CVS clinical cases Flashcards
if someone has swelling in lower limb which is painful and is common with people on long flights
DVT
what can DVT lead to if the symptoms are sudden breathlessness and pain to breath
pulmonary embolus
why specifically can a lower limb start to swell
DVT causes disruption to normal circulation and forms block of vessel leads to stasis of blood which leads to plasma leaking out the vessel and causing oedema
what does a DVT look like
swelling, pain, tender, inflammation, warmth
which veins are most at risk to DVT
femoral, popliteal, tibial vein, lesser saphenous, greater saphenous, iliac
how does immobility lead to DVT
lower limb muscles aid in return on blood to the heart
without it you only have the valves and little pressure from the heart
what is a thrombus
blood clot
what is virchows triad
theory concerning homeostasis thrombosis was the result of a delicate interplay between three factors which promote coagulation these are 1 changes in blood flow 2 changes in the vessel wall 3 changes in blood constituents
what is stasis
stagnation or cessation of blood flow
in stasis why is blood prone to clotting
platelets are in contact with the endothelium - clotting factors are not diluted by fast blood flow
inflow of anticoagulants uis slowed
what changes in the vessel wall can lead to DVT
damage to the lining of the vein due to inflammation (vasculitis)
chemotherapy
what causes changes in blood flow to result in DVT
thrombophilia - abnormal factor V leiden which makes clotting more likely cancer smoking contraceptive pill pregnancy
what is an embolus
material such as blood clot, fat, air, amniotic fluid or foreign body carried by the blood and lodged in a mother area
what is a venous thromboembolism
DVT
why is oxygen saturation lowered in pulmonary embolism
V/Q mismatch
there is ventilation but no perfusion of blood due to clot
how does D -Dimer test for DVT/VTE
what are the problems with the test
when you have a DVT you get large amount of D-dimer which is a product of fibrin breakdown
sesntivte test but not specific to DVT - can be caused by other diseases such as eclampsia, kidney disease, infection, liver disease
what techniques can be used to test for VTE
doppler ultrasund
V/Q scan
computed tomography pulmonary angiogram (CTPA)
what treatments are there for DVT or pulmonary embolism
warfarin (pills) - monitored low molecular weight heparin (anticoagulant) - acute action (sub cutaneous) Xa inhibitors - rivaroxaban - apixaban - edoxaban
what is warfarin
Warfarin inhibits the effective synthesis of biologically active forms of the vitamin K-dependent clotting factors: II, VII, IX and X, as well as the regulatory factors protein C, protein S and protein Z.
anticoagulant - used in cases of thrombophilia
how would you reverse warfarin
give Vit K
in extreme cases give large amounts of prothrombin
what advice would you give someone to reduce DVT and pulmonary embolism
stop smoking lose weight regular walking keep hydrated compression stocking
what is a cerebral infarction
stroke
what is a stroke and what can it be caused by
rapidly developing loss of brain function due to disturbance in the blood supply to the brain
it can occur via blockage by thrombus (ischaemic stroke)
or by haemorrhage (haemorrhage stroke)
what is a cerebral haemorrhage
rupture of a blood vessel can produce bleeding
when an aneurysm ruptures - 15-20% of all strokes and are deadly
best preventative by controlling high blood pressure
what is a TIA
mini stroke
temporary disruption of the circulation to part of the brain due to embolism or thrombosis to brain arteries
most common symptoms are loss of vision in one eye and weakness or numbness in one limb or part of limb
patient recovers within 24 hours
what are the symptom of stoke and how can it be identified
weakness of the arm or leg slurring of speech (dysarthria) drooping of the corner of the mouth dysphagia expressive dysphagia (struggle to speak or understand others)
what is FAST
face
arm
speech
time
what are the signs of a stroke or TIA
signs detected by clinician
sings of atrial fibrillation
hypertension
possible bruit (turbulent flow caused by atherosclerosis in coronary artery)
what are the risk factors of stroke
advanced age hypertension previous stroke or TIA diabetes high cholesterol smoking atrial fibrillation
what are the possible rules of blood clot in stroke
aorta - brachiocephalic artery - right common carotid artery - right internal carotid artery
aorta - left common carotid artery - left internal carotid artery
what investigations can you do for stroke
CT can of head
ultrasound of carotid artery may show evidence of narrowing (TIA)
echocardiogram of the heart to see if clot in atria
ECG may show evidence of atrial fibrillation
on a CT scan what are the visual difference of a haemorrhage compared to infarction
haem - white area to show bleeding
infarction - cell death - dark swollen area
why would someone with stroke be given digoxin
