Cardiovascular Medicine Flashcards
CHEST PAIN: Describe the characteristic, and contrasting, features of chest pain resulting from MI, aortic dissection, pleural disease, oesophageal disease and MSK disease
ACUTE CORONARY SYNDROME: Describe the causes, morphology, pathological consequences, typical history, examination features, differential diagnosis, management and complications of the acute coronary syndromes ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina (UA).
ACUTE CORONARY SYNDROME: Discuss the indications and contraindications for primary cutaneous intervention (PCI) and thrombolysis
ACUTE CORONARY SYNDROME: Describe the complications of acute myocardial infarction and describe their presention
ACUTE CORONARY SYNDROME: Describe the pharmacological methods of secondary prevention
- Statin: 80mg. To be taken at night, as time of maximum cholesterol synthesis
- Dual anti-platelet therapy: Aspirin and another anti-platelet (clopidogrel) 75 mg
- Clopidogrel may be discontinued after 1 year
- Aspirin is continued life-long
- Beta blocker
- ACEi
ACUTE CORONARY SYNDROME: Outline the principles of cardiac rehabilitation including advice regarding driving and employment
Principles of cardiac rehabilitation:
- An individualised programme made up of a mix of exercise and education sessions
- Often run twice a week
Driving:
- Do not need to inform the DVLA that you’ve had a heart attack however you should refrain from driving for:
- 1/52 if had angioplasty, which was successful
- 4/52 if had angioplasty after a heart attack but it wasn’t successful
- 4/52 if you had a heart attack and didn’t have angioplasty
- If driving a bus, coach or lorry you must inform the DVLA and stop driving for 6/52.
- Fill in a VOCH1 form.
- Must attend an assessment with your GP at 6/52 to see if you’re fit to drive again
Employment:
- If your job includes light duties then you may be able to return to work in 2/52
- If your job involves heavy manual tasks it may take months before you’re able to return
ANGINA PECTORIS: Define stable and unstable angina, describe the typical history, risk factors, underlying causes/pathology, relevant investigations and treatments, including their side effects
ANGINA PECTORIS: Outline treatment options of angioplasty or coronary artery bypass grafting
May be indicated if there is severe obstruction
ANGINA PECTORIS: Outline the employment and driving limitations of a diagnosis of angina
Driving:
- The DVLA do not need to be notified
- Driving can continue unless symptoms occur at rest, whilst driving or with emotion
- Able to recommence once symptoms are controlled
HGV drivers:
- All CV diagnoses lead to revocation of licenses for 6 weeks, or 3/12 with CABG
- Re-licensing can be permitted if exercise/other functional requirements are met
CARDIAC SURGERY: Describe the anatomy of the cardiac chambers, valves, coronary arteries, the great arteries and the cardiac conduction system
CARDIAC SURGERY: Describe the main incisions for cardiac surgery, outline the difference between the open and closed heart surgery and outline the principles involved in cardio-pulmonary bypass
Main incisions:
- Median sternotomy
- Anterolateral thoracotomy
- Posterolateral thoracotomy
- Bilateral transverse thoracotomy (clam shell)
Open vs closed heart surgery:
Open surgery is any surgery requiring cardio-pulmonary bypass, whereas closed heart surgery does not require a bypass
Principles of cardio-pulmonary bypass:
- Allows for a blood-free field for surgery
- A venous line is inserted into the right atrium to drain venous blood.
- Blood is temperature regulated and oxygenated by the bypass machine
- There is no coronary blood supply so the heart is arrested in a high potassium solution and cooled to 4-12 degrees to minimise the risk of ischaemic damage
CARDIAC SURGERY: Outline the surgical principles and operative risks involved in the treatment of coronary artery disease and valvular disease including types of prosthetic valve and anticoagulation
Surgical treatment of coronary artery disease
- CABG provides better symptomatic relief and requires fewer re-interventions than PCI
- Performed through a median sternotomy
- The left internal mammary artery is the most common conduit
Complications:
- MI
- Bleeding
- Arrthymias
- Stroke
- Tamponade
- Aortic dissection
- Respiratory/systemic complications
Surgical treatment of valvular disease:
Man-made valves
- Durable but thrombogenic, hence require anticoagulation with warfarin
- Examples: Ball-in-cage, bileaflet valve
Tissue valves
- May be homographs (human) or xeograph (pig)
- More prone to degenerative failure. Homographs are less prone to degenerative damage.
