Same again after 2 mins
- wait 2 more mins, no change, IV metoprolol/amiodarone/digoxin/ DC cardiovert
If unresponseive to chemical cardioversion or tachycardia or adverse signs (low BP, heart failure, low consciousness) - sedate and synchronised / DC cardioversion
- Ongoing management: Radiofrequency ablation of slow apathy, beta blockers, alternatives: Fleicanide, propafenone, verapamil
49
What are the complications of SVT?
Haemodynamic collapse
DVT
Systemic embolism
Cardiac tamponade
50
What is vasovagal syncope?
Loss of consciousness due to a transient drop in blood flow to the brain caused by excessive vagal discharge
51
What causes vasovagal syncope?
Very common cause of fainting
Precipitated by: Emotions (e.g. fear, severe pain, blood phobia) and Orthostatic stress (e.g. prolonged standing, hot weather)
52
What are the symptoms of vasovagal syncope?
Loss of consciousness lasting a short time
Patients may experience vagal symptoms (Sweating, dizziness, light-headidness) before passing out
There may be twitching of limbs during blackout
Recovery is normally quick
53
What are the signs of vasovagal syncope?
None
54
What are the investigations for vasovagal syncope?
ECG (Check for arrhythmia)
Echo (Check for outflow obstruction)
Lying/standing blood pressure (Check for orthostatic hypertension)
Fasting blood glucose (check for DM/hyperglcaemia)
55
What is Ventricular fibrillation?
Cause of cardiac arrest and sudden cardiac death. Ventricular muscle fibres contract randomly causing a complete failure of ventricular function.
56
What causes Ventricular Fibrillation?
Ventricular fibres contract randomly causing complete failure of ventricular function
Most cases occur in patients with underlying heart disease
57
What are the Risk factors for ventricular fibrillation?
```
Coronary artery diseae
AF
Hypoxia
Ischaemia
Pre-excitation syndrome
Drugs
Electrolyte imbalance
```
58
What are the signs and symptoms of Ventricular fibrillation?
```
History of: Chest pain, fatigue and palpitations
Known pre-existing conditions:
- CAD
- Cardiomyopathy
- Valvular heart disease
- Long QT syndrome
- Wolff-Parkinson white syndrome
- Brugada syndrome
```
59
What investigations are done for ventricular fibrillation?
ECG (Chaotic irregular deflections of varying amplitude)
Cardiac enzymes (troponin)
Electrolytes (Derangements cause arrhythmias)
Drug levels and toxicology screen
TFTs
Coronary angiography
60
How do you manage ventricular fibrillation?
Defibrillation and cardioversion
Full assessment of LVF, myocardial perfusion and electrophysiological stability
Most need an ICD
Beta blockers
May be treated with radiofrequency ablation
CABG prevents recurrent VF if ejection fraction is normal and ischaemia was the cause of the arrest
61
What are the complications of Ventricular fibrillation?
```
CNS Ischaemic injury
Myocardial injury
Post-defibrillaiton arrhythmias
Aspiration pneumonia
Defibrillation injury to self or others
Injuries from CPR and resuscitation
Skin burns
Death
```
62
What is Ventricular tachycardia?
A broad complex tachycardia originating from a ventricular ectopic focus.
63
What defines ventricular tachycardia?
3 or more ventricular extrasystoles in succession at a rate of more than 120bpm
Accelerated idioventricular rhythm refers to ventricular rhythms with rates of 60-100 bpm
64
What are the types of VT?
Monomorphic VT
Non-sustained VT (<30secs)
Sustained VT
65
What is Sustained VT associated with?
```
Late phasemyocardial infarction
Cardiomyopathy
Right ventricular dysplasia
Myocarditis
Drugs (flecainide and disopyramide)
```
66
What are the types of VT?
Fascicular tachycardia
Right ventricular outlflow tract tachycardia
Torsades de pointes
Polymorphic ventricular tachycardia
67
What is Fascicular tachycardia?
Not usually associated with underlying structural heart disease
Originates from left bundle branch
Produces QRS complexes of short duration (often misdiagnosed as SVT)
QRS has right bundle branch block pattern
68
What is Right ventricular outflow tract tachycardia?
Originates from right ventricular outflow tract
ECG typically shows right axis deviation, with a LBBB pattern
Tachycardia provoked by catecholamine release, sudden changes in heart rate and exercise
Responds to alpha blockers or calcium anatagonists
69
What is polymorphic ventricular tachycardia?
