CVD Flashcards
Hypertension: Definiton
Persistently raised arterial blood pressure.
BP is the force the blood exerts on the blood vessels.
BP reading above 135/85»_space; at home suspect hypertension.
BP reading above 140/90»_space; in clinic suspect hypertension.
White Coat Hypertension: Definiton
Raised BP in clinical setting, compared to normal life.
Stressed when being in clinic.
Fine otherwise.
Marked Hypertension: Definiton
BP fine in clinical setting.
However, higher in normal settings.
Typically life/work induced.
Hypertension: Epidemiology
11.8 million adults (26.2% of population), higher incidence in men and those over 60.
90% with primary hypertension/essential hypertension
10% with secondary hypertension
For every 10 diagnosed, 7 remain undiagnosed.
Hypertension: Aetiology
Primary»_space; arteriosclerosis or atherosclerosis
Arteriosclerosis»_space; hardening»_space; age-related, affects auto regulation
Atherosclerosis»_space; fat deposits»_space; aneurysm risk
Secondary»_space; due to disease
Hypertension: Risk Factors
Stress and anxiety
Age
Gender
Ethnicity»_space; black African and Caribbean more likely
Genetic factors
Social deprivation
Lifestyle»_space; smoking, alcohol, salt, obesity, lack of exercise
Co-morbidities
QRISK3 risk > 10%
Hypertension: Stages
Stage 1 hypertension-
Clinic blood pressure ranging from 140/90 mmHg - 159/99 mmHg
Subsequent ABPM daytime average or HBPM average blood pressure of 135/85 mmHg - 149/94 mmHg.
LIFESTYLE ADVICE AND MONITOR
Stage 2 hypertension-
Clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg.
ABPM daytime average or HBPM average blood pressure of 150/95 mmHg or higher.
TREAT
Stage 3 or severe hypertension-
Clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher.
IMMEDIATE REFERAL
Hypertension: Investigations
Blood pressure cuff, measure both arms, if the difference is 15 mmHg repeat, record the higher one.
High BP»_space; repeat 3 times, take the lower of the least 2.
Confirm diagnosis by doing-
ABPM»_space; 2/hr during waking hours»_space; average 14 measurements.
HBPM»_space; 2 taken 1 min apart, recorded 2x a day for 4-7 days»_space; average of all readings.
Carry out investigations for target organ damage and QRISK3
» ECG for left-ventricular hypertrophy.
» Renal function test and urine tests.
» Eye screening/fundoscopy»_space; positive test is flame shaped haemorrhage
Hypertension: Management
Lifestyle changes: low calorie and low salt diet, exercise 3-5 times a week, stress, smoking, alcohol.
Patient information leaflets.
Under 40»_space; refer for secondary HTN investigations.
Under 80 with stage 1 HTN»_space; treatment if there is organ damage, CVD, renal disease, diabetes.
Anyone with stage 2 hypertension»_space; treat.
Refer to NICE guidelines for pharmacological treatment.
» ACEi - Angiotensin-converting enzyme (ACE) inhibitors»_space; works on RAAS system
» ARB - Angiotensin receptor blockers»_space; works on RAAS system
» CCB - Calcium channel blockers»_space; reduces heart and vessel muscle contraction (shouldn’t be given to patients with heart failure, except amlodipine)
ACEi or ARB»_space; for type II diabetes, for under 55 year age, for non-black African background
CCB»_space; for age over 55, for black African background
Severe and Accelerated Hypertension: Definition
If BP 180/120 and symptoms present»_space; same day referral.
Severe Hypertension: only raised BP
Accelerated Hypertension/Malignant Hypertension: includes target organ damage.
» eye check, urine sample, ECG
Risk factors: essential/primary HTN, secondary HTN, younger age on onset of HTN, commoner in black/afro-caribbean races.
Can be fatal»_space; heart failure, cerebral haemorrhage, renal failure.
If 180/120 and no symptoms»_space; investigate and consult.
Hypertension: Complications
Increased risk of:
Coronary Heart Disease
Left Ventricular Hypertrophy
Heart failure
Arrhythmias
Stroke
Infarction
Chronic Kidney Disease
Peripheral Artery Disease
Hypertension is biggest risk factor of CVD.
Secondary Hypertension: Definition
Hypertension or high blood pressure that is secondary to a disease or condition.
Secondary Hypertension: Epidemiology
10% of all hypertension cases.