- Do not require anticoagulation.
CARDIAC SURGERY: Classify cardiac trauma (penetrating vs non-penetrating)
Penetrating:
- CXR is vital and should be upright if possible
- Signs/symptoms suggestive of cardiac tamponade:
- Beck’s triad: Hypotension, muffled heart sounds and raised JVP
- Prevents ventricular expansion/filling, reducing CO
- Rounded heart border on CXR
Non-penetrating a.k.a. blunt:
- CXR, supine (as spinal fracture not ruled out)
- CT often required
- Cardiac contusion can occur, and cause ECG changes similar to that of a MI
- Management in conservative
CARDIAC SURGERY: Outline the clinical presentation and treatment of myxoma and the surgical treatment of constrictive pericarditis
Clinical presentation of myxoma1:
- Symptoms of mitral valve obstruction (as most common in the left atrium)
- Dyspnoea
- Syncope
- Pulmonary oedema
- CHF
- Embolic manifestations
- Fatigue
Surgical treatment of constrictive pericarditis:
- Pericarditis prevents cardiac enlargement
- Surgical treatment is complete pericardectomy
1: A neoplasm found in the R/L atrium, mostly occuring on the left.
ACUTE PULMONARY OEDEMA: Describe the typical history, clinical features, common causes, ddx, investigtions and management of pulmonary oedema
CONGESTIVE CARDIAC FAILURE: Describe heart failure and classify common causes
Heart failure: Inability of the heart to meet the oxygen demands of tissues, due to an inabilty to act as a pump.
Common causes:
- IHD*
- Valvular disease*
- Hypertension*
- Myocarditis*
- Rarer causes: Cardiomyopathy, congenital heart disease, cor pulmonale, alcohol/drugs, AF/heart block, anaemia
- Toxin-induced: Heroin, alcohol, cocaine, amfetamines, lead
- Infection
- Endocrine disease: DM, thyroid disease, phaeochromocytoma, acromegaly
- Systemic collagen vascular disease
- Chemotherapy induced
CONGESTIVE CARDIAC FAILURE: Describe the typical history, clinical examination findings, investigations and management
CONGESTIVE CARDIAC FAILURE: Outline the drugs used in the long-term management of CCF
ACEis
Beta-blockers
Diuretics
Nitrates
Digoxin
Ivbradine
Vasopressin antagonist
HEART VALVE DISEASE: Classify the causes of valvular heart disease and outline the common symptoms and non-invasive assessment
Causes: (congenital, rheumatic, infective and ischaemic)
- Degenerative
- Infective: Rheumatoid fever, endocarditis
- Congenital: Marfan’s syndrome, Down syndrome, Ehlers-Danlos syndrome, bicuspid aortic valve
- Systemic autoimmune diseases: RA, SLE, AS, SLE, antiphospholipid antibody syndrome
- Ischaemic: Post-MI papillary muscle dysfunction
Common symptoms:
- Symptoms related to reduced cardiac output: Dyspneoa, fatigue, increasingly symptomatic on exertion
- Palpitations
Non-invasive assessment
- ECHO (transoesophageal)
- ECG
- CXR
HEART VALVE DISEASE: Outline the reasoning for performing right and left heart catheterisation
Heart catheterisation may be diagnostic or therapeutic.
Diagnostic: Allows for the severity of valvular abnormalities to be assessed. Contrast can be introduced to allow for blood flow to be analysed.
Blood samples may be taken to analyse metabolite concentrations (e.g. lactate).
