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Vascular System and Medical Emergencies > Cardiovascular disease > Flashcards

Cardiovascular disease Flashcards

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USMLE® Step 1 flashcards
1
Q

Frequency of self-reported CV disease in perio pts

A

20%

85% of referred pts to hospital could have been managed by GDP with more confidence

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2
Q

What could go wrong in CV pts in the dental chair?

A 
Develop chest pain 
-angina or MI
Develop a tachycardia 
-get palpitations or breathlessness 
Develop a bradycardia 
-get dizzy, blackout
Develop heart failure 
-breathlessness, sometimes very acute and very severe
Suddenly die 
-ventricular tachycardia or fibrillation
Get endocarditis 
-don’t worry, they’ll be out of your surgery by then
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3
Q

Questions you should ask when faced with pts with definite/ possible CV disease

A

Will they tolerate my treatment?
-almost always yes
Will my treatment complicate their condition or treatment?
-very rarely
Will their condition or treatment complicate my treatment?
-often, particularly bleeding risk
Should I tell anyone about them?
-yes, if you uncover cardiac symptoms (chest pains, breathlessness, blackouts, dizziness) or signs (irregular pulse, high/ low BP, swelling)

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4
Q

Consequence of malfunction: myocardium (pump of the heart)

A

Heart failure

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5
Q

Consequence of malfunction: valves (so blood only goes the way it is supposed to)

A

Heart failure

Endocarditis

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6
Q

Consequence of malfunction: conduction system (electrical system)

A

Arrhythmia (tachycardia, bradycardia, sudden death)

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7
Q

Consequence of malfunction: coronary blood supply (the arteries that take blood to your heart, these develop narrowings)

A

Angina

Myocardial infarction

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8
Q

Heart failure

A

When the pump isn’t effective it causes heart failure

Conditions that affect efficiency of pump (< cardiac output) cause heart failure

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9
Q

Common causes of heart failure

A 
Previous heart attacks (MI)
High BP
Genetic causes
Drugs (chemotherapy)
Idiopathic
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10
Q

Standard assessment of pump function

A 
Transthoracic endocardiography (ultrasound)
-dilated with impaired function (cardiomyopathy)
Can show what ventricles and valves are like. Right ventricle shown near the top, left ventricle lower with aorta on the right.
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11
Q

Symptoms of heart failure

A 
Breathlessness (> fluid p in lungs)
-if it gets worse with less exertion could be a heart problem
Swelling (> fluid p in venous system)
Dizziness
Tiredness
Weight loss
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12
Q

Left and right heart failure

A

< cardiac output increases fluid p in lungs (left heart failure), < venous return to the heart via vena cava (right heart failure) and compensatory responses cause fluid retention and vasoconstriction

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13
Q

Clinical signs of heart failure

A 
Low BP
High pulse rate
Crepitations in lungs
> jugular venous p
Pitting ankle oedema/ ascites
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14
Q

When the valves go wrong (reguritant or stenosed) it causes

A

The same symptoms as heart failure

-aortic stenosis: valve becomes thicker and doesn’t open as it should

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15
Q

Causes of valve disease

A 
Degeneration (i.e. it just happens)
Rheumatic fever
Congenitally abnormal valve
Endocarditis
Papillary muscle rupture after MI
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16
Q

Infective endocarditis symptoms

A 
Like a really bad systemic infection
-night sweats
-fever
-rigors
-weight loss
But with bonus of infected lumps flying around blood stream 
-causing embolic complications
And your heart valves being eaten away
-causing valve regurgitation and heart failure
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17
Q

Who is at risk of infective endocarditis

A

More likely in artificial valves or abnormal valves
Elderly
IV drug abusers
In people with previous endocarditis

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18
Q

Possible infective endocarditis organisms

A

Large range, usually Streptococcal or staphylococcal

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19
Q

Infective endocarditis causes valve damage and embolisation

A 
Cerebral abscesses
Aortic and mitral vegetations
-lumps on valves caused by emboli
Retinal emboli (Roth spots)
Digital emboli 
-same cause as splinter haemorrhages, Janeway lesions etc.
-not that common
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20
Q

Arrhythmia

A

Proper cardiac function orchestrated by electrical conduction system of heart
Most rhythm abnormalities are too fast or too slow
-tachycardia >100bpm
-bradycardia <60bpm
-both are treated very differently

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21
Q

How are cardiac rhythm and conduction examined?

