CVS Flashcards
Define aortic dissection
Where there is a break in the lumen of the aorta that causes blood to flow between the layers of the wall creating a false lumen.
Most commonly affects around the ascending aorta and aortic arch.
What is the presentation of aortic dissection?
- Tearing chest pain of sudden onset
- Radiating to back
- HTN
- Hypotension as the dissection becomes more severe
What is the management of aortic dissection?
Type A (ascending aorta): - surgical management but manage HTN to between 120-100 systolic
Type B (descending aorta):
Supportive
Manage HTN with IV labetalol
What are the possible end results of atherosclerosis?
- Angina
- Acute coronary syndrome
- TIA
- Strokes
- Peripheral arterial disease
- Chronic mesenteric ischaemia
Define peripheral arterial disease
PAD results from atherosclerosis and narrowing of the arteries supplying the limbs and periphery
Define critical limb ischaemia
is the end stage of peripheral arterial disease where there is an inadequate supply of blood to a limb to allow it to function normally at rest
Define intermittent claudication
is the symptom of having ischaemia in a limb during exertion that is relieved by rest. it is typically a crampy, achy pain in the calf muscles associated with muscle fatigue when walking beyond a certain intensity.
What is Leriche’s syndrome and what is the clinical presentation?
Associated with occlusion in the distal aorta or proximal common iliac artery
Clinical triad:
- thigh/buttock claudication
- Absent femoral pulses
- Male impotence
What are the examination findings in peripheral vascular disease?
Weak peripheral pulses Pallor Cold Skin changes Buerger's test
What are the investigations in peripheral vascular disease?
ABPI (>0.9 normal)
Arterial doppler
Angiography (CT or MRI)
What are the 6P’s in critical limb ischaemia
Pain Pallor Paraesthesia Pulselessness Paralysis Perishing cold
What is the management of intermittent claudication?
- Lifestyle changes to reduce risk factors
- Optimal medical tx for comorbidities
- Medical treatments: Atorvastating 80mg, Clopidogrel 75mg, naftidrofuryl oxalate (vasodilator).
- Surgical treatments: angioplasty and stenting, bypass surgery
What is the management for critical limb ischaemia?
Urgent referral to vascular Analgesia Urgent revascularisation by: - angioplassty and stending - bypass surgery
What are the causes of primary and secondary hypertension?
Primary has no particular cause
Secondary: ROPE - Renal diseease Obesity Pregnancy induced Endocrine
What are the complications of HTN?
Ischaemic heart disease Cerebrovascular accident Hypertensive retinopathy Hypertensive nephropathy Heart failure
What are the investigations done in order to assess for end organ damage in HTN?
Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria to assess for kidney damage
Bloods for HbA1c, renal functiona nd lipids
Fundus examination for hypertensive retinopathy
ECG for cardiac abnormalities
What is the medical options of HTN?
ACE inhibitor Beta blocker Calcium channel blocker Diuretic (thiazide like) ARB
What is the medical management ladder in HTN?
Step 1:
- Aged less than 55 and non-black use ACE inhibitor
- Aged over 55 or black use Calcium channel blocker
Step 2: A+C or A+D or C+D (if black use ARB instead of A)
Step 3: A+C+D
Step 4: A+C+D+additional
Additonal: if K+ <4.5mmol then spironolactone. If >4.5 alpha or beta blocker
Give the pathophysiology of venous ulcers
Occurs due to pooling of blood and waste products in the skin secondary to venous deficiency (varicose veins, DVT, phlebitis etc)
What are the distinguishing features of venous ulcers?
- Odematous flushed skin
- Hyperpigmentation to skin
- Varicose eczema
- Tend to be larger
- Irregular boarder
- More likely to bleed
- Pain relieved by elevation and worse on hanging
What is the management of venous ulcers?
Treat underlying cause
Good wound care
Tissue viability nurse
Plastic surgery input
Define Patent ductus arteriosis
The ductus arterosus normally stops functioning within 1-3 days of birth but when it doesn’t it’s called patent ductus arterosus.
It can be due to maternal infections such as rubella or genetic. Prematurity is a key risk factor.
Small PDA can be asymptomatic throughout childhood and present with heart failure like symptoms later in life.
Describe the pathophysiology of patent ductus arteriosus
pressure in the aorta is higher than that in the pulmonary vessels, so blood flows from the aorta to the pulmonary artery.
This creates a left to right shunt where blood from the left side of the heart crosses to the right side increasing the pressure in the pulmonary vessels thus causing pulmonary hypertension leading to right sided heart strain.
Pulmonary hypertension and right sided heart strain lead to right ventricular hypertrophy.
The increased blood flowing through the pulmonary vessels and returning to the left side of the heart leads to left ventricular hypertrophy.