Same ECG as torsades de pointes but in sinus rhythm
ECG tract similar to AF with pre-excitation
Less common than torsades de pointes
Leads to cardiogenic shock
Occur in acute MI and deteriorate into VF
70
What causes ventricular tachycardia?
Ischaemic heart disesae
Underlying non-ischaemic cardiomyopathy
Chagas disease
71
What are the Risk factors for ventricular tachycardia?
```
Coronary artery disease
Acute MI
Left venrticular systolic dysfunction
Hypertrophic cardiomyopathy
Long/Short QT syndrome
Brugada syndrome
Ventricular pre-excitation
Arrhythmogenic right ventricular cardiomyiopathy
Electrolyte imbalance
Drug toxicity
Chagas disese
Family history of sudden death
Mental or phsyical stress
```
72
What are the symptoms of Ventricular tachycardia?
Chest pain
Palpations
Dyspnoea
Syncope
73
What are the signs of Ventricular tachycardia?
```
Respiratory distress
Bibasal crackles
Raised JVP
Hypotension
Anxiety
Agitation
Lethargy
Coma
```
74
What investigations are done for Ventricular tachycardia?
```
ECG
Electrolytes
Level of therapeutic drugs (e.g. digoxin)
Evaluate for MI
CXR
Arrhythmia
```
75
What is seen on ECG on Ventricular tachycardia?
```
Rate >100 bpm
Wide QRS complex
Presence of AV dissociation
Fusion beats
Retrograde ventriculoatrial conduction
```
76
How do you manage ventricular tachycardia?
ABCs of resuscitation and provide basic and advanced life support
Pulseless VT - treat as if VF
Unstable VT (Reduced cardiac output) - Unsychronised defibrillaiton, respond to low levels of energy. Amiodarone often used for haemodynamically unstable VT, replenish electrolyte imbalance
Refractory VT - after 300mg amiodarone, followed by infusion of 900mg over 24hrs
77
When is an implantable cardiac defibrillatory used for?
Sustained VT causing collapse
Sustained VT with ejection fraction <35%
Previous cardiac arrest due to VT/VF
MI complicated by non-sustained VT
78
What are the complications for Ventricular tachycardia?
Congestive cardiac failure and cardiogenic shock
| VT deteriorates to VF`
79
What is Wolff-Parkinson white syndrome?
Congenital abnormality which can result in SVTs that use an accessory pathway.
It is a pre-excitation syndrome
Early activation of the ventricles due to impulses bypassing the AB node via an accessory pathway
80
What causes wolff-parkinson-white syndrome?
```
The accessory pathway (Bundle of Kent) is likely to be congenital
Associated with:
- Congenital cardiac defects
- Ebstein's anomaly
- Mitral valve prolapse
- HOCM
```
81
What is Ebstein's anomaly?
Congenital malformation of the heart characterised by displacement of septal and posterior tricsupid leaflets
82
What are the signs and symptoms of WPW?
SVT in early childhood
Often asymptomatic
Symptoms: Palpitations, light-headidness, syncope
Paroxysmal SVT followed by polyuria, due to atrial dilatation and release of ANP
Sudden death - if SVT deteriorates into VF
Clinical features of associated cardiac defects
83
What are the investigations for WPW?
ECG normal if condition speed of the impulse along the necessary pathway matches the conduction speed down bundle of His
ECG (Short PR interval, Broad QRS complexes, Delta waves)
May be in SVT (AVRT)
Bloods - check for electrolyte imbalance
Echocardiogram - check for structural anomalies of heart
84
What is Cardiac failure?
Clinical syndrome characterised by:
Breathlessness, fatigue, ankle swelling, tachycardia, tachypnoea, pulmonary rales, pleural effusion, raised JVP, peripheral oedema, hepatomegaly
85
What are the different types of Cardiac failure?
Acute vs Chronic
Systolic vs Diastolic
High and Low output
86
What causes cardiac failure?
Valvular heart disease
Heart failure to secondary myocardial disease
High output heart failure
87
Which valvular disease causes cardiac failure?
```
Aortic stenosis
Aortic or mitral regurgitation
Atrial septal defect
Ventricular septal defect
Tricuspid incompetence cause excessive preload
```
88
What heart failure issecondary to myocardial disease?
Coronary heart disease
Hypertension
Cardiomyopathies
Drugs (beta blockers, CCBs, anti-arrhythmis, cytotoxic)
Toxins (alcohol, cocaine, mercury, cobalt, arsenic)
Endocrine (Diabetes, cushing's, hypothyroidism, adrenal insufficiency)
Nutritional (thiamine, selenium, obesity, cachexia)
Infiltrative (Sarcoidosis, amyloidosis, haemochromatosis, connective tissue disease)
Infective (Chaga's disease, HIV)
89
What are the causes of high output heart failure?
