Cardiovascular Diseases Flashcards
1
Q
what is hypertension
A
high blood pressure
140/90mmHg
2
Q
what does the framingham study show about bp
A
bp -> risk of stroke + cvd
risk rises exponentially
age plays role
3
Q
whats stage 1 hypertension
A
140/90mmHg
ABPM daytime average - 135/85
4
Q
whats stage 2 hypertension
A
160/100 mmHg or higher
ABPM daytime average 150/95 mmHg
5
Q
whats stage 3 hypertension
A
Clinic systolic blood pressure is 180/120 mmHg
6
Q
whats primary hypertension
A
no cause can be found
80-90% cases
7
Q
whats secondary hypertension
A
cause can be found
10-20% cases
may be curable
incidence highest in younger patients
8
Q
what risk factors are for hypertension
A
Cigarette smoking - adds 20/10 mmHg Diabetes mellitus increase MI Renal disease Male Hyperlipidaemia Previous MI or stroke Left ventricular hypertrophy
9
Q
what controls BP
A
Cardiac output, SV + HR
Peripheral vascular resistance
10
Q
what is the Renin-Angiotensin-Aldosterone System responsible for
A
maintenance of sodium balance
control of blood volume
control of blood pressure
11
Q
what is the renin angiotensin system stimulated by
A
fall in BP
fall in circulating volume
sodium depletion
12
Q
what does Angiotensin II do
A
vasoconstrictor
anti-natriuretic peptide
stimulator of aldosterone - anti-diuretic, release from the adrenal glands
13
Q
how does the symp NS control BP
A
- vasoconstriction - inc peripheral resistance
- reflex tachycardia, increased stroke volume = inc cardiac output
14
Q
whats the aetiology of hypertension
A
polygenic
- major genes (angiotensin, diabetes)
- poly genes (obesity, race, BP)
polyfactorial
- environment (diet)
- individual and shared (stress, PA)
age, genetics, environment, weight, alcohol, race
15
Q
BP tends to rise with age, possibly as a result of decreased arterial compliance.
A
buh
16
Q
Mental and physical stress both increase blood pressure
A
jk
17
Q
Caucasians have a lower BP than African populations living in the same environment
A
hhj
18
Q
what investigations would you carry out for secondary hypertension
A
Renal function and urinalysis Renal imaging – Ultrasound – MRA renal arteries Aldosterone to renin rati
19
Q
what are causes of secondary hypertension
A
- renal disease (renal stenosis)
- drug induced (NSAIDs, oral contraceptive)
- pregnancy
- endocrine
- vascular (aortic coarctation)
- sleep apnoea
20
Q
how do you identify true hypertension
A
20-30 clinic readings
must use ambulatory blood pressure monitoring
or home blood pressure monitoring
sometimes if no nocturnal dip in pressure
21
Q
what is white coat hypertension
A
normal bp apart from one reading
22
Q
what is masked hypertension
A
bp looks normal but then shoots up
23
Q
to diagnose hypertension must first assess risks, what might these be
A
Previous MI, stroke, IHD Smoking Diabetes mellitus Hypercholesterolaemia Family history Physical Examination
24
Q
how can you assess end organ damage
A
ECG
echocardiogram
proteinuria
renal US
25
what can you use to assess/quantify risk
the assign risk calculator/ Q-risk
26
what drugs should you use to treat hypertension in a young patient
ACE inhibitor
| ramipril
27
what drugs should you use to treat hypertension in an elderly patient
Calcium Channel Blocker
| Thiazide –Type Diuretic
28
In Stage 1:
offer antihypertensive drug treatment to people aged under 80 years with ABPM >135/85 with target organ damage, renal disease, diabetes etc
ggg
29
in Stage 2
| Offer antihypertensive drug treatment to people of any age with ABPM> 150/95
erf
30
in step 1 treatment, what drug would you give to patients aged >55 and black people
calcium channel blocker
| thiazide like diuretic (black)
31
in step 1 treatment, what drug would you give to patients aged <55 for hypertension
ACEI/ARB
32
what drug would you add on in step 2 treatment of hypertension
add Thiazide-type diuretic such as indapamide to CCB or ACEI/ARB
33
what drug would you add on in step 3 treatment of hypertension
Add CCB, ACEI, Diuretic together
beta-blocker if stil incomplete effect
34
what drugs are angiotensin converting enzyme inhibitors (ACEI)
RAMIPRIL, PERINDOPRIL
35
what are some contraindications to ACE Inhibitors
Renal artery stenosis
Impaired renal function
Hyperkalaemia
Fertile female - teratogenic
36
what drug-drug interactions are there with ACEI
NSAIDs
Potassium supplements
Potassium Sparing diuretics
37
what Angiotensin II Antagonists drugs are there, what do they do
LOSARTAN, VALSARTAN, CANDESARTAN, IRBESARTAN
competitively block the actions of angiotensin II at the angiotensin AT1 receptor
38
what is a side effect of ACEI
dry cough
39
what drugs are calcium channel blockers that vasodilate
Amlodipine/Felodipine
reduce peripheral resistance
40
what drugs are calcium channel blockers that reduce the HR
Verapamil/Diltiazem
Block the L-type calcium channel in the myocytes
41
what are adverse drug reactions to CCB
Flushing
Headache
Ankle oedema
Indigestion and reflux oesophagitis
42
what drugs are Thiazide Type Diuretics and what do they do
Indapamide, Clortalidone
Urinary excretion of sodium
Resistance vessel dilatation
43
what drug is an Alpha-adrenoceptor antagonists and what do they do
DOXAZOSIN
Selectively block post synaptic a1-adrenoceptors
Oppose vascular smooth muscle contraction in arteries
44
what drug would you use for hypertension in pregnancy
METHYLDOPA
Nifedipine MR
-centrally acting agent
45
what anti-hypertensive drug would you not give to a pregnant patient
ACE or ARB
46
what does preeclampsia increase the risk of in women
Stroke
Heart failure
Atrial fibrillation
47
what is a hypertensive emergency
Severely elevated BP (BP>180/120 mmHg) with evidence of acute target organ damage
need admission
no ACE or ARB
48
what is a hypertensive urgency
Severely elevated BP with NO evidence of acute target organ damage
dont need admission, start on dual oral therapy
49
whats orthostatic hypotension
sudden drop in blood pressure when you stand from a seated/lying position
a blood pressure decrease of 20 mmHg systolic and/or a diastolic pressure of 10 mmHg within three minutes of standing.
prevalence in older hypertensive patients
50
what are the causes of orthostatic hypotension
```
Ageing
Diabetes
Antihypertensive drugs
Auto-immune systemic diseases
Neurological syndromes: pure autonomic failure, Parkinson’s disease
```
51
how can you treat orthostatic hypotension
Teach manoeuvres either mobilising volume from the lower parts of the body or stimulating pressure receptors leading to vasoconstriction
at night, tilt bed in head up position
52
what is ATHEROMA /ATHEROSCLEROSIS
Formation of focal elevated lesions (plaques) in intima of large and medium-sized arteries
53
what can the consequences of atheroma be
ischaemia
angina due to myocardial ischaemia
complicated by thtomboembolism
54
whats atheriosclerosis
```
Not atheromatous
age related change in muscular arteries
smooth muscle hypertrophy, reduplication of internal elastic laminae
intimal fibrosis
= dec vessel diameter
```
55
what is the earliest lesion of atheroma
fatty streak
yellow linear elevation of intimal lining
lipid laden macrophages
children
56
whats early atheromatous plaque
Young adults onwards
Smooth yellow patches in intima
Lipid-laden macrophages
57
describe a fully developed atheromatous plaque
central lipid core (rich in cellular lipids/debris from macrophages)
with fibrous tissue cap, covered by arterial endothelium
collagen provide structural strength
inflammatory cells in fibrous cap, recruited from endothelium
highly thombogenic rim of foamy macrophages
58
what cells reside in the fibrous cap of atheromas
Inflammatory cells (macrophages, T-lymphocytes, mast cells
59
what occurs late in plaque development
Dystrophic calcification extensive
60
where do atheromas usually form
Form at arterial branching points/bifurcations (turbulent flow)
61
what are the features of a complicated atheromatous plaque
```
established atheromatous plaque
+
haemorrhage into plaque
plaque rupture/fissuring
Thrombosis
```
62
what is the biggest risk factor for atheroma
Hypercholesterolaemia
| lack of functional receptors for LDL cholesterol = elevate cholesterol
63
what are signs of HYPERLIPIDAEMIA
Biochemical evidence: LDL, HDL, total cholesterol, triglycerides
```
Corneal arcus (premature) (lipid in iris)
Tendon xanthomata (knuckles, Achilles)
Xanthelasmata (lipid in eyelid, yellow)
```
64
what are risk factors FOR ATHEROMA
```
Smoking
Hypertension
Diabetes mellitus
Male
Elderly
```
65
what is the process of developing ATHEROMATOUS PLAQUES
1. injury to endothelial lining of artery
2. chronic inflammatory and healing response of vascular wall to agent causing injury
- endothelial injury
- LDL accumulation in wall
- monocyte adhesion, migration to intima, foamy macrophages
- platelet adhesion
- smooth muscle recruitment
- smooth muscle proliferation , T cell recruitment
- lipid accumulation (extracellular and in foamy macrophages)
66
what can be the injury cause of developing atheroma
haemodynamic disturbances (turbulent flow)
hypercholesterolaemia
67
how are injured endothelial cells functionally altered
Enhanced expression of cell adhesion molecules (ICAM-1, E-selectin)
High permeability for LDL
Increased thrombogenicity
68
what happens in acute atherothrombotic occlusion
