Clinical Cardiovascular Flashcards
What is thrombophilia and what is it a risk factor for?
Heriditary tendency to develop thrombosis
Deficiencies in anticoagulant factors Protein C, S and antithrombin or mutations in factor V and prothrombin
What are the risk factors for DVT? 6
immobilisation (surgery, hospitalisation, flights), age, obesity, infection, combine contraception (makes blood more prone to clotting), hereditary factor (thrombophilia)
What are the symptoms of DVT?
Swelling and redness of leg, pain in leg, dilatation of surface veins (offer alternative channel to blockage), tenderness over surface veins
What must be carried out in order to exclude or confirm DVT?
Physical examination = unreliable to exclude DVT, need an ultrasound which shows absence or reduction of venous flow/presence of a thrombus
When would D dimer levels be tested?
In low probability situations where DVT is suspected
What is immediately given to someone with DVT?
Immediate anticoagulation with low molecular weight heparin
Then 3-6 months on warfarin
How can DVT be prevented?
Walking, compression stockings (stroke patients), long term warfarin, hospitalised patients given low molecular weight heparin
Atherosclerosis and atrial fibrilation with dilated atria can lead to what?
Cerebral infarction
What are risk factors for cerebral infarction?
Smoking, High BP, High cholesterol, diabetes, AF and possible warning TIAs (reversible min strokes)
What are the symptoms of cerebral infarction?
Weakness of arm/leg, slurring of speech (dysarthria), mouth drooping, dysphagia, expressive dysphasia,
What clinical signs may be found in cerebral infarction?
Evidence of AF, hypertension, possible bruit (noise of turbulent flow through stenosed vessel) heard over carotid in neck
What imaging would be done on a patient with cerebral infarction and what would they show?
Brain CT and MRI - swelling (cerebral oedema, this may further damage nerve cells due to increased cranial pressure) and infarction
Ultrasound of carotid - narrowing of carotid
ECG - AF
Echocardiogram - evidence of blood clot in atrial appendage
What prevention should be given to patients with AF or carotid atherosclerosis to prevent cerebral infarction?
AF - given warfarin
Carotid atherosclerosis - antiplatelets (aspirin), manage BP
Aortic stenosis affects what part of the heart?
Aortic valve
What is the difference between congenital and aquired artic stenosis?
Congenital - bicuspid not tricuspid valve
Aquired - due to aging get calcification of the aortic valve
Other than a narrowed aortic valve what other structural abnormality may be seen in aortic stenosis?
LV hypertrophy
Patients of which age and gender are at greatest risk of aortic stenosis?
Males over 65
What are the symptoms of aortic stenosis?
1) Angina
2) Breathlessness
3) Light headedness with exercise
What are the clinical signs of aortic stenosis?
1) Reduced pulse pressure (difference between systolic and diastolic BP)
2) Forceful apex beat
3) Ejection systolic heart murmur
What would the ECG of a patient with aortic stenosis show?
QRS increased in size (because of more muscular LV)
What would the echocardiogram of a patient with aortic stenosis show?
narrowed aortic valve and hypertrophied LV
When would a patient with aortic stenosis undergo surgery and what would that involve?
When the left ventricle starts to dilate
Involve valve replacement either prosthetic (metal and plastic) and require warfarin or tissue valves (pig valves) which dont require warfarin
What structural abnormalities would be seen in someone with systolic heart failure?
1) Dilated ventricles
2) May see regurgitation of mitral or tricuspid valve due to stretching of the valve ring
What is the most common prior event to systolic heart failure?
MI
Other than MI what 2 things can lead to systolic heart failure?
Viral myocarditis (also a common cause) Chemotherapy - poisons heart muscle
What is paroxysmal nocturnal dyspnoea and what is it a symptoms of?
Sudden breathlessness in the night - symptom of systolic heart failure
What is orthopnoea and what is it a symptom of?
Breathlessness when lying flat - systolic heart failure
What are the symptoms of systolic heart failure?
1) Fatigue
2) dyspnoea
3) orthopnoea
4) paroxysmal nocturnal dyspnoea
5) nocturia (passing excess urine in night)
6) ankle oedema
What are the clinical signs of systolic heart failure?
1) High JVP
2) Ankle oedema
3) Tachypnoea
4) Tachychardia
5) Hypotension
6) Loss of skeletal muscle mass (cachexia)
7) Anorexia
What is cachexia and what cardiovascular problem is it a clinical sign of?
