Cardiovascular Conditions Flashcards
Hypertension: Causes
Usually no cause
5% caused by renal disease, obesity, pregnancy, endocrine, drugs
(ROPED)
Hypertension: Diagnostic Criteria
- BP >140/90 in clinic
- BP >135/85 at home
Hypertension: Risk Factors (6)
- Alcohol
- Sedentary lifestyle
- DM
- Age
- Family history
- Ethnicity (afro-caribbean)
Hypertension: Investigations (2)
- Take BP in clinic but only home BP is diagnostic
- Rule out renal failure (dipstick), cardio complications (ECG), hypertensive retinopathy, DM
Hypertension: Treatment (3)
- When they have T2DM - give ACEi, may need CCB (calcium channel blocker), may still need thiazide-like diuretic
- When they don’t have DM and are <55 do same as above
- When they don’t have DM and are >55 or Afro-caribbean first give CCB then ACEi if needed then add thiazide-like diuretic
Ischaemic Heart Disease: Pathology
Atherosclerosis → endothelial dysfunction and injury causes lipid accumulation → local cellular proliferation → mural thrombi (plaque)
Ischaemic Heart Disease: Risk Factors (6)
- Family history
- Age
- Ethnicity (S. Asian)
- Smoking
- Alcohol
- Sedentary lifestyle
Ischaemic Heart Disease: Presentation
Presents with angina - pain in chest, neck, shoulders, jaws or arms. Starts with physical exertion. Relieved by rest
Ischaemic Heart Disease: Investigations (4)
- CT coronary angiography!
- Lipid profile - high LDL
- FBC - to exclude anaemia
- HbA1c - to exclude DM
Ischaemic Heart Disease: Treatment (3)
- Antiplatelet - aspirin/clopidogrel
- Lipid lowering - Statins
- Beta blockers for angina
Acute Coronary Syndrome: Description
Thrombus from an atherosclerotic plaque blocking a coronary artery
Causes Unstable Angina (ischaemia), STEMI (complete occlusion), NSTEMI (partial occlusion)
Acute Coronary Syndrome: Presentation
- Chest pain radiating to jaw/arms
- Sweating
Acute Coronary Syndrome: Investigations (4)
- If ECG shows ST elevation = STEMI
- If ECG shows ST depression, deep T wave inversion look at troponins
- If troponins normal = unstable angina
- If troponins are abnormal = NSTEMI
Acute Coronary Syndrome: Immediate Management
MONAC
Morphine
Oxygen (if sats ,92%)
Nitrate
Aspirin
Clopidogrel
Acute Coronary Syndrome: STEMI management (2)
- Give PCI (Percutaneous coronary intervention - minimally invasive procedure) **within 2 hours
- If PCI not possible give fibrinolysis (clot buster)
Acute Coronary Syndrome: NSTEMI/Unstable angina management (3)
- Use GRACE score to predict risk
- Low risk - aspirin
- Medium/High risk - angiography + PCI
Acute Coronary Syndrome: Secondary Prevention (4)
Give ACE inhibitors
Clopidogrel
Aspirin
Beta blocker
Angina: Definition
Chest pain/discomfort arising from the heart as a result of myocardial ischaemia
Can be stable - induced by effort and relieved by rest
Or unstable - increases in severity, occurs at rest or is of recent onset
Angina: Symptoms (4)
- Central crushing retrosternal chest pain that radiates to arms, jaw and neck
- Dyspnoea
- Palpitations
- Syncope
Angina: Differential Diagnosis (3)
- Pericarditis/Mycocarditis
- Pulmonary Embolism
- Chest Infection
Angina: Investigations (3)
- ECG - usually normal, may show ST depression and T wave inversion
- CT angiography - narrow coronary artery
- Bloods - check FBC (anaemia), cardiac enzymes, glucose, lipid profile
Angina: Treatment (5)
- Lifestyle changes
- Glyceryl Trinitrate (GTN) spray - 1st line (dilates coronary arteries)
- Beta blockers - reduce HR and force of contraction