Secondary Hypertension: Renal Diseases
All of these can cause secondary hypertension.
Poor blood flow to kidneys will cause kidneys to produce the hormone, renin, increasing bp.
Poor kidney function means kidneys can’t filter blood properly; excess fluid increase bp.
Impaired kidney function symptoms: haematuria, polyuria, proteinuria and elevated blood creatinine.
Renal artery stenosis»_space; narrowing of renal arteries due to
1. Plaques of fat due to high cholesterol
2. Fibromuscular dysplasia due to abnormal growth of cells in walls of renal arteries
Diabetic nephropathy»_space; complication of diabetes that can damage kidneys’ filtering system.
Chronic glomerulonephritis»_space; glomeruli inflammation and damage impairing filteration.
Polycystic kidney disease»_space; inherited condition of cysts on kidney impairing function.
Chronic tubulointerstitial nephritis»_space; kidney tubule inflammation.
Renovascular disease»_space; narrowed arteries leading to kidneys impairing function
Secondary Hypertension: Endocrine Diseases
All of these can cause secondary hypertension.
Endocrine system release hormones; hormones that affect bp.
Conn’s syndrome/primary aldosteronism»_space; adrenal gland produce too much aldosterone that increases uptake of sodium and water into blood stream.
Adrenal hyperplasia»_space; genetic disorders where adrenal glands unable to produced hormones.
Acromegaly»_space; pituitary gland produces too much growth hormone.
Cushing’s syndrome»_space; tumour on pituitary gland causes increased ACTH hormone»_space; acts on adrenal gland to increase cortisol release»_space; causes vasoconstriction»_space; increased bp.
Phaeochromocytoma»_space; tumour in adrenal gland causing overproducing of hormones controlling bp.
Causes irregular release of adrenaline and noradrenaline.
Symptoms include: anxiety, palpitations, tremor, sweating, headaches, flushing, tachycardia, bradycardia.
Secondary Hypertension: Congenital CVD
Can cause secondary hypertension.
Aortic Coarctation: narrowing of aorta after aortic arch»_space; heart has to pump harder to get blood pass narrowing.
» all branches before narrowing get blood at high bp»_space; all branches after narrowing get lower bp»_space; differing bp readings!
Secondary Hypertension: Pregnancy Induced
Pregnancy can also induce hypertension.
Gestational hypertension.
Postural Hypertension: Definition
Drop of blood pressure when a person stands up from sitting or laying.
Systolic bp falls by 20mmHg or more.
Diastolic bp falls by 10mmHg or more.
Postural Hypertension: Symptoms and Signs
Symptoms precipitated by head-up postural change and relieved by lying flat.
Light-headedness
Visual blurring
Dizziness
Weakness
Postural Hypertension: Risk Factors
Aortic stenosis
Anaemia
Blood loss
Primary hypoaldosteronism
Medications
Postural Hypertension: Investigation
Full Blood Count
Fasting glucose levels
ECG
ECHO
Measure bp with person lying on their back or sat down.
Measure bp again after person has been standing for at least 1 minute.
Postural Hypertension: Management
Manage underlying cause: anaemia, fluid loss, blood loss, etc.
Review medications
Consider referral
Atherosclerosis: Definition
“Atherosclerosis is progressive disease characterised by build-up of plaques in arterial walls.
CAD: atherosclerosis of coronary arteries.
Heart perfuses itself through coronary arteries.
Coronary flow occurs during diastole.”
Atherosclerosis: Aetiology
- Endothelial Injury: damage to endothelial lining»_space; caused by: hypertension, smoking, high cholesterol, and diabetes.
- Lipoprotein Accumulation: LDL cholesterol infiltrates damaged endothelium and accumulates in arterial wall.
- Oxidation of LDL: trapped LDL is oxidised, which triggers an inflammatory response»_space; oxidised LDL more likely to be taken by macrophages.
- Monocyte Recruitment and Foam Cell Formation: monocytes attracted to site of injury»_space; differentiate into macrophages. Macrophages engulf oxidised LDL, turning into foam cells»_space; hallmark of early atherosclerotic lesions known as fatty streaks.
- Plaque Formation: Over time, foam cells release cytokines to further promote inflammation and attract more immune cells. Smooth muscle cells form a fibrous cap over the lipid core.
- Plaque Growth and Complications: Plaques grow»_space; narrow the arterial lumen, restricting blood flow.
Plaques can become unstable»_space; rupture can lead to thrombosis»_space; MI.