rupture of plaque → acute event
Rupture exposes highly thrombogenic plaque contents (collagen, lipid, debris) to blood stream → activation of coagulation cascade and thrombotic occlusion
69
what happens if there is total occlusion of a vessel
otal occlusion → irreversible ischaemia → necrosis (infarction) of tissues
70
what happens if there is embolisation from atheromatous plaque
Detachment of small thrombus fragments from thrombosed atheromatous arteries → embolise distal to ruptured plaque
Embolic occlusion of small vessels → small infarcts in organs
71
what are the features of vulnerable plaques
Typically thin fibrous cap, large lipid core, prominent inflammation
72
what are preventative and therapeutic approaches to atheroma
```
Stop smoking
Control blood pressure
Weight loss
Regular exercise
Dietary modifications
```
73
what are secondary preventions to atheroma
Cholesterol lowering drugs,
aspirin
(inhibits platelet aggregation to decrease risk of thrombosis on established atheromatous plaques)
74
Normal Blood Flow is LAMINAR
| smooth, ordered
ggg
75
what is stasis
stagnation of flow
76
what is turbulence
forceful, unpredictable flow
77
what are the 2 types of abnormal blood flow
stasis
| turbulence
78
what are the component of Virchow’s Triad
Changes in the blood vessel wall
Changes in the blood constituents
Changes in the pattern of blood flow
79
what is thrombosis
Formation of a solid mass from the constituents of blood within the vascular system
80
what are the causes of thrombosis
Endothelial injury, atheromatous plaque
Stasis or turbulent blood flow
Hypercoagulability of the blood
81
what are the component of thrombus
lines of Zhan
platelets
fibrin meshwork
RBCs trapped
82
what do the consequences of thrombosis depend on
Site
Extent
Collateral circulation
83
what is an embolism
Movement of abnormal material in the bloodstream and its impaction in a vessel, blocking its lumen
84
whats an embolus
detached intravascular solid, liquid or gaseous mass
85
describe thrombus embolus
Systemic/Arterial Thromboembolus
Travel to wide variety of sites: lower limbs most common, brain, other organs
86
what are venous thromboembolus
Originate from deep venous thromboses (lower limbs)
travel to pulmonary circulation may occlude pulmonary artery
87
what is the consquence of multiple pulmonary embolism over time
pulmonary hypertension and right ventricular failure
88
what are risk factors for DVT and pulmonary thromboembolism
```
Cardiac failure,
severe trauma/burns
oral contraceptive
age
bes rest
obesity
```
89
can get fat embolus
ff
90
can get gas embolus, N2 form as bubbles which lodge in capillaries
yy
91
what is Rheumatic Fever
Disease of disordered immunity
Inflammatory changes in the heart and joints
“flitting” (painful) polyarthritis of large joints + skin rashes and fever
had recent streptococcal infection, string antibody reaction
Damage to heart tissue may be caused by combination of antibody-mediated and T cell-mediated reactions
causes mitral stenosis
92
whats pancarditis
inflammation affecting endocardium, myocardium, pericardium) in the acute phase; heart murmurs common
93
what are aschoff bodies
inflammatory cells, Seen in the heart in acute rheumatic fever
94
what can valvular heart disease be a result of
Valvular stenosis: valve thickened/calcified and obstructs normal blood flow into chamber/vessel
Valvular incompetence/regurgitation, loses normal function and fails to prevent reflux of blood after contraction of cardiac chamber
Vegetations: infective or thrombotic nodules develop on valve leaflets impairing normal valve mobility; may embolise
95
in chronic rheumatic heart disease what valvular abnormalities are there
fibrinoid necrosis of the valve cusps/chordae tendineae, form vegetations
thickening of mitral valve
96
what is ischaemia
Relative lack of blood supply to tissue/organ leading to inadequate O2 supply to meet needs of tissue/organ: hypoxia
97
what are the two types of hypoxic hypoxia
(a) Low inspired O2 level
| (b) Normal inspired O2 but low PaO2
98
what is stagnant hypoxia
Normal inspired O2 but abnormal delivery
99
what is cytotoxic hypoxia
Normal inspired O2 but abnormal at tissue level
100
what are factors affecting oxygen supply
1. Inspired O2
2. Pulmonary function
3. Blood constituents
4. Blood flow
5. Integrity of vasculature
6. Tissue mechanisms
101
what is ischaemic heart diease
supply issues - CA atheroma, pulmonary function
| demand issues - heart has high intrinsic demands
102
what type of angina is it with established atheroma in CA
stable angina
103
what type of angina is it with complicated atheroma in CA
unstable angina
104
what can happen if theres an atheroma in aorta
aneurysm
105
what are the consequences of atheroma
MI
Cerebral infarction
abdominal aortic aneurysm
106
what are the effects of ischeamia
functional - O2 supply fails to meet demand due to dec supply; inc demand; or both
biochemical - anaerobic metabolism, cell death
cellular - dif tissues have variable susceptibility to ischaemia
107
whats the outcome of ischeamia
No clinical effect
Resolution vs therapeutic intervention
Infarction
108
what is infarction
Ischaemic necrosis within a tissue/organ in living body produced by occlusion of either the arterial supply or venous drainage
109
what is the aetiolgoy of infarction
cessation of blood flow
| e.g. thrombosis, embolism
110
what are the stages of MI
Anaerobic metabolism, onset of ATP depletion
Loss of myocardial contractility (->heart failure)
Ultrastructural changes
in 20-30mins irreversible damage
111
what appearance change would see you due to infarcts in 12 hours
see swollen mitochondria on Electron Microscopy
112
what appearance change would see you due to infarcts in 24-48hrs
Pale infarct: e.g. myocardium, spleen, kidney. Solid tissues
Red infarct: e.g. in lung, liver Loose tissues, previously congested tissue
113
what appearance change would see you due to infarcts 72hrs onwards
Pale infarct - yellow/white and red periphery
Red infarct - little change
Microscopically: chronic inflammation; macrophages remove debris; granulation tissue; fibrosis
114
what will infarcts look like at the end
Scar replaces area of tissue damage
| Shape depends on territory of occluded vessel
115
what are transmural MI
ischaemic necrosis affects full thickness of the myocardium
116
what are Subendocardial infarction
ischaemic necrosis mostly limited to a zone of myocardium under the endocardial lining of the heart
117
what are acute infarcts classified by
whether there is elevation of the ST segment on the ECG
118
whats a non-STEMI
no ST segment elevation but a significantly elevated serum troponin level
correlate with a subendocardial infarct
119
what is angina
a discomfort in the chest and/or adjacent areas associated with myocardial ischaemia but without myocardial necrosis”
120
what causes MI and results in anginal symptoms
Mismatch between supply of O2 and metabolites to myocardium and the myocardial demand for them
due to reduction in CA blood flow to mycardium
- coronary atheroma
121
what is an obstructive plaque
obstructs > 70% lumen
122
what are acute coronary syndromes
Spontaneous plaquerupture & localthrombosis, with degrees of occlusion
123
how do you diagnose angina
history:
- site of pain
- character of pain (tight band, pressure)
- radiation sites
- aggravating (w exertion, stress)
124
what features in the history make angina less likely
Sharp/‘stabbing’ pain; pleuritic or pericardial.
Associated with body movements or respiration.
Very localised; pinpoint site.
lasting for hours
125
differential diagnosis for chest pain instead of angina?
```
Aortic dissection
pericarditis
pneumonia
pleurisy
cervical disease
```
126
when do you get symptoms of stable angina
breathlessness on exertion
| excessive fatigue on exertion
127
what classifies severity of angina
Canadian classification of angina severity
| 1-4
128
what does class 1 mean for severity of angina
physical activity does not cause angina, symptoms only on significant exertion.
129
what does 2 mean for severity of angina
Slight limitation of ordinary activity, symptoms on walking 2 blocks or > 1 flight of stairs.
130
what does 3 mean for severity of angina
Marked limitation, symptoms on walking only 1-2 blocks or 1 flight of stairs.
131
what does 4 mean for severity of angina
Symptoms on any activity, getting washed/dressed causes symptoms.
132
what are modifiable risk factors for angina
```
Smoking
Lifestyle- exercise & diet
Diabetes mellitus
Hypertension
Hyperlipidaemia
```
133
on examination for angina what is seen
Tar stains on fingers.
Obesity
Xanthalasma and corneal arcus (hypercholesterolaemia).
Hypertension
134
what investigations would you do for angina
Full blood count, lipid profile and fasting glucose; Electrolytes, liver & thyroid tests would be routine.
(CXR
electrocardiogram)
135
what specialist investigations are there for angina
exercise tolerance test
myocardial perfusion imaging
- comparison between stress and rest images
CT coronary angiography
136
when would you do an invasive angiography
Early or strongly positive ETT
Angina refractory to medical therapy.
Diagnosis not clear after non-invasive tests.
Young cardiac patients due to work/life effects.
