CV P2 Flashcards
Acute coronary syndrome
STEMI, NSTEMI, unstable angina
patho - thrombus
STEMI
complete occlusion of major coronary artery, full thickness damage to heart muscle, troponin release
NSTEMI
complete occlusion of minor artery or partial occlusion of major artery, partial thickness damage, troponin release
Unstable angina
angina of increasing frequency/severity, partial occlusion but no damage to heart, occurs on minimal exertion/at rest, no troponin
ACS RFs
ABCDEF
age, BP, cholesterol, diabetes, exercise, fags, fat, family
ACS Px
Silent MI - no chest pain - elderly, diabetic
signs distress, anxiety pallor pulse low/high BP high/low 4th heart sound signs of HF - raised JVP, 3rd heart sound, basal crepitations pansystolic murmur maybe
symptoms central chest pain N+V, fatigue sweaty SOB palpitations
ACS DDx
CV - acute pericarditis, myocarditis, aortic stenosis, aortic dissection, PE, cardiomyopathy
Resp - pneumonia, pneumothorax
GI - oesophageal spasm, GORD, acute gastritis, cholecystitis, acute pancreatitis
MSK - chest pain, broken ribs,
ACS Ix
ECG
STEMI - ST elevation, pathological Q waves, tall T waves, new LBBB
NSTEMI - ST depression, T wave inversion, maybe normal ECG
Unstable angina - normal ECG usually
Troponin - I/T - raised in MI
CXR
ECHO
Bloods - FBC, U+E, glucose, lipids,
ACS Mx
MONA Morphine Oxygen Nitrates - GTN spray Aspirin \+ P2Y12 inhibitor - clopidogrel, ticagrelor
BBs - atenolol
ACEi - ramipril
Statin - atorvastatin
Thrombolysis if indicated
PCI/CABG if indicated
Modify risk factors - stop smoking, lose weight, healthy diet, control diabetes
AAA
aneurysm - permanent dilatation of artery >50% normal
True - dilatation involves all layers of arterial wall
False - pseudoaneurysm, blood leaks through wall but contained by adventitia or perivascular tissue
degradation of elastic lamellae - leukocyte infiltrate - proteolysis and smooth muscle cell loss
AAA RFs
atherosclerotic damage, FHx, smoking, male, older, HTN, COPD, trauma, hyperlipidaemia
AAA Px
unruptured
asymptomatic
pain in abdo, back, loin, groin
pulsatile abdo swelling
ruptured abdo pain more pronounced pulsatile abdo swelling collapse, shock, hypotension, tachycardia anaemia, death
AAA DDx
GI bleed, ischaemic bowel, MSK pain, perforated GI ulcer, pyelonephritis, appendicitis
AAA Ix
Abdo USS
CT/MRI angiography
AAA Mx
Monitor small aneurysms
Modify RFs - BP, statins, smoking, diet
Surgery - open/endovascular
Ruptured - ABCDE, surgery, permissive hypotension
AAA Cx
tear in posterolateral aneurysm wall - retroperitoneal bleed - blood fills space, seals bleed for a while
Anterior wall bleed - severe, rapid
Thoracic aortic aneurysm
in aorta in thorax
TAA patho
strong genetic link
connective tissue disorders - Marfan’s, Ehlers-Danlos syndrome
Aortic dissection in some cases
TAA Px
asymptomatic
signs aortic regurgitation fever if infective cause collapse, shock, sudden death cardiac tamponade
symptoms
due to compression of local structures - hoarseness, cough SOB
haemoptysis
TAA Ix
CT/MRI
USS
ECHO
Aortography - xray + contrast
TAA Mx
Regular monitoring
Modify RFs - BP, cholesterol
Surgery
Aortic dissection
disruption of medial layer of wall, results in separation of aortic wall layers, false lumen formation
tear in intimal lining of aorta, blood enters aortic wall, separates intima from adventitia
causes - degenerative, atherosclerotic, inflammatory, trauma
Aortic dissection Px
Mimics MI
Distal extension - maybe AKI, acute lower limb ischaemia, visceral ischaemia
Peripheral pulses maybe absent
signs
HTN
maybe radio-radial delay (both radial pulses not in sync)
Shock
aortic regurgitation, coronary ischaemia, cardiac tamponade
symptoms
severe, central chest pain, tearing, may radiate to back, down arms
Aortic dissection Ix
CXR - widened mediastinum
CT, ECHO, MRI
ECG
Aortic dissection Mx
Control BP - metoprolol (BB), GTN (vasodilator)
Morphine
Surgery, replace, or insert stent
AF