- Amlodipine - Ca2+ channel blocker
- Coronary Artery Bypass Graft (CABG)
Heart Failure: Definition
- A clinical syndrome rather than one specific disease
- Symptomatic condition of breathlessness, fluid retention and fatigue associated with cardiac abnormalities that reduce cardiac output
Heart Failure: Epidemiology
Incidence of 10% in patients over 65
Heart Failure: Causes (5)
- IHD
- Hypertension
- Cardiomyopathy
- VHD
- CHD
Heart Failure: Risk Factors (3)
- Age - over 65
- Obesity
- Male
Heart Failure: Types
- Systolic - failure to contract, ejection fraction <40%
- Diastolic - inability to relax and fill, ejection fraction >50%
Heart Failure: Pathology (compensatory changes)
Compensatory changes - sympathetic stimulation (increases HR), increased RAAS (due to fall in CO, leads to increased water retention and oedema), cardiac changes (ventricular dilation and myocyte hypertrophy)
Heart Failure: Left HF (definition and symptoms)
- Reduced ejection fraction (systolic)
- Symptoms - pulmonary oedema, tachycardia, pleural effusion
Heart Failure: Right HF (definition and symptoms)
- Can be caused by left ventricular failure
- Symptoms - pitting oedema, ascites, weight gain (fluids)
Heart Failure: Investigations (3)
- ECG - may show underlying causes
- Bloods - Brain Natriuretic Peptide (released by ventricles with mycocardial wall stress)
- Cardiac enzymes - creatinine kinase, Troponin I, Troponin T, Myoglobulin
Heart Failure: Treatment (6)
- Lifestyle changes
- ACE inhibitors - dilates blood vessels
- Beta blockers
- Diuretics
- Heart transplant
- Oxygen (acute)
ECGs: Conduction Pathway
SA node → AV node → Bundle of His → Left and right Bundle Branches → Purkinje fibres
ECGs: Letters explained
- P wave - atrial depolarisation
- PR interval - atrial depolarisation and delay in AV junction
- QRS complex - ventricular depolarisation and atrial repolarisation
- T wave - ventricular repolarisation
ECGs: 12 Lead Placements
R - right arm
L - left arm
F - left leg
N - right leg
V1 - fourth intercostal space to the right of the sternum
V2 - fourth intercostal space to the left of the sternum
V3 - between V2 and V4
V4 - fifth intercostal space midclavicular line
V5 - level with V4 at left anterior axillary line
V6 - level with V5 at midaxillary line
ECGs: Limb Leads
I: -RA +LA
II: -RA +LL
III: -LA +LL
aVR: +RA
aVL: +LA
aVF: +LF
ECGs: 10 Rules of ECGs
- PR = 120-200s (3-5 small squares)
- QRS not wider than 110ms (3 little squares)
- QRS upright in leads I and II
- QRS and T waves have same direction in the limb leads (I, II and III)
- All waves negative in aVR lead
- R wave increases in size from V1-V4, S wave grows from V1 to V3 and is absent in V6
- ST segment is isoelectric in all leads except V1 and V2 where it may be slightly raised
- P waves upright in I and II and V2-V6
- There should be no Q waves larger than o.o4s in I, II, V2-V6
- T wave upright in I, II, V2-V6
Arrhythmias: Sinus Tachycardia (HR and treatment)
> 100 BPM
Treat with beta blockers (bisoprolol)
Arrhythmias: Atrial Flutter (HR, treatment)
Atrial HR = 300, ventricular rate = 150
Give beta blockers and amiodarone
Arrhythmias: AV Nodal Re-entry Tachycardia (definition, investigation, treatment)
impulse produces a circuit movement tachycardia in AV node.
ECG shows P waves not visible and QRS normal
Vagal manoeuvres or IV adenosine
Arrhythmias: AV Reciprocating Tachycardia (definition, treatment)
Circuit involving atria and ventricles.
