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Cardiovascular Diseases > CVD > Flashcards

CVD Flashcards

1
Q

Hypertension: Definiton

A

Persistently raised arterial blood pressure.
BP is the force the blood exerts on the blood vessels.

BP reading above 135/85&raquo_space; at home suspect hypertension.
BP reading above 140/90&raquo_space; in clinic suspect hypertension.

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2
Q

White Coat Hypertension: Definiton

A

Raised BP in clinical setting, compared to normal life.
Stressed when being in clinic.

Fine otherwise.

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3
Q

Marked Hypertension: Definiton

A

BP fine in clinical setting.
However, higher in normal settings.

Typically life/work induced.

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4
Q

Hypertension: Epidemiology

A

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.

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5
Q

Hypertension: Aetiology

A

Primary&raquo_space; arteriosclerosis or atherosclerosis
Arteriosclerosis&raquo_space; hardening&raquo_space; age-related, affects auto regulation
Atherosclerosis&raquo_space; fat deposits&raquo_space; aneurysm risk

Secondary&raquo_space; due to disease

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6
Q

Hypertension: Risk Factors

A

Stress and anxiety
Age
Gender
Ethnicity&raquo_space; black African and Caribbean more likely
Genetic factors
Social deprivation
Lifestyle&raquo_space; smoking, alcohol, salt, obesity, lack of exercise
Co-morbidities
QRISK3 risk > 10%

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7
Q

Hypertension: Stages

A

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

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8
Q

Hypertension: Investigations

A

Blood pressure cuff, measure both arms, if the difference is 15 mmHg repeat, record the higher one.
High BP&raquo_space; repeat 3 times, take the lower of the least 2.

Confirm diagnosis by doing-
ABPM&raquo_space; 2/hr during waking hours&raquo_space; average 14 measurements.
HBPM&raquo_space; 2 taken 1 min apart, recorded 2x a day for 4-7 days&raquo_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&raquo_space; positive test is flame shaped haemorrhage

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9
Q

Hypertension: Management

A

Lifestyle changes: low calorie and low salt diet, exercise 3-5 times a week, stress, smoking, alcohol.
Patient information leaflets.

Under 40&raquo_space; refer for secondary HTN investigations.
Under 80 with stage 1 HTN&raquo_space; treatment if there is organ damage, CVD, renal disease, diabetes.

Anyone with stage 2 hypertension&raquo_space; treat.

Refer to NICE guidelines for pharmacological treatment.
» ACEi - Angiotensin-converting enzyme (ACE) inhibitors&raquo_space; works on RAAS system
» ARB - Angiotensin receptor blockers&raquo_space; works on RAAS system
» CCB - Calcium channel blockers&raquo_space; reduces heart and vessel muscle contraction (shouldn’t be given to patients with heart failure, except amlodipine)

ACEi or ARB&raquo_space; for type II diabetes, for under 55 year age, for non-black African background
CCB&raquo_space; for age over 55, for black African background

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10
Q

Severe and Accelerated Hypertension: Definition

A

If BP 180/120 and symptoms present&raquo_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&raquo_space; heart failure, cerebral haemorrhage, renal failure.

If 180/120 and no symptoms&raquo_space; investigate and consult.

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11
Q

Hypertension: Complications

A

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.

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12
Q

Secondary Hypertension: Definition

A

Hypertension or high blood pressure that is secondary to a disease or condition.

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13
Q

Secondary Hypertension: Epidemiology

A

10% of all hypertension cases.

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14
Q

Secondary Hypertension: Renal Diseases

A

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&raquo_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&raquo_space; complication of diabetes that can damage kidneys’ filtering system.

Chronic glomerulonephritis&raquo_space; glomeruli inflammation and damage impairing filteration.

Polycystic kidney disease&raquo_space; inherited condition of cysts on kidney impairing function.

Chronic tubulointerstitial nephritis&raquo_space; kidney tubule inflammation.

