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Head, neck and thorax > lecture 3- Cardiovascular system > Flashcards

lecture 3- Cardiovascular system Flashcards

1
Q

what is atherosclerosis?

A
  • Calcified plaques in the intima of large and medium sized arteries
  • They begin as fatty streaks, some of which progress to plaques
  • Plaques can progressively enlarge causing stenosis and ischemia
  • They can rupture causing a thrombus formation, total occlusion and critical ischemia
  • Can put pressure on the underlying media causing an aneurysm
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2
Q

what are the risk factors for atherosclerosis?

A

o Increasing age
o Hypertension
o Smoking
o Diabetes
o Family history
o Alcohol
o Obesity

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3
Q

what conditions can atherosclerosis cause?

A

§ Ischemia / infarction – MI, angina, cardiac failure, TIA, stroke, peripheral vascular disease
§ Aneurysmal dilation- thoracic or abdominal aortic aneurysm

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4
Q

what is heart failure?

A
  • Describes cardiac ventricular dysfunction – the heart cannot pump enough blood around the body to meet the body’s blood flow requirements. Used to be called congestive heart failure, See it with people who have a pre existing disease
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5
Q

what are the causes and main symptoms if heart failure?

A

Causes:
* Most common in older patients
* Coronary heart disease
* High blood pressure
* Cardiomyopathy
* Arrhythmias, such as atrial fibrillation
* Damage to the heart valves
* Congenital heart disease
* Lifestyle factors – obesity, anaemia, excess alcohol, pulmonary hypertension

Symptoms :
* Breathlessness at rest or after activity
* Exhaustion most of the time
* Fainting / feeling lightheaded
* Swollen ankles and legs
There are 4 types – 1 – no limitation or symptoms during normal activity to 4 – symptoms even at rest with severe limitation

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6
Q

how do we diagnose heart failure

A
  • Blood tests to check for damage (peptides signal stress on the heart, CRP indicates inflammation, BNP to diagnose heart failure)
  • ECG and / or echocardiogram
  • Spirometry- what patient’s ejection paction is
  • CXR - only about 70% accuracy. But may see signs of heart failure such as pulmonary venous congestion, cardiomegaly, pulmonary oedema, pleural effusions.
  • US is the most common imaging used – transthoracic echocardiography. It can assess the appearance and function of the ventricles, assess the valve anatomy and function and look at the pericardial space
  • Cardiac CT can provide estimates of cardiac function and visualisation of cardiac structures
  • Cardiac MRI can provide highly accurate ejection fractions, identify abnormalities and is considered the gold standard imaging modality.
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7
Q

what are some complications associated with heart failure?

A
  • Prognosis is poor – up to 70% of patients die within 5 years.
  • Acute pulmonary oedema
  • Arrhythmias such as ventricular tachycardia (can lead to VF and death)
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8
Q

how do we treat heart failure?

A

o Make healthy lifestyle changes
o surgical management
 Implantable ICD or PPM (permanent pacemaker), cardiac transplant
o Treatment of complications
o Medication – betablockers most commonly
o Differential diagnosis
o Pneumonia
o PE
o Asthma

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9
Q

describe pericardial effusion and state its main causes

A

Description
* Occurs when excess fluid collects in the pericardial space (normally 30-50ml)
Causes
* Many! Including pericarditis (inflammation of the pericardium due to injury or disease), MI, RA, metastasis, particularly lung and breast.

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10
Q

what are the symptoms of pericardial effusion, and complications can occur?

A

Symptoms
* Presentation relates to the speed fluid has accumulated. Patients will have impaired cardiac function, due to the pressure.
* Symptoms can include dyspnoea, reduced exercise tolerance.

Complications
* Can lead to cardiac tamponade and death.

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11
Q

how do we diagnose pericardial effusion?

A
  • CXR – need at least 200ml of fluid to see on a CXR. But may see heart enlargement (looks like a water bottle), pulmonary oedema
  • Echo – method of choice as you can measure the amount of fluid and assess the impact on cardiac function
  • CT/ MRI – pericardium thickness of more than 4mm is considered abnormal
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12
Q

how do we treat pericardial effusion and what is the differential diagnosis?

