CVD Flashcards
Acute coronary syndrome
Def, Pathophys, classification, Sx, ix, mx
Acute coronary syndrome is a set of symptoms and signs that occur due to decreased blood flow to the heart at rest. It broadly refers to three distinct diagnoses: unstable angina, non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI).
Pathophysiology:
Narrowing of coronary arteries by atherosclerosis and plaque formation. In ACS, the symptoms occur at rest. This is because there is sudden plaque rupture and clot formation in the narrowed coronary arteries. If there is partial occlusion of the coronary artery this leads to ischaemia and chest pain at rest (unstable angina). If the coronary artery becomes more occluded or fully occluded this leads to significant hypoperfusion of the myocardium and ultimately leads to infarction (death) of the myocardial tissue (NSTEMI or STEMI).
Classification:
1. Unstable angina: caused by partial occlusion of a coronary artery. Troponin negative chest pain with normal/abnormal ECG signs.
2. Non-ST Elevation Myocardial Infarction: caused by severe but incomplete occlusion of a coronary artery. Troponin positive chest pain without ST elevation.
3. ST-Elevation Myocardial Infarction: caused by complete occlusion of a coronary artery. Troponin positive chest pain with ST elevation on ECG.
Sx:
- central/left-sided
- sudden onset
- crushing
- radiate to left arm, neck and jaw
- worsened by exercise may be improved by GTN
Ix:
- unstable angina: abnormal/normal ECG and normal troponin
- NSTEMI: abnormal/normal ECG (no ST elevation but maybe ST depression or T wave inversion) and raised troponin
- STEMI: persistent ST elevation/ new LBBB
Mx:
- M (morphine) O (O2) N (nitrates- peripheral vasodilator) A (aspirin- antiplatelet)
- STEMI: 1.O2 therapy 2.300mg aspirin 3.sublingual GTN 4.IV morphine 5.PPCI
- NSTEMI/unstable angina: 1.O2 therapy 2.300mg aspirin 3.sublingual GTN 4.IV morphine 5.antithrombin therapy (LMW heparin) 6.angiogram if high risk of mortality
- post: 1.Aspirin 75mg OM + second anti-platelet (clopidogrel 75mg OD or ticagrelor 90mg OD) 2.Beta blocker (normally bisoprolol) 3.ACE-inhibitor (normally ramipril) 4.High dose statin (e.g. Atorvastatin 80mg ON) 5.All patients should have an ECHO performed to assess systolic function and any evidence of heart failure should be treated.
Cardiac failure
Types, Sx, ix, mx
Classifications:
- low output= more common than high output
- high output= commonly caused by anaemia, pagets, pregnancy
- systolic= impairment of ventricular contraction, reduced ejection fraction, common causes are ischaemic heart disease and myocarditis
- diastolic= inability of ventricles to relax and fill properly (preserved ejection fraction), common causes are chronic hypertension, hypertrophic cardiomyopathy
NYHA classification:
• Class I - no limitation in physical activity, and activity does not cause undue fatigue, palpitations or dyspnoea.
• Class I| - slight limitation of physical activity, and comfort at rest. Ordinary physical activity causes fatigue, palpitations and/or dyspnoea.
• Class III - marked limitation in physical activity, but comfort at rest. Minimal physical activity causes fatigue (less than ordinary).
• Class IV - inability to carry on any physical activity without discomfort, with symptoms occurring at rest. If any activity takes place, discomfort increases.
Sx:
LHF:
- SOB
- orthophosphate
- paroxysmal nocturnal dyspnoea
- nocturnal cough (+/- pink frothy sputum)
- fatigue
- tachypnoea
- bibasal fine crackles
- cyanosis
RHF:
- ankle swelling
- weight gain
- nausea
- raised JVP
- pitting peripheral oedema
- heptomegaly
- ascites
- transudative pleural effusions
Ix:
- 1st line is NT-pro-BNP level
• 2000ng/L (236pmol/L): refer urgently for specialist assessment and TTE <2 weeks.