Renovascular disease&raquo_space; narrowed arteries leading to kidneys impairing function

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15
Q

Secondary Hypertension: Endocrine Diseases

A

All of these can cause secondary hypertension.
Endocrine system release hormones; hormones that affect bp.

Conn’s syndrome/primary aldosteronism&raquo_space; adrenal gland produce too much aldosterone that increases uptake of sodium and water into blood stream.

Adrenal hyperplasia&raquo_space; genetic disorders where adrenal glands unable to produced hormones.

Acromegaly&raquo_space; pituitary gland produces too much growth hormone.

Cushing’s syndrome&raquo_space; tumour on pituitary gland causes increased ACTH hormone&raquo_space; acts on adrenal gland to increase cortisol release&raquo_space; causes vasoconstriction&raquo_space; increased bp.

Phaeochromocytoma&raquo_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.

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16
Q

Secondary Hypertension: Congenital CVD

A

Can cause secondary hypertension.

Aortic Coarctation: narrowing of aorta after aortic arch&raquo_space; heart has to pump harder to get blood pass narrowing.
» all branches before narrowing get blood at high bp&raquo_space; all branches after narrowing get lower bp&raquo_space; differing bp readings!

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17
Q

Secondary Hypertension: Pregnancy Induced

A

Pregnancy can also induce hypertension.
Gestational hypertension.

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18
Q

Postural Hypertension: Definition

A

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.

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19
Q

Postural Hypertension: Symptoms and Signs

A

Symptoms precipitated by head-up postural change and relieved by lying flat.

Light-headedness
Visual blurring
Dizziness
Weakness

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20
Q

Postural Hypertension: Risk Factors

A

Aortic stenosis
Anaemia
Blood loss
Primary hypoaldosteronism
Medications

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21
Q

Postural Hypertension: Investigation

A

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.

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22
Q

Postural Hypertension: Management

A

Manage underlying cause: anaemia, fluid loss, blood loss, etc.
Review medications
Consider referral

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23
Q

Atherosclerosis: Definition

A

“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.”

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24
Q

Atherosclerosis: Aetiology

A
  1. Endothelial Injury: damage to endothelial lining&raquo_space; caused by: hypertension, smoking, high cholesterol, and diabetes.
  2. Lipoprotein Accumulation: LDL cholesterol infiltrates damaged endothelium and accumulates in arterial wall.
  3. Oxidation of LDL: trapped LDL is oxidised, which triggers an inflammatory response&raquo_space; oxidised LDL more likely to be taken by macrophages.
  4. Monocyte Recruitment and Foam Cell Formation: monocytes attracted to site of injury&raquo_space; differentiate into macrophages. Macrophages engulf oxidised LDL, turning into foam cells&raquo_space; hallmark of early atherosclerotic lesions known as fatty streaks.
  5. 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.
  6. Plaque Growth and Complications: Plaques grow&raquo_space; narrow the arterial lumen, restricting blood flow.
    Plaques can become unstable&raquo_space; rupture can lead to thrombosis&raquo_space; MI.
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25
Q

Atherosclerosis: Complication

A

Heart:
» IHD/CHD&raquo_space; angina
» Myocardial Infarction
» Heart Failure

Cerebral:
» Stroke
» Transient Ischaemic Attack (TIA)
» Vascular Dementia&raquo_space; tiny, asymptomatic strokes that present in old age

Limb:
» Peripheral Vascular Disease

Renal:
» Renal Artery Stenosis&raquo_space; hypertension
» Renal Failure&raquo_space; Chronic Kidney Failure

Aneurysms:
» Haemorrhage

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26
Q

Coronary Artery Disease: Definition

A

Coronary arteries unable to provide sufficient blood supply to heart.