Occupation or lifestyle with risk
137
what happens in a coronary angiography
under local anaesthetic
arterial cannula inserted into femoral/radial artery
into ostium of CA
radio opaque contrast injected, visualised on X-ray
138
what treatment strategies are there for angina
general - address risk factors, bp, cholesterol, PA
medical - druhs to reduce disease progression & symptoms
revascularisation - Percutaneous coronary intervention (PCI) & coronary artery bypass grafting
139
what medical treatment is there for angina for progression
Statins, if total cholesterol >3.5 mmol/l
ACE inhibitor, if inc CV risk and atheroma
Aspirin, 75mg or Clopidogrel if intolerant of aspirin
140
what medical treatment is there for angina for relief of symptoms
```
ß-blockers; achieve resting hr <60 bpm
Ca2+ channel blockers; achieve resting hr <60 bpm, produce vasodilation- amlodipine
Ik channel blockers, ^^
nitrates - vasodilation
K+ channel blockers - nicorandil
```
141
what is Percutaneous coronary intervention
coronary angioplasty and stenting
squash atheroma
effective for symotims
142
what patients get benefit from Coronary artery bypass surgery (CABG)
>70% stenosis of left main stem artery
| proximal three-vessel coronary artery disease
143
what vein is usually used for coronary artery bypass grafting
long saphenous vein
144
what is acute coronary syndrome
New onset of a collection of symptoms related to a problem with the coronary arteries
can lead to MI
145
what is the aetiology for acute coronary syndrome
smoking
alcohol
unhealthy food
146
what is stable angina
Caused by “stable” coronary lesion
Predictable symptoms due to narrowing
Symptoms relieved by rest
147
what is unstable angina
Caused by “unstable” coronary lesion
Unpredictable
May occur at rest
148
how do you diagnose myocardial infarction
Detection of cardiac cell death:
+ve cardiac biomarkers - troponin
AND one of
symptoms of ischaemia
new ECG changes
evidence of coronary problem on coronary angiogram or autopsy
149
what is a cardiac biomarker
troponin
| myoglobin
150
what are the types of myocardial ischaemia/infarction you get
plaque rupture w thrombus
endotherlial dysfunction
athersclerosis
supply-demand imbalance
151
what is the history for patients with acute coronary syndrome
Ischaemic-sounding chest pain
may radiate to neck/arm
“discomfort” or a “weight” or “tightening”
May be nausea, sweating, breathlessness
152
what are acute coronary syndrome risk factors
male, age, known heart disease, hypertension, diabetes, High cholesterol
Smoker
153
what would you see on examination for patients with acute coronary syndrome
May look very unwell if having a STEMI
May look completely fine
check HR, BP
listen for murmurs, crackles in chest
154
what investigations would you do for coronary syndrome
ECG
| blood test - troponin levels
155
what does ST segment depression mean
Partial coronary occlusion
156
what does ST segment elevation mean
Complete coronary occlusion
157
what is the issue with using ECG for patients with posterior myocardial ischeamia
may not see any ST elevation anywhere, even if the LCircumflex is completely blocked
BUT will see opposite changes in the leads opposite those looking at that area (V1-V2)
158
how can reperfusion therapy be carried out, what does it do
opens the blocked artery
mechanical - in cath lab w balloons and stents
pharmacological - strong blood thinner
159
when would you use thrombolysis for myocardial ischeamia
given in ambulance when going to hospitak
| v strong blood thinner
160
what are the risks of thrombolysis
Bleeding
Don’t give if recent stroke, or ever had a previous intracranial bleed
Caution if had recent surgery, on warfarin, severe hypertension
161
how do you manage acute coronar syndroe
```
Admit to hospital
ECG
Attach to a cardiac monitor
Gain iv access
Give O2 only if levels low
```
162
what treatment would you give for acute coronary s
Glycerol trinitrate (GTN) - vasodilator
Opiates - for pain
others - B blockers
- statins, lower cholesterol
- ACE inhibitor
163
what are some dual anti-platelet therapies
aspirin
clopidogrel
ticagrelor
164
what are some dual anti-coagulant therapies
heparin
| fondaparinux
165
what would you do for ACS in hospital
attach to cardiac monitor 24-48hrs
listen for murmurs
organise echocardiogram
166
whats cardiac tamponade what causes it
blood or fluids fill the pericardium - myocardial rupture and bleeds in
167
what mechanical complications can you get post MI
Myocardial rupture
Acute Ventricular Septal Defect
Mitral valve dysfunction due to papillary muscle rupture
168
what is target BP in over 80 yr olds
< 145/85
169
at what risk of cardiovascular disease should a patient be treated for hypertension
if risk exceeds 10% in 10 years
170
what is colliquitive necrosis
breakdown of tissue to liquid
| occurs in brain after infarction
171
what is coagulative necrosis
architecture of dead tissue is largely maintained
| e.g. heart
172
what is the definition of stable angina
A clinical syndrome of predictable chest pain or pressure precipitated by activities such as exercise or emotional stress, which increase myocardial oxygen demand.
173
what are the risk factors fir angina
```
Hypertension
Smoking
Hyperlipidaemia
Hyperglycaemia
male
```
174
why does an angina attack begin
result of mismatch between myocardial blood/ oxygen supply and demand
anything that increases HR, SV, BP
175
how can drugs help with angina
Decrease myocardial oxygen demand by reducing cardiac workload
Reduce heart rate
Reduce myocardial contractility
Reduce afterload
176
what drugs are rate limiting for angina
Beta-adrenoceptor antagonists
Calcium channel blockers
Ivabradine
177
what drugs are vasodilators
Calcium channel blockers
| Nitrates oral, sublingual
178
what drug is a K channel activator
nicorandil
179
What drug is a Na current inhibitor
Ranolazine
180
what do B blockers do?
block the sympathetic system
reversible antagonists of the B1 and B2 receptors
- dec determinant of myocardial O2 demand
- improved perfusion of the subendocardium by increasing diastolic perfusion time
181
what are adverse drug reaction of B blockers
Tiredness /fatigue
Lethargy
Impotence
Bradycardia
182
examples of beta blocker drugs
Bisoprolol, Atenolol
183
example fo CCB drugs
DILTIAZEM, VERAPAMIL - rate limiting, reduce HR and force of contraction
AMLODIPINE - reduce BP and afterload, vasodilator
184
what do CCBs do
Prevent calcium influx into myocytes and smooth muscle lining arteries and atrerioles by blocking the L-Type calcium channel
- rate limitng
- vasodilating
185
NEVER USE NIFEDIPINE IMMEDIATE RELEASE may precipitate acute MI or stroke
with CCB
ttg
186
what are some nitrovasodilators
GLYCERYL TRINITRATE (GTN)
ISOSORBIDE MONONITRATE
ISOSORBIDE DINITRATE
187
what do nitro-vasodilators do
relax almost all smooth muscle by releasing NO which then stimulates the production of cGMP which produces smooth muscle relaxation.
Reduce preload (peripheral venodilation) and afterload (arteriolar dilation)
188
what are some second line therapies for angina after B blockers/CCB
Nicorandil-Potassium channel activation
Ivabradine-Sinus node inhibition
Ranolazine-Late Na+ current inhibition
189
what are some anti-platelet therapies
aspirin
| P2Y12 inhibitors - clopidogrel, ticagrelor, prasugrel
190
what adverse effect can low dose aspirin cause
GI bleed
191
what are some cholesterol lowering drugs
statins
192
what is heart failure
impairment of the heart as a pump. It is caused by structural or functional abnormalities of the heart.
193
what are signs of heart failure
congestion in the lungs, shortness of breath, oedema in the lower extremities, and enlargement of the liver,
caused by the inability of the heart to pump blood at an adequate rate to the peripheral tissues and the lungs.
194
what is Left Ventricular Systolic Dysfunction
Decreased pumping function of the heart, which results in fluid back up in the lungs and heart failure
195
what is Left Ventricular Diastolic heart failure
Involves a thickened and stiff heart muscle
As a result, the heart does not fill with blood properly
This results in fluid backup in the lungs and heart failure
196
what are major risk factors for heart failure
hypertension
| MI
197
in heart failure
As circulatory volume increases the heart dilates, the force of contraction weakens and cardiac output drops further
leads to vasoconstriction, RAAS
hbj
198
what are loop diuretics
furosemide
diuretics induce profound diuresis by inhibiting the NA-K-Cl transporter in the Loop of Henle
prevent reabsorption of filtered Na and water
199
what drug drug interactions does frusemide have
vancomycin, lithium, NSAIDs - renal toxicity
200
what are Mineralocorticoid receptor antagonists
block receptors that bind aldosterone and other steroid hormone
201
what does ivabradine do
slows the heart rate through inhibition of the If channel in the sinus node
202
what is digoxin
Increases availability of calcium in the myocyte
| stronger contraction
203
how can you increase myocardial oxygen supply in. ACS
Thrombolysis
| Coronary vasodilation.
204
what are the 2 types of fibrinolytic drugs
```
Fibrin-specific agents such as
alteplase,
reteplase,
tenecteplase
All catalyse conversion of plasminogen to plasmin in the absence of fibrin.
```
Non–fibrin-specific agents such as streptokinase catalyse systemic fibrinolysis.