```
Anaemia
Pregnancy
Hyperthyroidism
Paget's disease of the bone
Arteriovenous malformations
beriberi
```
90
What are the symptoms of Left heart failure?
```
Dysonoea
Orthopnoea
Paroxysmal nocturnal dyspnoea
Fatigue
Poor exercise tolerance
Nocturnal cough +/- pink frothy sputum
Wheeze
Nocturia
Cold peripheries
Weight loss
Muscle wasting
```
91
What are the symptoms of acute left ventricular failure?
Dyspnoea
Wheeze
Cough
Pink frothy sputum
92
What are the symptoms of right heart failure?
```
Swollen ankles
Fatigue
Increased weight (Due to oedema)
Reduced exercise tolerance
Anorexia
Nausea
```
93
What are the signs of left heart failure?
Tachycardia
Tachypnoea
Displaces apex beat (LV dilatation)
Bilateral basal crackles
S3 gallop (caused by rapid ventricular filling)
Pansystolic murmur (due to functional mitral regurgitation)
94
What are the signs of acute left ventricular failure?
```
Tachypnoea
Cyanosis
Tachycardia
Peripheral shutdown
Pulsus alternans
Arterial pulse waveforms showing alternating strong and weak beats
Signs of left ventricular systolic impairment
Gallop rhythm
Wheeze
Fine crackles throughout lung
```
95
What are the signs of right heart failure?
```
Raised JVP
Hepatosplenomegaly
Ascites
Ankle/sacral pitting oedema
Signs of functional tricuspid regurgitation
Facial engorgement
Epistaxis
RV heave (Pulmonary hypertension)
```
96
What are the investigations for cardiac failure? (with a previous MI)
```
Overall LV dysfunction
Diastolic function
LV wall thickness
Valvular disease
Estimation of pulmonary artery systolic pressure
```
97
What are the investigations for cardiac failure? (without a previous MI)
```
Serum Naturietic peptides
(if high, >400, referral and assessment made within 6 weeks)
FBC
U&E and creatinine
LFTs
Glucose
Fasting lipids
TFTs
CXR
Urinalysis
Lung function tests
Cardiac MRI
Exercise testing
Radionuclide imaging
```
98
What can be seen on CXR for cardiac failure?
```
Cardiomegaly
Ventricular hypertrophy
Prominent upper lobe veins
Peribronchial cuffing
Diffuse interstitial or alveolar shadoing
Fluid in fissures
Pleural effusions
Kerley B lines
```
99
How do you stage heart failue?
Class I: NO symptoms
Class II: Slight limitation of physical activity by symptoms
Class III: Less than ordinary activity leads to symptoms
Class IV: Inability to carry out any activity without symptoms
100
What indicates a 2 week referral for special assessment and echo?
People with previous MI
People with history of MI with high levels of BNP (>/=400)
People with severe symptoms
Women who are pregnant
101
What indicates a 6 week referral?
```
No history of MI
BNP 100-400
Suspicion of heart failure
Another condition suspected
ECG abnormal
ECG normal but still strong suspicion of heart failure
```
102
What drugs are used for heart failure?
```
ACE inhibitors unless contraindicated (angio-oedema, B/L renal artery stenosis, hyperkalaemia)
Diuretics
Beta blockers
Angiotensin-II receptor antagonists
Mineralocorticoid/aldosterone receptor anagonists
Ivabradine
Digoxin
Opiates or opioids
```
103
What drugs are used to treat cardiovascular comorbidity?
Anticoagulants
| Statins
104
Which drugs are contra-indicated in heart failure?
Pro-anti-arrhythmics with negative ionotrope effects
CCBs
TCAs
Lithium
NSAIDs and COX-2 inhibitors
Corticosteroids
Drugs prolonging QT interval and potentially
105
What is cardiomyopathy?
Primary disease of the myocardium
106
What are the types of cardiomyopathy?
Dilated
Hypertrophic
Restrictive
107
What are the Risk factors for cardiomyopathy?
```
Majority idiopathic
Dilated cardiomyopathy
- Post viral myocarditis
- Alcohol
- Drugs (e.g. doxorubicin, cocaine)
- Familial
- Thyrotoxicosis
- Haemochromatosis
- Peripartum or postpartum
- Hypertension
- AI
- Congenital [X-linked]
Hypertrophic cardiomyopathy
- up to 50% are genetic - AI dominant
Restrictive cardiomyopathy
- Amyloidosis
- Sarcoidosis
- Haemochromatosis
- Scleroderma
- Loffer's eosinophilic endocarditis
- Endomyocardial fibrosis
```
108
What are the symptoms of dilated cardiomyopathy?