Atherosclerosis: Complication
Heart:
» IHD/CHD»_space; angina
» Myocardial Infarction
» Heart Failure
Cerebral:
» Stroke
» Transient Ischaemic Attack (TIA)
» Vascular Dementia»_space; tiny, asymptomatic strokes that present in old age
Limb:
» Peripheral Vascular Disease
Renal:
» Renal Artery Stenosis»_space; hypertension
» Renal Failure»_space; Chronic Kidney Failure
Aneurysms:
» Haemorrhage
Coronary Artery Disease: Definition
Coronary arteries unable to provide sufficient blood supply to heart.
Also»_space; Ischaemic Heart Disease or Coronary Heart Disease
Coronary Artery Disease: Epidemiology
CAD most common single cause of death in UK
Coronary Artery Disease: Aetiology
Plaque build up in the walls of the arteries that supply blood to the heart»_space; narrowing
Heart problems»_space; narrowing of coronary arteries.
Angina»_space; narrowing due to atherosclerosis (fat deposits).
Myocardial Infarction»_space; complete blockage and heart muscles dies.
Blockage of artery can be caused by blood clots-
» thrombosis: formation of clot within vein/ artery
» embolism: piece of clot breaks off and carried through ciruclation
Clots caused by: structuraly different or damaged blood vessels, blood stasis, cancer.
Collateral Circulation»_space; back up circulation to help main circulation.
End Arteries»_space; arteries that is the only supply to a certain area»_space; no back up.
Coronary Artery Disease: Risk Factors
Modifiable»_space; Smoking, hyperlipidaemia, hypertension, diabetes, obesity, exercise, diet
Non-modifiable»_space; Age, men, ethnicity, family history, diabetes
Coronary Artery Disease: Complications
Angina
Unstable angina
Myocardial infarction
Heart failure
Stroke
Sudden cardiac death
Anxiety and depression
Reduced quality of life
Stable Angina: Definition
Pain or constricting discomfort in the chest.
» caused by an insufficient blood supply to the myocardium.
Radiated to neck/shoulders/jaw/arms.
Occurs predictably with physical exertion or emotional stress
» relieved within 15 minutes of rest, or use of GNT.
Unstable Angina: Definition
New onset angina, or abrupt deterioration in previously stable angina.
» caused by an insufficient blood supply to the myocardium.
CHECK FOR MYOCARDIAL INFARCTION
Occurs sporadically and at rest.
» lasts longer than 15 minutes
» requires immediate REFERAL
Angina: Aetiology
Angina is usually caused by coronary artery disease.
Less commonly caused by valvular disease, hypertrophic obstructive cardiomyopathy, or hypertensive heart disease.
Angina: Risk Factor
Modifiable»_space; Smoking, hyperlipidaemia, hypertension, diabetes, obesity, exercise, diet
Non-modifiable»_space; Age, men (until menopause), ethnicity, family history, diabetes
Angina: Complications
Stroke
MI
Unstable Angina
Sudden cardiac death
Angina: Symptoms
Chest pain»_space; tight, dull, heavy»_space; spreads to arm, neck, jaw, or back.
Breathlessness»_space; dyspnea
Nausea
Referred pain in abdomen
Tiredness
Angina: Investigations
Blood tests»_space; find underlying cause
12-lead ECG»_space; pathological Q-waves
Specialist-
CT coronary angiography»_space; how blocked vessles are
Angina: Drug Management
Before confirmed diagnosis-
Aspirin»_space; consider if suspected Angina
GTN»_space; Glyceryl Trinitrate spray»_space; vasodilator by increasing Nitric Oxide (NO) levels
Referal to cardiologists.