cardiac glycoside which increases the refractory period decreasing rate in atrial fibrillation
reduces rate of heart but increases force of contraction so no loss in CO
how can stroke be prevented
early intervention of high blood pressure
early detection of atrial fibrillation
what is lisinopril
ACE inhibitor which reduce risk of stroke as reduce blood pressure
all things ending in -pril reduce blood pressure
stop conversion of AG1 - AG2 which means less vasoconstriction and less water retention
what is the difference between and symptom and a sign
symptoms is what the patient indicates from the disease
sign is what the clinician picks up on not apparent to the patient
what are the clinical symptoms and signs of myocardial infarction
symptoms:
severe crushing generalised in the chest by sudden onset
pain often spreads to arm and neck
associated with nausea, vomitting, sweatiness and breathlessness
signs:
distressed, low blood pressure and fast heart rate
could have pulmonary oedema
what is the difference between angina and MI
angina is reduced oxygen to the heart which can be exacerbated but MI is an specific block of the coronary system which shuts off blood to the heart and there is tissue death
what are the three factors of angina
constricting discomfort in the front chest and neck, jaw, shoulders
precipitated by physical exertion
received by rest of GTN within about 5 minutes
typical angina is all three
a-typical is 2 of the 3
non-anginas chest pain is one or zero
what is the biological cause of angina
usually due to flow limiting atherosclerosis resulting in schema of the heart
usually in normal situations you don’t have pain but when there is need for stress on the heart such as exercise there atherosclerosis stops blood flow and causes pain
what happens during a heart attack
atheroma causes narrowing of coronary vessels
if becomes unstable a piece may brea off and form a clot
this starves the heart of O2 causing muscle damage
what is a type 1 MI
plaque rupture with (non)occlusive thrombus
what is a type 2 MI
atherosclerosis and O2 imbalance
vasospasm
what are the two causes for heart arteries to narrow
atherosclerosis - fatty plaques in inner walls obstructing blood flow
coronary thrombosis
which part of vichrows triad is affected in MI
changes in the vessel wall
what are the risk factors in MI and angina
dyslipidaemia smoking diabetes hypetension male sex increasing age family history obesity
what investigations can be done to find angina or MI
ECG - look at ST segment - if ST elevation then there is coronary artery completely blocked
raised troponin in blood
echo cardiogram shows reduced contraction inaffected area
coronary angiogram
what surgical intervention can be done to manage atherosclerosis or blocking of CA
thrombolytic drugs or primary percutaneous intervention
what is simvastatin and why is it given to people at risk of MI
inhibition of HMG CoA reductase and therefore reduces production of cholesterol
what other drugs can be given to patients with angina or MI risks
beta blocker s- propranolol prolong diastole increase coronary filling time reduce sympathetic activity aspirin - blocks thromboxane clopidogrel - ADP receptor antagonists on platelets 9for stabel angina)
what is fallots tetralogy
lack of o2 to the body - it has 4 common effects
what does congenital mean
present from the birth
it does no mean genetic
what is an example of congenital being not genetic
congenital syphilis
what are the normal heart sounds
s1 is lub - closure of tricuspid and mitral valves
s2 is dub - closure of aortic and pulmonary valves
what are heart murmurs and give examples
additional sounds in the heart
aortic stenosis causes more sound during systole
aortic regurgitation - sound during diastole
what is a ventricular septal deficit
allows oxygenation blood to mix with deoxygenated mood causing the heart to work harder to provide enough oxygen to the body tissues
when does ventricular septal defect occur
can be present at birth and outgrown or acquire later such as during heart attack
can occur alone or with other congenital heart defects
what are the four characteristics of fallots teratology
pulmonary stenosis (narrowing)
overriding aorta
VSD
right ventricular hypertrophy
what is the route of blood in teratology of the heart
RA - RV - lungs - LA - LV - RV - Pulmonary artery - lung etc
why would someone appear blue in Fall - TerAT
cyanosis - blue / purple colour of the skin due to tissues near the surface of the skin being starved of O2
what is a tat spell
acute episode of hypoxia
shortness of breath - cyanosis
what causes a tat spell
initiated by events that cause decreased systemic vascular resistance leading to increased venous return and increased shunting through the VSD
what do older children in a Tat spell usually do
crouch or squat which increases systemic resistance and allows reversal of shunt
what are the symptoms and sings of teratology of the heart
difficulty feeding