A

Treatment
* Small amount of fluid is usually managed conservatively
* Large amount – can be drained

Differential diagnosis
* Cardiomegaly of another cause

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13
Q

describe mitral valve regurgitation, and what are the main causes.

A

Description
* Condition where the mitral valve leaks during systole (pumps blood into arteries) and so blood flows in the wrong direction from the left ventricle into the left atrium

Causes
* Chronic - Increasing age, congenital heart defects, calcium buildup preventing the valve from correctly functioning, cardiomyopathy
* Acute – MI, trauma

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14
Q

what are the symptoms and some complications that can occur with mortal valve regurgitation

A

Symptoms
* Acute – severe symptoms of heart failure, shock
* Chronic – heart murmur on examination, dyspnoea, arrhythmia or palpitations

Complications
* Heart failure, pulmonary hypertension, AF, sudden cardiac death.

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15
Q

how do we diagnose mitral valve regurgitation.

A
    • CXR – signs of left atrial enlargement (splaying of the carina, loss of the left atrial appendage), features of heart failure, pulmonary oedema
  • Echo – useful for assessing the cause and reviewing the left ventricle
  • CT / MRI – not commonly used but may have some uses in assessing the underlying cause
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16
Q

what is the treatment and differential diagnosis for mitral valve regurgitation?

A

Treatment
* Acute – mitral valve replacement
* Chronic – Drugs such as ACE inhibitors, anticoagulation.

Differential diagnosis
* Any causes of an enlarged heart and heart failure

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17
Q

what is coronary artery disease and what causes it?

A
  • Description
    o This mainly refers to the narrowing of the coronary arteries due to atherosclerosis (calcification). This results in myocardial ischaemia and globally is the leading cause of death
  • Causes
    o Atherosclerosis
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18
Q

what are the symptoms of coronary artery disease and how do we diagnose it?

A
  • Symptoms
    o May be asymptomatic but include chest pain and angina symptoms
  • Diagnosis
    o Coronary angiography and CTCA both look for luminal narrowing
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19
Q

what complications can occur with coronary artery disease, how do we treat it and what is the differential diagnosis?

A

Complications
o MI due to complete artery occlusion
o Heart failure

Treatment
o Drugs to vasodilate and reduce blood pressure. Anticoagulation
o Stents- holds artery open so blood flow can resume.
o Coronary artery bypass grafts- take arteries and veins from patients leg, and graft them to the heart so there is a new blood supply.

Differential diagnosis
o Pericardial effusion, pneumonia, aortic dissection etc

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20
Q

what does CABG stand form nd what is it?

A

coronary artery bypass graft

-surgical procedure to increase blood flow to myocardium due to coronary artery stenosis.

-both arteries and veins can be grafted from arm or leg.

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21
Q

what is atrial fibrillation and its main causes?

A

Description
* Is a supraventricular tachycardia with uncoordinated atrial electrical activation, and ineffectual atrial contraction leading to an irregular and often abnormally rapid ventricular rhythm – and arrhythmia)

Causes
* Hypertension, ischaemic heart disease, heart failure, valvular heart disease, lifestyle

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22
Q

what are the main symptoms associated with atrial fibrillation, and ho do we diagnose it?

A

Symptoms
* Often asymptomatic- incidental finding
* May have an irregular pulse, dyspnoea, chest pain, dizziness, syncope (fainting).

Diagnosis
* ECG, identifying the underlying cause.

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23
Q

what complications can occur with atrial fibrillation, and how do we treat it.

what is the differential diagnosis?

A

Complications
* Stroke, heart failure, increased all-cause mortality.

Treatment
* Anticoagulation for stroke prevention, drug treatments for rate control, cardioversion-. shock the patient while they are awake, a controlled defib, PPM
* Patients also tend to be on blood thinners.

Differential diagnosis
* Any of the other things we have talked about today!

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24
Q

what is abdominal aortic aneurysm, and what are the causes of it?

A

Description
* Also called a AAA
* Focal dilatation of the abdominal aorta > 3cm in diameter
Causes
* Increasing age, males more affected.

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25
Q

what are the symptoms of Abdominal aortic aneurysm (AAA) and what are some complications that can occur?