Once confirmed diagnosis-
Lifestyle advice
GTN spray
Drug treatment»_space; Beta-blocker (widening blood vessels) or CCB (slowing down heart beats) as first line
Drugs for secondary prevention of CVD
» low dose statin for CVD risk
» ACEi for diabetes
Angina: Surgical Management
If symptoms not satisfactorily controlled with drug treatment-
Consider revascularisation:
» coronary artery bypass graft (CABG)
» percutaneous coronary intervention (PCI)
MI/NSTEMI/Unstable Angina: Definition
MI: myocardial infarction»_space; myocardium dies due to complete loss of blood supply
NSTEMI: Non-ST segment elevation myocardial infarction»_space; myocradial damage due to some loss of blood supply
Unstable Angina»_space; pain due to lack of blood supply to myocardium
MI/NSTEMI/Unstable Angina: Pathophysiology
Plaques rupture or erode (statin to lower cholesterol)
Thrombus formation»_space; ruptured plaques lead to formation of blood clots »_space; partial or complete occlusion of coronary arteries (aspirin as blood thinner)
Myocardial ischemia»_space; occluded coronary arteries lead to reduced blood flow and reduced oxygen supply to heart tissue (GTN)
Myocardial infarction»_space; if blood flow not restored, prolonged ischemia leads to myocardial death
Release of cardiac biomarkers»_space; dead or dying heart cells release biomarkers that are used to diagnose»_space; troponins
Ventricular remodelling»_space; following infarction, heart may undergo structural changes»_space; long-term affect on heart function (ACEi, B-blocker)
MI/NSTEMI/Unstable Angina: Symptoms
Chest pain»_space; longer than 15 minutes
Referred pain to arm/shoulder/back/jaw
Associated symptoms-
Nausea and vomiting
Marked sweating
Breathlessness
Atypical presentation-
GI discomfort
Syncope
Elderly patients»_space; age-related nerve damage
Diabetes»_space; diabetes related nerve damage
MI/NSTEMI/Unstable Angina: Investigation
ECG
Troponin-
» marker of cardiomyocyte death»_space; troponin is protein needed for muscle contraction
» when released into circulation»_space; cardiac muscle damage
» used to differentiate between unstable angina and NSTEMI
» diagnosis requires serial readings
MI/NSTEMI/Unstable Angina: Management
URGENT same-day referal to cardiologists
IV Opiods or GTN»_space; pain relif
300mg loading dose Aspirin in hospital and 75mg daily dose»_space; blood thinner to reduce clotting
Oxygen
GRACE score»_space; estimates probability of cardiac death-
» low risk: aspirin and ticagrelor (antiplatelet)
» high risk: stent
STEMI: Definition
ST elevation myocardial infarction»_space; complete blockage of coronary artery»_space; causes MI
STEMI: Investigation
ST elevation visible on ECG
STEMI: Management
Offer coronary angiography (x-ray imaging with dye) and follow up PCI if-
» 21 hours of symptoms asn PCI can be delivered within 120 minutes
Offer fibrinolysis if-
» 12 hours of symptoms and PCI cannot be delievered within 120 minutes
POST MI: Rehabilitation
Cardiac Rehabilitation- exercise programme, stress management, health education
Considerations- driving, holiday, sex
Diet- mediterranean-style diet
Lifestyle- alcohol, exercise, smoking, weight loss
Vaccinations- annual flu, one-off pneumococcal
POST MI: Medication
Lifetime medication-
» ACEi: blood pressure management
» Aspirin and ticagrelor: dual antiplatelet therapy
» B-blocker: widening blood vessels
» Statin: reduce cholesterol
Aortic Coartication: Definition
Narrowing of aorta due to congenital reasons.
Aortic Coartication: Aetiology
Congenital
Aortic Coartication: Risk Factors
Men
Turner’s syndrome»_space; genetic: missing X chromosome
Aortic valve is bicuspid
Ventricular septal defect
Regurgitation or mitral stenosis
Aortic Coartication: Symptoms
Asymptomatic for many years
Headaches and nosebleeds»_space; due to HTN
Claudication (cramps/pain) and cold legs»_space; reduced blood flow to lower body
Aortic Coartication: Signs
HTN in upper limbs
Weak and delayed pulse in legs
Radiofemoral delay»_space; pulse in radial artery and femoral artery don’t match
Aortic Coartication: Investigations
Chest x-ray
Transthoracic echo
Scan of aorta
Aortic Coartication: Management
Referal»_space; surgery
Endocarditis: Definition
Inflammation of inner layer of heart called the endocardium.
Endocarditis: Aetiology
Typically due to a valve issue/replacement, a structural heart disease, vessle damage.
» would cause some form of endothelial damage.
These areas of endothelial damage provide focus for thrombosis»_space; embolism.
» bacteria enters and gets trapped in structural abnormality»_space; creates a thrombosis.
» piece breaks off»_space; septic emboli»_space; stroke.
Endocarditis: Acute
Symptoms and Signs:
» presents as rapid progressive disease
» high fevers, rigors, and sepsis
Aetiology:
» mostly in healthy hearts
» usually staphylcoccus aureus
Prognosis:
» acute endocarditis due to S.aureus associate with high mortality rate
» expect when due to IV drug use.