205
ticagrelor is more effective than clopidogrel as anti-platelt therapy
P2Y12 ADP receptor antagonist
use in combination with aspirin
gh
206
what are the main risk factors for CVD
diet, obesity, hypertension, diabetes, genetic, alcohol, smoking, PA
207
what are pro-atherogenics in diet
```
Cholesterol
Saturated FA
Trans FA
Sodium
Alcohol
```
208
what are anti-atherogenics in diet
```
poly unsaturated fatty acids PUFA
CHO-rich diet, carbohydrates
NSP, non-starch polysacharides
MUFA
Antioxidant?
Phytochemicals?
```
209
how much saturated FA's can women and men have each day
men - 30g
| women - 20g
210
what is the recommendation for salt intake
6g NaCl/day (2.3g
sodium)
P
211
what is oleic acid
Monounsaturated FA
reduces both total
and LDL cholesterol in the plasma
212
what is N-3 PUFA
fish oil
| reducing sudden death and non-fatal MI
213
what do whole grain foods do
oats lower serum cholesterol by 5-
8%
dec CVD risk
214
what is stroke
Neurological deficit (‘loss of function’)
of sudden onset,
lasting more than 24 hours,
of vascular origin
blocked or ruptured blood vessel in the brain causing a failure of neuronal function leading to some deficit in brain function
215
what is it called when you have stroke symptoms but lasts for less than 24 hrs
Transient Ischaemic Attack
216
what causes stroke
```
Blockage with thrombus or clot
Disease of vessel wall
Disturbance of normal properties of blood
Rupture of vessel wall
(haemorrhage)
```
217
what is a large artery disease how does it cause stroke
Carotid stenosis
| plaque in area of bifurcation, get a clot, can break off and travel to vessel in brain
218
what is Cardioembolic stroke how does it cause stroke
Atrial fibrillation commonest cause
clot break off in left atrium and travel to cerebral vessels
219
what is small vessel (lacunar) stroke
stroke in small arteries in the brain
220
what are risk factors for stroke
```
hypertension
smoking
age
fam history
waist - hip ratio
PA
diabetes
cholesterol
```
221
what is haemorrhage
rupture of bv in brain, causes pressure
222
what is the result of ischaemia
hypoxia
-> anoxia (no O2)
-> infarction -> necrosis
can also get oedema (swelling)
223
what is the penumbra
area around ischeamic core in brain
224
what vessels supply the brain
2 common carotid arteries
- external carotid
- internal carotid - anterior, middle, posterior
2 vertebral arteries
-> bascillar -> posterior cerebral artery
225
what does temporal lobe do
hearing
| intellectual and emotional functions
226
what does parietal lobe do
comprehend language
227
what does occipital lobe do
vision
228
what does frontal lobe do
smell
judgement
voluntary movement
229
what are the symptoms of stroke
```
Motor (clumsy or weak limb)
Sensory (loss of feeling)
Speech: Dysarthria/Dysphasia
Neglect / visuospatial problems
Vision: loss in one eye, or hemianopia
Gaze palsy
```
230
how do stroke units save more lives than a general ward
nursed appropriately
therapists involved early
CT scanning and medication
231
what should acute stroke therapies do
Restore blood supply.
Prevent extension of ischaemic damage.
Protect vulnerable brain tissue.
Avoid reperfusion injury
Be non-toxic
232
what drug may be given for stroke
thrombolysis
alteplase
restores blood flow
use within 90mins of stroke for best benefit
233
what investigations would you do for stroke
CT - first choice in emergency
- causes damage to hair
MRI - takes long
fast field cycling MRI
234
how can the clot be removed in stroke
catheter up to brain, pull out clot
| - thromboectomies
235
what other treatments can you give for stroke apart from thrombolysis
antiplatlets
statins
BP management
anticoagulation
236
what is the histology of the aorta
Tunica intima
Layer of endothelial cells
Subendothelial layer – collagen and elastic fibres
Separated from tunica media internal elastic membrane.
Tunica media
smooth muscle cells
secrete elastin in the form of sheets, or lamellae
Tunica adventitia
Thin connective tissue layer
Collagen fibres and elastic fibres
collagen in the adventitia prevents elastic arteries from stretching beyond their physiological limits during systole
237
what is an aneurysm
A localised enlargement of an artery caused by a weakening of the vessel wall
238
what are the types of aneurysm
true - saccular (one side), fusiform (both sides)
false
dissecting aneurysm
239
what is a false aneurysm
Rupture of wall of aorta with the haematoma either contained by the thin adventitial layer or by the surrounding soft tissue
240
what causes false aneurysm
Trauma
Iatrogenic
Inflammation ( eg endocarditis with septic emboli)
241
what is a true aneurysm
Weakness & dilation of wall
| Involves all 3 layers
242
what is presentation of aneurysms
Asymptomatic
Based on the location of the aneurysm.
Shortness of breath (associated aortic regurgitation)
Dysphagia and hoarseness
Back pain
Symptoms of dissection - sharp chest pain radiating to back (between shoulder blades), hypotension
Pulsatile mass
243
what investigations are done for thoracic aneurysms
```
CXR - widened mediastinum
CXR – widened mediastinum
Echocardiogram – assess aortic root size and aortic valve
CT angiogram aorta – diagnostic
MRI aorta - diagnostic
```
244
what is aortic dissection
Tear in the inner wall of aorta
Blood forces walls apart
Acute –medical/surgical emergency
Chronic
May occlude branches
Rupture - back into the lumen or externally in to pericardium (tamponade) or mediastinum
245
what are the Aetiological factors of aortic dissection
```
Hypertension
Atherosclerosis
Marfan's syndrome
Bicuspid aortic valve
Trauma
```
246
what symptoms are there for aortic dissection
Chest pain – severe, sharp, radiating to back (inter-scapular)
Collapse (tamponade, acute AR, external rupture)
Stroke (involvement of carotid arteries)
247
what is seen in examination for aortic dissection
```
Reduced or absent peripheral pulses
Hypertension or hypotension
BP mismatch between sides
Soft early diastolic murmur (aortic regurgitation)
Pulmonary oedema
```
248
what investigations are done for aortic dissection
ECG
CXR - widened mediastinum
Transthoracic echocardiogram (TTE)
CT angiogram aorta - confirms diagnosis
249
what treatment is there for aortic dissection
Type A
Blood Pressure control
beta blocker, IVI nitrate, calcium channel blocker, IVI Sodium nitroprusside
Emergency Surgery
Type B
bp control
Percuraneous (endo-vascular) intervention
250
what are infections that affect aortic dissection
Takayasu’s Arteritis
| Syphilis
251
what are some congenital aortic aneurysm diseases
Bicuspid Aortic Valve
Coarctation
Marfan’s Syndrome
252
what is bicuspid aortic valve
usually 3 valves in aorta, only 2
reduces tensile strength
prone to aortic valve stenosis/regurg
253
what is aortic coarctation
Aortic narrowing close to where
| Ductus arteriosus inserts
254
what r the 3 types of aortic coarctation
Pre-ductal can be life-threatening if severe narrowing
Ductal
Post-ductal, most common in adults – hypertension in upper extremities, weak pulses in lower limbs
255
what are signs of coarctation
```
Cold legs
Poor leg pulses
If before left subclavian artery:
Radial – radial and RIGHT radial-femoral delay
If after left subclavian artery:
No radial- radial delay
Right and left radio-femoral delay
```
256
how does the pulse change if coarctation is before left subclavian artery
radial and RIGHT radial-femoral delay
257
how does the pulse change if coarctation is after left subclavian artery
No radial- radial delay
| Right and left radio-femoral delay
258
what is treatment of coarctation
Percutaneous or surgical correction
259
what is Marfan's Syndrome
Fibrillin 1 gene
Connective tissue weakness
Aortic/ Mitral valve prolapse – regurgitation
260
what is an aneurysm
abnormal focal dilation of an arterial wall involving all 3 layers
most common type - infra renal aortic abdominal aneurysm
261
how do you screen and diagnose aneurysm
ultrasound
262
how do you do endovascular repair for abdominal aortic aneurysm
Femoral access
| Aortic Neck; fixation and seal with stent
263
what types of stents are there
```
Bare metal
-self expanding
-balloon expandable
Covered
-Hostile disease
-Aneurysm treatment
Drug eluting
```
264
what is open AAA repair
very invasive
Requires laparotomy
Requires aortic cross clamping and usually ICU care
Blood loss
265
what anatomical vascular imaging is there
Plain radiographs
catheter angiography
Ultrasound
Ct/mri
266
what functional vascular imaging is there
Radionuclide imaging
Mri functional imaging
ultrasound
267
what is a catheter angiography
VESSEL PUNCTURED AND CATHETERISED.
STERILE PROCEDURE
CONTRAST INJECTED USING PUMP INJECTOR
RAPID SERIES OF IMAGE ACQUISITION
268
what do you look for in circualtory imaging
Is there a blockage?
Is the occlusion/stenosis clinically significant?
Is there a leak?
aneurysm rupture
269
what are the limitations of CT
Leaks
Won’t identify small volume leaks
Snapshot images, cannot exclude intermittent bleeding
Blockages
Can’t always differentiate between acute and chronic thrombosis
270
what are the different phases of a CT scan
```
non-contrast
arterial phase
venous phase - see liver
nephrogenic phase - see renal system
delayed phase - wash out of contrast in abdominal structures
```
271
what are the ideal properties of contrast agents
HAS AN ATTENUATION COMPARABLE TO SURROUNDING SOFT TISSUES.