Vagal manoeuvres or IV adenosine
Arrhythmias: Wolff-Parkinson-White Syndrome (definition, investigation)
AVRT with extra bundle between atria and ventricles.
ECG shortened PR interval, slurred start and narrow QRS
Arrhythmias: Atrial Fibrillation (definition, causes, symptoms)
- Atrial rhythm 300-600BPM, HR 120-180. Most common arrhythmia. Irregular ventricular response to atrial impulses
- HF, hypertension, CAD, RHD, VHD
- Asymptomatic, palpitations, dyspnoea, chest pain
Arrhythmias: Atrial Fibrillation (investigation, treatment (3))
- ECG: irregularly irregular, F waves, no clear P waves, rapid and irregular QRS complex
- Bisoprolol, verapamil (calcium channel blockers), amiodarone, NO ASPIRIN
Arrhythmias: Atrial Fibrillation (CHADS2VASc Score)
Calculates stroke risk
- Congestive heart failure (1)
- Hypertension (1)
- Age ≥ 75 (2)
- Age 65-74 (1)
- DM (1)
- Stroke (2)
- Vascular disease (1)
- Female (1)
Score ≥ 2 give oral anticoagulation (warfarin)
Arrhythmias: Bradycardia (HR, causes)
<60 BPM
Intrinsic:
- Acute ischaemia, infarction of SAN, sick sinus syndrome
- Treat with atropine and pacemaker
Extrinsic:
- Drugs, hypothyroidism, hypothermia
- Treat underlying cause
Heart Block: First Degree (description, ECG, causes, symptoms)
- Delayed AV conduction
- Long PR interval (>0.22s)
- Causes: LEV’s disease, IHD, myocarditis, hypokalaemia
- Asymptomatic and no treatment
Heart Block: Second Degree (description, types)
- Some atrial impulses fail to reach ventricles
- Mobitz type 1 (AV node block) and 2 (Intra-nodal block)
Heart Block: Third Degree (description, causes, symptoms, ECG)
- Complete dissociation between atrial and ventricular activity
- Causes: CHD, infection, hypertension
- Symptoms: syncope, dyspnoea, chest pain, confusion
- ECG: P waves and QRS complexes independent
Heart Block: BBB (description, causes, L and R ECG, treatment)
- Complete block of a bundle branch
- Causes: actue (MI, myocarditis), chronic (hypertensive heart disease, cardiomyopathies)
- Right: R wave in V1 and V6
- Left: Slurred S wave in V1 and R wave in V5/6
- Treatment: pacemaker
Aortic Aneurysm: Definition
Weakening of vessel wall followed by dilation due to increased wall stress
Aortic Aneurysm: Risk Factors (6)
- Smoking!
- Family history
- Ehlers-Danlos
- Age
- Atherosclerosis
- Male
Aortic Aneurysm: AAA pathology, symptoms, investigations
- Degeneration of smooth muscle layer → loss of structural integrity of aortic wall → widening of vessel → mechanical stress → dilation and potential rupture
- May disrupt laminar blood flow and cause thrombi
- 85% occur below renal artery
- Usually asymptomatic unless it ruptures
- Diagnosis by ultrasonography
Aortic Aneurysm: Management (3)
- Presenting with rupture = urgent repair
- Symptomatic = repair regardless of diameter
- Asymptomatic = surveillance, repair in diameter >5.5cm (5cm of women)
Aortic Aneurysm: Ruptured AAA Symptoms (5)
Severe, tearing abdominal pain radiating to back, flank, groin.