Endocarditis: Sub-acute
Symptoms and Signs:
» delayed and presents with non-specific symptoms
» weight loss, fatigue, low fever, dyspnoea (shortness of breath)
Aetiology:
» mostly in pre-existing heart disease
» usually streptococcus viridans
Prognosis:
» after treatment, rarely leads to severe cardiac damage
Endocarditis: Signs
New mumur
Splinter haemorrhage»_space; small areas of bleeding under nails
Roth’s spots»_space; retinal haemorrhage
Oslers nodes»_space; tender pink/purpule nodules on distal ends of fingers and toes
Endocarditis: Management
Immdiate referal»_space; antibiotics or surgery
Heart Failure: Definition
Failure of heart to generate sufficient cardiac output to meet demands of the body.
Classified according to ejection fraction, time-course of heart failure, and symptomatic severity.
Ejection Fraction (HFrEF): <40% or 41%-49%
Ejection fraction is the fraction of blood leaving left ventricle due to dilation»_space; reduced perfusion to kidneys»_space; low BP response
Time course: acute or chronic
Symptomatic severity:
I — no limitation of physical activity, no fatigue, breathlessness, or palpitations with normal activity
II — slight limitation, comfortable at rest, normal activity results in breathlessness, fatigue, or palpitations
III — marked limitation, comfortable at rest but less than ordinary physical activity results in undue breathlessness, fatigue, or palpitations
IV — unable to carry out any physical activity without discomfort, symptoms can be present at rest, if any physical activity is undertaken discomfort is increase
Heart Failure: Epidemiology
Average age of first diagnosis is 76 years of age.
Slowly increases with age until 65 years of age, and then more rapidly.
Prognosis for end-stage heart failure is poor.
50% of people with heart failure die within 5 years of diagnosis.
Heart Failure: Aetiology
Complex syndrome
» maintenance of circulation is impaired due to structural/functional impairment of ventricular filling or ejection
Any factor that increases myocardial work may aggravate heart failure.
Heart Failure: Risk Factor
Cardiomyopathy
Hypertension
Myocardial infarction
Heart Failure: Symptoms
Breathlessness
Oedema
Fatigue
Light-headedness
Syncope
Paroxysmal Nocturnal Dyspnea
Orthopnoea (breathlessness whilst sleeping)
Heart Failure: Signs
Tachycardia»_space; fast heart beat
Laterally displaced apex beat, heart murmurs, and third and fourth hart sounds (gallop rhythm)
Hypertension»_space; hypertrophy of heart
Raised jugular venous pressure
Enlarged liver
Tachypnoea
Basal crepitations»_space; crackles heard at base of lung due to fluid
Peripheral effusions
Dependent oedema»_space; legs and sacrum
Obesity»_space; increased fluid retention and decreased physical activity
Heart Failure: Investigations
If acute HF»_space; immediate management»_space; loop diuretics
If chronic HF»_space; investigate:
Order bloods»_space; check brain natriuretic peptide - secreted by ventricles in response to increased myocardial wall stress-
» over 2,000ng/l: needs to be referred urgently within 2 weeks
» between 400-2,000ng/l: needs to be seen in 6 weeks
» no bnp: re-assess
NOTE: BNP MAY BE RAISED FOR OTHER REASONS
Diagnosis requires ECG
Transthoracic echo»_space; under 40% ejection fraction»_space; heart failure
Chest X-Ray»_space; ABCDE
» A: alveolar shadowing
» B: curly b-lines
» C: cardiomegaly: heart larger than 40% of cardiothoracic ratio
» D: pulmonary diversion
» E: effusion
Heart Failure: Management
HF with Preserved EF
HF with preserved ejection fraction»_space; manage comorbidities:
Weight loss
Smoking cessation
Salt and fluid restriction
Cardiac rehab
Vaccinations»_space; make sure up-to-date
Review medication»_space; reduce/stop drugs making condition worse»_space; CCB, NSAIDs, BB
Prescribe»_space; SGLT2
Heart Failure: Management
HF with Loss of EF
HF with loss of ejection fraction»_space; manage using prescriptions:
Admission for severe symptoms
Specialist advice for pregnant women
Acute management: (same for preserved and reduced EF)
» For fluid overflow»_space; loop diuretic- furosemide, bumetanide, torasemid
Chronic management:
ACEi and beta blockers at low doses and titrated up until maximum tolerated dose»_space; until side effects seen
» ACEi first, then BB
» If ACE and BB not controlling symptoms enough, offer an MRA (mineralocorticoid receptor antagonist) and SGLT2 inhibitors
Follow up according to case circumstances, monitor symptoms, fluid status, management plans
» OTHER MANAGEMENTS: antiplatelets, statins, screen for depression and anxiety, exercise referral, if indicated
Monitor BNP for those under 75 for optimum drug treatment
Refer to NICE guidelines for details
Heart Failure: Complications
Heart arrhythmias
Depression
Cachexia (wasting)
Kidney disease»_space; acute or chronic
Sexual dysfunction
Chronic heart failure
Hypercholesterolemia: Definition
Elevation of total cholesterol (TC) or low-density lipoprotein (LDL)-cholesterol or non-HDL-cholesterol in the blood.