supraventricular tachycardia
chaotic, irregular atrial rhythm
AVN respond intermittently -> irregular ventricular rate
No coordinated mechanical contraction of atria
risk of stroke from thromboembolism
also reduction in CO -> HF
Causes
idiopathic, HTN, HF, cardiac surgery, damage to atria…
AF Px
signs
irregularly irregular pulse
1st heard sound variable intensity
LVF signs
symptoms asymptomatic chest pain palpitaitons SOB, fatigue, syncope, TIA
AF DDx
AFl, atrial extrasystoles, SVTs, VT, WPW syndrome
AF Ix
ECG
absent P waves, rapid irregular QRS, absence of isoelectric baseline, variable ventricular rate
24hr ambulatory ECG for paroxysmal
Bloods - TFTs, FBC, renal function, electrolytes, LFTS, coag screen, cardiac enzymes
CXR - may show cardiac structural causes, eg mitral disease, HF
ECHO
CT/MRI brain if suggestion of stroke
AF Mx
Treat cause if due to precipitating event
Cardioconversion - DC shock, give LMWH (enoxaparin) as risk of thromboembolism with procedure
Anti-arrhythmic drug - amiodarone, flecainide
Verapamil, bisoprolol, digoxin - rhythm control
Anticoagulation - warfarin, aspirin, DOAC
CHA2DS2-VASc score to calculate stroke risk
Afl
organised abnormal atrial rhythm
caused by re-entry circuit in RA
Causes
idiopathic, CHD, HTN, HF, COPD, pericarditis, alcohol intoxication, structural abnormalities…
Afl Px
palpitations SOB Chest pain dizziness, syncope fatigue, HF, rapid pulse
Afl Ix
ECG
‘sawtooth’ appearance
narrow complex tachycardia
regular QRS
ECHO
CXR, TFTs, FBC, ESR, renal, LFTs…
Afl Mx
Electrical cardioconversion
Catheter ablation - try to block re-entrant wave
Amiodarone, bisoprolol
Anticoagulants
Heart block
AV block - block in AVN or bundles of His
Bundle branch block - block in lower conduction system
First-degree AV block
PR prolongation >0.22s
every atrial dep followed by conduction to ventricles but with delay
Causes - hypokalaemia, myocarditis, inferior MI, AVN blocking drugs (BBs, CCBs, digoxin)
Asymptomatic, no tx
Second-degree AV block
Mobitz T1
progressive lengthening of PR interval, then beat dropped and QRS missing
Causes - AVN blocking drugs, inferior MI
Light-headedness, dizziness, syncope
May need pacing
Mobitz T2
PR interval constant, but occasional atrial dep without ventricular dep (eg 2:1)
Causes - anterior MI, mitral valve surgery, SLE, lyme disease, rheumatic fever
SOB , postural hypotension, chest pain
Pacemaker insertion
Third-degree heart block
complete absence of AV conduction, P waves independent to QRS, AV dissociation
Causes - structural, MI, HTN, endocarditis, lyme
Tx depends on cause - pacemaker, atropine
RBBB
no dep down right branch, action of RV delayed, as dep has to spread across septum from LV
Causes - PE, IHD, septal defect
Wide physiological splitting of second heart sound
ECG - QRS >120ms, MARROW - first letter M, so lead 1 has complex resembling an M (R wave) and last letter is W, so lead 6 has complex resembling W (slurred S wave)
LBBB
Impulse has to spread from RV to LV
Causes - IHD, aortic valve disease
Reverse splitting of second heart sound
ECG - QRS >120ms, WILLIAM - first letter W, so lead 1 has complex resembling W (slurred S wave), 6th letter is M, lead 6 has complex resembling M (R wave)
Sinus tachycardia
> 100bpm
originates from SAN - normal P then QRS on ECG
Causes - anaemia, anxiety, exercise, pain, HT, PE
Tx cause, BB if necessary
AV nodal re-entrant tachycardia (AVNRT)
Two pathways in AV node - slow/fast - one acts as antegrade limb, the other retrograde
Px - rapid, regular palpitations, abrupt onset, chest pain, SOB
Neck pulsations - jugular venous pulsations due to atrial contractions against closed AV valves
polyuria - release of ANP in response to increased atrial pressures
ECG dx - sometimes BBB seen, P waves not seen or are immediately before/after QRS due to simultaneous atrial and ventricular activation
AV re-entrant tachycardia (AVRT)