A

Electrocardiogram
Usually measured from the surface of the body
More detailed intracardiac ECGs are used in Electrophysiology studies
12-lead ECG

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22
Q

12-Lead ECG

A

Limb leads I, II, III
Chest leads V1-V6
All leads record the same sequence
-P, QRS, T wave

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23
Q

P wave

A

Atrial depolarisation

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24
Q

QRS complex

A

Ventricular depolarisation

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25
Q

T wave

A

Ventricular repolarisation

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26
Q

Effect of faster heart rate on an ECG

A

The closer together the QRS complexes, the faster the heart rate

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27
Q

Narrow complex tachycardia ECG

A

Narrow QRS

Fast rate

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28
Q

Broad complex tachycardia ECG

A

Wide QRS
Fast rate
Could be associated with fatality unless shocked

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29
Q

Effect of a slower heart rate on an ECG

A

The further apart the QRS complexes, the slower the heart rate.

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30
Q

Complete heart block ECG

A 
No relationship between P waves and QRS
Slow rate
-atria and ventricles doing different things
-pt dizzy/ blacked out/ not their best
-need to be treated to prevent death
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31
Q

Types of tachycardia

A 
Atrial fibrillation
Atrial flutter
Supraventricular tachycardia (SVT)
Ventricular tachycardia
Ventricular fibrillation
Ectopic beats (not really a tachycardia)
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32
Q

Atrial fibrillation ECG appearance

A

No P waves, irregular QRS rate

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33
Q

Causes of atrial fibrillation

A 
Hypertension
Heart failure
Valve disease
Alcohol
Age
Obesity
Lung disease
Hyperthyroidism
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34
Q

Symptoms of atrial fibrillation

A

Often asymptomatic
Palpitations
Breathlessness
Dizziness

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35
Q

Atrial fibrillation risk

A

Increases risk of stroke

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36
Q

Atrial flutter ECG appearance

A

Rapid abnormal P waves

-often 2 per QRS

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37
Q

Causes of atrial flutter

A 
Hypertension
Heart failure
Valve disease
Alcohol
Age
Obesity
Lung disease
Hyperthyroidism
(as atrial fibrillation)
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38
Q

Symptoms of atrial flutter

A 
Often asymptomatic
Palpitations
Breathlessness
Dizziness
(as atrial fibrillation)
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39
Q

Risk of atrial flutter

A

Increases risk of stroke

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40
Q

Supraventricular tachycardia (SVT) ECG appearance

A

Narrow QRS complex tachycardia, often absent P waves

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41
Q

Causes of supraventricular tachycardia

A

Can probably happen to anyone, few presisposing factors

Can be born with accessory pathway that increases chances

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42
Q

Symptoms of SVT

A

Mainly palpitations

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43
Q

Risk from SVT

A

Rarely dangerous but affects QoL

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44
Q

Ventricular tachycardia ECG appearance

A

Broad QRS tachycardia

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45
Q

Causes of ventricular tachycardia

A

Anything that can cause heart failure

  • drugs (incl. anaesthetics)
  • genetic disorders
  • idiopathic
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46
Q

Symptoms of ventricular tachycardia

A

Palpitations
Dizziness
Sudden death/ syncope

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47
Q

Risk from ventricular tachycardia

A

Dangerous!