• 400-2000ng/L (47-236pmol/L): refer for specialist assessment and TTE <6 weeks.
• If ‹ 400ng/L: diagnosis of heart failure is less likely.
- 12 lead ECG
- TTE
• EF < 40% = HF with reduced ejection fraction (HFrEF, systolic dysfunction).
• EF >40% but with raised BNP = HF with preserved ejection fraction (HFpEF, diastolic dysfunction).
• EF 50-70% with normal BNP = normal.
- CXR
• A: Alveolar oedema (with ‘batwing’ perihilar shadowing)
• B: Kerley B lines (caused by interstitial oedema)
• C: Cardiomegaly (cardiothoracic ratio > 0.5)
• D: upper lobe blood diversion
• E: Pleural effusions (typically bilateral transudates)
• F: Fluid in the horizontal fissure
Mx:
- loop diuretics (eg. Furosemide)
- 1st line= ACE-I and beta blocker
DVT
Cause, Sx, ix, mx
Risk factors for DVT can be remembered with the mnemonic THROMBOSIS:
• Thrombophilia
• Hormonal (COCP, pregnancy and the postpartum period, HRT)
• Relatives (family history of VTE)
• Older age (>60)
• Malignancy
• Bone fractures
• Obesity
• Smoking
• Immobilisation (long-distance travel, recent surgery or trauma)
• Sickness (e.g. acute infection, dehydration)
Sx:
• Unilateral erythema, warmth, swelling and pain in the affected area
• Pain on palpation of deep veins
• Distention of superficial veins
• Difference in calf circumference if the leg is affected
• This should be measured 10cm below the tibial tuberosity
• 3cm difference between the legs is significant
Ix:
- wells score (cancer, paralysis, surgery, tenderness, swollen more than 3cm, pitting oedema, history of DVT)
- D-dimer
- Doppler ultrasound
- bloods (FBC, U&E, LFT and coag screen)
Mx:
- DOACs (apixaban) as first line anti coag
- second line is LMW heparin for at least 5 days with a target INR of 2.5
- in unprovoked DVT drop anti coags after 3 months
Hypertension
Def, classification, ix, mx
24 hour ambulatory bp > 135/85
Classification:
• Stage 1: Clinic => 140/90mmHg; ABPM => 135/85mmHg
• Stage 2: Clinic => 160/100mmHg; ABPM =>150/95mmHg
• Stage 3: Clinic systolic BP (SBP) => 180 or diastolic BP (DBP) =>120mmHg
Ix:
- 1st line is ABPM or home blood pressure monitoring
Mx:
- lifestyle changes
- start meds if high risk stage 1 or any stage 2
Ischaemic heart disease
Cause, rf, mx
Main cause is atherosclerosis
Rf:
- age
- fhx
- male
- high cholesterol
- smoking and alcohol
- diet
- sedentary lifestyle
- obesity
- stress
Mx:
- Primary prevention= Atorvastatin 20mg is offered as primary prevention to all patients with: Chronic kidney disease (eGFR less than 60 ml/min/1.73 m2) OR Type 1 diabetes for more than 10 years or are over 40 years OR GRISK3 above 10%
- secondary prevention= 4As
A – Antiplatelet medications (e.g., aspirin, clopidogrel and ticagrelor)
A – Atorvastatin 80mg
A – Atenolol (or an alternative beta blocker – commonly bisoprolol) titrated to the maximum tolerated dose
A – ACE inhibitor (commonly ramipril) titrated to the maximum tolerated dose
Myocarditis
Causes, Sx, ix, mx
Most common cause in UK are viruses with Cocksackie B the most common virus
Causes:
Viral Infections
• Cocksackie B virus
• COVID-19
• Adenovirus
• Epstein Barr Virus
Bacterial Infections
• Diphtheria
• Clostridia
• Neiseria gonorrhoea
Protozoan
• Trypanosoma cruzi
Auto-Immune
• Kawasaki disease
• Scleroderma, SLE, sarcoid and systemic vasculitides
Drug reactions
• Antipsychotics including clozapine
• Immune checkpoint inhibitors
• Mesalazine
Sx:
- sharp stabbing chest pain
- SOB
- palpitations
- lightheadedness
- syncope
- fever
- dull heart sounds
- pericardial rub if myopericarditis
Ix:
- ECG showing non-specific ST segment and T wave changes
- raised troponin and CK-MB
- inflammatory markers
- echocardiogram showing ventricular dysfunction
- cardiac MRI
- endomyocardial biopsy as GOLD STANDARD showing infiltration of inflammatory cells and myocardial necrosis
Mx:
- severe may require ITU and vasopressors
- corticosteroids for viral acute patients
Acute pericarditis
Causes, Sx, ix, mx
Causes:
Infective causes
• Viruses - viruses which cause pericarditis are coxsackie B viruses, echovirus, CMV, herpesvirus, HiV among other rarer causes.