Also called- dyslipidaemia
May be accompanied by decrease in HDL-cholesterol or an increase in triglycerides.
Increase in both cholesterol and triglycerides»_space; mixed/combined hyperlipidaemia.
Hypercholesterolemia: Aetiology
Primary»_space; underlying genetic cause
Specific gene- Familial Hypercholesterolemia (FH)
Multiple genes- interact with dietary and other factors such as smoking and physical inactivity»_space; non-familial hypercholesterolemia
Secondary»_space; resulting from another underlying disorder
Hypothyroidism
Nephrotic syndrome
Diabetes
Liver disease
Excess alcohol
Diet
Lifestyle
Pregnancy or menopause
Medications
Hypercholesterolemia: Risk Factor
Unhealthy diet
Genetics
Ethnicity
Medication
Obesity and BMI
CVD
Diabetes
Hypercholesterolemia: Symptoms and Signs
RARE:
Corneal arcus»_space; ring around eye
Lumps around eyes
Tendon Xanthomata»_space; cholesterol deposits»_space; soft, movable, on tendons and ligaments
Hypercholesterolemia: Investigations
Health check programme»_space; 40-74 invited every 5 years for free health check
Family history
Bloods»_space; incidental findings
Symptoms
Risk factors
Comorbidities
QRISK»_space; liklihood of developing CVD in next 10 years
Hypercholesterolemia: QRISK
QRISK»_space; below 10%
» advice on lifestyle changes
» review comorbidities
» review QRISK in 5 years
QRISK»_space; above 10%
» check for familial hypercholesterolemia
» exclude secondary causes- alcohol, diabetes, hypothyroidism, liver disease
» discuss lifestyle modifications
» offer statin after lifestyle assessment
Hypercholesterolemia: Management
Statin: a form of lipid-modification therapy
Cautions»_space; elderly, history of liver disease, patients at increased risk of muscle toxicity
Must do baseline bloods:
» Lipid measurement
» Creatinine Kinase (CK)»_space; check if persistant muscle pain
» Liver function test»_space; MOST IMPORTANT»_space; monitor within 3 months, and yearly
» Renal function
» HbA1c
» Thyroid function test
Primary Prevention»_space; at high risk of developing CVD
» statins 20mg
» lipid profile every 3 months
» aim to achieve more than 40% reduction in non-HDL lipid
Secondary Prevention»_space; already have CVD
» statins 80mg
» lipid profile every 3 months
Hypercholesterolemia: Complications
Side effects of statin:
Constipation, diarrhoea, nausea
Dizziness, headache, sleep disorder
Thrombocytopenia
Asthenia»_space; weakness and fatigue
Flatulence»_space; fart, GI discomfort
Myalgia»_space; muscle plain
High triglyceride levels»_space; high risk of acute pancreatitis
Hypercholesterolemia:
Familial Hypercholesterolemia
Genetic disorder
Suspect if:
» total cholesterol > 9 mmol/L
» non-HDL cholesterol > 7.5 mmol/L
» family history
Symptoms and Signs:
» tendon xanthomata: hard, nodular enlargements of tendons on knuckles
» corneal arcus: ring around eye
» xanthelasma: lumps around eyes
Refer to lipo-clinic
Heart Valves
LEFT SIDE:
Biscuspid/mitral valve»_space; atrioventricular valve»_space; between left atrium and left ventricle
Aortic valve»_space; semi-lunar valves»_space; between left ventricle and aorta
RIGHT SIDE:
Tricuspid valve»_space; atrioventricular valve»_space; between right atrium and right ventricle
Pulmonary valve»_space; semi-lunar valves»_space; between right ventricle and pulmonary artery
Heart Sounds: Definition
Normal heart siunds caused by closing of heart valves during the cardiac cycle.