Describe the presentation of the patent ductus arteriosus
Can be picked up during newborn examination if a murmur is heard but may also present with:
- SOB
- difficulty feeding
- poor weight gain
- LRTI
What murmur is heard with a patent ductus arteriosus?
A normal first heart sound with a continuous crescendo-decrescendo “machinery” murmur
How is a patent ductus arteriosus diagnosed?
confirmed by echo
Describe the management of patent ductus arteriosus
typically patients monitored until 1 year of age using echos.
After 1 year, highly likely that PDA will close spontaneously and trans-catheter or surgical closure can be performed.
Indomethacin
Give the pathophysiology of atrial septal defects
ASD leads to shunt with blood moving from left to right.
This means blood continues to flow to the lungs and pt does not become cyanotic but increased flow to right side leads to right sided overload and right heart strain.
This can lead to right heart failure and pulmonary hypertension.
What are the different types of atrial septal defects?
- Ostium secondum where the septum secondum fails to fully close leaving a hole in the wall
- Patent foramen ovale, where the foramen ovale fails to close
- Ostium primum where the septum primum fails to filly close. This tends to lead to atrioventriculalr valve defects .
What are the complications of atrial septal defects?
Stroke with VTE**
AF or atrial flutter
Pulmonary HTN or R sided HF
Eisenmenger syndrome
Give the presentation of atrial septal defects
mild-systolic, crescendo-decrescendo murmur loudest at the upper left sternal border with fixed split second heart sound.
May be asymptomatic and present later with dyspnoea, HF or stroke.
Childhood symptoms are: SOB Difficulty feeding Poor weight gain LRTI
What is the management of atrial septal defects?
Refer to paeds cardio
Surgically closing with a transvenous catheter closure or open heart surgery.
Anti-coagulants to reduce risk of clots and stroke in adults
What is the condition association and pathophysiology of ventricular septal defects?
Commonly associated with Down’s syndrome and Turner’s syndrome.
Left to right shunt leads to right sided overload, R HF and increased flow into the pulmonary vessels.
Describe the presentation of ventricular septal defects
Typically asymptomatic but if symptomatic: Poor feeding Dyspnoea Tachypnoea Failure to thrive
What are the examination findings in ventricular septal defect?
pan-systolic murmur more prominently heard at the left lower sternal border in the third and fourth intercostal spaces.
There may be a systolic thrill on palpation
What are the causes of a pan-systolic mumur?
Ventricular septal defect
Mitral regurg
Tricuspid regurg
What is the management of ventricular septal defects?
Can be corrected surgically using a transvenous catheter closure via the femoral vein or open heart surgery.
There is an increased risk of infective endocarditis therefore prophylactic antibiotics should be considered during surgical procedures
Define tetralogy of fallot
There are four coexisting pathologies:
- Ventricular septal defect
- Overriding aorta
- Pulmonary valve stenosis
- Right ventricular hypertrophy
Give the pathophysiology of tetralogy of fallot
Overriding aorta and pulmonary stenosis encourage blood to be shunted from the R heart to the left causing cyanosis.
Right ventricular hypertrophy develops due to increased resistance leading to right to left cardiac shunt.
Blood bypasses the lungs and thus cyanosis occurs. The degree to which this happens depends on severity of pulmonary stenosis.
What are the risk factors for tetralogy of fallot?
Rubella infection
Increased age of the mother
Alcohol consumption in pregnancy
Diabetic mother
What are the investigations and findings in tetralogy of fallot?
Echo
Doppler flow studies
CXR showing boot shaped heart due to R ventricular thickening
Ejection systolic murmur
Describe the presentation of tetralogy of fallot
Severe cases will present with HF before 1 year and S+S
Signs and symptoms: Cyanosis Clubbing Poor feeding Poor weight gain Ejection systolic murmur heard loudest in the pulmonary area "tet spells"
What are “tet spells”
intermittent symptomatic periods where the right to left shunt becomes temporarily worsened precipitating a cyanotic episode.
What are the treatment options for tet spells?
Squat/knees to chest
Medical:
- Supplementary oxygen
- B blockers
- IV fluids
- Morphine
- Sodium bicarbonate
- Phenylephrine infusion
What is the management of tetralogy of fallot?
Neonates: prostaglandin infusion to maintain ductus arteriosus.
Total surgical repair by open heart surgery is the definitive treatment but mortality is around 5%
What is ebstein’s anomaly and the conditions that it is associated with?
Where the tricuspid valve is set lower in the R side of the heart causing a bigger right atrium and a smaller R ventricle.
Associated with cyanosis and Wolf-parkinson-white syndrome
Describe the presentation of ebstein’s anomaly?