48
Q

Ventricular fibrillation ECG appearance

A

Coarse fibrillation waves with no organised QRS

49
Q

Ventricular fibrillation causes

A 
Anything that can cause heart failure
-drugs (incl. anaesthetics)
-genetic disorders
-idiopathic
(as ventricular tachycardia)
50
Q

Symptoms of ventricular fibrillation

A

Sudden death

51
Q

Risk from ventricular fibrillation

A

Lethal if untreated promptly

52
Q

Ectopic beats ECG appearance

A

Extra occasional narrow or broad isolated QRS complexes

53
Q

Causes of ectopic beats

A

Common in normal people

More common in any heart disease

54
Q

Symptoms of ectopic beats

A

Palpitations

Skipped/ missed beats

55
Q

Risk from ectopic beats

A

Rarely significant

56
Q

Types of bradycardia

A 
Sinus bradycardia
Slow atrial fibrillation/ flutter
2nd degree heart block
Complete (3rd degree) heart block
Asystole
57
Q

Sinus bradycardia ECG appearance

A

Normal ECG but slow

58
Q

Slow atrial fibrillation/ flutter ECG appearance

A

Normal ECG but slow

59
Q

Sinus bradycardia causes

A

Drugs
Fitness
Conduction disease
Hypothyroidism

60
Q

Symptoms of sinus bradycardia

A

Often asymptomatic

Tiredness

61
Q

Risk from sinus bradycardia

A

Little/ none

62
Q

Slow attrial fibrillation/ flutter causes

A 
Drugs
Fitness
Conduction disease
Hypothyroidism
(as atrial fibrillation)
63
Q

Symptoms of slow atrial fibrillation/ flutter

A

Tiredness
Dizziness
Breathlessness

64
Q

Risk from slow atrial fibrillation/ flutter

A

Increases risk of stroke

65
Q

2nd degree heart block ECG appearance

A

Intermittent failure to conduct between P wave and QRS

66
Q

Causes of 2nd degree heart block

A

Drugs
Conduction disease (age)
Surgery
Aortic endocarditis

67
Q

Symptoms of 2nd degree heart block

A

Often none

Dizziness

68
Q

Risk from 2nd degree heart block

A

May worsen to complete heart block

69
Q

Complete heart block ECG appearance

A

No relationship between P waves and QRS, slow QRS rate

70
Q

Complete heart block causes

A

Drugs
Conduction disease (age)
Surgery
Aortic endocarditis

71
Q

Symptoms of complete heart block

A

Tiredness/ dizziness/ breathlessness

Sudden death/ syncope

72
Q

Risk from complete heart block

A

Dangerous! Heart can stop at any time

73
Q

Asystole ECG appearance

A

Flatline

74
Q

Causes of asystole

A

Anything that can cause heart failure; drugs (inc anaesthetics), genetic disorders, idiopathic
Conduction disease

75
Q

Symptoms of asystole

A

Sudden death

76
Q

Risk from asystole

A

Lethal if untreated promptly

77
Q

Risk factors for coronary artery disease

A 
Smoking
High cholesterol
High blood pressure
Diabetes
Overweight
Poor diet
Lack of physical activity
Other atherosclerotic conditions (stroke, peripheral vascular disease)
Family history
Genetics
Male sex
Age
78
Q

Angina

A

When coronary artery disease becomes obstructive, this can cause angina
“Plaque/s” that cause angina are stable; a strong fibrous cap protects the blood from exposure to the lipid core of the lesion, preventing thrombosis

79
Q

Angina symptoms

A

Recurrent feeling of chest pressure/ heaviness/ pain/ indigestion
Sometimes radiates to arm, neck or back
Rarely lasts more than 10 mins

80
Q

Precipitation of angina

A

Exertion or stress
-circumstances where heart needs > blood supply
Rarely is at rest

81
Q

Is angina dangerous

A

No but “unstable angina” is a sign of risk and warrants immediate assessment
-could be > frequency, duration, or onset at rest

82
Q

Myocardial infarction (MI)

A

Occurs when an atherosclerotic plaque in a coronary artery ruptures, triggering thrombus formation
-causes permanent death of some myocardium (unlike angina)

83
Q

MI symptoms

A

Usually causes chest discomfort similar to angina; it is not always severe
MI pain tends to last longer than angina

84
Q

When can MI occur?