A

Symptoms
* Most are asymptomatic until they rupture so often an incidental finding.
* Patients may have pain or a pulsatile mass

Complications
* Rupture – 70% mortality before surgery

26
Q

how do we diagnose AAA

A

Ultrasound:
* Best for screening and surveillance due to speed and no radiation dose
* Sensitivity and specificity of nearly 100%
* But can be affected by patient body habitus or overlying bowel gas
* Cannot plan surgery from US alone

EVAR:
* Endovascular aneurysm repair
* For both elective and emergency repair
* Inserted via the common femoral artery.
* Complications include endoleak, stent migration, infection
* Patients need lifelong monitoring to monitor the graft (ensure its not moved) and check for complications
* Usually an incidental finding

27
Q

how do we treat AAA and what is the differential diagnosis?

A

Treatment
* Generally, surveillance for less than 5cm and surgery for >5cm. Have an ultrasound to monitor it, as less than 5cm it means it has less chance of rupturing
* May have an EVAR procedure- bigger version of a stent

Differential diagnosis
* Aortic dissection

28
Q

what is atherosclerosis in the lower limbs/ peripheral arterial disease?

what are the main causes and symptoms?

A

Description
* Plaques causing stenosis in the arteries of the legs.

Causes
* Risk factors include
* Diabetes, smoking, advancing age, hypertension, obesity

*Symptoms
* Leg pain when walking, cramping in the thigh or calf, weakness or pins and needles in the lower legs or feet, coldness in the feet, weak pulse in the feet

29
Q

how dow e diagnose atherosclerosis in the lower limbs?

A
  • On plain film you may see atherosclerotic plaques in the vessels
  • US – can evaluate the arterial wall. US will see calcification as hyperechoic foci and when large, acoustic shadowing.
  • CTA – uses contrast to look for luminal narrowing
30
Q

what complications can occur from atherosclerosis in the lower limb, and what is the differential diagnosis?

A

Complications
* Severe pain, critical limb ischaemia- low blood supply to lower leg , death of tissue due to infection, amputation due to gangrene

Treatment
* Lifestyle changes
* Angioplasty- blow balloon up into the artery or bypass graft

Differential diagnosis
* Gout, arthritis

31
Q

what is an ischaemic stroke?

A

Description
* A stroke is a sudden onset of focal neurological deficit of presumed vascular origin
* An ischaemic stroke (87%), is due to infarction in the central nervous system. There is interruption of blood flow through an intercranial artery leading to deprivation of oxygen. If circulation is not re-established there will be cell death. Patient has neurological symptoms. is a blockage but can cause a bleed.
* Hemorrhagic stroke- been a bleed. see if they can thrombolise the patient.

32
Q

what are the main causes and symptoms of an ischaemic stoke?
what complications can occur?

A

Causes
* Artheroschlerotic, tumour, thrombus, hypertension

Symptoms
* Paralysis or numbness of face, confusion and difficulty speaking, headache, vision problems, unilateral weakness

Complications
* Can haemorrhage, can have complications such as aspiration pneumonia and PE. Seizures,

33
Q

how do we diagnose an ischameic stroke?

A

o Non contrast CT brain – ischemic or hemorrhagic
o CT perfusion – functional scan
o CT angiography – identify the location of a clot / narrowing and look at blood supply
o CT is the most often used primary imaging method. It is quick, inexpensive and available
o But is limited in the acute phase – may not show changes in the deep grey matter in the early phase

o Aim of CT in the acute phase are to
§ Exclude hemorrhage, which would preclude thrombolysis
§ Look for any signs of ischemia- where the brain is not getting any blood flow.
§ Exclude other causes like a tumour
o Earliest CT sign is a hyperdense vessel sign – representing the clot
o As time progresses and changes become chronic you will see low density.

34
Q

diagnosing an ischameic stroke with MRI

A
  • More time consuming but has a higher sensitivity and specificity for diagnosing ischemic infarction in the initial stages
35
Q

how do we treat an ischaemic stroke and what is the differential diagnosis?

A

Treatment
* Need to have fast treatment to encourage reperfusion
* Thrombolysis- intense blood thinning medication to thin any clots, clot retrieval out of the brain.

Differential diagnosis
* Ischaemic versus haemorrhagic

36
Q

what is a hemorrhagic stroke, and the main causes and symptoms of it

A

Description
* Is a type of intracranial haemorrhage, defined by accumulation of blood in the brain parenchyma (functional tissue). Happens when there is a rupture of a small blood vessel.