Painful pulsatile mass
Hypovolemic shock
Syncope
Nausea/ Vomiting
Aortic Dissection: Description
A tear in the intimal layer of the aorta which leads to a collection of blood between the intima and medial layers
Aortic Dissection: Epidemiology
- Most common in men 40-60
- 65% are in ascending aorta
Aortic Dissection: Pathology
Tear in intimal layer → blood through media propagating distally or proximally → false lumen → can occlude flow through branches → ischaemia of supplied regions
Aortic Dissection: Symptoms (4)
- Severe tearing pain in chest radiating to back
- Hypotension
- Asymmetrical blood pressure
- Syncope
Aortic Dissection: Diagnosis (3)
- ECG
- Chest X-ray
- CT scanning
Aortic Dissection: Treatment (5)
- Beta blockers
- Opiods for pain control
- Surgery
- Antihypertensives to prevent relapse
Peripheral Vascular Disease: Pathology
- Atherosclerosis leads to claudication of vessels
- Similar to ischaemic heart dissease but not in heart, commonly legs
Peripheral Vascular Disease: Risk Factors (4)
- Smoking
- Diabetes
- Sedentary lifestyle
- Age >40
Peripheral Vascular Disease: Symptoms (3)
- Intermittent claudication - pain in lower limbs on exercise, relieved on rest
- When severe, unremitting pain
- Leg may be pale, cold, loss of hair, skin changes, weak pulse
Peripheral Vascular Disease: Investigation
Ankle Brachial Pressure Index (ABPI) - <0.90
Peripheral Vascular Disease: Treatment (4)
- Stop smoking!
- Regularly exercise
- Statins
- Dual Antiplatelet Therapy - Aspirin and Clopidogrel
Peripheral Vascular Disease: Critical Leg Ischaemia (symptoms and treatment)
- 6 ps - pain, pallor, poikilothermia (temp issues), pulselessness, paresthesia (burning sensation), and paralysis
- Treat with revascularisation or amputation
Valve Defects: Mitral Stenosis (description, cause, epidemiology, symptoms)
- Mitral valve narrowing between left atria and ventricle
- Caused by rheumatic heart disease
- Rare in the UK
- Symptoms - atrial fibrillation, mid diastolic low rumbling murmur
Valve Defects: Mitral Stenosis (pathology)
Blood can’t flow effectively form left atrium to left ventricle → blood builds up in left atrium → left atrium gets hypertrophy → left atrium gets bigger meaning blood backflows into lungs → shortness of breath, pulmonary oedema → pulmonary hypertension → right heart failure
Valve Defects: Aortic Regurgitation (Causes, pathology, symptoms)
- Causes - Ehlers-Danlos Syndrome, Marfans syndrome (connective tissue diseases)
- Left ventricle contracts → blood enters aorta → during diastole aortic valve doesn’t close properly → blood goes back into left ventricle
- Symptoms - early diastolic soft rumbling murmur, collapsing pulse (Corrigan’s pulse)
Valve Defects: Mitral Regurgitation (pathology, causes, symptoms)
- Valve is weak → left ventricle contracts and some blood leaks back to left atria → congestive heart failure
- Causes - IHD, rheumatic heart disease (damage)
- Symptoms - pan systolic high pitched whistling murmur
Valve Defects: Aortic stenosis (epidemiology, pathology, symptoms)
- Most common valve defect
- Valve gets calcified as you get older → blood can’t easily get from left ventricle to aorta → left ventricle hypertrophies → blood build up and heart failure
- Symptoms - exertional syncope (light headed on exertion), slow rising pulse, ejection systolic high pitched crescendo-decrescendo murmur
Pericarditis: Pericardium physiology
- Fibrous, fluid-filled sack that surrounds the muscular body of the heart made of external fibrous layer and internal serous layer with pericardial cavity between with 50mL lubricating serous fluid
- Keeps heart in place, prevents heart overfilling, reduces friction, protects from infection
Pericarditis: Pathology
Pericardium becomes inflamed → fibrinous reaction → adhesions within pericardial sac → haemorrhagic effusion may develop
Pericarditis: Causes (4)
- Infection (HIV, TB, fungal)
- MI
- Autoimmune
- Dressler Syndrome
Pericarditis: Symptoms (4)
- Central severe sharp chest pain - may radiate, relieved by sitting forward
- Dyspnoea
- Hiccups
- Fever
Pericarditis: Investigations (3)
- ECG - concave ST, PR depression
- Bloods - cardiac enzymes, ESR, C-reactive protein, FBC
- Echocardiogram
Pericarditis: Treatment (2)
- NSAIDS
- Colchicine - inhibits migrations of neutrophils to site of inflammation
Pericarditis: Complications (3)
- Pericardial effusion - fluid in pericardial sac
- Cardiac tamponade - pericardial effusion restricting diastolic ventricular filing
- Chronic constrictive pericarditis - persistent inflammation
Endocarditis: Causes (2)
- Mostly Staph Aureus (surgery, diabetes, IV)
- Streptococcus viridans (dental)
Endocarditis: Symptoms
FROM JANE
Fever
Roth’s spots - retinal haemorrhages
Osler’s nodes - painful spots on hand
Murmur
Janeway lesion - painless spots
Anaemia
Nail-bed splinter haemorrhages
Emboli
Endocarditis: Investigations (4)
- Transoesophageal Echo (TOE) - diagnostic
- ECG
- Chest X-ray (CXR)
- Blood cultures
Endocarditis: Treatment
Antimicrobials - penicillin (benzylpenicillin or gentamycin) for staphylococcus, vancomycin or rifampicin if not
Shock: Cardiogenic (causes, pathology, symptoms, treatment)
- Causes by heart failure (MI, cardiac arrest)
- Pathology - decreased cardiac output (heart isn’t pumping hard enough) reduces mean arterial pressure
- Symptoms - tachycardia (pumping faster to compensate low cardiac output), tachypnoea (high resp rate), reduced urine output, reduced BP (less fluid volume)
- Treatment - Resuscitation
Shock: Hypovoleamic (description, pathology, symptoms, treatment)
- Low fluid volume because of haemorrhage or dehydration
- Pathology - reduced mean arterial pressure results in reduced cardiac output
- Symptoms - tachypnoea, weak rapid pulse, high capillary refill time
- Treatment - resuscitation, give fluids, give vasodilator
Shock: Septic (description, symptoms, treatment)
- Toxins in blood usually due to bacterial infection
- Symptoms - presents in many ways, tachycardia, D+V, confused, low sats and urine output
- Treatment - broad spectrum antibiotics (treat infection), treat other symptoms (fluids, oxygen)
Shock: Sepetic (pathology)
Pathology - endotoxins directly damage endothelial cells → NO release → mast cells release histamine → macrophages and neutrophils release pro-inflammatory cytokines → increased vascular permeability → release of tissue factor → clotting
Shock: Anaphylactic (description, pathology, symptoms, treatment)
- Severe allergic reaction
- Pathology - histamine release → vasodilation → hypoxia
- Symptoms - tongue swelling, puffy face, breathing difficulties, rashes, itchy
- Treatment - resuscitation, adrenaline
Cardiomyopathy: Risk Factors (5)
- Family history
- Hypertension
- Obesity
- Diabetes
- Previous MI
Cardiomyopathy: Hypertrophic Cardiomyopathy (epidemiology, cause, pathology)
- Most common cause of sudden death in young adults
- Caused by autosomal dominant mutation
- LV becomes hypertrophied → hypertrophy is asymmetrical blocking LV outflow tract during systoles
Cardiomyopathy: Hypertrophic Cardiomyopathy Investigations (3)
- Microscopic - myocyte and myofibrils in disarray
- ECG - Abnormal, deep T wave inversion
- Echocardiogram
Cardiomyopathy: Hypertrophic Cardiomyopathy Treatment (4)
- Amiodarone
- Calcium channel blocker (amlodipine)
- Beta blocker (atenolol)
- Surgery
Cardiomyopathy: Dilated Cardiomyopathy (epidemiology, pathology, investigations, treatment)
- Most common
- Walls normal or thin → weak contraction → less pumped out → biventricular congestive HF
- Investigations - CXR shows large heart, ECH, Echo
- Treatment - treat symptoms (HF and AF)
Cardiomyopathy: Description
A disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body.
