Cardiovascular - Level 3 Flashcards
Definition of accelerated hypertension?
- Severe increase in blood pressure to 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilledema (swelling of the optic nerve);
- Also known as malignant hypertension
Epidemiology of accelerated hypertension?
- Average age is 40 years
- Men more commonly
- Black ethnicity
Causes of accelerated hypertension?
o Renovascular disease – renal artery stenosis o Renin-secreting neoplasms o Renal vasculitis – scleroderma, polyarteritis, SLE o Phaeochromocytoma o Cocaine abuse o MAOIs, COCP o Glomerulonephritis o Pre-eclampsia/Eclampsia o Hyperthyroidism/Hypothyroidism o Cushing’s syndrome o Acromegaly
Symptoms of accelerated hypertension?
- May be asymptomatic
- Symptoms
o Headache
o Fits
o N&V
o Visual disturbances
o Chest pain
o Neurological changes
Initial investigations to perform in accelerated hypertension?
- Blood pressure – lying and standing and in both arms
- Fundoscopy
- Bloods
o FBC, clotting, U&E, LFTs, TFTs, glucose, troponin - Urine dipstick
- CXR – cardiac size, cardiac failure
- ECG – LVH
Investigations to find cause of accelerated hypertension?
o CT/MRI of head/kidneys o Plasma renin o Plasma aldosterone o 24-hour urine VMA and metanephrin levels o ANA
Referral in people with accelerated hypertension?
- Refer for same-day specialist assessment if >180/120 and:
o Signs of retinal haemorrhage or papilloedema OR
o Signs of new onset confusion, CP, HF, AKI
Management of accelerated hypertension?
- Reduce BP over 24-48 hours
o IV labetalol (alternatives nitroprusside /nicardipine)
Every 10 minutes according to response
o If LV failure – IV furosemide, GTN and nifedipine
Definition of pericarditis?
- Acute inflammation of pericardium (membranous sac surrounding heart) and can co-exist with myocarditis
PAthology of pericarditis?
o Pericardial vascularisation and infiltration with leukocytes
o Exudate and adhesion within pericardial sac and serous effusion
Epidemiology of pericarditis?
o 5% of ED visits with chest pain
o Usually post-viral or idiopathic
o Can become recurrent if >1 episode
Causes of pericarditis?
o Myocardial infarction (including Dressler’s syndrome)
o Viral - Coxsackie, Echovirus, EBV
o Bacterial - Pneumococcus, meningococcus, haemophilus, staphylococcus, TB
o Neoplasms, Uraemia, SLE, rheumatoid arthritis
o Drug - Hydralazine, procainamide
Symptoms of pericarditis?
o Chest pain
Sharp, central or retrosternal
Radiates to neck, trapezius ridge or shoulders
Worse on deep inspiration, exercise, swallowing and lying flat
Relieved by sitting up and leaning forward
o May have cough, chills, weakness
Signs of pericarditis?
Pericardial friction rub
Often intermittent, positional and elusive
Louder during inspiration and may be heard on systole and diastole
Scratchy superficial sound, loudest in midline and lower left parasternal edge
Low grade fever
Tachycardia
Tachypnoea
Investigations of pericarditis?
ECG
o Concave-upward ST segment elevation
o PR depression in limb and pre-cordial leads
o Reciprocal PR elevation and ST depression in aVR
CXR
o Flask-shaped cardiac silhouette sign of large pericardial effusion
Bloods
o FBC, U&Es, CRP, ESR and troponin
Blood cultures if evidence of sepsis
Echocardiogram
o If pericardia effusion or cardiac tamponade suspected
Management of pericarditis?
o Benign or self-limiting
o Rest
o High dose NSAIDs (naproxen 250mg TDS/QDS) +/- PPI cover
Give 7-14 days then taper off
Management of pericardial effusion in pericarditis?
o Senior help, immediate echocardiogram
o Pericardiocentesis under US and then drainage or open thoracotomy
Management of constrictive pericarditis in pericarditis?
o Pericardial resection
Prognosis of pericarditis?
- Most improve over days to weeks
- Recurrence in around 1 in 3 patients
Definition of pericardial effusion?
- Accumulation of fluid in pericardial sac
Causes of pericardial effusion?
o Viruses (Coxsackie, flu, EBV, mumps, varicella, HIV)
o Bacteria (pneumonia, rheumatic fever, TB, staphs)
o Fungi
o MI and Dressler’s syndrome
o Drugs – Procainamide, hydralazine, penicillin
o Others – uraemia, RA, SLE, trauma, surgery, malignancy
Symptoms of pericardial effusion?
o SOB
o Symptoms of pericarditis – sharp chest pain, radiating to scapular ridge, relieved by sitting up and worsening with inspiration
o Syncope
o Cough
Signs of pericardial effusion?
o Raised JVP (prominent X descent)
o Bronchial breathing at left base (Ewart’s sign)
o Look for signs of cardiac tamponade
Tachycardia, pulsus paradoxus, hypotension, raised JVP, muffled S1 and S2
Investigations of pericardial effusion?
- Bloods
o FBC, U&Es, CRP, cardiac enzymes
o Blood cultures if needed - CXR
o Enlarged, globular heart - ECG
o Low voltage QRS complexes and alternating QRS morphologies - Echocardiogram
o Echo-free zone surrounding heart