Symptoms of heart failure (fatigue, dyspnoea)
Arrhythmias
Thromboembolism
Family history of sudden death
109
What are the symptoms of hypertrophic cardiomyopathy?
```
No symptoms
Syncope
Angina
Arrhythmias
Dyspnoea
Palpitations
Family history of sudden death
```
110
What are the symptoms of Restrictive cardiomyopathy?
```
Dyspnoea
Fatigue
Arrhythmias
Ankle or abdominal swelling
Family history of sudden death
```
111
What are the signs of dilated cardiomyopathy
```
Raised JVP
Displaced apex beat
Functional mitral and tricuspid regurgitations
Third heart sound
Tachycardia
Hypotension
Pleural effusion
Oedema
Jaundice
Hepatomegaly
Ascites
AF
```
112
What are the signs of hypertrophic cardiomyopathy?
Jerky carotid pulse
Double apex beat
Ejection systolic murmur
Systolic thrill at lower left sternal edge
113
What are the signs of restrictive cardiomyopathy?
```
Raised JVP (Kussmaul's sign)
Palpable apex beat
Third heart sound
Ascites
Ankle oedema
Hepatosplenomegaly
```
114
What is Kussmaul's sign?
Paradoxical rise in JVP on inspiration due to restricted filling of ventricles
115
What investigations are done for Cardiomyopathy?
```
CXR (Cardiomegaly, heart failure)
ECG
Echocardiography
Cardiac catheterisation
Endomyocardial biopsy
Pedigree or genetic analysis
```
116
What is seen on ECG in cardiomyopathy?
```
All of them:
- Non-specific ST changes
- Conduction defects
- Arrhythmias
Hypertrophic:
- Left axis deviation
- Signs of LVH
- Q waves in inferior and lateral leads
Restrictive:
- Low voltage complexes
```
117
What is seen on echocardiogram in cardiomyopathy?
Dilated
- Dilated ventricles with global hypokinesia and low ejection fraction
- Mitral regurgitation, tricuspid regurgitation and LV thrombus
Hypertrophic
- Ventricular hypertrophy (asymmetrical septal hypertrophy)
Restrictive:
- Non-dilated non-hypertrophied ventricles
- Atrial enlargement
- Preserved systolic function
- Diastolic dysfunction
- Granular or sparkling appearance of myocardium in amyloidosis
118
What is constrictive pericarditis?
Chronic inflammation of the pericardium with thickening and scarring of the pericardial layers. It limits the ability of the heart to function normally, as it is encased in a right pericardium
119
What causes constrictive pericarditis?
```
Often under diagnosed, difficult to distinguish restrictive cardiomyopathy and other causes of RHF
Can occur after any pericardial disease process
- Idiopathic
- Virus
- TB
- Mediastinal irradiation
- Post-surgical
- Connective tissue diseases
```
120
What are the symptoms of constrictive pericarditis?
Early subtle symptoms with slow progression of:
- Dyspnoea
- Ascites
- Oedema
- Advanced symptoms (Jaundice, cachesxia)
121
What are the signs of constricitve pericarditis?
```
Raised JVP + Kussmaul's sign
Pulsus paradoxus
Diastolic pericardial knock
Quiet heart sounds
Pulsatile hepatomegaly
Splenomegaly
```
122
What investigations are done for constrictive pericarditis?
CXR (small heart +/- calcification of pericardium)
Echo (Diagnostic and distinguishes from constrictive and restrictive)
MRI (allows assessment of thickness of pericardium)
CT (Same as MRI)
Pericardial biopsy (indicated if infective cause)
123
What is infective endocarditis?
An infection involving the endocardial surface of the heart, including the valvular structures, the chordae tendinae, sites of septal defects, or the mural endocardium
124
What causes infective endocarditis?
```
Streptococci (40%) - s. viridans
Staphylococcus (35%) - S. aureus
Enterococci (20%) - E. faecalis
Other organisms
- Haemophilus
- Actinobacilus
- Cardiobacterium
- Coxiella burnetti
- Eikenella
- Kingella
- Chlamydia
- Histoplasma
Others (SLE, malignancy)
```
125
What are the risk factors for infective endocarditis?