accessory pathway connecting atria and ventricles, impulses can travel down/up this pathway
WPW
accessory pathway - bundle of Kent, no slowing of conduction between atria and ventricles (as AVN does) -> pre-excitation
ECG - short PR, wide QRS, begins with delta wave
Tachyarrhythmia only with premature beat from SAN, then signal travels as normal, then up accessory pathway - re-entry circuit -> tachyarrhythmia
Px - palpitations, dizziness, SOB, syncope
AVRT and AVNRT Tx
Emergency cardioconversion if haemodynamically unstable
Stable - breath holding, carotid massage, valsalva
IV adenosine
Surgery - catheter ablation of accessory pathway
Ventricular tachycardias
VF - very funny
VT - very tidy
Ventricular ectopic
premature ventricular contraction
patient complains of extra beats, missed beats, heavy beats, may feel uncomfortable, faint/dizzy, pulse irregular
ECG - QRS widened
Reassure, BB if symptomatic
Prolonged QT syndrome
QT prolonged
Causes - congenital, hypokalaemia, hypocalcaemia, drugs (amiodarone, TCAs), bradycardia, acute MI, diabetes
Px - syncope, palpitations
ECG
Tx cause, if acquired - IV isoprenaline
Cardiomyopathy
disease of the myocardium, affects mechanical/electrical function of heart, all carry arrhythmic risk
generally inherited genetic conditions, some acquired types
RFs - FHx, HTN, obesity, diabetes, previous MI
Hypertrophic cardiomyopathy
ventricular hypertrophy - thickening of muscle
non-compliant ventricles impair diastolic filling - reduced SV and CO
thick, powerful heart -> disarray of cardiac myocytes - conduction affected
Px signs - cardiac arrhythmia - ejection systolic murmur - jerky carotid pulse symptoms - chest pain/angina - SOB - dizziness, palpitation, syncope
DDx
other causes of LVH - obesity, athletic training, amyloidosis
Ix ECG - LVH with progressive T wave inversion, deep Q waves ECHO CXR Genetic analysis
Mx
Amiodarone - anti-arrhythmic
CCB - verapamil
BB - atenolol
Dilated cardiomyopathy
dilated LV which contracts poorly
Caused by - ischaemia, alcohol, thyroid disorder, genetic, cytoskeletal gene mutations
Px signs - arrhythmias - increased JVP - HF signs - since heart can't contract symptoms - SOB, fatigue
Ix
CXR
ECG - tachycardia, arrhythmia, non-specific T wave changes
ECHO - dilated ventricles
Mx
Tx HF and AF
Diuretics, ACEi, digoxin, BBs, nitrates
Restrictive cardiomyopathy
increased myocardial stiffness - ventricle incompliant - impaired filling/dilatation - is restrictive
Causes - amyloidosis, idiopathic, sarcoidosis, endomyocardial fibrosis
Px similar to constrictive pericarditis signs - elevated JVP - hepatic enlargement, ascites, oedema - S3, S4 symptoms - SOB, fatigue - embolic symptoms
Ix
CXR, ECHO, ECG
Cardiac catheterisation to diagnose
Mx Poor prognosis Cardiac transplantation HF - diuretics, ACEi BBs, CCBs for arrhythmias
Arrhythmogenic right ventricular cardiomyopathy
progressive fatty and fibrous replacement of ventricular myocardium
cause unknown, is genetic
Px
arrhythmia, RHF, syncope
Ix
ECG - maybe normal, T wave inversion
ECHO
Genetic testing
Mx
BBs - atenolol
Amiodarone for symptomatic arrhythmias
Cardiac transplant
Heart failure
CO is inadequate for body requirements
Cor pulmonale
abnormal enlargement of right heart from disease of lungs/pulmonary blood vessels - eg COPD
HF patho
Systolic
inability of ventricle to contract normally, reduced CO (EF <40%) - IHD, MI, cardiomyopathy
Diastolic
inability of ventricle to relax and fill normally, SV decreased - hypertrophy, constrictive pericarditis, tamponade, restrictive cardiomyopathy, obesity, aortic stenosis (causes LVH)
Left / right sided / CCF
Low-output cardiac failure
CO reduced and failure to increase with exertion - excessive preload (fluid overload, mitral regurgitation), pump failure, excessive afterload (HTN, aortic stenosis)
High-output
CO normal but fails to rise to meet demands - anaemia, pregnancy, hyperthyroidism, Paget’s
Causes
IHD, HTN, MI, alcohol excess, cardiomyopathy, valvular
