CVS Flashcards
SA node -
the dominant pacemaker with an intrinsic rate of 60-100 bpm
(NORMAL HEART RATE) - the fastest depolarising tissue
ECG paper:
- Horizontally: • One small box = 0.04s/40ms • One large box = 0.20s - Vertically: • One large box = 0.5mV
Cardiac output (L/min) =
Stroke volume (L) x Heart rate (BPM)
HEART SOUNDS:
- S1 - mitral and tricuspid valve closure
- S2 - aortic and pulmonary valve closure
- S3 - in early diastole during rapid ventricular filling, normal in children and pregnant women, associated with mitral regurgitation and heart failure
- S4 - ‘Gallop’, in late diastole, produced by blood being forced into a stiff hypertrophic ventricle - associated with left ventricular hypertrophy
ANGINA:
Aspirin:
Betablockers - 1st line antianginal: Reduce force of contraction of heart E.g. Bisoprolol and atenolol
Glyceryl Trinitrate (GTN) spray - 1st line antianginal:
- Nitrate that is a venodilator
Ca2+ channel antagonists/blocker: verapamil
- Primary arterodilators
- Dilates systemic arteries = BP drop
ACUTE CORONARY SYNDROME:
includes
STEMI, unstable angine, NSTEMI
- Pain relief:
• GTN spray
• IV opioid
- Anti-emetic
- Oxygen
- Antiplatelets:
- aspirin
- 2Y12 inhibitors (oral): Inhibit ADP-dependant activation of IIb/IIIa glycoproteins thereby preventing amplification response of platelet aggregation : - E.g. Clopidogrel, Prasugrel & Ticagrelor
- Glycoprotein IIb/IIIa antagonists (IV): E.g. Abciximab, Tirofiban and Eptifbatide
- Beta blockers (IV & oral):
• E.g. Atenolol (IV then oral) or Metoprolol (IV then oral)
- Statins (oral):
• HMG-CoA reductase inhibitors
• E.g. Simvastatin, Pravastatin and Atorvastin
- ACE inhibitors (oral):
• E.g. Ramipril and Lisonopril
• Monitor renal function
- Coronary revascularisation:
• PCI
• CABG - high risk mortality in high risk groups e.g. recent MI
- ACUTE MYOCARDIAL INFARCTION:
Tx:
Pre-hospital:
• Aspirin 300mg chewable
• GTN (sublingual)
• Morphine
Hospital:
• IV morphine
• Oxygen if their sats are below 95% or are breathless
• Beta-blocker - Atenolol
• P2Y12 inhibitor - Clopidogrel
Coronary revascularisation:
• PCI:
- Presented to all patients who present with an acute STEMI who can be transferred to a primary PCI centre WITHIN 120 MINUTES of first medical contact
- If not possible then give patient fibrinolysis and then transfer to PCI centre after infusion
• CABG
- Fibrinolysis - enhance the breakdown of occlusive thromboses by the activation of plasminogen to form plasmin
Cardiac failure:
def
Tx:
The inability of the heart to deliver blood and thus O2 at a rate that is commensurate with the requirement of metabolising tissue of the body
- Diuretics:
• Promote sodium and thus water loss thereby reducing ventricular filling pressure (preload) decreasing systemic and pulmonary congestion
• symptomatic relief
• Loop diuretic - furosemide
• Thiazide diuretic - bendroflumethiazide (inhibit sodium reabsorption in the distal convoluted tubule)
• Aldosterone antagonist (thereby inhibiting ADH release resulting in water loss) - spirolactone & epelerone - note with these beware of renal impairment and hyperkalaemia
-ACE inhibitors:
• Ramipril, enalipril, captopril
• Side effects: cough (since inhibit ACE and thus the breakdown of substance P and bradykinin which results in cough)
• If cough is a problem then can give angiotensin receptor blockers (not as effective as ACE-inhibitors) e.g. canderstan or valsartan
-Beta-blockers:
• Bisoprolol, nebivolol, carvedilol
• Start at low dose and titrate upwards
• DO NOT GIVE TO ASTHMATICS
-Digoxin
-Inotropes
- Biventricular failure:
- Shortness of breath due to right ventricular failure
* Leg oedema due to left ventricular failure
• VALVULAR HEART DISEASES:
- MITRAL VALVE DISEASE
- Mitral stenosis
Tx:
Its a mechanical problem and medical therapy does not prevent progression
- Beta-blockers e.g. Atenolol and digoxin which control heart rate and thus prolong diastole for improved diastolic filling
- Diuretics for fluid overload e.g. Furosemide
- Percutaneous mitral balloon valvotomy:
- Mitral valve replacement
- MITRAL REGURGITATION:
Def
Tx:
Backflow of blood from the left ventricle to the left atrium during systole
- Medications:
• Vasodilators such as ACE-inhibitors e.g. Ramipril or Hydralazine (smooth muscle relaxer)
• Heart rate control for atrial fibrillation with Beta blockers (Atenolol), Calcium channel blockers and digoxin
• Anticoagulation in atrial fibrillation and flutter
• Diuretics for fluid overload e.g. Furosemide
- AORTIC REGURGITATION:
Main causes
RF
Tx:
- Main causes:
• Congenital bicuspid aortic valve (BAV) - chronic
• Rheumatic fever - chronic
• Infective endocarditis - acute
• Risk factors: - SLE
- Marfan’s and Ehlers-Danlos syndrome - connective tissue disorders
- Aortic dilatation
- Infective endocarditis or aortic dissection
- Vasodilators such as ACE-inhibitors such as Ramipril will improve stroke volume and reduce regurgitation but only if patient is symptomatic or has hypertension