```
Abnormal valves
Prosthetic heart valves
Turbulent blood flow
Recent dental work/poor dental hygiene [S. viridans]
Dermatitis
IV injections
Renal failure
Organ transplantation
DM
Post-operative wounds
Hypertrophic cardiomyopathy
```
126
What are the symptoms of infective endocarditis?
```
Fever/chills
Night sweats
Fatigue
Anorexia
Weight loss
Myalgias
Weakness
Arthralgias
Headache
SOB
Chest pain
Back pain
```
127
What are the signs of infective endocarditis?
```
Meningeal signs
Cardiac murmur
Janeway lesions
Osler nodes
Roth spots
Splinter haemorrhages
Cutaneous infarcts
Palatal petechiae
```
128
What investigations are done for infective endocarditis?
```
FBC (Anaemia, leucocytosis)
Serum chemistry panel with glucose
Blood cultures
Rheumatoid factor
ESR
Complement levels
CT (Valvular abnormalities)
MRI (Cerenral lesions)
ECG (prolonged PR interval, non-specific ST/T wave abnormalities, AV block)
Echocardiogram
Urinalysis (RBC casts, WBC casts, proteinuria, pyuria)
```
129
How do you manage infective endocarditis?
ABx for 4-6 weeks
Blind therapy of native valve (Amoxicilin +/- gentamicin)
Blind therapy of prosthetic valve (Vancomycin + Gentamicin + Rifampicin)
On clinical suspicion: Benzylpenicillin + Gentamicin
Staphylococci (Flucloxacillin/vancomycin + gentamicin)
Enterococci (Amoxicillin + gentamicin)
Culture negative (Vancomycin + gentamicin)
130
What are the complications for infective endocarditis?
```
Congestive heart failure
Systemic embolisation
Anterior mitral valve vegetation >10mm
Valvular dehiscence, rupture or fistula
Splenic abscess
Mycotic aneurysms
```
131
What is Ischaemic heart disease?
Angina with acute coronary syndrome (unstable angina, STEMI and NSTEMI)
132
What is angina pectoris?
Stable ischaemic heart disease and low-risk unstable angina are most commonly caused by atheromatous plaques int he coronary arteries that obstruct blood flow.
Anginal symptoms are clinical manifestations of ischaemia
133
What causes angina pectoris?
Atheromaous plaque leading to obstruction of coronary blood flow in the most common cause
Damage to the arterial wall produces an inflammatory response and the development of atheromatous plaques
134
What are the risk factors for angina pectoris?
```
Advancing age
Smoking
Hypertension
Elevated LDL cholesterol
Isolated low HDL cholesterol
Diabetes
Inactivity
Obesity
Family history of premature IHD
Illicit drug abuse
Male sex
Hypertriglyceridaemia
Mental stress/depression
Plasma biomarkers
Polluted air
Aortic stenosis
Hypertrophic obstructive cardiomyopathy
```
135
What are the symptoms of angina pectoris?
Central chest tightness or heaviness brought on by exertion and relieved by rest
May radiate to one or both arms, neck, jaw or teeth
Dyspnoea
Nausea
Sweatiness
Faintness
136
What are the signs of angina pectoris?
Dyspnoea
Tachycardia
Hypoxia
Xanthoma or Xanthelasma
137
What are the investigations for angina pectoris?
```
Resting ECG
Lipid profile (elevated LDL)
Fasting glucose (Raised in diabetes)
FBC
LFTs (baseline pre-statins)
TFTs
Cardiac enzymes
Echo
```
138
How do you manage angina pectoris?
Modify CVS risk factors:
GTN for symptomatic relief
Offer a beta blocker or CCB
If not controlled, switch to other option or combo of both
Consider adding: long acting nitrates, ivabradine or Ranolazine
IF using CCB with a beta blocker/ivabradine - use slow release (Nifedipine, amlodipine or felodipine)
IF cannot tolerate Beta blocker or CCB, consider long-acting nitrate, ivabradine or ranolazine
If not contraindicated: Aspirin (Or clopidogrel)
If stable angina + Diabetes [Ace inhibitor]
Stains should be prescribed for all patients with stable angina due to atherosclerotic disease
139
What is done if they have a poor response to medical therapy?
If poor response to medical therapy, can do percutaneous transluminal coronary angioplasty
Prinzmetals - treat with CCBs +/- long actin nitrates - aspirin and B blockers worsen it!
Syndrome X - CCB
140
What is Prinzmetal angina?
Variant angina - temporary increase in coronary vascular tone (vasospasm) causing a marked, but transient reduction in luminal diametes
141
What are the complications of angina pectoris?