• Bacteria - staphylococcus, pneumococcus, streptococcus (rheumatic carditis), haemophilus and M. tuberculosis.
• Fungi and parasites (rare)
Malignant causes
• Lung cancer
• Breast cancer
• Hodgkin’s lymphoma
Cardiac causes
• Heart failure may cause pericarditis
• Post-cardiac injury syndrome (Dressler’s syndrome) including post- traumatic
• Radiation - often secondary to therapy for other malignancies
Drugs and toxin causes
• Anthracycline chemotherapy (Doxorubicin)
• Hydralazine
• soniazid
• Methyldopa
• Phenytoin
• Penicillins (hypersensitivity)
Rheumatological disease
• Systemic lupus erythematous (SLE)
• Rheumatoid arthritis
• Sarcoidosis
• Vasculitides (Takayasu’s, Behcet’s)
Sx:
- pleuritic chest pain
- postural chest pain (worse when lying flat and relieved when leaning forward)
- fever
- pericardial friction rub (high pitched scratching noise heard over left eternal border during expiration)
- pericardial effusion and cardiac tamponade signs (hypotension, raised JVP and muffled heart sounds)
Ix:
- 1st line is ECG showing widespread saddle ST elevation and PR depression
- consistently elevated troponin
- raised inflammatory markers
- echocardiogram to assess for pleural effusion
Mx:
Idiopathic or viral:
- 1st line NSAIDs and PPI for 1-2 weeks
- 2nd line colchicine
- 3rd line corticosteroids
Bacterial:
- 1st line IV abx +/- pericardiocentesis if purulent
Non-infective:
- 1st line corticosteroids
Aortic valve regurgitation
Def, causes, Sx, ix, mx
Aortic valve fails to prevent blood from leaking back across the valve during diastole
Causes:
- Acute Aortic Regurgitation
• Infective endocarditis: infective process leads to valve destruction and leaflet perforation. Most common acute cause of acute AR.
• Aortic dissection: primarily causes regurgitation due to dilatation of aortic root (functional AR).
• Traumatic rupture of valve leaflets: blunt chest trauma or deceleration injury can disrupt valve leaflets leading to valve incompetence.
• latrogenic causes: balloon valvotomy or TAVI.
• Non-native aortic valve regurgitation: valve replacements can be complicated by acute AR. Tissue prosthetic valves may degenerated and mechanical valves may thrombose causing incomplete closure of the valve or paravalvular leak.
- Chronic Aortic Regurgitation
• Rheumatic heart disease - most common in developing countries.