A 
At any time:
-at rest
-on exertion
-while asleep etc.
Can be immediately fatal or lead to lifelong heart failure
85
Q

Investigation and treatment of CV disease

A

MI –> angina, arrhythmia, heart failure, valve disease
Valve disease –> endocarditis, arrhythmia, hear failure
Heart failure –> arrhythmia, valve disease
Endocarditis –> valve disease, heart failure, arrhythmia
Arrhythmia –> angina, heart failure

86
Q

How can we tell if someone has coronary artery disease?

A 
Exercise ECG
-easy but inaccurate
Myocardial perfusion scan
-slightly more accurate
Angiography
-either by CT or invasive angiography
-investigation of choice
87
Q

Treatment of coronary artery disease

A

Lifestyle modification
Cholesterol lowering (usually statin treatment)
Antiplatelets lowers MI risk (usually aspirin)
Address other risk factors; BP, diabetes
These improve prognosis but do not reduce angina frequency

88
Q

Lifestyle modification for treatment of coronary artery disease

A 
Stop smoking
Take more exercise
Eat heart healthy diet 
-5-6 veg/ fruit per day
-low processed food
-oily fish
-olive oil
-nuts/ seeds
Lose weight
89
Q

If CAD is causing angina what treatment would be necessary

A

Lifestyle modification
Cholesterol lowering (usually statin treatment)
Antiplatelets lowers MI risk (usually aspirin)
Address other risk factors; BP, diabetes
these improve prognosis but not angina frequency
No need to treat further if not bothersome
Medication to < angina attacks
If medication not working/ side effects; stenting or coronary artery bypass grafting
these improve angina but do not improve prognosis

90
Q

Is it MI? Or is it trapped wind?

A

Two key investigations: ECG and serum troponin measurement

  • if ECG shows ST elevation it is an ST elevation MI
  • if ECG is normal or shows other changes it may be a non-ST elevation MI (NSTEMI), or trapped wind
  • in both STEMI and NSTEMI serum troponin will be raised, but may take some hours to rise, so often treat as MI until results known
91
Q

What changes in an ECG could indicate an NSTEMI

A

Normal
ST depression
T wave inversion

92
Q

Management of STEMI and NSTEMI

A

Immediate dual antiplatelet therapy and pain relief
-paramedics usually give the aspirin and opiates
-oxygen should be avoided and nitrates are useless for MI
Anticoagulation for 24-72 hours
Both should have angiography and if possible stenting
-STEMI immediately
-NSTEMI within 72 hours or sooner if complications
Secondary prevention
Cardiac rehabilitation

93
Q

Immediate dual antiplatelet therapy (DAPT)

A

Aspirin plus Ticagrelor, Prasugrel or Clopidogrel

94
Q

Anticoagulation for 24-72 hours

A

Heparin

Fondapariux or similar

95
Q

Secondary prevention of STEMI and NSTEMI

A 
DAPT for a year then Aspirin alone
Statin
Betablocker for a year
ACE inhibitor
Treatment of any complication (heart failure, arrhythmia, etc)
96
Q

Cardiac rehabilitation

A

Exercise
Education
Diet
Smoking cessation

97
Q

Investigation of heart failure

A

Mainstay is transthoracic echocardiography (ultrasound) to detect ventricular impairment
Also newer test for elevated serum B-type Natriuretic Peptide (BNP)
-goes up if you have heart failure
Other tests include cardiac MR

98
Q

Treatment of heart failure

A 
Predominantly medical (drugs)
-ACE inhibitors
-betablockers
-aldosterone antagonists (spironolactone or eplerenone)
-diuretics
-ivabradine
Correction of other causes
-anaemia
-thyroid dysfunction
Management of complications (arrhythmia)
Some heart failure pts benefit from cardiac resynchronisation therapy (CRT - special form of pacemaker)
99
Q

Investigation of valve disease

A

Diagnosis usually by transthoracic echocardiography (ultrasound)
Transoesophageal echocardiography gives better images particularly of mitral valve but is not pleasant for pt

100
Q

Treatment of symptomatic (usually breathlessness) valve disease

A

Valve surgery probably appropriate
-done by cardiothoracic surgeon, not cardiologist
Valve can be replaced with metallic prosthesis, biological prosthesis (tissue from animal or human donor) which requires open heart surgery
For aortic stenosis we now sometimes use TAVI (transcatheter aortic valve implantation)

101
Q

Metallic valves warning

A

Require lifelong warfarin, and this can only be stopped if bridged with Heparin. (Anticoagulation for e.g. AF can often be stopped without bridging Heparin).