```
Unstable angina
Chronic heart failure
Myocardial infarction
Acute stroke
Depression
```
142
What is Unstable angina?
Absence of Biochemical evidence of myocardial damage. Characterised by specific clinical findings of prolonged angina at rest
143
What are the causes of unstable angina?
Coronary artery disease underlying in nearly all patients with acute MI
Coronary artery narrowing caused by a thrombus that develops on a disrupted atherosclerotic plaque and is usually non-occlusive
Less common causes: Intense vasospasm of a coronary artery (Prinzmental's angina)
144
What are the risk factors for unstable angina?
```
Female sex
Personal history
Increasing age
Family history of CAD
Hypertension
Smoking
DM
Hyperlipidaemia
Peripheral vascular disease
Chronic kidney disease
Elevated CRP
Mediastinal radiation
Obesity/lack of exercise
High altitude
```
145
What are the symptoms of unstable angina?
Angina type pains randomly, occurs at rest
146
What are the signs of unstable angina?
```
Pulse high or low
Arrhythmias
BP disturbances
New heart murmurs
Signs of complications (HF, shock)
Signs of HF: Increased JVP, S3, basal crepitaitons
Pericadial friction rub
```
147
What are the investigations for unstable angina?
```
FBC
U&Es
CRP
Glucose
Lipid profile
Cardiac enzymes (not raised)
ECG (ST depression or T wave inversion)
CXR
Echo (Rest/stress)
Coronary angiography
```
148
What is the management of unstable angina/NSTEMI?
Admit to coronary care unit
Oxygen, IV access, motor vital signs and serial ECG
GTN
Morphine
Metoclopramide (counteract nausea from morphine)
Aspirin
Clopidogrel
LMWH (Enoxaparin)
Beta blocker
G1pIIb/IIIA inhibitors considered (e.g. tirofiban) in patients: Undergoing PCI or high risk
Glucose-insulin infusion of Blood glucose >11
Antiplatelet therapy + statin w/ beta blocker, ACEi + cardiac rehab
149
What are the complications of unstable angina?
Of treatment (Bleeding and thrombocytopenia)
Congestive heart failure
Ventricular arrhythmia
150
What is the definition of NSTEMI?
Acute ischaemic myocyte necrosis. The initial ECG may show ischaemic changes such as ST depression, T wave inversions of transient ST elevation
151
What are the cuases of NSTEMI?
Transient or near-complete occlusion of a coronary artery or acute factor that deprives the myocardium of oxygen
152
What are the risk factors for NSTEMI?
```
Atherosclerosis
Diabetes
Smoking
Dyslipidaemia
Family history of premature CAD
Age >65
Hypertension
Obesity and metabolic syndrome
Cocaine use
Physical inactivity
Depression
Stent thrombosis or restenosis
CKD
Surgical proceduees
Sleep apnoea
```
153
What are the symptoms of NSTEMI?
```
Chest pain
Diaphoresis
Recurrent PCI or CABG
SOB
Weakness
Anxiety
Nausea
Vomiting
Abdominal pain
Emotional
```
154
What are the signs of NSTEMI?
Hypertension
Hypotension
Arrhythmias
S3/S4
155
What are the investigations of NSTEMI?
```
FBC
U&Es
CRP
Glucose
Lipid profile
Cardiac enzymes (Raised)
BNP (Raised >400)
ECG (Depression or t-wave inversion)
CXR (HF, pulmonary oedema)
```
156
What are the complications of NSTEMI?
```
Cardiac arrhythmias
Congestive heart failure
Cardiogenic shock
Ventricular rupture or aneurysms
Acute mitral regurgitation
Post-MI pericarditis (Dressler syndrome)
Venous thromboembolism
Depression
In-stent thrombosis
```
157
What is Dressler syndrome?
Secondary form of pericarditis that occurs in the setting of cardiac injury e.g MI
158
What is a STEMI?
Acute MI, is myocardial cell death that occurs becuase of a prolonged mismatch between perfusion and demand. Caused predominantly by complete atherosclerotic occlusion of the artery
159
What causes a STEMI?
Myocardial O2 demand excess O2 supply
Usually due to atherosclerosis
Rarer causes: Coronary artery spasm, artheritis, vasculitis and emboli
160
What are the risk factors for STEMI?
```
Male
DM
Family history
Hypertension
Hyperlipidaemia
Smoking
Age
Obesity
Sedentary lifestyle
Cocaine use
```
161
What are the symptoms of STEMI?