Mechanisms of HF increased preload increased afterload salt and water retention myocardial remodelling
HF Px
SOB, fatigue, ankle swelling
signs tachycardia displaced apex beat (LV dilatation) RV heave (pul HTN) added heart sounds - gallop (S3), murmurs, raised JVP hepatomegaly ascites peripheral oedema PO cyanosis pleural effusions
symptoms SOB, fatigue cold peripheries PND - paroxysmal nocturnal dyspnoea nocturnal cough (maybe pink frothy sputum) orthopnoea (SOB when lying down) wheeze light-headed/syncope
NYHA classification for severity I-IV
HF Ix
Bloods - brain natriuretic peptide - secreted in ventricles in response to increased myocardial wall stress - if normal, HF unlikely, and other blood tests
ECG - underlying causes - ischaemia, LVH, arrhythmia
ECHO
CXR - ABCDE Alveolar oedema (bat's wing shadowing) Kerley B lines - septal lines Cardiomegaly - cardiothoracic ratio >50% Dilated prominent upper lobe veins (upper lobe diversion) Pleural Effusions
HF Mx
lose weight, exercise, stop smoking
Diuretics - furosemide, thiazide, spironolactone
ACEi - ramipril, enalapril (S/E cough, hypotension, hyperkalaemia, renal dysfunction)
ARB
BB - bisoprolol
Surgery to repair cause, heart transplant
HF Cx
renal dysfunction
rhythm disturbances
DVT, PE…
HTN
High BP
Stage 1 - 140/90
Stage 2 - 160/100
Stage 3 - 180/110
HTN patho
Primary - unknown cause, 95% of cases
Secondary - inc renal disease, endocrine causes, aorta coarctation, drugs
HTN Px
Asym
Retinal haemorrhage, papilloedema, headaches - malignant htn
HTN Ix
24hr ABPM
Urinalysis, bloods, fundoscopy, ECG, echo
HTN Mx
Lifestyle
ACEi (under 55yo)/CCB (55+, afro-caribbean)
Then the other one
Then thiazide
Then another diuretic (spironolactone), alpha/beta blockers
IE
infection of endocardium
fever + new murmur = IE until proven otherwise
IE patho
Valves most commonly affected - mitral most commonly affected, tricuspid in IVDU
Valves do not have direct blood supply
Causes
S.aureus, S.viridans, candida…
RFs
valvular heart disease, valve replacement, congenital heart disease, IVDU, skin breaches
IE Px
Fever, rigors, night sweats, malaise, wt loss, anaemia, splenomegaly, clubbing, myalgia, anorexia
New murmur or change to murmur
Aortic root abscess - long PR, maybe complete AV block
Immune complex deposition vasculitis microscopic haematuria glomerulonephritis/AKI splinter haemorrhages Osler's nodes, Janeway lesions, Roth spots
Abscesses in organs from emboli
IE Ix
Modified Dukes Criteria to dx
Blood cultures - 3 sets, different times, different sites
Bloods - anaemia, neutrophilia, ESR/CRP raised
Urinalysis - for microscopic haematuria
CXR
ECG
ECHO
CT - look for emboli
IE Mx
ABs
Surgery if HF, valvular obstruction…
IE Cx
MI, pericarditis, arrhythmias, heart valve insufficiency, CCF, stroke sydromes
MI
necrosis of myocardial tissue due to ischaemia
NSTEMI/STEMI
from thrombus/atherosclerosis
MI Px
silent MI - elderly, diabetics
signs pale, clammy, sweaty distress, anxiety BP high/low 4th HS Signs of HF - raised JVP, 3rd HS, basal crepitations pansystolic murmur pericardial rub/PO
symptoms central chest main, crushing radiation to jaw, neck, left arm N+V SOB palpitations
MI Ix
ECG
STEMI - ST elevation, tall T waves, LBBB, later T wave inversion and pathological Q waves
NSTEMI - ST depression, T wave inversion, maybe no change
Cardiac enzymes - troponin, myocardial muscle creatine kinase (CK-MB)
CXR, ECHO, cardiac catheterisation and angiography
MI Mx
Pre-hospital Aspirin 300mg GTN Morphine, O2 Thrombolytic drugs if indicated - reteplase/tenecteplase
Hospital Morphine, O2 PCI - balloon angioplasty, stent CABG Thrombolytic drugs - streptokinase, alteplase, if indicated
secondary prevention
statins
aspirin
BBs, ACEi, clopidogrel
Stop smoking, lose weight, exercise, healthy diet
Acute pericarditis
inflammation of the pericardium
Acute pericarditis causes
Viral
Bacterial
Autoimmune