Also&raquo_space; Ischaemic Heart Disease or Coronary Heart Disease

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27
Q

Coronary Artery Disease: Epidemiology

A

CAD most common single cause of death in UK

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28
Q

Coronary Artery Disease: Aetiology

A

Plaque build up in the walls of the arteries that supply blood to the heart&raquo_space; narrowing

Heart problems&raquo_space; narrowing of coronary arteries.
Angina&raquo_space; narrowing due to atherosclerosis (fat deposits).
Myocardial Infarction&raquo_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&raquo_space; back up circulation to help main circulation.
End Arteries&raquo_space; arteries that is the only supply to a certain area&raquo_space; no back up.

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29
Q

Coronary Artery Disease: Risk Factors

A

Modifiable&raquo_space; Smoking, hyperlipidaemia, hypertension, diabetes, obesity, exercise, diet
Non-modifiable&raquo_space; Age, men, ethnicity, family history, diabetes

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30
Q

Coronary Artery Disease: Complications

A

Angina
Unstable angina
Myocardial infarction
Heart failure
Stroke
Sudden cardiac death

Anxiety and depression
Reduced quality of life

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31
Q

Stable Angina: Definition

A

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.

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32
Q

Unstable Angina: Definition

A

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

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33
Q

Angina: Aetiology

A

Angina is usually caused by coronary artery disease.
Less commonly caused by valvular disease, hypertrophic obstructive cardiomyopathy, or hypertensive heart disease.

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34
Q

Angina: Risk Factor

A

Modifiable&raquo_space; Smoking, hyperlipidaemia, hypertension, diabetes, obesity, exercise, diet
Non-modifiable&raquo_space; Age, men (until menopause), ethnicity, family history, diabetes

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35
Q

Angina: Complications

A

Stroke
MI
Unstable Angina
Sudden cardiac death

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36
Q

Angina: Symptoms

A

Chest pain&raquo_space; tight, dull, heavy&raquo_space; spreads to arm, neck, jaw, or back.

Breathlessness&raquo_space; dyspnea
Nausea
Referred pain in abdomen
Tiredness

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37
Q

Angina: Investigations

A

Blood tests&raquo_space; find underlying cause
12-lead ECG&raquo_space; pathological Q-waves

Specialist-
CT coronary angiography&raquo_space; how blocked vessles are

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38
Q

Angina: Drug Management

A

Before confirmed diagnosis-
Aspirin&raquo_space; consider if suspected Angina
GTN&raquo_space; Glyceryl Trinitrate spray&raquo_space; vasodilator by increasing Nitric Oxide (NO) levels

Referal to cardiologists.

Once confirmed diagnosis-
Lifestyle advice
GTN spray
Drug treatment&raquo_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

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39
Q

Angina: Surgical Management

A

If symptoms not satisfactorily controlled with drug treatment-

Consider revascularisation:
» coronary artery bypass graft (CABG)
» percutaneous coronary intervention (PCI)

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40
Q

MI/NSTEMI/Unstable Angina: Definition

A

MI: myocardial infarction&raquo_space; myocardium dies due to complete loss of blood supply

NSTEMI: Non-ST segment elevation myocardial infarction&raquo_space; myocradial damage due to some loss of blood supply

Unstable Angina&raquo_space; pain due to lack of blood supply to myocardium

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41
Q

MI/NSTEMI/Unstable Angina: Pathophysiology

A

Plaques rupture or erode (statin to lower cholesterol)

Thrombus formation&raquo_space; ruptured plaques lead to formation of blood clots &raquo_space; partial or complete occlusion of coronary arteries (aspirin as blood thinner)

Myocardial ischemia&raquo_space; occluded coronary arteries lead to reduced blood flow and reduced oxygen supply to heart tissue (GTN)

Myocardial infarction&raquo_space; if blood flow not restored, prolonged ischemia leads to myocardial death

Release of cardiac biomarkers&raquo_space; dead or dying heart cells release biomarkers that are used to diagnose&raquo_space; troponins

Ventricular remodelling&raquo_space; following infarction, heart may undergo structural changes&raquo_space; long-term affect on heart function (ACEi, B-blocker)