- evidence of HF
- gallop rhythm heard on auscultation
- cyanosis
- SOB/ tachypnoea
- Poor feeding
- Collapse or cardiac arrest
What are the investigations and their findings for ebstein’s anomaly?
ECG:
- arrhythmias
- R atrial enlargement
- RBBB
- L axis deviation
CXR:
- cardiomegaly
- R atrial enlargement
Echo to confirm diagnosis and assess severity
What is the management of ebstein’s anomaly?
Medical:
- treat arrhythmias and HF
- Prophylactic antibiotics to prevent infective endocarditis
Definitive management is by surgical correction of underlying defect
What are the risk factors for infective endocarditis?
- rheumatic valve disease
- prosthetic valves
- congenital heart defects
- IVDU
- others: recent piercings
What are the causative organisms of Infective endocarditis?
Staph aureus is now the most common cause. Also common in acute presentation and IVDUs
Staph epidermidis commonly colonise indwelling lines and is most common in patients following prosthetic valve surgery
What are the signs of tricuspid regurgitation?
pan-systolic murmur (louder on inspiration)
prominent V waves in JVP
pulsatile hepatomegaly
left parasternal heave
What are the causes of tricuspid regurgitation?
Right ventricular infarction Pulmonary HTN Rheumatic heart disease Infective endocarditis Ebstein's anomaly Carcinoid syndrome
What is acute pericarditis?
Inflammation of the pericardium. It is one of the differentials of any patient presenting with chest pain
What are the signs and symptoms of acute pericarditis?
Chest pain: may be pleuritic. Often relieved by sitting forward
Non-productive cough
Dyspnoea
Flu-like symptoms
Signs:
- Pericardial rub
- tachypnoea
- tachycardia
What are the causes of acute pericarditis?
- viral infections (coxsackie)
- Tb
- Uraemia
- trauma
- post MI, dressler’s syndrome
- connective tissue disease
- hypothyroidism
- malignancy
What are the investigations and their findings for acute pericarditis?
ECG changes:
- saddle-shaped ST elevation
- PR depression
Transthoracic echo
What is the management of acute pericarditis?
- treat underlying cause
- combination of NSAIDs and colchicine is now first line
What is the causes of constrictive pericarditis?
- any cause of acute pericarditis
- especially Tb
What are the features of constrictive pericarditis
- dyspnoea
- RHF: elevated JVP, ascites, oedema, hepatomegaly
- JVP shows prominent x and y descent
- pericardial knock - loud S3
- Kussmaul’s sign is positive
What is seen on CXR for constrictive pericarditis?
Pericardial calcification
What is the definition of aortic stenosis?
Narrow aortic valve that restricts from blood flow from the left ventricle into the aorta.
Aortic valve is usually made up on 3 leaflets but in aortic stenosis, they can have anywhere between one - four leaflets.
Describe the presentation of aortic stenosis
May be asymptomatic and found incidentally or:
- chest pain
- dyspnoea
- syncope
symptoms are typically worse on exertion
Describe the signs of aortic stenosis
Ejection systolic murmur heard loudest at the aortic area
- it has a crescendo-decrescendo character
- radiates to the carotid.
Other signs:
- ejection click
- palpable thrill
- slow rising pulse and narrow pulse pressure
What are the causes of aortic stenosis?
- Degenerative calcification (>65)
- Bicuspid aortic valve (<65)
- William’s syndrome
- post-rheumatic disease
- subvalvular: HOCM
What is the investigation and management for aortic stenosis?
If asymptomatic, then observe patient
if symptomatic, valve replacement
ECHO is the gold standard investigation for diagnosis
Give the features of aortic regurgitation
- early diastolic murmur: intensity increased by handgrip manoeuvre
- collapsing pulse
- wide pulse pressure
- Quincke’s sign
- De musset’ s sign
What are the causes of aortic regurgitation?
Rheumatic fever
Infective endocarditis
Connective tissue diseases (RA/SLE)
Bicuspid aortic valve
What are the causes of mitral stenosis?
RHEUMATIC FEVER
Mucopolysaccharidoses
Carcinoid
Endocardiall fibroelastosis
What are the features of mitral stenosis?
Mid-late diastolic murmur Loud S1, opening snap Low volume pulse Malar flush AF
What can be seen on CXR for mitral stenosis?
L atrial enlargement
What can be seen on echo for mitral stenosis?
normal cross sectional area of the mitral valve is 4-6sq cm. A ‘tight’ mitral stenosis implies a cross sectional area of <1sq cm
Give the pathophysiology of mitral regurgitation
When blood leaks back through the mitral valve on systole. Myocardium can thicken over time and eventually go into irreversible HF
2nd most common valve disease after aortic stenosis
What are the risk factors for mitral regurgitation?