Acute onset chest pain >20 mins
Central, heavy, tight crushing pain
Radiates to arm, neck, jaw or epigastrium
Occurs at rest
More severe and frequent pain that previously occurring stable angina
Associated with: Breathlessness, sweating, palpitations, nausea and vomiting
162
What are silent infarcts?
Occur in elderly and diabetic patients.
| Present with syncope, pulmonary oedema, epigastric pain and vomiting
163
What are the signs for STEMI?
```
May be no clinical signs
Pale
Sweating
Restless
Distress
Low-grade pyrexia
Check both radial pulses to rule out aortic dissection
Pulse high or low
Arrhythmias
Disturbances of BP
New heart murmurs
Signs of complications
Signs of heart failure
Pericardial friction rub or peripheral oedema
```
164
What are the investigations for STEMI?
```
FBC (Anaemia)
U&Es (Can be normal, high or low)
Glucose
Lipid profile (normal or elevated)
ECG (STEMI)
Cardiac troponin (Raised)
ABG (<90%)
CXR (Pulmonary oedema, widened mediastinum, cardiomegaly, pacemaker, sternal wires, clear lung fields)
Transthoracic echo (L ventricular regional wall motion abnormalities, valvular defects, Right ventricular function, pericardial effusion)
```
165
What is the management of STEMI?
Clopidogrel
- 600mg if PCI
- 300mg if underlying thrombosis and <75 yo
- 75 mg if underlying thrombosis and >75
- Maintenance of 75mg a day for a year
If undergoing primary PCI:
- IV heparin
- Bivalirudin (antithrombin)
Thrombolysis:
- Fibrinolytics e.g. streptokinase and tPA (alteplase)
- Considered if within 12 hrs of chest pain with ECG changes and not contraindicated
- Rescue PCI may be performed if continued chest pain or ST elevation
166
What drugs are used for secondary prevention?
```
Dual antiplatelet therapy (Aspirin + Clopidogrel)
Beta blockers
ACE inhibitors
Statins
Control Risk Factors
```
167
What are the complications of STEMI?
```
Death
Arrhythmias
Rupture
Tamponade
Heart failure
Valve disease
Aneurysm
Dressler's syndrome
Embolism
Reinfarction
```
168
How do you measure prognosis of STEMI?
TIMI score or Killip classification
169
What is TIMI score?
```
Age >/= 65
>/= 3 CAD risk factors (HTN, hypercholesterolaemia, diabetes, family history of CAD, smoking)
Known CAD
ASA use in past 7 days
Severe angina
EKG ST changes
Positive cardio marker
```
170
What is Killip classification?
Class I: No evidence of heart failure
Class II: Mild to moderate heart failure
Class III: Overt pulmonary oedema
Class IV: Cardiogenic shock
171
What is myocarditis?
Acute inflammation and necrosis of cardiac muscle
172
What causes myocarditis?
50% idiopathic
Viruses (Coxsackie B, EBV, CMV, Adenovirus, Influenza, Hepatitis, Mumps, Rubella, Polio, HIV)
Bacteria (Post-streptococcal, TB, Diphtheria, Clostridia, meningococcus, mycoplasma, brucellosis)
Fungal (Candidiasis)
Protozoal (Trypanosomiasis (chaga's disease))
Helminths (Trichinosis)
Non-infective (Systemic: SLE, Sarcoidosis, polymyositis, sulphonamides)
Drugs (chemo, penicillin, chloramphenicol, sulphonamides, methyldopa, spironolactone, phenytoin, carbamezapine)
Others (Cocaine, heavy metals, radiation, toxins, vasculitis)
173
What are the symptoms of myocarditis?
Prodromal flu-like illness (Fever, malaise, fatigue, lethargy)
Breathlessness
Palpitations
Sharp chest pain
174
What are the signs of myocarditis?
```
Signs of pericarditis
Tachycardia
Soft S1
S4 gallop
Signs of complications (e.g. HF, arrhythmia)
```
175
What are the investigations for myocarditis?
```
FBC (Leucocytosis)
U&E
ESR/CRP raised
Cardiac enzymes - raised
Negative antimyosin scintigraphy excludes acute myocarditis
Tests to identify cause
ECG (non-specific T wave and ST changes, atrial arrhythmias, transient AV block, PERICARDITIS - saddle-shaped ST elevation)
CXR (Normal, may show cardiomegaly)
Pericardial fluid drainage
Echo
Myocardial biopsy
```
176
What is Pericarditis?
inflammation of the pericardium. Acute form defined as new-onset inflammation. Either fibrinous (dry) or effusive with a purulent, serous or haemorrhagic exudate
177
What is the cause of pericarditis?