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42
Q

MI/NSTEMI/Unstable Angina: Symptoms

A

Chest pain&raquo_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&raquo_space; age-related nerve damage
Diabetes&raquo_space; diabetes related nerve damage

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43
Q

MI/NSTEMI/Unstable Angina: Investigation

A

ECG

Troponin-
» marker of cardiomyocyte death&raquo_space; troponin is protein needed for muscle contraction
» when released into circulation&raquo_space; cardiac muscle damage
» used to differentiate between unstable angina and NSTEMI
» diagnosis requires serial readings

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44
Q

MI/NSTEMI/Unstable Angina: Management

A

URGENT same-day referal to cardiologists

IV Opiods or GTN&raquo_space; pain relif
300mg loading dose Aspirin in hospital and 75mg daily dose&raquo_space; blood thinner to reduce clotting
Oxygen

GRACE score&raquo_space; estimates probability of cardiac death-
» low risk: aspirin and ticagrelor (antiplatelet)
» high risk: stent

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45
Q

STEMI: Definition

A

ST elevation myocardial infarction&raquo_space; complete blockage of coronary artery&raquo_space; causes MI

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46
Q

STEMI: Investigation

A

ST elevation visible on ECG

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47
Q

STEMI: Management

A

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

48
Q

POST MI: Rehabilitation

A

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

49
Q

POST MI: Medication

A

Lifetime medication-
» ACEi: blood pressure management
» Aspirin and ticagrelor: dual antiplatelet therapy
» B-blocker: widening blood vessels
» Statin: reduce cholesterol

50
Q

Aortic Coartication: Definition

A

Narrowing of aorta due to congenital reasons.

51
Q

Aortic Coartication: Aetiology

A

Congenital

52
Q

Aortic Coartication: Risk Factors

A

Men
Turner’s syndrome&raquo_space; genetic: missing X chromosome
Aortic valve is bicuspid
Ventricular septal defect
Regurgitation or mitral stenosis

53
Q

Aortic Coartication: Symptoms

A

Asymptomatic for many years
Headaches and nosebleeds&raquo_space; due to HTN
Claudication (cramps/pain) and cold legs&raquo_space; reduced blood flow to lower body

54
Q

Aortic Coartication: Signs

A

HTN in upper limbs
Weak and delayed pulse in legs
Radiofemoral delay&raquo_space; pulse in radial artery and femoral artery don’t match

55
Q

Aortic Coartication: Investigations

A

Chest x-ray
Transthoracic echo
Scan of aorta

56
Q

Aortic Coartication: Management

A

Referal&raquo_space; surgery

57
Q

Endocarditis: Definition

A

Inflammation of inner layer of heart called the endocardium.

58
Q

Endocarditis: Aetiology

A

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&raquo_space; embolism.
» bacteria enters and gets trapped in structural abnormality&raquo_space; creates a thrombosis.
» piece breaks off&raquo_space; septic emboli&raquo_space; stroke.

59
Q

Endocarditis: Acute

A

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.

60
Q

Endocarditis: Sub-acute

A

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

61
Q

Endocarditis: Signs

A

New mumur
Splinter haemorrhage&raquo_space; small areas of bleeding under nails
Roth’s spots&raquo_space; retinal haemorrhage
Oslers nodes&raquo_space; tender pink/purpule nodules on distal ends of fingers and toes

62
Q

Endocarditis: Management

A

Immdiate referal&raquo_space; antibiotics or surgery

63
Q

Heart Failure: Definition

A

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&raquo_space; reduced perfusion to kidneys&raquo_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

64
Q

Heart Failure: Epidemiology

A

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.

65
Q

Heart Failure: Aetiology

A

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.

