Cardiovascular Lectures Flashcards
List 7 risk factors for atherosclerosis.
1) age
2) smoking
3) hypercholestrolaemia
4) hypertension
5) diabetes
6) obesity
7) family history
Define neointima.
Hyperplasia of vascular smooth muscle cells in tunica intima.
List the 4 stages of atherosclerosis.
1) fatty streaks
2) intermediate lesion
3) advanced lesion / fibrous plaque
4) ruptured plaque
List 2 contents of a fatty streak.
1) lipid-laden macrophages
2) T lymphocytes
List 3 contents of an intermediate lesion.
1) foam cells
2) T lymphocytes
3) vascular smooth muscle cells
List 5 contents of an advanced lesion/fibrous plaque.
1) foam cells
2) T lymphocytes
3) vascular smooth muscle cells
4) dense fibrous cap
5) fibrin
Define foam cells.
Heavily lipid-laden macrophages.
What forms the dense fibrous cap?
Vascular smooth muscle cells.
List 2 proteins found in the dense fibrous cap.
1) collagen - strength
2) elastin - flexibility
List 2 ways dense fibrous caps are maintained.
1) resorbed
2) redeposited
Define restenosis.
Recurrence of vascular narrowing following surgery.
What type of stents prevent restenosis?
Drug eluting stent. Stents that slowly release drugs.
List 2 drugs released by drug eluting stents.
1) taxol
2) sirolimus
What is the intrinsic rate of the SA node?
60-100bpm.
What is the intrinsic rate of the AV node?
40-60bpm.
What is the intrinsic rate of the ventricular cells?
20-45bpm.
What is ECG standard calibration? (2)
1) 25mm/s
2) 0.1mV/mm
What occurs during the P wave?
Atrial depolarisation.
What happens during the QRS complex?
Ventricular depolarisation (+ atrial repolarisation).
What happens during the T wave?
Ventricular repolarisation.
What happens during the PR interval?
Atrial depolarisation + AVN delay.
What is the J point?
Point between QRS complex and ST segment.
What are the measurements of ECG paper? (3)
Horizontal 1) small box - 0.04s 2) large box - 0.20s Vertical 3) large box - 0.5mV
How do you determine a regular heart rate using ECG paper?
300 rule.
Describe the 300 rule. (2)
1) count number of big boxes between two QRS complexes
2) divide 300 by this number
How do you determine a irregular heart rate using ECG paper?
10 second rule.
List 4 non-modifiable risk factors for angina.
1) gender
2) family history
3) personal history
4) age
List 6 modifiable risk factors for angina.
1) smoking
2) diabetes
3) hypertension
4) hypercholesterolaemia
5) sedentary lifestyle
6) stress
List the 3 key features of angina.
1) heavy, central, tight pain radiating to arms, neck and jaw
2) brought on by exertion
3) relieved by rest or sub-lingual GTN
How is angina graded? (3)
1) typical angina - 3/3 key features
2) atypical angina - 2/3 key features
3) non-angina chest pain - 0-1/3 key features
Describe CT angiograms in relation to ischaemic heart disease diagnosis. (2)
1) good at excluding IHD
2) bad at diagnosing IHD
How do β1 blockers treat ischaemic heart disease? (4)
1) reduce heart rate (-ve chronotrope)
2) reduce contractility (-ve ionotrope)
3) reduce heart work
4) reduce O2 demand
How do nitrates treat ischaemic heart disease. (5)
1) vasodilate systemic veins
2) reduce venous return to heart
3) reduce preload
4) reduce heart work
5) reduce O2 demand
How do Ca2+ channel antagonists treat ischaemic heart disease? (5)
1) vasodilate systemic arteries
2) decrease blood pressure
3) reduce afterload
4) reduce heart work
5) reduce O2 demand
List 2 methods of revascularisation to treat ischaemic heart disease.
1) PCI - percutaneous coronary intervention (stent)
2) CABG - coronary artery bypass graft (graft)
List 2 blood vessels used for CAGB.
1) saphenous vein
2) internal mammary artery
List 3 clinical conditions of acute coronary syndromes
1) unstable angina
2) NSTEMI
3) STEMI
What is the initial management of a myocardial infarction? (4)
MONA
1) morphine
2) oxygen
3) nitrates
4) aspirin
What is the clinical significance of troponin?
Highly sensitive marker for cardiac muscle injury.
Describe troponin testing for acute coronary syndromes.
1) troponin not elevated - no MI
2) troponin elevated after 6 hours repeat after 3 more hours
3) significant rise or fall of troponin - MI
List 5 drugs involved in secondary prevention of acute coronary syndrome.
1) aspirin
2) P2Y12 inhibitor
3) statin
4) ACE inhibitor
5) β1 blocker
What is a 2mmHg rise in systolic blood pressure associated with? (2)
1) 7% increase in ischaemic heart disease mortality
2) 10% increase in stroke mortality
When is hypertension suspected?