Neoplastic - secondary metastatic tumours - lung, breast, lymphoma
Trauma, iatrogenic
Others - amyloidosis, aortic dissection, pulmonary arterial HTN
Acute pericarditis Px
signs
pericardial friction rub (crunching snow)
tachycardia
tachypnoea
fever
lymphocytosis
signs of effusion - pulsus paradoxus, Kussmaul’s sign
symptoms chest pain - sharp, pleuritic, radiates to arm, worse on inspiration or lying flat SOB Cough, non-productive Hiccups - phrenic involvement viral symptoms
Acute pericarditis Ix
ECG
diffuse ST elevation (all leads)
Saddle-shaped ST elevation
PR depression
Bloods - FBC, ECR, CRP, troponin
CXR
Acute pericarditis Mx
Tx cause
NSAIDs - ibuprofen, also aspirin
Colchicine for 3 months
Maybe prednisolone
Pericardiectomy
Pericarditis Cx
Pericardial effusion, tamponade, constrictive pericarditis, chronic pericardial effusion (slow fluid accumulation, rarely causes tamponade)
Constrictive pericarditis
rigid pericardium
Con. pericarditis patho
Causes - idiopathic, viral, TB, mediastinal irritation, post-surgical
restricts ventricular filling
Con pericarditis Px
signs Kussmaul's sign - rise in JVP, increased neck vein distension during inspiration pulsus paradoxus - systolic BP drops >10mmHg during inspiration diffuse heart sounds, eg apex beat HSM ascites oedema RHF signs atrial dilatation
symptoms fatigue hiccups anxiety/confusion hoarseness/cough
Con pericarditis DDx
Restrictive cardiomyopathy, dilated cardiomyopathy, pericardial effusion
Con pericarditis Ix
CXR ECG - low voltage QRS ECHO CT/MRI - to distinguish from restrictive cardiomyopathy Cardiac catheterisation
Con pericarditis Mx
Resection of pericardium
Pericardial effusion
accumulation of fluid in the pericardial sac (there is normally 50ml)
Cardiac tamponade
pericardial effusion raises intrapericardial pressure, reducing ventricular filling, dropping CO
Pericardial effusion causes
idiopathic acute pericarditis malignancy TB myocardial rupture aortic dissection (great vessels in pericardium)
Pericardial effusion Px
signs soft, distant heart sounds apex beat obscured raised JVP bronchial breathing at left base
symptoms
SOB
chest pain
nausea
Tamponade Px
high pulse, low BP high JVP Kussmaul's sign Pulsus paradoxus reduced CO
Pericardial effusion Ix
CXR - large globular heart
ECG - low voltage QRS, sinus tachycardia
ECHO
Tamponade Dx
CXR - large globular heart
Beck’s triad - falling BP, rising JVP, muffled heart sounds
ECG - low voltage QRS
ECHO
Pericardial effusion Mx
most resolve spontaneously
treat cause
pericardial fenestration - create window to allow slow fluid release
tamponade Mx
pericardiocentesis - drain fluid, risk of cardiac arrest
Peripheral arterial disease
narrowing of artery, from atherosclerosis/thrombus, leads to insufficient perfusion of limb and lower limb ischaemia
PAD patho
3 main patterns of Px: intermittent claudication cramping/burning/aching pain in calf, thigh, buttock after walking certain distance, relieved by rest pain in calf - femoral disease pain in buttock - iliac disease
critical limb ischaemia
rest pain, typically nocturnal
acute limb-threatening ischaemia
sudden decrease in arterial perfusion, limb threatened
RFs
smoking, diabetes, high cholesterol, HTN, physical inactivity, obesity
PAD Px
signs absent pulses cold, white legs atrophic skin punched out ulcers Buerger's angle (angle that leg goes pale when raised off couch) <20 degrees CRT >15s
symptoms
claudication
ischaemic rest pain - relieved by hanging foot out of bed
PAD DDx
Lower limb pain - sciatica, spinal stenosis, DVT, entrapment syndromes, muscle/tendon injury
OA, neuropathy
PAD Ix
Buerger’s angle <20 degrees, CRT >15s
ESR/CRP - exclude arteritis
FBC - exclude anaemia/polycythaemia
ECG - look for cardiac ischaemia
ABPI - the smaller the ratio of BP in ankle/arm, more severe
USS, MRI/CT angiography
PAD Mx
Quit smoking, exercise, healthy diet
Tx HTN, statins, clopidogrel, vasoactive drugs (naftidrofuryl oxalate)