66
Q

Heart Failure: Risk Factor

A

Cardiomyopathy
Hypertension
Myocardial infarction

67
Q

Heart Failure: Symptoms

A

Breathlessness
Oedema
Fatigue
Light-headedness
Syncope
Paroxysmal Nocturnal Dyspnea
Orthopnoea (breathlessness whilst sleeping)

68
Q

Heart Failure: Signs

A

Tachycardia&raquo_space; fast heart beat
Laterally displaced apex beat, heart murmurs, and third and fourth hart sounds (gallop rhythm)
Hypertension&raquo_space; hypertrophy of heart
Raised jugular venous pressure
Enlarged liver
Tachypnoea
Basal crepitations&raquo_space; crackles heard at base of lung due to fluid
Peripheral effusions
Dependent oedema&raquo_space; legs and sacrum
Obesity&raquo_space; increased fluid retention and decreased physical activity

69
Q

Heart Failure: Investigations

A

If acute HF&raquo_space; immediate management&raquo_space; loop diuretics

If chronic HF&raquo_space; investigate:

Order bloods&raquo_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&raquo_space; under 40% ejection fraction&raquo_space; heart failure

Chest X-Ray&raquo_space; ABCDE
» A: alveolar shadowing
» B: curly b-lines
» C: cardiomegaly: heart larger than 40% of cardiothoracic ratio
» D: pulmonary diversion
» E: effusion

70
Q

Heart Failure: Management

HF with Preserved EF

A

HF with preserved ejection fraction&raquo_space; manage comorbidities:
Weight loss
Smoking cessation
Salt and fluid restriction
Cardiac rehab
Vaccinations&raquo_space; make sure up-to-date

Review medication&raquo_space; reduce/stop drugs making condition worse&raquo_space; CCB, NSAIDs, BB

Prescribe&raquo_space; SGLT2

71
Q

Heart Failure: Management

HF with Loss of EF

A

HF with loss of ejection fraction&raquo_space; manage using prescriptions:
Admission for severe symptoms
Specialist advice for pregnant women

Acute management: (same for preserved and reduced EF)
» For fluid overflow&raquo_space; loop diuretic- furosemide, bumetanide, torasemid

Chronic management:
ACEi and beta blockers at low doses and titrated up until maximum tolerated dose&raquo_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

72
Q

Heart Failure: Complications

A

Heart arrhythmias
Depression
Cachexia (wasting)
Kidney disease&raquo_space; acute or chronic
Sexual dysfunction
Chronic heart failure

73
Q

Hypercholesterolemia: Definition

A

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&raquo_space; mixed/combined hyperlipidaemia.

74
Q

Hypercholesterolemia: Aetiology

A

Primary&raquo_space; underlying genetic cause
Specific gene- Familial Hypercholesterolemia (FH)
Multiple genes- interact with dietary and other factors such as smoking and physical inactivity&raquo_space; non-familial hypercholesterolemia

Secondary&raquo_space; resulting from another underlying disorder
Hypothyroidism
Nephrotic syndrome
Diabetes
Liver disease
Excess alcohol
Diet
Lifestyle
Pregnancy or menopause
Medications

75
Q

Hypercholesterolemia: Risk Factor

A

Unhealthy diet
Genetics
Ethnicity
Medication
Obesity and BMI
CVD
Diabetes

76
Q

Hypercholesterolemia: Symptoms and Signs

A

RARE:
Corneal arcus&raquo_space; ring around eye
Lumps around eyes
Tendon Xanthomata&raquo_space; cholesterol deposits&raquo_space; soft, movable, on tendons and ligaments

77
Q

Hypercholesterolemia: Investigations

A

Health check programme&raquo_space; 40-74 invited every 5 years for free health check
Family history
Bloods&raquo_space; incidental findings
Symptoms
Risk factors
Comorbidities
QRISK&raquo_space; liklihood of developing CVD in next 10 years

78
Q

Hypercholesterolemia: QRISK

A

QRISK&raquo_space; below 10%
» advice on lifestyle changes
» review comorbidities
» review QRISK in 5 years