» 2 primary sounds»_space; LUB-DUB
S1: LUB-
» closing of atrioventricular valves
» mitral (L) and tricuspid (R) valves
» systole
S2: DUB-
» closing of semi-lunar valves
» aortic (L) and pulmonary (R) valves
» diastole
Cardiac Murmurs: Definition
Additional heart sounds.
Secondary to turbulent blood flow.
S3-
» low pitched sounds
» shortly after S2
» rapid filling during early diastole
S4-
» occurs just before S1
» atrial contraction
» stiffened or hypertrophic ventricles
Cardiac Murmurs: Types
Innocent or Physiological Murmurs-
» harmless
» often found in children and preganant women
» not indicative of heart condition
Pathological Murmurs-
» caused by underlying heart conditions
Cardiac Murmurs: Aetiology
Common causes of heart murmur-
Valvular stenosis:
» Narrowing of a heart valve, restricting blood flow.
» Aortic stenosis, Mitral stenosis
Valvular regurgitation:
»A valve fails to close correctly
» Causing blood to flow backwards
» Aortic regurgitation, Mitral regurgitation
Septal defects:
» Holes in the heart’s septum, allowing abnormal blood flow between chambers
» Atrial septal defect, Ventricular septal defect
Aortic Stenosis: Definition
Narrowing of aortic valve, leading to obstruction of left ventricular outflow.
Chronic and progressive disease
Aortic valve:
» 3 semi-lunar cusps
» between left ventricle and aorta
» 3 pocket-like sinuses that fill during ventricular contraction and supply coronary arteries
Aortic Stenosis: Aetiology
Calcified aortic valve-
» most common
» age-related
» inflammatory process
» thickening followed by fiborisis and calcification
Bicuspid aortic valve-
» congenital heart disease
» 2 cusps fuse during development
Rheumatic fever-
» systemic disease affecting connective tissue
» rheumatic fever is secondary to unresolved streptococcus pyogenes infection
» autoimmune reaction leads to rheumatic heart disease (RHD)
» leads to fibrosis and scarring of valve leaflets
Aortic Stenosis: Pathophysiology
Obstruction of left ventricle outflow
» increased LV pressure
» LV hypertrophy
» ischaemia of left ventricular myocardium
» angina, arrythmias, LV failure
> > obstruction more pronounced on exertion
reduced left ventricle ejection fraction
Aortic Stenosis: Symptoms
Predominantly asymptomatic until moderate AS
Exercise induced syncope»_space; passing out
Angina
Dyspnoea»_space; shortness of breath
Aortic Stenosis: Signs
Reduced volume
Slow-rising carotid pulse
Cardiac murmur-
» during systole»_space; LUB
» high-pitched
» best heard at right upper sternal border»_space; 2nd intercostal space
» when patients sits forward
» may radiate to carotid arteries
Aortic Stenosis: Investigations
Eletrocardiogram (ECG)»_space; measures electrical activity of heart
Transthoracic Echocardiogram (TTE)»_space; uses sound waves to create an image of heart
Aortic Stenosis: Management
Referal to cardiology
Symptomatic»_space; surgical intervention
Asymptomatic»_space; monitoring
Aortic Stenosis: Complications
Left ventricular hypertrophy and failure»_space; sudden cardiac death, stroke
Aortic Regurgitation: Definition
Charecterised by leaking aortic valve, allowing blood to flow back from aorta to ventricle during diastole.
Chronic and progressive disease.
Aortic Regurgitation: Aetiology
Aortic valve conditions-
» infective endocarditis
» congenital
Aortic root conditions- (happen at root of aorta)
» Marfan’s syndome: genetic disease that weakens connective tissue
» aortic dissection: tear in aorta, requires surgery
» syphilis: causes inflammation of leaflets
Autoimmune conditions-
» Ankylosing spondylitis: causes inflammation of joints and ligaments of spine»_space; inflammation leads to weakened aortic wall»_space; enlarged aortic root»_space; thickened cusps
» Reiter’s disease: also called reactive athiritis»_space; inflammation that is secondart to previous infection
» Rheumatoid arthiritis: body attacks own joints tissue
Aortic Regurgitation: Pathophysiology
Reflux of blood back into left ventricle from aorta.