Percutaneous transmural angioplasty, surgical reconstruction, amputation
PAD Cx
Qol reduced, infection, poor tissue healing, ulceration, gangrene, amputation
Acute limb ischaemia
sudden decrease in arterial perfusion - thrombotic/embolic causes
Acute limb ischaemia Px
pale pulseless pain paralysed paraesthesia perishingly cold
Acute limb ischaemia Mx
Surgery/angioplasty
Heparin post-op
Shock
circulatory failure leads to inadequate organ perfusion
can result from inadequate CO, loss of SVR, or both
Shock patho
Hypovolaemic - haemorrhagic, burns, DKA, D+V
Cardiogenic - heart not pumping properly - MI, heart block, secondary causes of pump failure (PE, tension pneumothorax, tamponade)
Distributive - septic shock, anaphylactic, neurogenic (spinal cord transection, interrupts ANS, decreases SNS/increases PNS, decreased PVR)
Anaemic shock and cytotoxic shock also
Can classify haemorrhagic shock I-IV
Shock Px
reduced GCS, agitation, confusion pale skin, cold, sweaty, vasoconstricted cool peripheries - cyanosis tachycardia tachypnoea oliguria CRT increased weak rapid pulse pulse pressure reduced (MAP may be maintained)
Neurogenic
instant hypotension, warm flushed skin, priapism, bradycardia
Shock Ix
ABCDE General review of signs of shock Tachycardic and hypotensive If JVP raised, cardiogenic shock likely look for trauma
Shock Mx
Haemorrhagic
Stop bleed
Permissive hypotension
Blood, FFP, crystalloid/fluid boluses
Neurogenic
Fluids
peripheral vasoconstrictors to return tone to normal
Cardiogenic shock
inadequate tissue perfusion due to cardiac dysfunction
Cardiogenic shock Px
Signs of heart failure - raised JVP, gallop rhythm, basal crackles, PO
Signs of shock
Symptoms of condition, eg MI
Cardiogenic shock Ix
ECG changes
ECHO
MI troponin levels
basically look for cause
Cardiogenic shock Mx
ABCDE
Supportive
Tx cause
Surgery, eg if trauma is cause
Sepsis
infection and systemic inflammatory response (cytokine release) - dysregulated host response to infection
endothelial cell damage, vasodilation, increased capillary permeability, organ failure
septic shock - sepsis with lactate >2mmol/L or need vasopressors to maintain MAP >65
Sepsis RFs
age - old/very young instrumentation/surgery indwelling line, catheter alcohol abuse DM breach of skin immunocompromised high dose steroids, chemo IVDU pregnancy
Sepsis Px
earlier presentation of infection, rapid deterioration
pyrexia, rigors, vasodilation, warm peripheries, bounding pulse, N+V
Sepsis screening systolic BP<90 HR >130 sats <91% RR >25 reduced GCS Lactate >2mmol/L
Sepsis Ix
Assess risk - high/moderate-to-high/low
H+E
ABG for lactate, observations - HR, BP, RR, sats, temp, ECG, urine dip, urine output
Blood cultures, micro samples of sputum/urine, swab wounds
CXR/CT/MRI of suspected source
Sepsis Mx
Sepsis six resus bundle High flow O2 take blood cultures, consider infective source IV ABs IV fluid check Hb, serial lactates hourly urine output measurement
surgical involvement, eg wound debridement
Manage acute Cx - shock, AKI, DIC, ARDS, arrhythmias
Anaphylactic shock
acute life-threatening T1 IgE-mediated hypersensitivity reaction
rapid histamine release from mast cells, basophils - cap leakage, mucosal oedema, shock, asphyxia
Causes
drugs, latex, food, venom
Anaphylactic shock Px
Itching, sweating, D+V, erythema (red skin), urticaria (hives), oedema (larynx, tongue, lips)
Wheeze, laryngeal obstruction, cyanosis
Tachycardia, hypotension
Anaphylactic shock Ix
straight to Mx if suspected
Serum mast-cell tryptase to confirm - shows mast cell degranulation
Anaphylactic shock Mx
ABCDE
high flow O2
IM adrenaline - acts on beta receptors to dilate bronchi (0.5mg)
IV fluid
Chlorphenamine - H1 antihistamine
Hydrocortisone - suppresses prostaglandin and leukotriene mediators
Continuing resp deterioration - bronchodilator - salbutamol/ipratropium
Stable angina
chest pain from reversible myocardial ischaemia
Angina patho