Clinical BP 140/90 or higher.
How is a hypertension diagnosis confirmed?
Ambulatory blood pressure monitoring (ABPM).
Diagnosis of stage 1 hypertension. (2)
1) clinical BP - 140/90
2) ABPM - 135/85
Diagnosis of stage 2 hypertension. (2)
1) clinical BP - 160/100
2) ABPM - 150/95
Diagnosis of severe hypertension. (2)
1) systolic clinical BP - 180
2) diastolic clinical BP - 110
List 4 therapeutic target in blood pressure control.
1) peripheral vascular resistance*
2) cardiac output
3) RAAS/SNS
4) local vascular vasoconstrictors and vasodilators
List 8 types of antihypertensive drugs. What are the 3 most important?
1) ACE inhibitor**
2) angiotensin receptor blocker (ARB)**
3) calcium channel blocker**
4) renin inhibitor
5) α blocker
6) β1 blocker
7) centrally acting
8) aldosterone antagonist
What is the suffix of ACE inhibitors?
-pril.
List 3 clinical indications for ACE inhibitors.
1) hypertension
2) heart failure
3) diabetic nephropathy
List 7 adverse effects of ACE inhibitors.
Decreased angiotensin II 1) hypotension 2) acute renal failure 3) hyperkalaemia 4) congenital defects in pregancy Increased kinin 5) cough 6) rash 7) anaphylactoid reaction
What is the suffix of angiotensin II receptor blockers (ARBs)?
-sartan.
List 3 clinical indications for ARBs.
1) hypertension
2) heart failure
3) diabetic nephropathy (ACE inhibitors contraindicated)
List 5 adverse effects of angiotensin II receptor blockers (ARBs).
1) hypotension
2) hypokalaemia
3) renal dysfunction
4) rash
5) angio-oedema
Generally very well tolerated.
What is the suffix of calcium channel blockers?
-ipine. (dihydropyridines)
List 3 clinical indications for CCBs.
1) hypertension
2) IHD - angina
3) tachycardia
List 2 calcium channel blockers without the -ipine suffix.
1) verapamil
2) diltiazem
List 4 adverse effects of dihydropyridine calcium channel blockers.
Peripheral vasodilation
1) flushing
2) headache
3) oedema
4) palpitations
List 3 adverse effects of verapamil (calcium channel blocker).
1) negative chronotropic effects
2) negative ionotropic effects
3) constipation
List 4 clinical indications of β blockers.
1) hypertension
2) heart failure
3) IHD - angina
4) arrhythmia
List 2 β1 selective blockers.
1) metoprolol
2) bisoprolol
List 3 non-selective β blockers.
1) propranolol
2) nadolol
3) carvedilol
List 7 adverse effects of β blockers.
1) fatigue
2) headache
3) nightmares
4) bradycardia
5) hypotension
6) cold peripheries
7) erectile dysfunction (M)
List 4 conditions β blockers worsen.
1) asthma
2) COPD
3) heart failure
4) PVD
List 2 clinical indications for diuretics.
1) hypertension
2) heart failure (chronic)
List 4 classes of diuretics.
1) thiazides
2) loop diuretics
3) potassium sparing diuretics
4) aldosterone antagonists
Where do thiazides act?
Distal tubule.
Where do loop diuretics act?
Loop of Henle.
List 5 general adverse effects of diuretics.
1) hyperuricaemia
2) hyponatraemia
3) hypokalaemia
4) hypocalcaemia
5) hypomagnesaemia
(hyperuricaemia causes 2-5)
List 2 adverse effects specific to loop diuretics.
1) hypovolaemia
2) hypotension
List 2 adverse effects specific to thiazides.
1) erectile dysfunction
2) decreased glucose tolerance
List the treatment progression for a patient under 55. (4)
1) ARB / ACE inhibitor
2) + CCB
3) + thiazides
4) + aldosterone antagonist / β blocker
List the treatment progression for an Afro-Caribbean patient or a patient over 55. (4)
1) CCB
2) ARB / ACE inhibitor
3) + thiazides
4) + aldosterone antagonist / β blocker
Why is hypertension treatment for Afro-Caribbean patients different? (3)
1) lower renin efficacy
2) ARBs / ACE inhibitors less effective
3) use CCBs
What is and isn’t the main therapeutic target when treating chronic heart failure. (2)
1) decrease peripheral vascular resistance
NOT
2) increase force of heart contraction
List 5 types of drugs used to treat chronic heart failure.