Causes
* Can be spontaneous or can be from an ischemic stroke, a vascular malformation, a tumour or metasteses

Symptoms
* Similar to those of an ischemic stroke. Patient is more likely to have decreased consciousness. May also have headache, nausea and vomiting and seizures

37
Q

how do we diagnose a hemorrhagic stroke

A

Stroke- hemorrhagic CT
* Usually, the first modality used
* Imaging findings
* Hyperdense blood, often with surrounding edema
* Grey- swelling
* May also see midline shift,( brain pushed over due to increased pressure) hydrocephalus (increase in CSF and enlarged ventricles)

Stroke – hemorrhagic – MRI
* Findings depend on the size and age of the blood
* Can also show causes – small vessels1

38
Q

what complications are associate with a hemorrhagic stroke, how do we treat this and what is the differential diagnosis?

A

Complications
* Seizures, swelling of the brain, memory loss, vision and hearing problems, death

Treatment
* Management is time critical.
* Blood pressure needs to be controlled, management of any raised intercranial pressure (drain), surgery to evacuate the blood, management of seizures - intubation

Differential diagnosis
* Ischemic stroke

39
Q

what is a subarachnoid haemorrhage and its main symptoms

A
  • Also called a SAH
  • Description
    o Is a type of intracranial haemorrhage with blood in the subarachnoid space
  • Symptoms
    o Thunderclap headache
    o Collapse and loss of consciousness
40
Q

what are the causes and rusk factors that can cause a subarachnoid haemorrhage?

A

o There are 2 causes
§ Trauma
§ Spontaneous – which can be due to a ruptured aneurysm, various malformations (AVM, SAM), anticoagulation therapy

o Risk factors include:
o Patients tend to be older middle age, often less than 60
o Family history
o Hypertension
o Heavy alcohol consumption

41
Q

how do we diagnose SAH?

A

CT:
* CT normally performed first due to availability
* Will see hyperdense material in the subarachnoid space – most commonly around the circle of Willis

MRI:
* MRI is more sensitive than CT at both identifying hemorrhage and diagnosing the underlying cause
* BUT – poor availability, longer scan, greater difficulty with unstable and ventilated patients
* Will see blood as a hyperintensity in the subarachnoid space on FLAIR

42
Q

what complications can occur with SAH.

A

o Elevated intracranial pressure – may require a drain
o Ischaemia (may require balloon angioplasty)
o Neurogenic pulmonary oedema
o PEA (no measurable cardiac output at cardiac arrest – non shockable rhythm) pulseless electrical activity- can only do cpr on the patient.

43
Q

how do we treat SAH and what is the differential diagnosis?

A
  • Treatment
    o Varies depending on the underlying cause
  • Differential diagnosis
    o Meningitis- similar symptoms
    o Post thrombectomy iodine extravasation- contrast leak
44
Q

what is a central line, and why are they usually inserted?

A
  • Central venous catheter / central venous line / CVC
  • Generally seen in ED / ITU / theatre
  • Refers to a catheter that is inserted so the distal tip lies in the central vein
  • They are usually inserted because
    o the drugs given would be dangerous if they extravasate or would irritate the venous system
    o Difficult peripheral access
    o Measurement of cardiac output / central venous pressures
45
Q

what are the 4 main categories of central lines?

A

o PICC – peripherally inserted central catheters
o Non tunneled CVC’s e.g. short term in ITU or ED – Vascath
o Tunneled CVC’s – e.g. Hickman
o Implantable ports (may be in the chest or arm) – e.g. port-a-cath

46
Q

what veins are central lines most commonly inserted into?

A

o Internal jugular
o Subclavian
o Femoral (short term only)
o Brachial or cephalic (PICCS and implantable ports)
* The tip should be in the superior vena cava or at the cavo-atrial junction
* Positioning – the SVC begins behind the lower border

47
Q

what are PICC lines?

A
  • Peripherally inserted central catheters
  • Mainly used in oncology patients and chronic diseases e.g. cystic fibrosis
  • Can have long term central venous access without a tunneled port
  • Performed under local anesthetic.
  • Normally accessed through the brachial veins
  • Often done in theatre or in fluoroscopy
  • Have to chane widnows to see tip of the
48
Q

what is a vascath?