QRISK&raquo_space; above 10%
» check for familial hypercholesterolemia
» exclude secondary causes- alcohol, diabetes, hypothyroidism, liver disease
» discuss lifestyle modifications
» offer statin after lifestyle assessment

79
Q

Hypercholesterolemia: Management

A

Statin: a form of lipid-modification therapy
Cautions&raquo_space; elderly, history of liver disease, patients at increased risk of muscle toxicity

Must do baseline bloods:
» Lipid measurement
» Creatinine Kinase (CK)&raquo_space; check if persistant muscle pain
» Liver function test&raquo_space; MOST IMPORTANT&raquo_space; monitor within 3 months, and yearly
» Renal function
» HbA1c
» Thyroid function test

Primary Prevention&raquo_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&raquo_space; already have CVD
» statins 80mg
» lipid profile every 3 months

80
Q

Hypercholesterolemia: Complications

A

Side effects of statin:
Constipation, diarrhoea, nausea
Dizziness, headache, sleep disorder
Thrombocytopenia
Asthenia&raquo_space; weakness and fatigue
Flatulence&raquo_space; fart, GI discomfort
Myalgia&raquo_space; muscle plain

High triglyceride levels&raquo_space; high risk of acute pancreatitis

81
Q

Hypercholesterolemia:
Familial Hypercholesterolemia

A

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

82
Q

Heart Valves

A

LEFT SIDE:
Biscuspid/mitral valve&raquo_space; atrioventricular valve&raquo_space; between left atrium and left ventricle
Aortic valve&raquo_space; semi-lunar valves&raquo_space; between left ventricle and aorta

RIGHT SIDE:
Tricuspid valve&raquo_space; atrioventricular valve&raquo_space; between right atrium and right ventricle
Pulmonary valve&raquo_space; semi-lunar valves&raquo_space; between right ventricle and pulmonary artery

83
Q

Heart Sounds: Definition

A

Normal heart siunds caused by closing of heart valves during the cardiac cycle.
» 2 primary sounds&raquo_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

84
Q

Cardiac Murmurs: Definition

A

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

85
Q

Cardiac Murmurs: Types

A

Innocent or Physiological Murmurs-
» harmless
» often found in children and preganant women
» not indicative of heart condition

Pathological Murmurs-
» caused by underlying heart conditions

86
Q

Cardiac Murmurs: Aetiology

A

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

87
Q

Aortic Stenosis: Definition

A

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

88
Q

Aortic Stenosis: Aetiology

A

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

89
Q

Aortic Stenosis: Pathophysiology

A

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

90
Q

Aortic Stenosis: Symptoms

A

Predominantly asymptomatic until moderate AS

Exercise induced syncope&raquo_space; passing out
Angina
Dyspnoea&raquo_space; shortness of breath

91
Q

Aortic Stenosis: Signs

A

Reduced volume
Slow-rising carotid pulse

Cardiac murmur-
» during systole&raquo_space; LUB
» high-pitched
» best heard at right upper sternal border&raquo_space; 2nd intercostal space
» when patients sits forward
» may radiate to carotid arteries

92
Q

Aortic Stenosis: Investigations

A

Eletrocardiogram (ECG)&raquo_space; measures electrical activity of heart
Transthoracic Echocardiogram (TTE)&raquo_space; uses sound waves to create an image of heart

93
Q

Aortic Stenosis: Management

A

Referal to cardiology

Symptomatic&raquo_space; surgical intervention
Asymptomatic&raquo_space; monitoring

94
Q

Aortic Stenosis: Complications

A

Left ventricular hypertrophy and failure&raquo_space; sudden cardiac death, stroke

95
Q

Aortic Regurgitation: Definition

A

Charecterised by leaking aortic valve, allowing blood to flow back from aorta to ventricle during diastole.
Chronic and progressive disease.