1) ACE inhibitors
2) ARBs
3) β blockers
4) aldosterone antagonist
5) diuretics
List the treatment progression for chronic heart failure. (4)
1) ACE inhibitor + β blocker (low dose, slow up-titration)
2) + aldosterone antagonist
3) ARB (ACE inhibitor intolerant)
4) hydralazine + nitrate (ARB + ACE inhibitor intolerant)
How do nitrates work? (3)
1) arterial and venous dilators
2) decrease preload and afterload
3) lower blood pressure
List 4 anti-arrhythmic drug classes.
1) class I - sodium channel blockers
2) class II - β blockers
3) class III - action potential prolongers
4) class IV - calcium channel blockers
List 2 drugs that prolong cardiac action potentials.
1) amiodarone
2) sotalol
List 6 adverse effects of amiodarone.
1) interstitial pneumonitis
2) abnormal liver function
3) hypo/hyperthyroidism
4) slate grey skin discolouration
5) corneal micro-deposits
6) optic neuropathy
What drug does amiodarone have a severe drug reaction with and why? (3)
1) warfarin
2) displaces albumin bound warfarin
3) increased free warfarin
What adverse effect does diltiazem have?
Negative chronotropic effects.
What is the suffix of β blockers?
-olol.
List the 5 main risk factors for acute coronary syndrome.
1) smoking
2) hypertension
3) hypercholesterolaemia
4) diabetes mellitus
5) family history
List 4 ischaemic heart disease conditions.
1) stable angina
2) unstable angina (ACS)
3) STEMI (ACS)
4) NSTEMI (ACS)
List 3 acute coronary syndrome conditions.
1) unstable angina
2) STEMI
3) NSTEMI
List 3 cardiomyopathy conditions.
1) hypertrophic cardiomyopathy
2) dilated cardiomyopathy
3) arrhythmogenic cardiomyopathy
What is crucial when diagnosing cardiomyopathies.
Family evaluations.
Why does chronic pericardial effusion rarely cause cardiac tamponade?
Slow accumulation of pericardial effusion allows parietal pericardium to adapt.
How is a clinical diagnosis of acute pericarditis made? (3)
2/3
1) chest pain
2) friction rub
3) ECG changes
What is the main differential diagnosis of acute pericarditis?
Myocardial ischaemia/infarction.
Describe pulsus paradoxus. (8)
1) pericardial pressure increases on inspiration
2) increased venous return to RA
3) increased blood flow to RV (suction)
4) increased right heart filling applies pressure to left heart
5) decreased pericardial compliance due to pathology (e.g. cardiac tamponade)
6) decreased space for left heart
7) decreased LA and LV filling
8) decreased systolic blood pressure > 10mmHg
What is the recurrence rate of acute pericarditis?
15-30%.
How does colchicine effect the recurrence rate of acute pericarditis?
50% decrease.
List 2 side effects of colchicine.
1) nausea
2) diarrhoea
What is key to diagnosing acute pericarditis? (2)
ECG changes.
1) depressed PR segment
2) saddle-shaped elevated ST segment
Describe NYHA classification of heart failure. (4)
1) class I - no limitation (asymptomatic)
2) class II - slight limitation (mild HF)
3) class III - marked limitation (moderate HF)
4) class IV - inability to carry out any physical activity without discomfort (severe HF)
What is the function of hydralazine?
Arterial vasodilator.
What is the function of nitrates?
Venous vasodilators.
List 8 structural heart defects.
1) atrial septal defect
2) ventricular septal defect
3) atrio-ventricular septal defect
4) patent ductus arteriosus
5) coarctation of aorta
6) bicuspid aorta
7) pulmonary stenosis
8) tetralogy of Fallot
Describe Eisenmenger’s syndrome. (7)
1) ventricular septal defect
2) high pressure pulmonary blood flow
3) pulmonary vasculature damages
4) pulmonary blood flow resistance increases
5) RV pressure increases
6) shunt direction reverses (RV—>LV)
7) patient becomes blue
What is amiodarone?
Antiarrhythmic medication.
What is a normotensive ABPM?
<135/85.
What does ABPM stand for?
Ambulatory blood pressure monitoring.
What does a sudden decrease of blood pressure result in?
Increased stroke risk.
What is the target blood pressure for hypertensive patients? (2)
1) clinic BP < 140/90 (< 80 years old)
2) clinic BP < 150/90 (> 80 years old)
How much weight loss has roughly the same effect as 1 antihypertensive medication?
5-10kgs.
Why do medications not prevent progression of mitral and aortic stenosis?
They are both mechanical problems.
List 7 types of rate controlling drug.
1) β blockers
2) CCB
3) KCB
4) NCB
5) digoxin
6) amiodarone
7) ivabradine
List 3 types of diuretic drugs.
1) loop diuretics (e.g. furosemide)
2) thiazides (e.g. metolazone)
3) potassium sparing diuretics (e.g. spironolactone)
List 4 types of anticoagulants.