• Age-related calcification
• Congenital bicuspid aortic valve
• Connective tissue disorders: Marfan’s syndrome, Ehler’s Danlos
• Infective endocarditits
• Rheumatological conditions: rheumatoid arthritis, ankylosing spondylitis, APLS, giant cell arteritis
Sx:
- Acute AR
• Sudden cardiovascular collapse
• Acute pulmonary oedema - shortness of breath, sweating, pallor, peripherally vasoconstricted
- Chronic AR
• More insidious, slower onset
• Exertional dyspnoea, orthopnoea, PND
• Stable angina even in absence of coronary artery disease (due to reduction in diastolic coronary perfusion)
- Signs
• De Quincke’s sign - nail bed pulsation
• Waterhammer pulse
• De Musset’s sign - head hobbing
• Corrigan’s sign - dancing carotids
• Muller’s sign - pulsation of the uvula
• Traube’s sign - pistol shot (bruit heard on auscultation of femoral pulse)
Auscultation:
- Early diastolic murmur - heard best at the aortic region, leaning forward and on expiration. Soft S1 and occasional ejection flow murmur.
Ix:
- obs showing widened pulse pressure
- ECG showing LVH and p mitrale in chronic AR
- inflam markers for infective endocarditis
- definite diagnosis is transthoracic echocardiogram
- cardiac MRI for moderate to severe
- invasive cardiac catheterisation to gauge severity
Mx:
- normally monitored
- beta blockers+/- losartan
- surgical intervention is symptomatic, poor LVEF or significant enlargement in aorta
Aortic stenosis
Def, causes, Sx, ix, mx
Narrowing and tightening of the aortic valve leasing to reduced blood flow from the left ventricle into the aorta
Cause:
- senile calcification >65
- congenital bicuspid valve <65
- rheumatic heart disease
- Williams syndrome (supravalvular stenosis)
Sx:
- syncope
- angina
- dyspnoea
- slow rising carotid pulse
- narrow pulse pressure
- heaving non-displace apex beat
- harsh ejection systolic murmur heard best at the second intercostal space on the right that radiates to carotids
- soft s2 heart sound
Ix:
- ECG showing LVH, left axis deviation and poor R wave progression
- CXR showing cardiomegaly and pulmonary oedema
- Echocardiogram for definite diagnosis
- exercise testing for severity
- cardiac MRI
Mx:
- diuretics, beta blockers and ACE-I
- surgery if symptomatic, low LVEF
Atrial fibrillation
Def, types, causes, Sx, ix, mx
Irregular, uncoordinated atrial contraction at a rate of 300-600 bmp. Delay at AVN means only some of the atrial impulses are conducted to the ventricles
Classification:
- acute <48 hours
- paroxysmal <7 days and intermittent
- persistent >7 days but is amenable to cardioversion
- permanent >7 days and is not amenable to cardioversion
Causes:
- most common is ischaemic heart disease
- HTN
- rheumatic heart disease
- myocarditis
- dehydration
Sx:
- palpitations
- chest pain
- SOB
- lightheadedness
- syncope
- irregularly irregular pulse rate with variable volume pulse
- single waveform on jugular venous pressure
Ix:
- 12 lead ECG as definitive diagnosis showing absence of p waves with an irregularly irregular rhythm
Mx:
- a to e for emergency
- 1st line is synchronised DC cardioversion +/- amiodarone
- 1st line for chronic is beta blocker (bisoprolol) or CCB (diltiazem)
- 2nd line dual therapy
- digoxin for those with non-paroxysmal and sedentary
- DOACs as first line anticoagulants
Atrial flutter
Def, Pathophys, causes, Sx, ix, mx
Atrial flutter is a common supraventricular tachycardia (SVT). It is characterised by an abnormal cardiac rhythm with an atrial rate of 300 beats/min and a ventricular rate that can be fixed or variable that causes symptoms.
Pathophysiology:
Atrial flutter is caused by an aberrant re-entrant circuit within the right atrium which cycles at 300bpm. This circuit activates the AV node but because this node has a relatively long refractory period it is not able to conduct impulses down the His-Purkinje system at such a fast rate.