Stable - induced by effort, relieved by rest, 3 features:
- constricting/heavy discomfort to chest, jaw, neck, shoulders, arms
- symptoms brought on by exertion
- symptoms relieved in 5 mins by rest or GTN
3 features = typical angina, 2 = atypical, 1 = non-anginal chest pain
Unstable angina
crescendo angina, angina of increasing frequency or severity, occurs on minimal exertion/rest
Both cases - mismatch between blood supply and metabolic demand
Causes - atherosclerosis, valvular disease, aortic stenosis, arrhythmias, anaemia
Angina RFs
FHx, smoking, diabetes, metabolic syndrome, HTN, obesity, lack of exercise, cardiac abnormalities
Stable angina Px
Provoked by exertion - after meal, cold, windy, exercise, angry/excited
signs
sweaty
distressed
symptoms central chest tightness or heaviness pain may radiate SOB nausea, feeling faint
Stable angina Ix
ECG - may be normal, ST depression, flat/inverted T waves Treadmill test/exercise ECG Bloods - FBC to exclude anaemia ECHO CXR Coronary angiography
Stable angina Mx
Modify RFs - stop smoking, exercise, lose weight, atorvastatin
Aspirin
GTN - dilates systemic veins, reducing venous return to heart, reduces preload, also dilates coronary arteries
BBs - atenolol, bisoprolol
CCB - verapamil
Long acting nitrates
Ivabradine - HCN channel blocker, reduces HR
Maybe surgery - PCI, CABG
Structural heart defects
1% of all live births have some form of cardiac defect
Causes of congenital heart disease maternal prenatal rubella infection maternal alcohol misuse single genes - trisomy 21 drugs - thalidomide, amphetamines, lithium diabetes of mother genetic abnormalities
Atrial septal defect
abnormal connection between atria, often first dx in adulthood
Patho
LAp > RAp
shunt left-to-right, thus NOT blue, acyanotic
increased flow into right heart and lungs
RV compliant, easily dilates, but can result in:
- RVH
- Pulmonary HTN
- Eisenmenger’s - high pressure pulmonary flow, damages pulmonary vasculature, resistance to blood flow through lungs increases, RV pressure increases, shunt direction reverses, patient becomes blue, clubbing
Large defect
significant flow through right heart - dilatation, SOBOE, increased chest infections
Small
small increase in flow through right side, no dilatation, no symptoms
Px
atrial arrhythmias from RA dilatation, pulmonary flow murmur, fixed split second heart sound (delayed closure of pulmonary valve - more blood has to get out)
SOBOE
Ix
CXR
ECG
ECHO
Mx
Surgical closure
Bicuspid aortic valve
2 cusps instead of 3
commonly causes aortic stenosis, degenerates, becomes regurgitant
Ventricular septal defects
abnormal connection between two ventricles
Patho
LVp > RVp
L-R shunt, NOT blue, acyanotic, increased flow through lung
Large defects
large volumes of blood through heart vessels, pulmonary HTN, Eisenmenger’s, then R-L shunt, cyanotic
Small defects
asymptomatic, IE risk, no intervention needed
Px LARGE defects small breathless skinny baby increased RR tachycardia cyanosis murmurs SMALL defects loud systolic murmur thrill (buzzing sensation) well grown, normal HR, normal heart size
Ix
CXR
Mx
surgical closure
Atrio-ventricular septal defects
hole in centre of heart
Instead of two separate AV valves, just one big malformed one, associated with Down’s
Px COMPLETE defect breathless neonate poor weight gain, feeding torrential pulmonary flow, can result in Eisenmenger, cyanosis PARTIAL defect can present in late adulthood SOB, tachycardia, exercise intolerance
Mx
Surgical repair
Patent ductus arteriosus
persistent communication between proximal left pulmonary artery and descending aorta
foetal life - pulmonary vascular resistance high (bronchioles filled with fluid), vessels constricted (lack of O2), right heart pressure exceeds left, flow from RA to LA through foramen ovale, also from pulmonary artery to aorta through ductus arteriosus