Therapeutic: Balloon valvuloplasty
HEART VALVE DISEASE: Outline the indications for medical or surgical treatment of valvular heart disease affecting the aortic and mitral valves
CONGENITAL HEART DISEASE: Outline the pathophysiological complications that may occur as a result of adult cyanotic congenital heart disease
- Eisenmenger’s sydrome (shift to R → L shunt due to pulmonary hypertension)
- Polycythaemia and pulmonary hypertension
- Infective endocarditis
- Gout (2° to raised uric acid)
- Cardiomegaly
- Heart failure
CONGENITAL HEART DISEASE: Define the Eisemenger syndrome including the clinical features and underlying pathophysiology
Eisenmenger sydrome: Describes a shift from a L→R shunt to a R→L shunt, due to pulmonary hypertension
Clinical features:
- Cyanosis
- Dyspnoea, fatigue, syncope, exercise intolerance
- Chest pain
- Haemoptysis
- Examination findings:
- Cyanosis, clubbing, plethora
- Right ventricular heave
- Ejection systolic murmur, best heard at the left sternal edge
- Graham Steell murmur: Diastolic murmur due to incompetent pulmonary valves in patients with pulmonary hypertension
Pathophysiology
Increased pulmonary flow leads to increased vascular resistance and pulmonary hypertension. This causes reversal of the congenital shunt, with blood flow now seen from right to left. There is associated hypertrophy of the right ventricle.
INFECTIVE ENDOCARDITIS: Define bacterial endocarditis and who is at risk
Bacterial endocarditis: Infection of the lining of the heart
*A fever and a new murmur is endocarditis until proven otherwise*
At risk groups:
- Valve replacement/disease/congenital cardiac defects
- IVDU
- Following open heart surgery
- Immunocompromised
- Poor dentition
INFECTIVE ENDOCARDITIS: Describe typical clinical examination features and list common infecting bacteria
Typical clinical features:
- Acute febrile illness with a new murmur
- Non-specific constitutional symptoms: Night sweats, malaise, fatigue, anorexia, weight loss, myalgias
- Weakness, arthralgias and headache could be constitutional symptoms or due to septic emboli
Common infecting bacteria:
- Streptococci viridans *most common*
- Staph aureus and Strep epidermis
INFECTIVE ENDOCARDITIS: Describe the histological changes seen and the pathological complications of infective endocarditis
Histological changes:
- Valvular necrosis and destruction
Pathological complications:
- Valvular damage → incompetency → congestive heart failure
- Systemic emboli: Renal, cerebral, venous thromboembolism
INFECTIVE ENDOCARDITIS: Outline important investigations
- Blood cultures: Taken from 3 sites, 1 hour prior to initiation of antibiotic therapy
- Bloods: FBC, ESR, U&Es, d-dimer
- Urinalysis: May demonstrate active sediment, as a consequence of septic emboli
- ECG: May see PR prolongation, non-specific ST/T wave abnormalities, AV block
- ECHO: Role in assessment of prognosis, embolic risk prediction and management during follow-up
INFECTIVE ENDOCARDITIS: Outline the common antibiotic regimen and describe the role of antibiotic prophylaxis in patients with pre-existing valve disease
Common antibiotic regimen:
- Empirical therapy:
- Native valves - amoxicillin
- Prosthetic valves - vancomycin, rifampicin and low dose gentamicin
- Consult a microbiologist early
- Antibiotic selection depends on whether there are native or prosthetic valves
Role of antibiotic prophylaxis in pre-existing valve disease:
- Recommended only for patients with underlying cardiac conditions associated with the highest risk of developing
ATRIAL FIBRILLATION: Describe the risk factors, classification, clinical features and investigations for this condition
ATRIAL FIBRILLATION: Discuss the management of AF (rate vs rhythm control).