Can be idiopathic or due to systemic conditions e.g. SLE
90% of cases either idiopathic or due to viral infections (e.g. Coxsackie virus, mumps, Ebv, cytomegalovirus, varicella, rubella, HIV)
Systemic AI disease (Rheumatoid arthritis, systemic sclerosis, reactive arthritis IBD)
Bacterial, fungal and parasitic infections
178
What are the risk factors for Pericarditis?
```
Male sex
Age 20-50 years
Transmural MI
Cardiac surgery
Neoplasm
Viral and Bacterial infections
Uraemia or on dialysis
Systemic AI disorders
Pericardial injury
Mediastinal radiation
```
179
What are the symptoms of pericarditis?
Dull, sharp, burning or pressing
Either barely perceptible or up to a severe level
Felt in substernal or precordial region
Radiaitng to the neck, trapezius ridge (usually left) or shoulders
Aggravated by inspiration, swallowing, coughing and lying flat
Relieved by sitting and leaning forward
Non-productive cough, chills and weakness
If cardiac tamponade, present with Beck's triad
180
What is Beck's triad?
Hypotension
Elevated systemic venous pressure
Muffled heart sounds
181
What are the signs of pericarditis?
```
Pericardial friction rub on auscultation
Tachypnoea
Tachycardia
Fever
Dyspnoea & Orthopnoea noticeable when cardiac tamponade develops
Abdominal pain in children
```
182
What are the investigations for Pericarditis?
```
FBC
U&Es
ESR/CRP
Cardiac enzymes (normal)
Blood cultures
ASO titres
ANA
Rheumatoid factor
VIral serology
CXR (Normal, may be globular)
```
183
What is the management for Pericarditis?
```
NSAIDs (Naproxen)
Colchicine with significantly fewer recurrences
PPI with High-dose NSAIDs
Cessation of possible drug causes
Treat with antimicrobials appropriately
Uraemic pericarditis
```
184
What are the complications of pericarditis?
Pericardial effusion with or without cardiac tamponade
| Chronic constrictive pericarditis
185
What is Rheumatic fever?
An inflammatory multisystem disorder, occurring following group A beta-haemolytic streptococci (GAS) infection
186
What are the causes of rheumatic fever?
Pharyngeal infection with lancefield group A beta-hemolytic streptococci triggers Rheumatic fever 2-4 weeks later
Antibody to the carbohydrate cell wall of the streptococcus cross-reacts with valve tissue (antigenic mimicry) and may cause permanent damage to the heart valves
187
What are the risk factors for rheumatic fever?
Genetic susceptibility
Malnutrition
Poverty
188
What are the symptoms of Rheumatic fever?
2-5 weeks after pharyngeal infection
General (malaise, fever, anorexia)
Joints (Painful, swollen, reduced movement/function)
Cardiac (Breathlessness, chest pain, palpitations)
189
What are the signs of Rheumatic fever?
Diagnosis made using Jones' criteria.
Evidence of recent strep infection + 2 major criteria / 1 major and 1 minor criteria
Need evidence of GAS infection
- Positive throat culture
- Rapid streptococcal antigen test positive
- Elevated/rising streptococcal antibody titre
- Recent scarlet fever
190
What are the major Jones' criteria?
CArol SES
- Carditis (Tachycardia, murmur, pericardial rub, cardiomegaly, conduction defects)
- Athritis (Usually large joints)
- Subcutaneous nodules (Small firm painless nodules on extensor surfaces)
- Erythema marginatum (rash with red, raised edges and clear centre, mainly on trunk and proximal limbs)
- Syndenham's chorea (Rapid involuntary, irregular movements with flowing/dancing quality)
191
What are the Minor Jones' criteria?
- Pyrexia
- Raised ESR/CRP
- Arthralgia
- Prolonged PR interval
- Previous rheumatic fever
192
What investigations are done for Rheumatic fever?
FBC
ESR/CRP
Rising antistreptolysin O tire
Throat swab (Culture for GAS, rapid streptococcal antigen test)
ECG (Saddle-shaped ST elevation and PR segment depression, arrhythmias)
Echocardiogram (Pericardial effusion, myocardial thickening or dysfunction, valvular dysfunction)
193
How can you tell where a MI is on ECG?
ST elevation in different leads:
Anterior/septal - V1-4
Lateral - V5, V6, I
Inferior - II, III, aVF