INEXPENSIVE
INERT
EQUAL DISTRIBUTION IN AND OUT OF SELECTED BODY COMPARTMENTS
PAINLESS
EASE OF USE
272
what intravenous contrast is used
IODINE
| high density
273
how does Ultrasound work
electricity
- > Ultrasound waves (via piezoelectric effect)
- > reflects back, off boundaries in tissues
- > turned back into electricity
- > converted into pictorial form
274
what is US B-mode
Scans an anatomical plane
Gives anatomical representation of structures
brightness 2D image
275
what is US M-mode
Fixed plane over time axis
To assess heart valve movement as well as heart chamber dimension and function
2D image
276
what is US doppler scanning
Flow alters frequency of ultrasound waves returning to the probe.
To show direction/velocity of flow.
Common clinical use include the detection of deep vein thrombosis (DVT).
277
what is the US contrast
Contrast made from microbubbles
| Inert gas, surrounded by a shell
278
what are the indications for US contrast
Characterising lesions (dynamic uptake pattern)
Assessment of organ perfusion
Delineating organ edge (eg. For irregularity of heart valves)
Alternative to CT/MRI if unable to tolerate/allergic to other forms of contrast.
279
what is windowing
changes shading of pixels to make easier for human eye to appreciate particular structures
280
what are varicose veins
A varicose vein is a dilated and tortuous, often superficial vein
n lower limbs
due to valvular failure
281
what veins are there anteriorly in lower limb
Dorsal venous arch drains into the LSV, which passes anterior to the medial malleolus - > femoral vein
282
what veins are there posteriorly in lower limb
The plantar venous arch drains into the SSV which travels posterior to the lateral malleolus, up the posterior aspect of the leg and drains into the popliteal vein
283
what assists flow against gravity in veins in lower limbs
Valves
Calf muscle pump
Perforating veins to drain blood into the deep system
284
what are causes of valvular failure
DVT
Hormonal changes
large pelvi tumour
surgery/trauma
285
what occurs if one valve fails
venous pressure increases, there is dilatation of the distal vein and further valvular incompetence.
286
what are the risk factors for varicose veins
```
Age
Females
Pregnancies
DVT
Standing for long periods (occupation)
Family history
```
287
how do you diagnose varicose veins
```
Burning
Itching
Heaviness
Tightness
Swelling
Discolouration
```
288
what are special tests you can do to diagnose varicose veins
Tap test
Trendelenburg test
Doppler
289
what investigations do you do for varicose veins
US
290
how do you treat varicose veins
First line: Endovenous treatment
Second line: Ultrasound guided foam sclerotherapy
Third line: Open surgery
if intervention unsuitable - compression hosiery
291
what is endovenous treatment
The LSV or SSV is cannulated under ultrasound guidance
catheter passed up
causes injury to vein, cause fibrosis and occlusion of vessel = disappearance of vein
292
what is chronic venous insufficiency
Failure of calf muscle pump
Superficial venous reflux
Deep venous reflux
Venous obstruction
cam lead to impaired tissue perfusion
293
what are signs of chronic venous insufficiency
```
Oedema
Telangiectasia
Eczema
Haemosiderin pigmentation
Hypopigmentation
ulcers
```
294
what are venous ulcers
```
Breach in the skin between the knee and ankle joint, present for >4 weeks
Granulomatous (red) base
Shallow
Exudative, oedematous
Painless, pulses present
```
295
what investigations do you do for venous ulcers
History
Examination
ABPI
ankle brachial pressure index
296
what treatment is there for venous ulcers
Exclude arterial disease (ABPI)
Wound care – little role for systemic antibiotics
Elevation
Compression bandaging
Shockwave therapy
297
what is lymphoedema
primary - congenital, puberty, or >35
| secondary - malignancy, surgery
298
what is the treatment of lymphoedema
Elevation
| Drainage
299
what is chronic limb ischaemia
Atherosclerotic disease of the arteries supplying the lower limb
300
what are the risk factors for limb ischeamia
```
Male
Age
Smoking
Hypercholesterolemia
Hypertension
Diabetes
```
301
what is in the history of chronic limb ischaemia
Claudication: Exercise tolerance, effect of incline, change over time, relieved by rest? Where in the leg, type of pain.
Rest pain: Type of pain, relieving factors
Tissue loss: Duration, history of trauma, peripheral sensation
302
what would you see/do on examination for chronic limb ischaemia
Ulceration
Pallor
Hair loss
feel - temp, capillary refill, sensation, pulse
auscultate - w doppler
303
what are special examination tests for chronic limb ischaemia
Ankle Brachial Pressure Index
| Buerger’s test
304
what investigations would you do for chronic limb ischaemia
Duplex
CT/MRI
Digital subtraction angiography
305
how do you treat chronic limb ischaemia
```
combo of antiplatelet + statins
control BP
smoking cessation
diabetic control
PA
```
306
how can you revascularize chronic limb ischaemia
Open Surgery
| Endovascular intervention
307
what is acute limb ischaemia
Arterial embolus: MI, AF, proximal atherosclerosis (NOT DVT/PE)
Thrombosis: Usually thrombosis of a previously diseased artery.
Trauma
Dissection
Acute aneurysm thrombosis
308
what is the presentation of acute limb ischaemia
```
Pain
Pallor
Pulse Deficit
Paraesthesia
Paresis/Paralysis
Poikilothermia (cold)
```
309
history of acute limb ischaemia
```
Cardiac history
Onset/duration of symptoms
History of chronic limb ischaemia
Risk factors for CLI
Functional status
```
310
how do you manage acute limb ischaemia if limb is salvageable
embolectomy
| thrombectomy/thrombolysis
311
how do you manage acute limb ischaemia if limb is not salvageable
palliate
| amputate
312
what is diabetic foot disease
foot ulcer
313
how do you manage diabetic foot disease
Prevention
Diligent wound care
Infection – consider systemic antibiotics
revascularization - by angioplasty/stent
amputate
314
what is the interstitium of the lung
connective tissue space
around the airways and vessels
and the space between the basement membranes of the alveolar walls
315
what is restrictive lung disease
restrict lung expansion on inspiration
Reduced Lung Compliance
low FEV1 & Low FVC but FEV1/FVC normal ratio
Reduced Gas Transfer
- Diffusion abnormality
Ventilation/Perfusion Imbalance
316
how does restrictive lung disease present
DYSPNOEA
Shortness of Breath on exertion
Shortness of Breath at rest
Respiratory Failure – Type 1
Heart Failure
317
what is the outcome of interstitial lung injury in chronic response
Fibrosis or End-Stage Honeycomb Lung
318
what is diffuse alveolar damage
```
acute response to interstitial lung disease
Protein rich oedema
Fibrin
Hyaline membranes
Denuded basement membranes
Epithelial proliferation
Fibroblast proliferation
Scarring - interstitium and airspaces
```
319
what can cause DADs
Major trauma
Chemical injury / toxic inhalation
Circulatory shock
Drugs
320
what is sarcoidosis
```
A multisystem granulomatous disorder
of unknown aetiology
histological - non-caseating granuloma
F>M
multisystem - lymph nodes, lungs etc involved
upper zone disease
```
321
how does sarcoidosis present
```
1 Young adult
joint pain
Erythema nodosum - red spotty painful legs
Bilateral hilar lymphadenopathy
red eyes
2 Incidental abnormal CXR or CT
3 SOB, cough and abnormal CXR
```
322
how do you diagnose sarcoidosis
```
Clinical findings
CXR - spotty lungs, lymph gland swelling at hilum bilaterally
pulomary function tests
bloods, urine, eye exam
(bronchoscopy)
biopsy
```
323
what is Hypersensitivity Pneumonitis
granulomatous response to interstitial lung disease
| antigens - Thermophilic actinomycetes, bird proteins, fungi
324
how does Hypersensitivity Pneumonitis present acutely
Fever, dry cough, myalgia,
Chills 4-9 hours after Ag exposure
Crackles, tachyopnoea, wheeze
Precipitating antibody
325
how does Hypersensitivity Pneumonitis present chronically
Insidious
Malaise, SOB, cough
Low grade illness
Crackles and some wheeze
326
what is usual interstitial pneumonitis
```
scarring of lung tissue
seen in
Connective tissue diseases
Drug reaction
Post infection
Industrial exposure
```
327
what is the histopathology of interstitial pneumonitis
Patchy interstitial chronic inflammation
Type II pneumocyte hyperplasia
Smooth muscle and vascular proliferation
328
what is idiopathic pulmonary fibrosis
usual interstitial pneumonitis
eldery
m>f
reduces gas transfer
329
how does idiopathic pulmonary fibrosis present
Dyspnoea, Cough,
Basal Crackles, Cyanosis, Clubbing
restrictive pulmonary function test
330
how do you treat mild sarcoidosis
no treatment
331
how do you treat erythema nodosum (red spots on leg)