- INFECTIVE ENDOCARDITIS:
Tx:
- Staphylococcus aureus (IVDU, diabetes and surgery) - most common cause
- Pseudomonas aeruginosa
- Streptococcus viridans (dental problems) - GRAM POSITIVE, alpha haemolytic and optochin resistant (Strep. mutans, strep, sanguis, strep. milleri & strep. oralis)
- Antibiotic treatment (which one is decided on organism ascertained from cultures) for 4-6 weeks
- If not staphylococcus then use penicillin ideally Benzylpenicillin & Gentamycin (doesn’t work on own since cannot get through bacterial cell wall)
- If staphylococcus then use Vancomycin & Rifampicin (if MRSA)
• Hypertrophic cardiomyopathy (HCM):
Def + Tx:
- Ventricular hypertrophy/thickening of the muscle
- Amiodarone - anti-arrythmatic medication, if at high risk of arrhythmia then can place an implantable cardiac defibrillator
- Calcium channel blocker e.g. Verampil
- Beta-blocker e.g. Atenolol
Arrythmogenic right ventricular cardiomyopathy:
Progressive genetic cardiomyopathy characterised by progressive fatty and fibrous replacement of ventricular myocardium
Beta-blockers e.g. Atenolol for patients with non-life-threatening arrhythmias
• Amiodarone for symptomatic arrhythmias
• Occasionally cardiac transplant indicated i.e. in cardiac failure or devastating arrhythmia
BICUSPID AORTIC VALVE (BAV): ATRIAL SEPTAL DEFECTS (ASD): VENTRICULAR SEPTAL DEFECTS (VSD): -explained \+/- Tx:
- 2 instead of three cusps– early stenosis
-Shunt is left-to-right
Thus NOT blue i.e. acyanotic
-20% of all congenital heart defects
• Higher pressure in left ventricle than right ventricle =left-to-right shunt = acyanotic. If moderately sized lesion; furosemide, ACE inhibitor e.g. ramipril and digoxin may suffice
PATENT DUCTUS ARTERIOSUS:
persistent communication between the proximal left pulmonary artery and the descending aorta (after birth)
Eisenmenger’s syndrome with differential cyanosis that is clubbed and blue toes BUT pink and not clubber fingers
-Indometacin (prostaglandin inhibitor) can be given to stimulate duct closure
- COARCTATION OF THE AORTA:
- TETRALOGY OF FALLOT:
A narrowing of the aorta at, or just distal to, the insertion of the ductus arteriosus (distal to the origin of the left subclavian artery)
Most common form of CYANOTIC congenital heart disease: - A large, maligned Ventricular Septal Defect (VSD (right to left): surgical treatment during first two years of life due to the progressive cardiac debility and cerebral thrombosis risk
Heart abnormalities
- COARCTATION OF THE AORTA: PATENT DUCTUS ARTERIOSUS: BICUSPID AORTIC VALVE (BAV): ATRIAL SEPTAL DEFECTS (ASD): VENTRICULAR SEPTAL DEFECTS (VSD): TETRALOGY OF FALLOT:
DEXTROCARDIA:
• Heart points to the right side of chest instead of to the left
ACUTE PERICARDITIS:
def
Tx:
• Acute inflammation of the pericardium; with or without effusion
- Restrict PA
- NSAID e.g Ibuprofen for two weeks or Aspirin for two weeks
- Colchicine for 3 weeks however is limited by nausea and diarrhoea but does reduce recurrence
• Recurrent or relapsing pericarditis: - About 20% develop idiopathic relapsing pericarditis (within 6 weeks during weaning off NSAIDs OR intermittently)
- first line is oral NSAIDs e.g. Ibuprofen
- Colchicine more effective than Aspirin alone
- In resistant cases, oral corticosteroids e.g. Prednisolone may be effective, and in some patients, pericardiectomy (removal of part/most of the pericardium) may be appropriate
HYPERTENSION:
Normal
Stages
Treatment GOAL is 140/90mmHg
this is the commonest cause of … and a makor risk of …
Tx:
140/90mmHg=normotensive
Stage 1 hypertension:
- More than or equal to 140/90mmHg clinic BP
- Daytime average Ambulatory blood pressure monitoring (ABPM - 24hr BP monitor) or Home blood pressure monitoring (HBPM); greater than or equal to 135/85mmHg
Stage 2 hypertension:
- More than or equal to 160/100mmHg clinic BP
- Daytime average ABPM or HBPM greater than or equal to 150/95mmHg
Severe hypertension:
- Clinic systolic BP greater than or equal to 180mmHg and/or
diastolic BP greater than or equal to 110mmHg
- Start immediate anti-hypertensive drug treatment!
140/90mmHg
cardiac failure … atherosclerosis and cerebral haemorrhage
ACD pathway:
A - ACE-inhibitor e.g. Ramipril or Enalapril, or Angiotensin receptor blocker (ARB) (use if ACEi is contraindicated e.g. due to cough) e.g. Candesartan or Losartan
C - Calcium channel blocker (CCB) e.g. Nifedipine or Amlodipine
D - Diuretics e.g. Bendroflumethiazide (thiazide, distal tube - less potent) or Furosemide (loop diuretic, loop of henle - more potent)
NOTE: Beta-blocker e.g. Bisoprolol or Metoprolol (B1 selective) are NOT the FIRST LINE TREATMENT FOR HYPERTENSION but consider in young people especially if they are intolerant of ACEi/ARB
Less than 55 yrs old:
- Ramipril/Candesartan - + Nifedipine
- + Bendroflumethiazide - + Furosemide
Older than 55 yrs/black/African-Caribbean origin:
- Ramipril/Candesartan + Nifedipine
- + Bendroflumethiazide
- + Furosemide