A

:
* Generally used for emergency dialysis
* Larger diameter than most CVC’s

49
Q

what is a Hickman catheter?

A
  • Tunneled line
  • Typically inserted into the jugular vein and the proximal tubing is tunneled through the subcutaneous tissue to a skin incision on the chest.
  • Used commonly for chemotherapy drugs, parenteral nutrition and long-term antibiotics
  • A lot of care involved with it, it can’t get wet.
50
Q

what is a port-a-cath?

A

implantable port)
* Used for patients requiring long term venous access
* They can last for years (PICC last for weeks or months)
* They require less upkeep (PICC require daily flushing)
* They are waterproof

51
Q

port-a-caths are useful for patients who…

A
  • Useful for patients who
  • Need long term IV medicine – commonly chemotherapy or antibiotics
  • Peripheral access where cannulation is difficult
  • To withdraw blood on a regular basis
  • Entirely under the skin, access it through a port.
52
Q

what is a pacemaker?

A
  • Inserted to improve patient outcome by cardiac pacing.
  • This includes
    o stimulating a faster heart rate when the heart is beating too slowly (Bradycardia causing syncope)
    o Maintaining a suitable heart rate and rhythm – e.g. patients in AF
    o In patients with heart block – pulse sent from SA node to AV is delayed or absent
    o It can reduce symptoms of heart failure such as breathing problems and lower limb oedema.
    o It can prevent syncope
    o Most pacemakers are demand pacemakers so only pace on demand.
  • They can be temporary – usually done in an acute setting to support a patient with bradycardia until the cause is reversed or a permanent pacemaker is inserted
53
Q

what are the different types of permanent pacemakers?

A

o Single chamber pacemaker
* 1 wire which is connected to the right atrium or right ventricle
o Duel chamber pacemaker
* 2 wires which are connected to the right atrium and right ventricle
o Biventricular pacemaker
* 1 wire which is connected to the right atrium or right ventricle
* 3 wires connected to the right atrium, right ventricle and left ventricle

54
Q

How are pacemakers inserted?

A
  • Inserted under local anaesthetic in the subclavian region on the left or right side (to avoid the dominant side)
  • Leads are placed via the cephalic or subclavian vein
  • The right atrial lead is passed into the right atrial appendage
  • The right ventricular lead is passed to the right ventricular apex
  • The left ventricular pacing leads are placed in the coronary sinus veins
  • Leads are tested before they are connected to the generator.
55
Q

what does a dual lead pace maker look like on a chest x ray?

A

o Atrial lead in the right atrial appendage usually pointing cranially
o Right ventricular lead is in the RV apex pointing up towards the upper heart border
o On a lateral image both leads should point anteriorly

56
Q

what does a single lead pacemaker look like on a chest x ray?

A
  • Lead sits within the right atrium or the right ventricle depending on the clinical presentation
57
Q

what is a complication of a permanent pacemaker?

A

Lead fracture- compression of the lead between the clavicle and the first rib or entrapment of the lead by soft tissue in the costoclavicular space.

58
Q

what is an AICD ICD’s

A
  • Automatic implantable cardioverter defibrillators
  • Device recognises ventricular tachycardia and fibrillation and terminates it by delivering an electrical shock
  • They are generally implanted in patients with cardiomyopathy who are at risk of VT,VF and sudden cardiac death
  • The thicker bit at the end of the lead is the shock coil
  • Also useful in patient monitoring of VF and VT.
  • You will often find both an ICD and a PPM used to treat the arrthymia and act as a fail safe system.
59
Q

what is an implantable loop recorder?

A
  • Small device that sits under the skin for cardiac monitoring
  • Continuously performs ECG’s and stores any arrhythmias for review.
  • Can be activated by abnormal heart rhythm or by the patient manually
60
Q

what are sternotomy wires

A
  • Sternotomy wires are stainless steel wires used to hold the sternum together after heart surgery and a median sternotomy
  • Needed to maintain the stability of the sternum during respiration
  • Can be single wires or a figure of 8 layout
61
Q

what is a heart valve replacement?

A
  • All 4 heart valves can be surgically replaced.
  • Most common are the aortic and mitral valves
  • They are sometimes replaced via a catheter from a femoral artery approach called a TAVI

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