Outline assessment of the need of anticoagulation using a risk scoring system
Management
Rate control:
- beta blocker or rate limiting calcium channel blocker
- May be used in combination if uneffective
- Digoxin
Rhythm control - indicated in younger patients with new onset AF, reversible cause identified or AF causing heart failure
- Cardioversion - electrical or pharmacological
Assessing requirement for anticoagulation:
LMWH should be provided upon admission
Assessment of need for further anticoagulation should be made using the CHA2DS2VASc tool to assess risk of cerebrovascular incident
Males with a score of 1 or more, and females with a score of 2 or more, should receive anticoagulation.
The HASBLED tool can be used to assess the risk of bleeding.
ATRIAL FIBRILLATION: List the different oral anticoagulants, outlinings any key advantages and disadvantages
Oral anticoagulants:
DOACs
Advantages: Do not require monitoring
Disadvantages: No antedote available
Warfarin
Advantages: Used for patients with prosthetic heart valves, antedote available
Disadvantages: Requires monitoring, narrow therapeutic range
VENOUS THROMBO-EMBOLIC DISEASE: Identify the usual initial anatomic location of deep venous thrombosis. Describe the risk factors, clinical features and investigations for this condition.
Initial anatomic location:
- Low limbs
- CAUTION as there is potential for the thrombus to dislodge and to travel to the lung, causing a PE
Risk factors:
- Thromboembolic risk factors: Immobilisation, pregnancy, malignancy, OCP use, surgery
- Lower limb trauma
- Increasing age
- Smoking
Clinical features:
- Redness, swelling, tenderness of the affected limb
- Assymetrical oedema
Investigations:
- Wells’ score
- D-dimer - indicated if Wells’ score is < 2. If elevated then venous duplex US should be performed
- Venous duplex ultrasound1
- Whole leg ultrasound
- INR and aPTT
1: Abnormal result includes inabilty to compress the vessel, reduced/absent spontaneous flow
VENOUS THROMBO-EMBOLIC DISEASE: Describe the pathophysiology of chronic venous insufficiency and the postphlebitic syndrome.
Chronic venous insuffiency: Venous pooling is seen secondary to reduced venous return, causing increased venous pressure. Venous return may be interrupted due to incompetence of venous valves and/or muscular pump insufficiency
Postphlebitic sydrome: Describes s_ymptomatic chronic venous insufficiency following DVT_, such as due to venous damage or valve incompetence caused by DVT. Proximal DVT, recurrent DVT and BMI >22 are all risk factors for the syndrome.
VENOUS THROMBO-EMBOLIC DISEASE: Describe the range of clinical presentation and the associated pathology of pulmonary embolic disease
Clinical presentation:
- Sudden onset dyspnoea
- Chest pain
- Haemoptysis
- Signs of concurrent DVT (embolisation of initial thrombus)
- Risk factors present: Recent surgery, immobilsation, pregnancy, up to 6/52 postpartum, active cancer
Associated pathology:
- Right ventricle over distention and reduced CO
- Reduced RV output leads to reduced LV preload. As left ventricular filling and CO are reduced, lowered mean arterial pressure leads to hypotension and shock.
VENOUS THROMBO-EMBOLIC DISEASE: Discuss the treatment of a deep vein thrombosis, the methods of administering and monitoring appropriate anticoagulants. Outline the indications for primary thrombo-prophylaxis.
Treatment of DVT
- Anticoagulant therapy
- Generally DOAC for at least 3/12
- For patients at high risk of bleeding IV UFH is recommended (short half life and can be reverse by protamine)
- Physical activity
Administering methods
- See above
Indications for primary thrombo-prophylaxis
- Assess VTE risk using local criteria. LMWH should be administered to at risk groups, or consider an alternative according to renal function and patient comorbidites
VENOUS THROMBO-EMBOLIC DISEASE: Administer a VTE risk assessment using a recognized risk scoring system (name scoring system)
Wells’ Criteria for DVT: Can be used to assess the risk of DVT
- There is also a Wells’ criteria for PE
Geneva Score: Can be used to assess the risk of PE