Female Lower body mass Age Renall dysfunction Prior MI Prior mitral stenosis or valve prolapse Collagen disorders
What are the causes of mitral regurgitation?
- following coronary artery disease or MI, as a result of damage to its supporting structures
- mitral valve prolapse: when the leaflets of the mitral valve are deformed so the valve doesn’t close properly
- Infective endocarditis
- Rheumatic fever
- Congenital
What are the symptoms of mitral regurgitation?
Most are asymptomatic, but if there is:
- fatigue
- SOB
- oedema
What are the signs of mitral regurgitation?
- pansystolic murmur
- described as ‘blowing’
- heard best at the apex and radiating into the axilla
What are the investigations and findings in mitral regurgitation?
ECG: borad P wave, indicative of atrial enlargement
CXR: cardiomegaly with enlarged left atrium and ventricle
Echo: Crucial to DIAGNOSIS
What are the treatment options in mitral regurgitation?
Medical management in acute cases:
- nitrates
- diuretics
- positive inotropes
- intra-aortic balloon pump
If HF:
- ACEi, B-blockers and spironolactone
In acute, severe: surgery
Repair over replacement has lower mortality and higher survival rates but if not possible then replace with either artificial or a pig valve.
Describe the presentation of myocarditis
- usually <50yr
- 2-3 week hx of viral syx
- Recent travel?
Symptoms:
- fatigue
- chest pain
- dyspnoea/orthopnoea
- palpitations, syncope
What is the examination findings for myocarditis
S3 and S4 gallops
Pericardial rub
Tachycardia
What are the investigations and findings for myocarditis?
ECG:
- ST depression or elevation
- T wave inversion
- AV node block
Bloods: raised troponin and CK-MB
CXR: enlarged heart and/or HF
Echo: ventricular dilatation and abnormal wall movement
Biopsy: definitive test but v risky so not done often
Cardiac MRI:: useful to differentiate myocarditis and ischemia/infarction
What is the management of myocarditis?
Acute + haemodynamically stable:
- supportive care
- treat underlying cause
If ventricular dysfunction: ACEi/ARB
Acute + haemodynamically unstable:
- IV arterial vasodilator
Refractory/end stage:
- Heart transplant
- L ventricular assist device
Define infective endocarditis
A condition caused by infection of the endocardium by bacteria. Most commonly occur at sites of previous damage but can affect normal ones as well. S. Aureus will commonly infect tricuspid valve in IVDU
What are the risk factors for infective endocarditis?
Valvular damage:
- previous rheumatic heart disease
- age related vascular degeneration
- prosthetic valve
IVDU
Describe the signs and symptoms of infective endocarditis
Acute presentation:
- fever and new heart murmur
- petechiae
- haematuria
- cerebral emboli
Textbook signs of IE:
- janeway lesions
- Osler’s nodes
- vasculities
- thrombocytopaenia
- malignancy
What is the diagnosis of infective endocarditis?
MAJOR:
- positive blood culture for infective organisms on 2 separate tests if >12 hours apart
- Echo shows strictures, unusual blood flow, abscesses
- new valve regurgitation
MINOR:
- fever >38
- predisposition to IE
- unusual echo
- immunological factors present
- blood culture positive
IE definitely present:
- 2 major or
- 1 major, 3 minor
- 5 minor
What are the indications for surgery in Infective endocarditis?
IE resistant to abs Fungal disease resistant to tx IE causing embolic events IE with CHF Structural damage on echo
What is the presentation of left atrial myxoma?
Popping sound in early diastole
Loud 1st heart sound
What is the normal cardiac axis?
-30 to 90
What is used for medical cardioversion?
Flecanide
What is incorporated in the CHA2DS2-VASc score?
Congestive HF 1 HTN or anti-hypertensives 1 Age >75 2 DM 1 Stroke/TIA previously 2 Vascular disease 1 Age 65-74 1 Sex: Female 1
Which artery stemming from the aorta can impact descending aortic dissection?
Left renal artery
What is nicorandil used for?
Angina
What is the presentation of cardiac tamponade?
Classical features - Beck’s triad:
hypotension
raised JVP
muffled heart sounds
Pulsus paradox
What is the stepwise approach to heart failure treatment?
- ACEi and B-blockers
- Aldosterone antagonist
- Specialist led: Ivabradine, digoxin, hydralazine + nitrate, sacubitril-valsartan or cardiac resychronisation
Which is the only calcium channel blocker licensed for heart failure?
Amlodipine
What is the mechanism of action of calcium gluconate?
Stabilises the myocardium and does NOT lower potassium
What is the management of a new BP of >180/120 and no worrying signs?
1st line: urgent investigation for end organ damage
What is secondary prevention for patients with stroke and AF?
Apixaban or warfarin