NSAIDS
332
how do you treat skin lesions from sarocidosis
topical steroids
333
what can sarcoidosis result in if there are extra-pulmonary complications
progressive resp failure
bronchiectasis
haemoptysis, pneumothorax
334
how do you manage idiopathic pulmonary fibrosis
oral anti fibrotic, pirfenidone
palliative care
surgery - transplant
335
what is atrial fibrillation
rapid and irregular beating of the atrial chambers
no P wave sometimes, QRS irregular
pulse irregular
do ECG
336
how does atrial fibrillation present
Asymptomatic
Palpitations, dyspnoea, chest pain, fatigue
Embolism
337
what investigations would you do for atrial fibrillation
Document arrhythmia on ECG – 12 lead, 24 hour recording, event recorder
Blood tests esp thyroid function
Echocardiogram
338
what therapeutic approaches are there for atrial fibrillation
Beta blocker/ca-antagonist/digoxin versus class Ic/III drugs
Electrical approaches
Pace & ablation of AV node (ocassionally)
Substrate modification eg Pulmonary vein isolation, surgical procedures
anticoagulation
339
what is supraventricular tachycardia and what are its signs
AV-nodal re-entrant tachycardia, very fast HR
palpitations, dyspnoea, dizziness
340
what is ventricular fibrillation
rapid and irregular electrical activity renders the ventricles unable to contract in a synchronised manner
341
what is ventricular tachycardia
ventricles depolarising irregularly and rapidly
Palpitations, CP, dyspnoea, dizziness, syncope
Usually structural heart disease
342
what is long QT syndrome
congenital or acquired
343
what indications are there for implantable cardioverter defibrillator
Cardiac arrest due to VF/VT not due to transient or reversible cause eg early phase of acute MI
Sustained VT causing syncope or significant compromise
Sustained VT with poor LV function
344
indication for pacemakers
temporary- intermittent or sustained symptomatic bradycardia
permanent - 2nd/3rd degree AV block
345
brain natriuretic peptide levels elevated in heart failure
fssf
346
what is sinus arrest
sinoatrial node of the heart transiently ceases to generate the electrical impulses
AV node takes over after few seconds
347
what are atrial ectopic beats
extra heartbeat caused by a signal to the upper chambers of the heart (the atria) from an abnormal electrical focus
atrial premature beat
348
what are ventricular ectopic beats
premature ventricular contractions
349
what is an arrhythmia
A deviation from the “normal” rhythm of the heart
350
what us the resting membrane potential of myocardial cells
-90mV
351
what antiarrhythmic drug classification
The Vaughan Williams classification
352
what are class 1 antiarrhytmic drugs
Sodium Channel Blockers
- dec amplitude of AP
- reduce velocity of conduction
quinidine, lidocaine, flecainide
353
what are class 2 antiarrthymic drugs
Beta Blockers
block sympathetic innervation
atenolol, bisoprolol
354
what are class 3 antiarrthymic drugs
Potassium Channel blockers
inc AP duration
for life threatening V tachycardia
amiodarone
355
what are the side effects of amiodarone
Pulmonary fibrosis
Slate – grey pigmentation
Corneal deposits
LFT abnormalities
356
what are class 4 antiarrhythmic drugs
Calcium Channel Blockers
slows HR and AV node conduction
verapamil, diltiazem
357
what is digoxin
```
class 5 antiarrhythmic
Inhibits the sodium-potassium ATPase pump
long half life
```
358
what are the results of digoxin toxicity
Nausea and vomiting
Xanthopsia - yellow vision
Bradycardia
Tachycardia
359
what can you use to treat digoxin toxicity
stop
| digibind
360
what is adenosine
Slows/ Blocks conduction through the AV node
| v short half life
361
what are indications for anti- coag in heart failure
Atrial fibrillation
| Risk of stroke, peripheral emboli
362
what are some oral anticoagulants
Vitamin K antagonist
Warfarin
Direct Thrombin Inhibitor
Dabigatran
Direct Xa inhibitors
363
what are the side effects of warfarin
Bleeding
Interaction with multiple other drugs
Pregnancy
Teratogenic
364
what is darcy's law
blood flow = dif in pressure/resistance
365
what is congestion
Relative excess of blood in vessels of tissue or organ
- passive
- acute or chronic
366
what is congestive cardiac failure
```
Heart unable to clear blood, right & left ventricles
dec CO
dec filtration rate
inc Na and H2O retention
inc fluid in body
```
367
what are the effects of congestive cardiac failure
RV and LV cannot clear blood from ventricles
Back pressure, blood dammed back in veins
Lungs - pulmonary oedema
Left heart failure – blood dams back into lungs
Clinically, crepitations in lungs, tachycardia
Liver - central venous congestion
Right heart failure- blood dams back to systemic circulation
inc JVP, hepatomegaly, peripheral oedema
368
what is the effect of right heart failure
blood dams back to systemic circulation
| inc JVP, hepatomegaly, peripheral oedema
369
what is the effect of left heart failure
Back pressure, blood dammed back in veins
Lungs - pulmonary oedema
Left heart failure – blood dams back into lungs
Clinically, crepitations in lungs, tachycardia
370
describe the normal microcirculation
Constant movement of fluid through capillary beds
hydrostatic pressure from heart
Balanced by osmotic pressures and endothelial permeability
Filtration from capillary beds to interstitium
371
venous side
capillary oncotic pressure > capillary hydrostatic pressure
reabsorption
dda
372
arterial side
capillary hydrostatic pressure> capillary oncotic pressure
filtration
ssf
373
what 3 components affect net flux and filtration
Hydrostatic Pressure
Oncotic Pressure
Permeability characteristics and area of Endothelium
374
what is oedema
Accumulation of abnormal amounts of fluid in the extravascular compartment
- intercellular tissue compartment (extracellular fluid)
- body cavities
375
what is peripheral oedema
increased interstitial fluid in tissues
376
what are effusions
fluid collections in body cavities
Pleural, pericardial, joint effusions
Abdominal cavity - ascites
377
what is oedema transudate
Alterations in the haemodynamic forces which act across the capillary wall
Not much protein/albumin (few cells)
Lots of H2O & electrolytes
Low specific gravity
378
what is oedema exudate
```
Part of inflammatory process due to inc vascular permeability
Tumour, inflammation, allergy
Higher protein/albumin content (cells)
H2O & electrolytes
High specific gravity
```
379
what is the pathophysiology of pulmonary oedema from left ventricular failure
transudate
inc left atrial pressure -> passive retrograde flow to pulmonary veins, capillaries and arteries
inc pulmonary vascular pressure
inc pulmonary blood volume
inc Pc -> inc filtration and pulmonary oedema
380
what is the pathophysiology of pulmonary oedema in the lungs
perivascular and interstitial transudate
progressive oedematous widening of alveolar septa
accumulation of oedema fluid in alveolar spaces
381
what are the different pathophysiologies of peripheral oedema
Right heart failure – cannot empty RV in systole
Blood retained in systemic veins -> inc P in capillaries -> inc filtration -> peripheral oedema
also portal venous congestion via liver
congestive cardiac failure
382
what is the pathophysiology of lymphatic blockage
Lymphatic Obstruction – hydrostatic pressure upset
| If lymphatic system blocked -> lymphoedema
383
what is the pathophysiology of oedema in abnormal renal function
Salt (NaCl) and H2O retention
```
dec renal function
inc salt and H2O
inc intravascular fluid volume
secondary inc Pc
= oedema
```
384
what can cause abnormal renal function
Primary: acute tubular damage eg hypotension
Secondary in heart failure - reduced renal blood flow
385
what is the Pathophysiology of low protein oedema
capillary oncotic pressure requires normal protein levels
| Hypoalbuminaemia -> dec oncoticC -> inc filtration
386
what is the Pathophysiology of permeability oedema
Endothelial Permeability - exudate
Damage to endothelial lining
inc "pores" in membrane -> osmotic reflection coefficient of endothelium dec towards zero
Proteins and larger molecules can leak out
387
what is the definition of heart failure
clinical syndrome comprising of dyspnoea, fatigue or fluid retention due to cardiac dysfunction, either at rest or on exertion, with accompanying neurohormonal activation
388
what is the mean age for heart failure
74 years
389
what are increasing risk factors for chronic heart failure (CHF)
obesity
hypertension
diabetes
ageing population
390
what are the symptoms of HF
breathlessness
Fatigue
Oedema
Reduced exercise capacity
391
what are the signs of HF
```
Oedema
Tachycardia
raised JVP
chest crepitations or effusions
3rd heart sound
Displaced or abnormal apex beat