abnormal L-R shunt (aorta to pulmonary artery), lung circulation overloaded, Eisenmenger’s, right sided cardiac failure (RVH in response to increased afterload)
Px continuous 'machinery' murmurs bounding pulse Eisenmenger's, clubbed cyanosis, blue toes, but pink and not clubbed fingers SOB
Ix
CXR
ECG - LA abnormality, LVH
ECHO
Mx
Indometacin (prostaglandin inhibitor) - stimulate duct closure
Surgical closure
Coarctation of the aorta
narrowing of aorta just distal to insertion of ductus arteriosus (distal to origin of left subclavian artery)
Patho
narrowing just after arch
excessive blood flow through carotid and subclavian vessels into systemic vascular shunts to supply rest of body
stronger perfusion to upper body rather than lower
decreased renal perfusion -> systemic HTN even after surgical correction
body grows collateral vessels around narrowing
Px
Right arm HTN
Bruits over scapulae and back from collateral vessels
murmur
HTN in upper limbs
Radial pulse before femoral pulse - discrepant BP
headaches and nose bleeds from HTN
Ix
CXR
ECG - LVH
CT
Mx
Balloon dilatation and stenting
Tetralogy of fallot
most common form of cyanotic congenital heart disease, consists of:
- VSD
- pulmonary stenosis
- RVH
- overriding aorta
patho
stenosis of RV outflow leads to RVp>LVp
blue blood passes from R-L, patients are BLUE, cyanotic
Px central cyanosis low birth weight and growth delayed puberty systolic ejection murmur SOBOE
Ix
CXR - boot-shaped heart
Mx
Surgery
Pulmonary stenosis
narrowing of outflow of RV
can be valvar, subvalvar, supravalvar
Px RV failure as neonate collapse poor pulmonary blood flow RVH tricuspid regurgitation mild - well tolerated for years
Mx
Surgery - balloon valvuloplasty - inflates balloon to crush stenosis
shunt to bypass blockage
Aortic stenosis
narrowing of aortic valve
Patho
Causes - calcification, bicuspid aortic valve calcified, rheumatic heart disease
narrowing obstructs LV emptying, increases afterload, LVH, then relative ischaemia of LV (hypertrophy = higher blood demand) -> angina, arrhythmias, failure
increased IE risk
Px
Classic triad - angina, syncope, heart failure
EJECTION SYSTOLIC CRESCENDO-DECRESCENDO MURMUR
Prominent S4 from LVH
soft/absent S2
slow rising carotid pulse (pulsus tardus), decreased pulse amplitude (pulsus parvus)
Ix
ECHO
ECG - LVH,
CXR
Mx
Surgical aortic valve replacement - TAVI (transcutaneous aortic valve implantation)
Mitral regurgitation
Backflow of blood from LV to LA during systole
Patho
Abnormalities of valve leaflets, chordae tendineae (mitral valve prolapse), papillary muscles
Compensatory mechanisms - LA enlargement, LVH (LV puts in same effort to pump less blood, so needs to pump harder to maintain CO), then progressive HF
Px
PANSYSTOLIC MURMUR
soft S1, left-sided murmur so heard loudest on inspiration
prominent S3 in congestive HF
SOBOE, fatigue, lethargy, palpitations, symptoms of RHF
Ix
ECG - LA enlargement (broad P wave), maybe AF, LVH
CXR
ECHO
Mx ACEi - act as vasodilator - SM relaxer HR control - BBs, CCB Diuretics for fluid overload Mitral valve replacement
Aortic regurgitation
Leakage of blood into LV during diastole
Causes - rheumatic fever, bicuspid aortic valve, IE
LV dilatation, LVH to compensate
Px
EARLY DIASTOLIC MURMUR
apex beat displaced laterally
SOBOE, palpitations, angina, syncope
Ix
CXR
ECHO
ECG - LVH signs
Mx
Vasodilator - ACEi
Valve replacement
Mitral stenosis
obstruction of LV inflow from LA - prevents proper filling during diastole
Patho
LA dilatation - pulmonary congestion, AF, RHF symptoms from pulmonary venous HTN, haemoptysis from rupture of bronchial vessels from elevated pulmonary pressure
Causes - rheumatic fever, IE, calcification
Px MID-DIASTOLIC MURMUR loud S1, opening snap malar flush on cheeks - due to low CO low pulse volume peripheral oedema ruddy complexion - mitral facies SOB fatigue, palpitations, chest pain, haemoptysis
Ix
CXR
ECG
ECHO
Mx
BBs, CCBx, diuretics
Percutaneous mitral balloon valvotomy
mitral valve replacement
