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My cardiovascular Flashcards

1
Q

Name the main cardiac conditions within iscaemic heart disease

A

Angina
Myocardial infarction
Chronic congestive heart failure
Sudden death

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2
Q

Name the three main acute coronary syndromes

A

Acute myocardial infarction - STEMI and NSTEMI
Unstable angina
Tako-Tsubo cardiomyopathy

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3
Q

How does myocardial infarction occur?

A

Rupture or erosion of a coronary artery plaque, leading to thrombosis blockage
Ischaemia of cardiac myocytes - death

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4
Q

Symptoms of myocardial infarction

A
  • Crushing chest pain, radiating to the left arm
  • Sweating
  • Nausea
  • Vomiting
  • Dyspnoea (shortness of breath)
  • Fatigue
  • Palpitations
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5
Q

Risk factors for MI

A

Increasing age
Male
Family history of IHD (MI in 1st degree relative <60)
Smoking
Hypertension
Hyperlipidaemia
Diabetes mellitus
Obesity, sedentary lifestyle
Renal failure
Left ventricular systolic dysfunction

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6
Q

Differential diagnoses for MI

A

Stable and unstable angina
Pneumonia
Pneumothorax
Oesophageal spasm
GORD
Acute gastritis
Pancreatitis
Musculoskeletal chest pain

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7
Q

How is an MI managed in the ambulance?

A

Aspirin
Pain relief - GTN spray and diamorphine
Oxygen therapy if the patient is hypoxic

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8
Q

How is an MI managed in hospital?

A
  • Apirin
  • Antiplatelets
  • Nitrates
  • Beta blockers
  • Statins
  • Reperfusion therapy - PCI or CABG
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9
Q

Tests for MI

A

ECG: ST elevation if STEMI
Peaked T waves followed by T inversion, Q waves
Cardiac enzymes: Troponin T, Troponin I

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10
Q

Describe type I myocardial infarction

A

The most common
Spontaneous MI with ischaemia
Due to a primary coronary event, eg atherothrombosis

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11
Q

Describe type II myocardial infarction

A

Mismatch in oxygen demand and supply to the myocardium
Due to

  • anaemia
  • bleeding
  • drug abuse
  • aortic dissection
  • coronary artery dissection
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12
Q

What is type III MI?

A

Sudden cardiac death - electrical failure, heart stops beating

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13
Q

What is type IV MI?

A

MI due to PCI, during the procedure or due to stent thrombosis

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14
Q

What is type V MI?

A

Due to a CABG procedure

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15
Q

What is a Q-wave MI?

A

An MI which results in new pathological Q waves on an ECG. These Q waves are very wide and deep.

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16
Q

Describe a STEMI

A

ST-elevation myocardial infarction.
Due to complete occlusion of a major coronary artery previously affected by atherosclerosis.
This causes full-thickness damage to the heart muscle.
On ECG - tall T waves and ST elevation

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17
Q

Describe an NSTEMI

A

Non-ST-elevation myocardial infarction
Due to either complete occlusion of a minor coronary artery, or partial occlusion of a major coronary artery due to atherosclerosis.
Retrospective diagnosis made after troponin results.
Causes only partial thickness damage of heart muscle.
On ECG - ST depression and/ or T wave inversion

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18
Q

What is the difference between an NSTEMI and unstable angina?

A

In an NSEMI, there is an occluding thrombus which leads to myocardial thrombosis. