Cardiovascular disease Flashcards
What is atherosclerosis
Combination of atheromas(fatty deposits in the artery walls) and sclerosis(process of hardening or stiffening of the blood vessel walls)
What does atherosclerosis lead to
Affects medium and large arteries
Causes deposition of lipids in the artery wall, followed by development of fibrous atheromatous plaques
What do atheromatous plaques cause
Stiffening of the artery walls leading to hypertension
Stenosis leading to reduced blood flow(angina)
Plaque rupture giving off a thrombus that blocks a distal vessel leading to ischaemia(ACS)
Non-modifiable risk factors for atherosclerosis
Older age
Family history
Male
Modifiable risk factors for atherosclerosis
Smoking Alcohol consumption Poor diet(high sugar and trans-fats) Low exercise Obesity Poor sleep Stress
Medical co-morbidities that increase the risk of atherosclerosis
Diabetes Hypertension CKD Inflammatory conditions(RA) Atypical antipsychotic meds
End results of atherosclerosis
Angina MI TIA Stroke Peripheral vascular disease Mesenteric ischaemia
When should patients be offered a statin
QRISK score of 10% or more
All patients with CKD or T1DM for more than 10 yrs
When does NICE recommend checking lipids after statins
At 3 months and increasing dose to aim for a greater than 40% reduction in non-HDL cholesterol
What should be checked besides lipids in patients taking statins
LFTs within 3 months of starting a statin and again at 12 months
Statins can cause a transient and mild rise in ALT and AST in first few weeks
Secondary prevention of cardiovascular disease(4 A’s)
Aspirin(plus second antiplatelet such as clopidogrel for 12 months)
Atorvastatin 80mg
Atenolol(or bisoprolol) titrated to max tolerated dose
ACE inhibitor(ramipril)
Notable side effects of statins
Myopathy(check CK in patients with muscle pain or weakness)
T2DM
Haemorrhagic strokes(rare)
Signs of cardiogenic shock
Signs of inadequate blood flow include low urine production (<30 mL/hour), cool arms and legs, and altered level of consciousness.
People may also have a severely low blood pressure and heart rate.
What is cardiogenic shock
Cardiogenic shock occurs when there is failure of the pump action of the heart, resulting in a decrease in cardiac output causing reduced end-organ perfusion
This leads to acute hypoperfusion and hypoxia of the tissues and organs, despite the presence of an adequate intravascular volume.
Definition of cardiogenic shock
Sustained hypotension (systolic blood pressure (BP) <90 mm Hg for more than 30 minutes)
Tissue hypoperfusion (cold peripheries, or oliguria <30 ml/hour, or both).
Causes of cardiogenic shock
MI.
Myocardial contusion (often from steering wheel impact).
Acute dysrhythmia compromising cardiac output.
Acute mitral regurgitation (usually as a complication of MI due to ruptured chordae tendinae).
Ventricular septal rupture (usually occurring as post-MI complication).
Cardiac rupture (rupture of the wall of the left ventricle can occur post-MI or due to cardiac trauma).
HOCM
Myocarditis.
Post-cardiac surgery
Causes of cardiogenic shock not due to an intrinsic heart problem
Severe PE
Pericardial tamponade or severe constrictive pericarditis
Tension pneumothorax
Myocardial suppression due to bacteraemia or sepsis (although, strictly speaking, this may be defined as septic shock)
Suppression of myocardial contractility by drugs (eg, beta-blockers) or due to metabolic disturbance (eg, acidosis, hypokalaemia or hyperkalaemia, hypocalcaemia)
Thyrotoxic crisis
Risk factors for cardiogenic shock
More likely to develop in the elderly and in those with diabetes
Anterior and right-ventricular MI are associated with an increased risk.
History of previous infarction, peripheral vascular disease, cerebrovascular disease and multi-vessel atheroma increases the likelihood of the development of cardiogenic shock.
Correctable underlying causes of cardiogenic shock
Potentially correctable underlying causes such as tension pneumothorax, massive PE, occult haemorrhage or hypovolaemia, sepsis, pericardial tamponade, anaphylaxis or respiratory failure should be kept in mind while assessment is carried out
Purpose of haemodynamic monitoring in cardiogenic shock mx
Haemodynamic monitoring using a Swan-Ganz catheter can help to differentiate cardiogenic shock from other causes of shock such as hypovolaemia. (Arterial line, simple central venous line for CVP monitoring and a PiCCO® line are alternatives to a Swan-Ganz catheter.)
Pharmacological inotropic support usage in cardiogenic shock
Although inotropes increase cardiac output, they may also increase mortality due to increased tachycardia and myocardial oxygen consumption leading to arrhythmia and myocardial ischaemia
No data supporting any specific inotropic or vasodilation therapy
What is intra-aortic balloon pump(IABP) counterpulsation
IABP counterpulsation increases cardiac output and improves coronary artery blood flow.
Although evidence suggests that IABP may have a beneficial effect on some haemodynamic parameters, there is no strong evidence of survival benefits to support the use of IABP in infarct-related cardiogenic shock
Which type of carcinoid tumours result in pathological changes to the heart
Only carcinoid tumours that invade the liver
What causes cardiac manifestations in carcinoid syndrome
The cardiac manifestations are caused by the paraneoplastic effects of vasoactive substances such as 5-hydroxytryptamine (5-HT or serotonin), histamine, tachykinins, and prostaglandins released by the malignant cells rather than any direct metastatic involvement of the heart
Characteristic pathological findings of carcinoid heart disease
endocardial plaques of fibrous tissue
Results in distortion of valves causing either stenosis, regurgitation or both