```
392
how do you diagnose HF
1) symptoms/signs of HF (rest/exercise)
2) objective evidence of cardiac dysfunction
3) response to therapy (diuretics)
393
how do you obtain objective evidence of cardiac dysfunction
| what investigations do you do
Echocardiography, Radionuclide ventriculography,
MRI,
left ventriculography
394
what is the prognosis of heart failure
60% one year survival rate
395
how can you screen for heart failure
12 lead ecg
| BNP brain natriuretic peptide, elevated in HF
396
what can cause heart failure, the underlying abnormality
almost any structural cardiac abnormality
```
LV systolic dysfunction
Valvular heart disease
Pericardial constriction or effusion
Cardiac arrhythmias: tachy or brady
Myocardial ischaemia/infarctio
```
397
what can cause LV systolic dysfunction
Ischaemic heart disease
Dilated cardiomyopathy
Severe aortic valve disease or mitral regurgitation
398
how can you diagnose LVSD
```
detailed history
antibodies
ECG
(CXR)
always do echo
coronary angiography
```
399
why is an echocardiography an essential investigation for heart dysfunction
can identify and quantify
LV systolic dysfunction
Valvular dysfunction
Pericardial effusion / tamponade
may not identify constriction or shunts
400
what is LV ejection fraction
a continuous biological variable
assess how impaired LV is
disease can inc or dec it
401
what is the LVEF in severe cases
<30%
402
what rule can you use to estimate volume of LV
Biplane modified Simpson’s Rule
volume of each slice = area x thickness
403
what is MUGA scan
obtain an accurate figure for the LVEF
| Ionising radiation
404
what can you use to grade heart failure
new york association classification
1 (no limitation) - 4 (severe)
405
how do you grade severity of HF
Degree of LV impairment
NYHA class ie severity of symptoms
Degree of elevation of BNP
406
what pharmacological treatment is there for HF
```
Diuretics
ACE inhibitors
Betablockers
Aldosterone receptor blockers
Now ARNI (Angiotensin receptor and Neprolysin Inhibitor)
```
407
what drug should not be used in acute HF
beta blockers
408
what is mitral stenosis
narrowing of mitral valve
409
what can cause mitral stenosis
rheumatic heart disease
congenital MS
systemic conditions
410
what is the pathophysiology of mitral stenosis
MV orifice <2 cm2
atrium-vent p gradient inc
LA p increase
pulmonary venous and capillary p increase
PVR (pulm vascular resist) inc
pulm arterial p inc and pulom hypertension
right heart dilatation, tricuspid regurg and pulmonary regurg
411
what does m stenosis severity depend on
Trans-valvular pressure gradient
Trans-valvular
flow rate
412
what are the signs of m stenosis
Dyspnoea
Haemoptisis: rupture of thin-walled veins
Systemic embolisation: LA and LAA enlargement
Infective endocard
Chest pain
Hoarseness (compression of the L recurrent laryngeal nerve)
413
what do you do in clinical examination for m stneosis
```
Mitral facies - pink cheeck
Pulse – normal
JVP – prominent a wave
Tapping apex beat and diastolic thrill
RV heave
Auscultation
```
414
what investigations do you do for mitral stenosis
```
ECG
(cardiac catherisation)
CXR - LA enlargement
echocardiography - thickening and scarring of leaflets
cardiac magnetic resonance
```
415
how would you treat m stenosis pharmacologically
Diuretics and restriction of Na intake
AtriaiFib: SinusRhythm restoration or ventricular rate control
Anticoagulation: all those with AF, debatable in SR
416
what intervential treatment can you do for m stenosis
Valvotomy (balloon vs surgical)
| MV replacement
417
what is the aetiology of m regurg
```
Rheumatic Heart Disease
Mitral valve prolapse (MVP)
IE
Degenerative
Functional MR due to LV and annular dilatation
```
418
what is the pathophysiology of mitral regurg
```
orifice not fixed
affected by:
Preload
Afterload
LV contractility
-> annular enlargement
-> regurg vol increases
```
LV compenstion
acute - end systolic pressure inc and end systol volume dec, wall tension dec
chronic - EDV inc and ESV returns to normal
eccentric LVHypertrophy develops
419
what can cause acute m regurg
valve perforation, chordal/papillary muscle
420
what are the signs of acute m regurg
Breathlessness: pulm oedema, cardiogenick shock
421
what are the signs of chronic m regurg
Fatigue, exhaustion (low CO), Right heart failure
| Dyspnoea or palpitations due to AFib
422
what clinical examinations do u do for m regurg
```
Pulse – normal or reduced in heart failure
JVP – prominent if RH failure present
Brisk and hyperdynamic apex beat
RV heave
Auscultation
```
423
what investigations do u do for mitral regurg
```
ECG - LA enlargement
CXR
cardiac catheterisation
echocardiography
magnetic resonance
```
424
what is the medical treatment for acute m regurg
preload and afterload reduction may be life-saving (sodium nitroprusside, dobutamine, IABP)
425
what is the aetiology of aortic stenosis
Degenerative
Rheumatic
Bicuspid, usually tricuspid
426
what is the patho-physiology of a stenosis due to rheumatic disease
fusion of the commissures and retraction and stiffening of the free cusp margins
427
what is the patho-physiology of a stenosis due to degenerative disease
slow inflammatory process resulting in thickening and calcification of the cusps from base to free margins
428
what is the patho physiology of a stenosis
```
inc LV systolic p
Severe concentric hypertrophy and inc LVMass
inc lV end diastolic p
inc myocardial O2 consumption
MI
LV failure
```
429
what are the symptoms of a stenosis
Long asymptomatic phase
```
cardinal symptoms
Chest pain (angina)
Syncope/Dizziness (exertional pre-syncope)
Breathlessness on exertion
Heart failure
```
430
what clinical examinations do you do for a stenosis
```
Pulse – small volume and slowly rising
JVP – prominent if RH failure present, low BP
Vigurous and sustained apex beat
RV heave
Auscultation
```
431
what investigations for a stenosis
```
ECG
CXR
cardiac catheterisation
echocardiography
magnetic resonance
```
432
what treatment is there for a stenosis
limited to those who develop heart failure
aortic valve replacement/repair
433
what causes aortic regurg
Dilated aorta
Connective tissue disorders
Bicuspid aortic valve
Rheumatic heart disease
Endocarditis
434
what is pathophysiology of m regurg
```
inc LV end diastol vol and LV systol pressure
LV hypertrophy and dilatation
inc myocardial O2 demand
MI
LV failure
```
435
symptoms of chronic a regurg
Long asymptomatic phase
| Exertional breathlesness
436
symptoms of acute a regurg
badly tolerated as wall tension cannot acutely adapt
437
what clinical examinations do you do for a regurg
Pulse – large volume and collapsing (Corrigan sign)
Wide pulse pressure
Hyperdynamic, displaced apex beat
Auscultation
438
what investigations do you do for a regurg
```
ECG
CXR
cardiac catherisation
echocardiogtaphy
magentic resonance
```
439
treatment for a regurg
Vasodilator therapy shown to delay the timing for surgical intervention
440
what surgery can you do for ischeamic heart disease
```
Coronary Artery Bypass Grafting (Sternotomy)
- reversed saphenous vein
- internal mammary arteries
- radial arteries
cardiopulmonary bypass
```
441
what are sternotomy related problems
Wire infection
Painful wires
Sternal dehiscence
Sternal malunion
442
what are some post-op problems in cardiac surgery
Cardiac Tamponade
Death
Stroke
443
what r causes of valvular heart disease
```
Degenerative
Congenital
Infective
Inflammatory
LV or RV dilatation
```
444
what is chronic rheumatic heart disease
heart valves damged due to rheumatic fever (inflammation due to infection)
445
what are indications for surgery in endocarditis
Severe valvular regurgitation - heart failure
Large vegetations
Persistent pyrexia
Progressive renal failure
446
what types of prosthetic heart valves are there
biological - no warfarin required
| mechanical - warfarin required for life but lasts >40years
447
what causes endocarditis
Strep viridans - subacute
| Staph aureus - acute
448
how can you treat endocarditis
antibiotics or surgery
449
what is infective endocarditis
infection involving the endocardial surface
- Valvular structures
- Chordae tendineae
- Sites of septal defects
M>F
450
what are risk factorsfor endocarditis
```
Mitral valve disease
Rheumatic heart disease
Congenital heart disease
Degenerative heart disease
Asymmetrical septal hypertrophy
Intravenous Drug abusers
Alcoholic cirrhosis
Diabetic mellitus
```
451
how does valve become infected
Mechanical endothelial disruption exposures extracellular matrix protein _ production of tissue factors.
Deposition of fibrin and platelets_ Non-bacterial thrombotic endocarditis (NBTE).
NBTE facilitates bacterial adherence and infection.