Loss of skeletal muscle mass
Sign of systolic heart failure
What would an echocardiogram of a patient with systolic heart failure show?
Dilated ventricles
Possible leaky valves (due to stretching of the valve ring)
What would an ECG of a patient with systolic heart failure look like?
Abnormal due to underlying disease
What peptide would be raised in a blood test of a patient with systolic heart failure?
Brain natiuretic peptide
What medication is used to treat systolic heart failure?
1) Loop diuretic (furosemide)
2) Potassium retaining diuretic (spiralatone)
3) ACE inhibitor
4) Beta blocker
Why might some patients with systolic heart failure be given a pacemaker?
To resynchronise right and left ventricular systolic contraction
What are patients with systolic heart failure advised to do on a daily basis?
Daily weighing and check fluid retention
What are the 3 possible prior warning symptoms of VF?
1) Palpitations
2) Light headedness
3) Chest pain
What is long QT syndrome?
Genetic syndrome where patients have a normal heart structure but they are susceptible to VF
VF normally comes after shock in these patients
What is the possible structural abnormality in some patients who experience VF?
Hypertrophied ventricles due to high BP or genetic disease (eg. hypertrophic cardiomyopathy)
What happens when a patient goes into VF?
Rapid loss of consciousness with no heart beat, commonly occurs after MI and with heart failure
1) Patient motionless and unresponsive
2) Deep snoring, no signs of breathing
3) No pulse detected, sudden and dramatic collapse
What would an ECG of a person in VF look like?
Completely random with no waves
What is the immediate response to a patient thats gone into VF and what is the definitive treatment?
Immediate - ABC strategy Airways - extend neck Breathing - O2, bag and mask Circulation - can be supported by external cardiac massage Definitive treatment = DC electric shock
In someone has a family history of VF what medication may be used and what devices may be implanted?
Medication = beta blockers to reduce risk of ventricular rhythm abnormalities
AID (Automatic internal defibrilators may be inserted) - like a pacemaker for patients who survive VF or are at high risk of a first event
What manoeuvre may trigger emboloisation of a DVT leading to PE?
Valsalva manouvre
What is chest pain of pleuritic nature?
Chest pain that is worsened on breathing
What are the symptoms of PE (5)?
1) Dyspnoea
2) Tachypnoea
3) Chest pain of pleuritic nature
4) Cough
5) Haempotysis
What percentage of cases of sudden death are attributable to PE?
15%
What would a CT of a patient with PE show?
Blood clot in pulmonary artery
What are the clinical signs of PE? 8
1) Cyanosis
2) Circulatory instability (due to decreased blood flow through lungs)
3) Collapse
4) Pleural friction rub heard over affected area
5) Strain on RV (felt on chest wall)
6) Raised JVP
7) Hypoxaemia on blood gases
8) Lung scan shows lack of blood flow
What is the treatment of PE?
1) High flow O2
2) IV thrombolytic drugs
3) Anticoagulants - initially low molecular weight heparin, later oral warfarin
What structural abnormalities occur in AF?
1) Dilated atria
2) Fibrosis of atrial muscle
What is AF?
Disordered atrial activity due to disorganised atrial electrical discharge, often originating at pulmonary vein insertion
What are the likely prior events to AF? 6
1) Hypertension
2) Primary heart disease
3) Lung diseases
4) Alcohol abuse
5) Hyperthyroidism
6) Heart failure
Hyperthyroidism could lead to which cardiovascular abnormality?
Atrial Fibrilation
What are the symptoms of AF? 4
1) Palpitations
2) Tired/breathlessness with exercise
3) Angina
4) Ankle oedema
What would an ECG of a patient with AF look like?
Completely random
An irregularly irregular pulse is a sign of what cardiovascular abnormality?
AF
What drugs would be given to a patient with AF?
Rate control - digoxin, beta blockers, verapamil
Rhythm control - amiodarone or DC cardioversion
Warfarin and occasional replacement of warfarin with aspirin
What medical procedures may be carried out as medical intervention on a patient with AF?
1) DC cardioversion (electrically shock all myocytes back into same rhythm)
2) Electrically isolate the pulmonary veins by surgery or by catheter ablation
What would patients with AF be advised to avoid?
Alcohol, stimulant such as nicoteine and caffeine
What happens to the structure of the heart in complete heart block and what does this cause?