1) warfarin
2) DOACs - direct oral anticoagulants (e.g. apixaban)
3) heparin
4) LMWH - low molecular weight heparin (e.g. fondaparinaux)
List 3 vasodilator drugs.
1) nitrates
2) hydralazine
3) prazosin
Why are heart valves generally infected in infective endocarditis?
Limited blood supply, therefore limited white blood cell migration.
Why are heart valves more likely to get infected in infective endocarditis?
Decreased blood supply to heart valves, therefore decreased white blood cell migration.
List 2 differences between Osler’s nodes and Janeway lesions.
1) fingers/toes (Osler’s) vs palms/soles (Janeway)
2) tender (Osler’s) vs non-tender (Janeway)
List the 2 phases of aortic dissection.
1) initial event, severe ripping pain and pulse loss, bleeding stops
2) secondary event, building pressure causes a rupture into either pericardium, mediastinum or pleural space.
List 4 types of supraventricular tachycardias.
1) atrial fibrillation
2) atrial flutter
3) atrioventricular re-entrant tachycardia
4) atrioventricular nodal re-entrant tachycardia
Describe WilliaM and MarroW. (5)
1) acronym for ECG bundle block diagnosis WilliaM - left bundle branch block 2) W shaped QRS complex in V1 3) M shaped QRS complex in V6 MarroW - right bundle branch block 4) M shaped QRS complex in V1 5) W shaped QRS complex in V6
List 3 vagal manoeuvres.
1) Valsalva manoeuvres - forced exhalation against closed airways
2) diving reflex - submerging head in water
3) Czermak-Hering test - massaging carotid arteries
What does the amplitude of a deflection in an ECG relate to?
Mass of myocardium.
What does the width of deflection in an ECG relate to?
Speed of conduction.
List 3 things that cause a small P wave.
1) atrial fibrillation
2) obesity
3) hyperkalaemia
What causes a tall P wave?
Right atrial enlargement.
What causes a broad bifid P wave?
Left atrial enlargement.
List 2 things that cause a broad QRS complex.
1) bundle branch block
2) accessory depolarisation pathway (pre-excitation)
List 3 things that cause a small QRS complex.
1) obesity
2) pericardial effusion
3) infiltrative cardiac disease
List 2 causes of a tall QRS complex.
1) left ventricular hypertrophy
2) thin
What is the time period of the QT interval?
380-450ms (heart rate corrected)
List 4 things a T wave inversion can indicate.
1) ischaemia
2) infarction
3) hypertrophy
4) cardiomyopathy
List 4 causes of bradycardia.
1) conduction tissue fibrosis
2) ichaemia
3) inflammation
4) drugs, e.g. β1 blockers
What part of the heart does the right coronary artery supply?
Inferior.
What part of the heart does the circumflex artery supply?
Lateral.
What part of the heart does the left anterior descending artery supply?
Anterior.
List the 4 lateral ECG leads.
1) I
2) aVL
3) V5
4) V6
List the 3 inferior ECG leads.
1) II
2) III
3) aVF
List the 3 anterior ECG leads.
1) V2
2) V3
3) V4
What is the septal ECG lead?
V1
What is the systematic approach to reading ECGs?
1) rate
2) rhythm
3) axis
4) P, PR, QRS, ST, QT
List the 2 types of atrial fibrillation.
1) paroxysmal - self terminating
2) persistent
What is the normal time period for a PR interval?
120-200ms.
What is the normal time period for a QRS complex?
<120ms.
What are accessory pathways?
Congenital remnant muscle strands between atrium and ventricles.
What is an electrical storm?
3 or more sustained episodes of ventricular tachycardia or ventricular fibrillation during 24 hours.
What is the main side effect of ACE inhibitors?
Persistent dry cough (5-35%).
What is the main contraindication of prescribing β blockers?
Asthma.
What age do cardiomyopathy’s present?
Adolescence.
What is the diagnostic criteria for pericarditis? (4)
2 out of 4
1) chest pain
2) pericardial rub
3) saddle-shaped elevated ST segment (ECG)
4) pleural effusion (echocardiogram)
What is Dressler’s syndrome?
Post MI autoimmune pericarditis.
What is a common side effect of GTN spray?
Syncope.
How are patients with angina mistaken for myocardial infraction? (4)
1) patient has angina pain
2) patient takes GTN
3) patient faints
4) appears as if they’ve had an MI
What is Prinzmetal angina?
Angina caused by coronary artery spasm.
List 3 features of unstable angina.
1) recent onset
2) deteriorates (increasing frequency and severity)
3) increased MI risk
What is generally used to treat MIs, PCI or CABG?
PCI.
List 3 reasons when CABG is preferred to PCI.
1) old age
2) diabetes mellitus
3) abnormal heart structure
List 2 reasons why aspirin is good to treat MI.
1) antiplatelet
2) vasodilator —> reduces afterload