Instead there is a degree of block meaning that only 2:1, 3:1, 4:1 or rarely 5:1 atrial impulses are conducted to the ventricle.
Causes:
- COPD
- obstructive sleep apnoea
- pulmonary embolism
- pulmonary hypertension
- ischaemic heart disease
- sepsis
Sx:
- palpitations
- lightheadedness
- syncope
- chest pain
- irregular irregular pulse (variable block)
Ix:
ECG features:
- regular rhythm
- saw tooth baseline with repetition at 300bpm
- narrow QRS complex
• 150bpm if 2:1
• 100bpm if 3:1
• 75bpm if 4:1
• 60bpm if 5:1
Mx:
- a to e for emergency
- 1st line is synchronised DC cardioversion +/- amiodarone
- 1st line for chronic is beta blocker (bisoprolol) or CCB (diltiazem)
- 2nd line dual therapy
- digoxin for those with non-paroxysmal and sedentary
- DOACs as first line anticoagulants
Wolff-Parkinson-white syndrome
Def, types, Sx, ix, mx
Congenital pre-excitation syndrome that occurs due to the presence of an accessory electrical pathway between atria and ventricles. Predisposes the patient to SVT
Classification:
- type A- pathway between left atrium and ventricles
- type B- pathway between right atrium and ventricle
Sx:
- often asymptomatic
- palpitations
- dizziness
- syncope
Ix:
- 1st line ECG showing delta waves, short PR interval, broadened QRS complex
- echocardiogram
- cardiac catheterisation
Mx:
- emergency= 1st line is synchronised DC cardioversion is adverse signs or vagal manouvres then adenosine if stable with narrow complex or IV procainamide then DC cardioversion if stable with broad complex
- long term= anti-arrhythmics (eg. Amiodarone or sotalol), definite mx is radio frequency ablation
- meds that block AVN are contraindicated
Acute bradycardia
Def, Sx, ix, mx
Heart rate <60 bpm. Most common cause is sick sinus syndrome due to the dysfunction of pacemaker cells
Sx:
- lightheadedness
- syncope
- fatigue
- SOB
Ix:
- ECG to determine underlying cause
- TTE if considering MI or aortic valve disease as cause
Mx:
- 1st line is 500 micrograms atropine IV (up to 3mg)
Mitral valve stenosis
Def, Sx, causes, ix, mx, comp
Def:
Mid-diastolic, low-pitched “rumbling”. Loud S1
due to thick valves, Opening snap after S2.
Sx:
Palpable tapping apex beat, prominent S1. Malar flush. Afib
- No symptoms until orifices <2cm2
- Symptoms due to pulmonary hypertension:
dyspnoea, haemoptysis, recurrent bronchitis
- Eventually right HF symptoms: fatigue, leg
swelling
- Due to large left atrium -> AFib: palpitations,
systemic embol
- Face : Mitral facies / malar flush (due to
↓CO)
- Pulse : AFib
- RV : heaving, sustained
- Apex: localised, tapping
- HS: Loud S1, loud P2(pulmonary HTN),
opening snap
- Murmurs: mid diastolic murmur rumbling
at apex
Causes:
• Rheumatic heart disease
• Infective endocarditis
• Calcification/fibrosis in elderly
Ix:
- CXR: Small heart with enlarged left atrium, Calcified mitral valve, Sign of pulmonary oedema
- ECG: AF, Bifid P wave/P mitrale, Right axis deviation/ tall R waves in lead V1 (Right ventricle
hypertrophy)
- Echocardiogram
- Cardiac catheterisation (indicated in): Previous valvotomy, sign of other valve disease, angina, severe, pulmonary hypertension, calcified mitral valve
Mx:
- AF: digoxin and anticoagulation
- Pulmonary oedema : diuretics
- Trans-septal balloon valvotomy (pliable, non-
calcified valve)
- Closed valvotomy
- Open valvotomy
- Mitral valve replacement
Complications:
- Results in right-sided heart failure
- To maintain CO, left atrial pressure↑»left atrial hypertrophy and dilatation»_space;pulmonary venous, arterial and right heart pressure ↑»_space; pulmonary oedema»_space;pulmonary HTN»_space; right ventricular hypertrophy, dilatation failure and subsequent tricuspid regurgitation
Mitral valve regurgitation
Def, Sx, causes, ix, mx, comp
Def:
Regurgitation refers to a ‘leaking’ of blood through the valve during ventricular systole. It can be classified as primary or secondary:
• Primary: refers to pathology affecting components of the valve itself. Degenerative disease is the most common cause.