  • bleeding disorder for the rest of their life
  • affects childbirth, child at risk of developmental disorders
  • dental surgery/ chemotherapy not possible
102
Q

Investigation of arrhythmias

A

Diagnosis made by ECG at time of symptoms
-easier said than done - often needs multiple 24hr recordings, home recorders, smartphone apps or implanted loop recorder
Other investigations look for causes
-echo for heart failure, valve disease
-angio for CAD
-family screening/ testing for genetic conditions

103
Q

Treatment of arrhythmias

A

Vary according to specific type of arrhythmia

104
Q

Treatment of atrial fibrillation

A

Slow rate with beta blockers, digoxin, or calcium channel blockers
Anticoagulate with warfarin or NOAC if high stroke risk
-calculate CHADS2-VASc score

105
Q

Atrial flutter treatment

A

Sam as AF:
Slow rate with beta blockers, digoxin, or calcium channel blockers
Anticoagulate with warfarin or NOAC if high stroke risk
-calculate CHADS2-VASc score

106
Q

Supraventricular tachycardia (SVT) treatment

A

Attacks can be terminated by vagal manoeuvers, iv Adenosine, DC Cardioversion (electric shock)
Recurrent attacks can be < by regular anti-arrythmic drugs
-betablockers
-Flecainide
-Amiodarone etc.
Can usually be cured by invasive ablation, requires Electrophysiological study

107
Q

Ventricular tachycardia treatment

A

Usually requires immediate DC Cardioversion (shock)
Recurrence prevented by regular anti-arrythmic drugs
-betablockers
-Amiodarone. Common to require Implantable Cardioverter Defibrillator unless having acute MI

108
Q

Ventricular fibrillation treatment

A

Always requires immediate DC Cardioversion (shock)
Recurrence prevented by regular anti-arrythmic drugs
-betablockers
-Amiodarone Common to require Implantable Cardioverter Defibrillator unless having acute MI

109
Q

Ectopic beats treatment

A

Reassurance
Sometimes betablockers
Very rarely ablation

110
Q

Treatment of bradyarrhythmia

A

Pacemaker insertion

111
Q

Devices

A

Dual Chamber Pacemaker
Implantable Cardioconverter/ Defibrillator
Cardiac Resynchronisation Therapy (CRT)

112
Q

Dual Chamber Pacemaker

A

Treats bradyarrhythmia

Does nothing for tachycardia or VF

113
Q

Implantable Cardioverter/ defibrillator

A

Treats ventricular tachycardia or VF

Can also pace bradycardias

114
Q

Cardiac Resynchronisation Terhapy (CRT)

A

Treats heart failure
Can also pace bradycardia (CRT-P)
CRT-D also has ICD

115
Q

When should you defer treatment?

A

Urgent tx rarely warrants deferral; risk of deterioration theoretical in almost all situations
Stable angina not a reason to defer tx
-but > pain/ pain at rest may well be
Stable heart failure (breathless on exertion but can lie flat at night, is on tx) not a reason to defer
-but > breathlessness and/ or oedema may be
Recent MI (within 6 weeks)
-defer until 3-6 months post MI, longer if possible
Frequent attacks of disabling tachycardia
If pts awaiting stents / bypass / valve surgery but are stable, then can proceed with tx

116
Q

Adrenaline, locals and heart problems

A 
Risk very low
Risk arises from systemic administration
Could immediately give nitrates to lower BP and reduce possible angina pain
MI?
Get help
117
Q

High frequency descaler/ apex locator and pacemakers

A

High magnetic fields can inactivate/ interfere with function
Need to talk to cardiologist/ pacemaker clinic at local hospital
-write to them or phone them

Vascular System and Medical Emergencies (5 decks)

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