Cardiomyopathy: Arrhythmogenic Cardiomyopathy (causes, symptom, investigations, treatment)
- Caused by desmosome gene mutations
- Main symptom is arrhythmia
Investigations
- Histologically
- ECG - T wave inversion and epsilon wave in leads V1, 2 and 3
- Genetic testing
Treatment
- Beta blockers (bisoprolol)
- Amiodarone for arrhythmia
Cardiomyopathy: Restrictive Cardiomyopathy (pathology, causes, investigations, treatment)
- Ventricles stiffer → less CO → HF
- Caused by amyloidosis, sarcoidosis or idiopathic (spontaneous)
- Investigations - CXR, ECG (low amplitude signals, small QRS), Echo
- Treatment - treat underlying cause, heart transplant
Rheumatic fever: Definition
Systemic infection common in developing countries from a Lancefield group A B-haemolytic streptococci
Rheumatic fever: Pathology
An antibody from the cell wall cross-reacts with valve tissue which can cause permanent damage to the heart valves
Rheumatic Fever: Symptoms (4)
- Fever
- Tachycardia
- Arthritis
- Chest pain
Rheumatic Fever: Investigations (major 4, minor 3)
- Major
- Carditis - tachycardia, murmurs, pericardial rub
- Arthritis
- Erythema marginatum - rash with raised edges and clear centre
- Sydenham’s chorea - involuntary, semi-purposeful movements
- Minor
- Fever
- Arthralgia - joint stiffness
- Prolonged PR interval
Rheumatic Fever: Treatment (3)
- Rest
- Analgesia
- Benzylpenicillin IV
Structural Heart Defects: Bicuspid Aortic Valve Defect (epidemiology, pathology, investigations, treatment)
- Affects 1-2%
- Aortic valve only has 2 cusps → aortic stenosis and aortic regurgitation
- Investigations - Ech, ECG
- Management - surgical valve replacement
Structural Heart Defects: Atrial Septal Defect (description, symptoms, investigations, treatment)
- Holes in the septum dividing left and right atria
- Mostly asymptomatic, ejection systolic murmur
- Investigations - echocardiogram, ECG
- Treatment - most close by themselves before 10 years old
Structural Heart Defects: Atrio-Ventricular Septal Defect (epidemiology, description, treatment)
- Very rare
- Hole in the middle of heart involving ventricular and atrial septum
- Treatment - pulmonary artery banding in large defect reducing flow to lungs. Partial defect left alone
Structural Heart Defects: Ventricular Septal Defect (description, symptoms, investigations, treatment)
- Holes in the septum dividing left and right ventricles
- Asymptomatic if small, large shows exercise intolerance, poor weight gain harsh systolic murmur
- Investigations - Echocardiogram, ECG
- Treatment - Do nothing if small, if large consider surgical repair
Structural Heart Defects: Tetralogy of Fallot (description, investigation, treatment)
- 4 issues - large ventricular septal defect, overriding aorta, right ventricle outflow obstruction, right ventricle hypertrophy
- Investigations - echocardiogram
- Treatment - surgical repair
Structural Heart Defects: Patent Ductus Arteriosus (description, investigations, treatment)
- Connection from pulmonary artery to aorta shunts blood from pulmonary artery to aorta in utero. Sometimes doesn’t close
- Investigations - echocardiogram, machine like continuous murmur
- Treatment - surgical closure (prostgland inhibitor)
Structural Heart Defects: Coarctation of Aorta (description, investigations, treatment)
- Aorta narrowed at ductus arteriosus
- Investigations - CXR (dilated aorta indented at site of coarctation), ECG (LV hypertrophy), CT
- Treatment - Surgical repair (risk of aneurysm at site of repair), balloon dilation