96
Q

Aortic Regurgitation: Aetiology

A

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&raquo_space; inflammation leads to weakened aortic wall&raquo_space; enlarged aortic root&raquo_space; thickened cusps
» Reiter’s disease: also called reactive athiritis&raquo_space; inflammation that is secondart to previous infection
» Rheumatoid arthiritis: body attacks own joints tissue

97
Q

Aortic Regurgitation: Pathophysiology

A

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&raquo_space; decreased perfusion

Left ventricle hypertrophy
» cardiac output must be maintained&raquo_space; valve insufficiency means total volume being pumped increases&raquo_space; ventricle size increases to compensate&raquo_space; LV hypertrophy

98
Q

Aortic Regurgitation: Symptoms

A

Predominantly asymptomatic

Symptoms are of LV failure&raquo_space; angina, dyspnoea

99
Q

Aortic Regurgitation: Signs

A

Bounding or collapsing pulse&raquo_space; water hammer pulse
Displaced apex beat&raquo_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

100
Q

Aortic Regurgitation: Investigations

A

Chest X-ray&raquo_space; black and white image of chest organs
ECG
TTE

101
Q

Aortic Regurgitation: Management

A

Refer to cardiology

Treat underlying causes
Surgical intervention

102
Q

Mitral Stenosis: Definition

A

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

103
Q

Mitral Stenosis: Aetiology

A

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

104
Q

Mitral Stenosis: Pathophysiology

A

Narrowed mitral valve
» reduced outflow from left atrium to left ventricle
» increased left atrial pressure&raquo_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)

105
Q

Mitral Stenosis: Symptoms

A

Predominantly asymptomatic until moderate stenosis

Dyspnoea
Productive cough&raquo_space; blood flecked, frothy sputum
Palpatations&raquo_space; secondary to AF

106
Q

Mitral Stenosis: Signs

A

Small volume pulse
Irregularly irregular pulse (if AF)
Elevated jugular venous pressure (JVP)
Mitral facies&raquo_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

107
Q

Mitral Stenosis: Investigations

A

ECG
TTE

108
Q

Mitral Stenosis: Management

A

Referal to cardiology

Symptomatic&raquo_space; prescribe diuretic and surgical intervention
Asymptomatic&raquo_space; monitoring

109
Q

Mitral Regurgitation: Definition

A

Charecterised by leaking of mitral valve from the left ventricle into the left atrium.
Acute or chronic

110
Q

Mitral Regurgitation: Aetiology

A

Papillary muscle rupture&raquo_space; sudden and severe

Degenerative disease
Rheumatic heart disease
Infectious endocarditis
Dilated cardiomyopathy or hypertrophic cardiomyopathy
Rheumatic autoimmune diseases
Collagen diseases&raquo_space; Marfan’s syndrome or Ehlers-Danlos syndrome

111
Q

Mitral Regurgitation: Pathophysiology

A

Chronic-
Left atrial dilation&raquo_space; increase in left atrial pressure
» regurgitant flow compensated by atrial dilatation

Chronic-
Left atrial dilation&raquo_space; no change in left atrial pressure
» regurgitant flow compensated by atrial dilatation

112
Q

Mitral Regurgitation: Symptoms

A

Predominantly asymptomatic

Dyspnoea&raquo_space; breathlessness
Orthopnoea&raquo_space; breathless lying down
Fatigue and lethargy

113
Q

Mitral Regurgitation: Signs

A

Laterally displaced apex
Signs of right heart failure&raquo_space; peripheral oedema

Cardiac murmur
» mid-systolic click and prominant S3
» systolic murmur
» best heard at mid-clavicular line
» radiates to axilla

114
Q

Mitral Regurgitation: Investigations

A

Chest x-ray
ECG
TTE

115
Q

Mitral Regurgitation: Manegement

A

Refer to cardiology

Mild to moderate and asymptomatic&raquo_space; monitor
Severe and symptomatic&raquo_space; surgical intervention

116
Q

Mitral Regurgitation: Complications

A

Risk of presenting as subacute infective endocarditis

Cardiovascular Diseases (1 decks)

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