• Secondary: refers to regurgitation due to changes to left ventricle
Sx:
- Pan-systolic, high-pitched “whistling” murmur.
Radiates to left axilla. +/- S3.
- Pulse : sinus rhythm or AF
- Apex : forceful, displaced, systolic thrill
- Sounds: Soft S1, split S2, loud P2 . maybe a mid-systolic click (sudden prolapse of the valve)
- Mitral area thrill. Heart failure and pulmonary oedema. Afib.
- Causes:
• Idiopathic weakening of the valve with age
• Ischaemic heart disease
• Infective endocarditis
• Rheumatic heart disease
• Connective tissue disorders, such as Ehlers-
Danlos syndrome or Marfan syndrome
Ix:
- CXR: Left atrial and left ventricular enlargement, Increased cardiac thoracic ratio, Valve calcification
- ECG: Bifid P wave, Left ventricular hypertrophy (tall R wave in leads 1, V6 and deep S wave is V1 and V2), AF might be present
- Exercise testing – to assess a patients overall functional capacity.
- Echocardiogram + Doppler
- Cardiac catheterization: often for surgical planning or assess pulmonary hypertension
Mx:
- Prophylaxis against Infective endocarditis
- If fast AF : rate control (beta-blockers)+ anticoagulated
- Pulmonary oedema / HF; diuretic (spironolactone)
- ACE inhibitor
- Surgery
Comp:
- Results in Congestive HF and left sided heart failure
• Mitral valve regurgitation > left atrial dilatation. Stroke volume ↓ due to regurgitation, thus LV hypertrophy to increase stroke volume and hence CO.
• Later = R sided HF
Tricuspid regurgitation
Def, cause, Sx, ix, mx
Occurs when the tricuspid valve fails to prevent blood leaking back into the right atrium during systole
Causes:
- infective endocarditis
- rheumatic heart disease
- chronic lung disease
- PE
- pulmonary stenosis
Sx:
- asymptomatic
- fatigue
- ankle and abdominal swelling
- signs of right sided heart failure
- pansystolic murmur loudest in the left parasternal region and on inspiration
Ix:
- ECG showing nothing, peaked p waves or incomplete RBBB
- TTE
Mx:
- monitored if non severe
- treat underlining cause eg. Abx for infective endocarditis
- loop diuretics for right sided heart failure
- ring annuloplasty or valve replacement if severe or symptomatic
Pulmonary stenosis
Def, cause, Sx, ix, mx
Obstructs blood flow from the right ventricle into the pulmonary bed resulting in a high pressure gradient across the pulmonary valve during systole
Causes:
- tetralogy of fallot
- noonan syndrome
- Williams syndrome
- congenital rubella
Sx:
- dyspnoea
- fatigue
- peripheral oedema
- ascites
- dysmorphic facies id noonans or Williams
- raised JVP
- right ventricular heave
- ejection systolic murmur that radiates to left shoulder and best heard on expiration
- widely split S2 and delayed P2
Ix:
• ECG: p pulmonale, right axis deviation, and right ventricular hypertrophy.
• CXR: prominent pulmonary arteries and post-stenotic dilatation.
• Echocardiogram: degree of stenosis and ventricular function.
Mx:
- valvutomy or ballon angioplasty if severe