» happens during diastole
Reduced coronary perfusion
» coronary arteries perfused during diastole
» due to decreased diastole pressure»_space; decreased perfusion
Left ventricle hypertrophy
» cardiac output must be maintained»_space; valve insufficiency means total volume being pumped increases»_space; ventricle size increases to compensate»_space; LV hypertrophy
Aortic Regurgitation: Symptoms
Predominantly asymptomatic
Symptoms are of LV failure»_space; angina, dyspnoea
Aortic Regurgitation: Signs
Bounding or collapsing pulse»_space; water hammer pulse
Displaced apex beat»_space; laterally and down
Cardiac murmur-
» high-pitched, blowing sound
» diastolic murmur
» best heard at third or fourth left parasternal intercostal space
» patient should lean forward and hold their breath at end of exhalation
Aortic Regurgitation: Investigations
Chest X-ray»_space; black and white image of chest organs
ECG
TTE
Aortic Regurgitation: Management
Refer to cardiology
Treat underlying causes
Surgical intervention
Mitral Stenosis: Definition
Narrowing of mitral valve, causing reduced blood flow to the left ventricle from atrium.
Chronic and progressive disease
Mitral valve:
» also called bicuspid valve
» 2 semi-lunar cusps
» between left atrium and left ventricle
» 2 sinuses: anterior and posterior: attached by chordae tendineae and papillary muscle
Mitral Stenosis: Aetiology
Rheumatic fever-
» systemic disease affecting connective tissue
» rheumatic fever is secondary to unresolved streptococcus pyogenes infection
» autoimmune reaction leads to rheumatic heart disease (RHD)
» leads to fibrosis and scarring of valve leaflets
» causes stenosis: narrowing
Mitral Stenosis: Pathophysiology
Narrowed mitral valve
» reduced outflow from left atrium to left ventricle
» increased left atrial pressure»_space; left atrial hypertrophy
> > pressure can back into pulmonary vein from atrium
increased pulmonary capillary pressure
pulmonary hypertension
> > can lead to right ventricular hypertrophy and failure (RVF)
Mitral Stenosis: Symptoms
Predominantly asymptomatic until moderate stenosis
Dyspnoea
Productive cough»_space; blood flecked, frothy sputum
Palpatations»_space; secondary to AF
Mitral Stenosis: Signs
Small volume pulse
Irregularly irregular pulse (if AF)
Elevated jugular venous pressure (JVP)
Mitral facies»_space; distinct facial appearance: rosy cheeks and bluish face
Cardiac murmur-
» low-pitched, rumbling
» diastolic murmur
» best heard at apex of the heart
» opening snap after S2
» patient in left lateral position during expiration
Mitral Stenosis: Investigations
ECG
TTE
Mitral Stenosis: Management
Referal to cardiology
Symptomatic»_space; prescribe diuretic and surgical intervention
Asymptomatic»_space; monitoring
Mitral Regurgitation: Definition
Charecterised by leaking of mitral valve from the left ventricle into the left atrium.
Acute or chronic
Mitral Regurgitation: Aetiology
Papillary muscle rupture»_space; sudden and severe
Degenerative disease
Rheumatic heart disease
Infectious endocarditis
Dilated cardiomyopathy or hypertrophic cardiomyopathy
Rheumatic autoimmune diseases
Collagen diseases»_space; Marfan’s syndrome or Ehlers-Danlos syndrome
Mitral Regurgitation: Pathophysiology
Chronic-
Left atrial dilation»_space; increase in left atrial pressure
» regurgitant flow compensated by atrial dilatation
Chronic-
Left atrial dilation»_space; no change in left atrial pressure
» regurgitant flow compensated by atrial dilatation
Mitral Regurgitation: Symptoms
Predominantly asymptomatic
Dyspnoea»_space; breathlessness
Orthopnoea»_space; breathless lying down
Fatigue and lethargy
Mitral Regurgitation: Signs
Laterally displaced apex
Signs of right heart failure»_space; peripheral oedema
Cardiac murmur
» mid-systolic click and prominant S3
» systolic murmur
» best heard at mid-clavicular line
» radiates to axilla
Mitral Regurgitation: Investigations
Chest x-ray
ECG
TTE
Mitral Regurgitation: Manegement
Refer to cardiology
Mild to moderate and asymptomatic»_space; monitor
Severe and symptomatic»_space; surgical intervention
Mitral Regurgitation: Complications
Risk of presenting as subacute infective endocarditis