failure to gain weight
retarded growth of phyla development
what is the shunt operation in surgical treatment of fallot of the heart
shunt from aorta or branch of artery from the arm to the pulmonary artery - ie more blood back to lungs for re-oxygenation (could be subclavian artery to pulmonary artery)
palliative
what is the blalock thomas taussig procedure
total repair - curative - of teratology of fallot
when is corrective surgery carried out for teratology of the heart, what is the mortality and when does it do
around 6 months old
less than 5% mortality
receive right ventricular flow - repair VSD and resection of muscle
what happens if ToF goes untreated
rapid increase in RV hypertrophy due to pulmonary stenosis
lead to HF
35% mortality in first year of life
50% mortality in first 3 years of life
what happens if ToF undergoes total surgical repair
improved haemodynamics and often good to excellent cardiac function
no exercise tolerance
progressive leaky pulmonary valve
survival rates much improved
what are the signs of ToF
heart murmur
clubbing
polycythemia
tat spells
what are the symptoms of ToF
low blood SaO2 = cyanosis
difficulty feeding
failure to gain weight
retarded growth
what is aortic stenosis
narrowing of the aortic valve
what are the symptoms of aortic stenosis
heart murmur
angina pectoris
difficulty breathing
syncope - fainting
what are the three common symptoms of valve diseases
lightheadedness
chest pain
short of breath
why does breathlessness occur in aortic stenosis
narrowing of aortic valve so hypertrophy of LV
stiffening of LV and diastolic impairment (impair filling)
why do you feel lightheaded in an aortic stenosis
Lv baroreceptors sense high LV pressure
indue hypotension, bray cardia which lads to syncope
what is the mechanism of fainting in aortic stenosis
MAP increases due to pressure from hypertrophy of LV - increased Barorecerptor firing - decrease in symptoms tone and increases in para symptoms
why do you have chest discomfort in aortic stenosis
increased LV demand for oxygen from hypertrophy - low perfusion and increased demand in some patients with CAD
why does exercise exacerbate symptoms in aortic stenosis
increased O2 requirements, increased heart rate
greater impact of obstruction to flow from heart
what is the heart murmur of aortic stenosis and where is it best heard
right sternal boarder
second intercostal space
systolic ejection murmur
what is the clinal term to describe narrowing of heart valve
stenosis - abnormal narrowing of structure - most aortic stenosis’ are congenital bicuspid
how does blood pressure differ in aortic stenosis
always higher in every region of LA and LV it becomes less when in the aorta
if left untreated what happens with aortic stenosis
heart failure - 2 year average survival
syncope - 3 year average survival
angina - 5 year average survival
what are the clinal signs of aortic stenosis
loud ejection systolic heart murmur
reduced pulse pressure
forceful apex beat
what surgical interventions are there for aortic stenosis
if the LV strats to dilate then surgery is considered
the aortic valve can be replaced by open chest surgery or percutaneous route
valves are either made from metal or plastic (prosthetic) or pig valves (tissue valves)
what are the primary and secondary intervention of aortic stenosis
with artificial valves require life long anticoagulant treatment with warfarin
patients with tissue valves do not require warfarin
how can flu be associated with systolic heart failure
myocarditis - inflammation of the heart muscle - inflammatory cardiomyopathy
caused by infection, immunology, drugs
what are viral causes of myocarditis
adenovirus parovirus coxackie virus HIV enterovirus rubella polia CMV
what does myocarditis do to the heart muscle
heart muscle becomes thick and swollen
what are the symptoms of systolic heart failure
tiredness, breathlessness - especially when lying flat or suddenly at night (paroxysmal nocturnal dyspnoea)
ankle swelling
passing lots of urine at night
what are the clinical signs of systolic heart failure
tachycardia - greater than 110
hypotension - less than 100 systolic
pitting oedema
why does tachycardia and hypotension occur in systolic heart failure
enlarged ventricles fill with blood
the ventricles pump out less than 40-50% of the blood
what would a blood test show of someone with systolic heart failure
raised BNP - brain natriuretic peptide
what would an x ray show for someone with systolic heat failure
A - alveolar oedema B - Kelry B lines (interstitial oedema) C - cardiomegaly D - dilated prominent upper lobe vessels E - pleural Effusion
what do inotropic agents do
increases force of contraction o the heart - increases ventricular performance and EDV
what is an LVAD
left ventricular assist device
helps pump heart - need warfarin as risk of thrombosis
what treatments are there for systolic heart failure
furosemide (loop diuretic), ACE inhibitor (ramipril), beta blocker (propranolol)