452
how can endothelial valve be damaged
```
Turbulent blood flow
electrodes
catheters
inflammation
degenerative valve disease
```
453
how do you diagnose IE
Bacteraemia with audible murmur
Atypical presentation: elderly or immunocompromised patients
Acutely :fever, embolic signs/symptoms or decompensated HF
Subacute: fever, non-specific constitutional symptoms or palpitation and immunologic/vascular phenomena
454
what are common symptoms of IE
```
fever/chills
night sweats, malaise, fatigue
weakness
headache
SoB
```
455
clinical signs of IE
```
Cardiac murmur
Janeway lesions - haemorgae on palms
Cutaneous infarcts
osler nodes
splinter haemorrhages
```
456
investigations of IE
```
Blood culture
FBC.ESR/CRP- elevated acute inflammatory makers
renal failure
Urinalysis- +ve for blood
ECG: PR interval prolongation >200ms
CXR: Pulmonary congestion or abscess.
echocardiography
```
457
what IV antibiotics would you give more community acquired IE
ampicillin
cloxacillin
getamicin
458
what IV antibiotics would you give more nosocomial IE
vancomyicin
getamicin
rifampin
459
what should be done for high risk patients for IE
antibiotic prophylaxis
460
how can you prevent IE
```
Strict dental and cutaneous hygiene
Disinfection of wounds
Eradication or decrease of chronic bacterial carriage :skin, urine
No self-medication with antibiotics
limit invasive procedures
```
461
what is a thrombus
blood clot in flowing blood
fibrin
platlets
red blood cells
462
what usually causes venous thrombus
stasis (immobility)
hypercoagulability (pregnancy, cancer, sepsis)
vessel damage
463
what is a thromboembolisms
Movement of blood clot along a vessel
464
what are risk factors for venous thromboembolisms
```
hypertension
copd
obesity
congenital heart disease
fracture
```
465
VTembolism
f>m in young
m>f elderly
hth
466
how does DVT present
```
Unilateral limb swelling
Persisting discomfort
Calf tenderness
[Warmth]
[Redness- erythema]
[Prominent collateral veins]
[Unilateral pitting oedema]
```
may be silent
467
how can you diagnose DVT
Clinical assessment and pretest probability score (Wells score)
Blood test: D-dimer if low pre-test probability score
Imaging: Compression ultrasound if positive D-dimer or high pre-test probability score
468
what is a D-dimer
Breakdown product of cross-linked fibrin
Produced during fibrinolysis
High sensitivity for VTE
Low specificity for VTE
469
what are Symptoms and signs of PE
```
Pleuritic chest pain
Breathlessness- dyspnoea
[Blood in sputum- haemoptysis]
Rapid heart rate- tachycardia
Pleural rub on auscultation
```
470
what are Symptoms and signs of massive PE
```
Severe dyspnoea of sudden onset
Collapse
Blue lips and tongue - cyanosis
Tachycardia
Low blood pressure
Raised jugular venous pressure
```
May cause sudden death
471
what imaging can you do diagnose PE
Isotope ventilation/perfusion scan
| CT pulmonary angiogram
472
how can you treat PE
Anticoagulation is main treatment
473
for PE what treatment can you give IV
low molecular weight heparin
474
for PE what treatment can you give through GI tract
Direct Oral Anticoagulants
Direct thrombin inhibitors
warfarin
475
what is dilated cardiomyopathy
the ventricular function is impaired
| heart muscle becomes weakened and enlarged, cant pump blood as well
476
what is the aetiology of dilated cardiomyopathy
genetic and familial, SCN5A gene
inflammatory
toxic - drugs
injury
477
what are symptoms of dilated cardiomyopathy
Progressive, slow onset, dyspnoea, fatigue, orthopnoea, PND, ankle swelling, weight gain of fluid overload, cough.
478
on examination what would you see for dilated cardiomyopathy
Poor superficial perfusion, thready pulse, irreg if in AF, SOB at rest, narrow pulse pressure, JVP elevated+/- TR waves, displaced apex, S3 and S4, MR murmur often, pulmonary oedema, pleural effusions, ankle oedema
479
what investigations for dilated cardiomyopathy
```
Repeated ECG
CXR
N termial pro Brain Natriuetic Peptide
Basic bloods FBC, U+E
Echo
CMRI, probably best imaging modality
Coronary angiogram
```
480
how would u treat dilated cardiomyopathy
general measures
- correct anaemia
- remove exacerbating drugs
specific
- ACEI
- beta blockers
- spironolactone
- anticoag
481
what is restrictive and infiltrative cardiomyopathy
physiology of filling and myocyte relaxation capacity, the systolic function may or not be impaired
inability to fill well a ventricle whose wall has reduced compliance
482
what investigations for restrictive cardiomyopathy
```
Repeated ECG
CXR
N termial pro Brain Natriuetic Peptide
Basic bloods FBC, U+E
echo
CMRI
```
483
how would you treat restrictive cardiomyopathy
Limited diuretic use as low filling pressures will cause problems
Beta blockers limited ACEI use
Anticoagulants as required
cardiac transplant
484
what is hypertrophic cardiomyopathy
impaired relaxation, affect diastole
systolic function with some functional abnormality
thickened myocaridum, less compliant
sarcomere gene defect, autosomal dominant
wall thickness >14mm or >12mm
485
symptoms for hypertrophic cardiomyopathy
Breathless, palpitations, syncope, exertional symptoms
486
on examination what can be seen for hypertrophic cardiomyopathy
Notched pulse pattern
Irreg pulse if in AF or ectopy
Double impulse over apex, thrills and murmurs,
LVOT murmur will increase with valsalve and decrease with squatting
JVP can be raised in very restrictive filling
487
investigations for hypertrophic cardiomyopathy
ECG
Echo
CMRI
488
treatment for hypertrophic cardiomyopathy
general -
Avoid heavy exercise
Avoid dehydration
specific
Drugs to try and enhance relaxation
beta blockers, verapamil, disopyrimide
If in AF anticoagulate
Obstructive form; surgical or alcohol septal ablation
489
what is myocarditis
Acute or chronic inflammation of the myocardium, viral
| Can impair myocardial function, conduction and generate arrhythmia
490
what is the pathology of myocarditis
Infiltration of inflammatory cells into the myocardial layers, reduced function and heart failure, heart block as conduction system is involved and arrhythmias
491
what are symptoms of myocarditis
Heart failure with fatigue, SOB,
May not have fever
Signs of HF
492
investigations for myocarditis?
```
ECG
biomarkers
echo
CMRI
viral dna PCR
```
493
treatment for myocarditis
Supportive with treatment of heart failure and support for brady and tachy arrhythmias.
Immunotherpay if biopsy or other Ix point to a specific diagnosis
Stop possible drugs or toxic agent exposure
494
what is pericarditis
Inflammation of the pericardial layers with or without myocardial involvement
495
causes of pericarditis?
bacterial, post MI, perforation, dissection of proximal aorta, neoplasia
496
symptoms and signs of pericarditis
```
chest pain with pleuritic features and postual features
Fever
pyrexia
pericardial rub
JVP, raised
low BP
```
497
investigations for pericarditis
ECG and echo, troponin might be raised
498
how do you treat pericarditis
Viral is conservative
idiopathic gets colchicine and limited use of NSAIDs
Bacterial must be drained even if small effusion and antimicrobials
499
what is pericardial effusion
buildup of extra fluid in the pericardium
| tamponade or not
500
what are the symptoms of pericardial effusion
fatige, SOB, dizzy with low BP, occasionally chest pain.
| pulsus paradoxus, JVP raised, low BP, +/- rub, +/- muffled HS
501
tests for pericardial effusion
echo, CXR can show large cardiac shadow
502
treatment for pericar effusion?
drainage Send for MCS, neoplasic cells, protein and LDH
might need surgery if persistant
503
what is constrictive pericarditis
pericardium becomes thickened and scarred
impaired filling although myocardium is normal
504
causes of constrictive pericarditis
idopathic, radiation, post surgery, autoimmune, renal failure, sarcoid.
505
signs and symptoms of constrictive pericarditis
fatigue, SOB, cough
right heart failure with oedema, ascites, high JVP, jaundice, hepatomegally, AF, TR, pleural effusion, pericardial knock
506
investigations for constrictive pericarditis
echo and right heart cath to differentiate from restrictive cardiomyopathy
507
treatment for constrictive pericarditis
careful and limited diuretics and pericardectomy
508
what can be the cause of congenital heart disease
Copy number variation (CNV)
Single nucleotide variation(SNV)
Multifactorial
teratogens
509
what is downs syndrome
trisomy 21
15% atrio ventricular septal defects
duodenal atresia
510
what is turners syndromee
```
45 chromosomes, X
coarctation of aorta
short stature
gonadal dysgenesis
puffy hands
```
511
what syndromes can cause neck webbing and what is it
Excess nuchal folds
```
Turner syndrome
l Noonan syndrome
l CFC syndrome
l Leopard syndrome
l Costello syndrome
```
512
what is noonan syndrome
```
Pulmonary stenosis
l Short stature
l neck webbing
l cryptorchidism
l characteristic face
l PTPN11 gene (chr 12)
```
513
what is 22q11 deletion syndrome
```
C ardiac malformation
A bnormal facies
T hymic hypoplasia
C left palate
H ypoparathyroidism
22 q11 deletion
```
Speech delay/palatal dysfunction common
514
what is Williams syndrome
```
Deletion of Elastin on
chromosome 7
Deletion of contiguous
genes
LIM kinase
```
```
Aortic stenosis
(supravalvar)
l Hypercalcemia
l 5th finger clinodactyly
l characteristic face
l cocktail party manner
```
515
what are some teratogens
```
Fetal alcohol syndrome
Antiepileptic drugs
l Rubella
l Maternal Diabetes
Mellitus
```
516
what is marfans syndrome
```
Autosomal dominant
Multisystem
Connective tissue
Fibrillin 1 gene
chromosome 15q21
```
tall stature
517
what can you use to diagnose marfans
Ghent 2010
| need 2 positive findings
518
how can you treat marfans syndrome
```
echocardiogram
l b blockers
l Angiotensin II Receptor
Blockers
l Prophyllactic aortic surgery
```
519
what is long QT syndrome
```
Romano-Ward syndrome
Syncope,
“seizure”
sudden death
Emotion, exercise, drugs
ECG shows prolonged QTc
interval
Repolarisation anomalies
```
520
what is brugada syndrome
```
SCD or VF/VT and
l Type 1Brugada ECG
l Other features:
l prolonged PR interval
l enlarged LV/poor LV function
l more common in young men
especially of far Eastern origin
```