Could be…
Fibrosis of AV node (cell death due to age)
Necrosis or infarction of AV node as a result of coronary artery disease
Failure of transmission by the AV node, atria and ventricles contract independently - ventricles thus at a slower rate
Which patients are at higher risk of developing complete heart block?
Elderly patients that have had an MI (infarction of AV node)
Patients taking beta blockers or rate lowering drugs (which block the AV node)
What is the differences in clinical presentation of chronic and acute complete heart block?
Chronic - tiredness/breathlessness with exercise
Acute - light headedness/collapse with loss of consciousness
If a patient suffers from an acute complete heart block with the primary cause of CAD which other symptoms are likely to present?
MI of Angina
What are the clinical signs of complete heart block?
Pulse and BP low
Can get cardiac syncope (loss of consciousness due to lack of blood getting pumped to brain by heart)
What would the ECG of a patient with complete heart block look like?
Completely independent P and QRS complexes
What is the immediate treatment of a patient with acute complete heart block?
1) Atropine (blocks vagus nerve and ACh allowing heart rate to rise)
2) Temporary pacemaker as soon as in hospital
When is a permanent pacemaker given to someone with complete heart block and what kind of pacemaker is it?
If complete heart block persists after recovering from MI or stopping rate lowering drugs
Dual chamber - wire from atria detects contraction and causes ventricular contraction
What are the risk factors for MI? 6
1) Smoking
2) Hypertension
3) High cholesterol
4) Obesity
5) Diabetes
6) Lack of exercise
What would an ECG of a patient with MI show?
ST elevation
What protein would be raised on the blood test of a patient with MI?
Raised troponin
What would an echocardiogram of a patient with MI show?
Reduced contraction of the affected part
What would a coronary angiogram show in MI?
Atheromatous stenosis or thrombosis
What are the clinical signs of MI? 5
1) Low BP
2) Tachychardia
3) Breathlessness (dyspnoea)
4) Fluid heard on lungs due to pulmonary oedema
5) Patient clearly distressed
What are the symptoms of MI? 4
1) Crushing chest pain radiating to left neck and arm
2) Associated nausea and vomiting
3) Sweatiness
4) Breathlessness
What causes an MI?
Coronary thrombosis or coronary atheroma
Which patients are at greater risk of MI?
Males
Elderly
Patients with a family history of MI
What is the immediate medical intervention in MI? 3
1) Morphine (pain relief)
2) High flow O2
3) Oral aspirin
What surgical intervention is carried out in MI?
Primary percutaneous intervention, clot is removed and stent is inserted
This has now largely replaced thrombolytic drugs
What is primary prevention of MI?
Avoidance of risk factors
What drugs are used to prevent MI? 5
1) Aspirin
2) Clopidogrel (antiplatelet action)
3) Beta blockers
4) Statins
5) ACEi
What 4 things make up Fallot’s tetralogy?
1) Ventricular septal defect
2) Pulmonary stenosis
3) Overriding aorta
4) Right ventricular hypertrophy
What shunt occurs in Fallot’s tetralogy?
Right to left shunt
What are TET spells and when do they occur and how do children deal with them?
Occur in Fallot’s tetralogy - marked sudden increase in central cyanosis followed by syncope, may result in hypoxic brain injury and death
Children squat to increase systemic vascular resistance and temporarily reverse shunt
What would an echocardiogram of Fallot’s tetralogy show?
Abnormal anatomy and Shunt
Couer en sabot (bootlike) appearance of heart
Eisenmenger complex (a defect of IV septum with pulmonary hypertension and a consequent right to left shunt through the defect)
What are the clinical signs and symptoms of Fallot’s tetralogy? 8
1) Low blood O2 with or without cyanosis
2) Difficulty in feeding and gaining weight
3) Retarded growth and physical development
4) Dyspnoea on exertion
5) Heart murmur (stenosed vessel)
6) Clubbing
7) Polycythaemia (large amount RBCs)
8) TET spells
What is the treatment of TET spells?
1) Oxygen
2) Potent pulmonary vasodilator
3) Potent systemic vasoconstrictor
What temporary surgical intervention is carried out in Fallot’s tetralogy?
Anastamosis between subclavian artery and pulmonary artery = more blood to lungs
What curative surgery is carried out in Fallot’s tetralogy?
Relieve pulmonary stenosis by removal of muscle and repair of VSD, despite surgery still at greater risk of sudden cardiac death and heart failure
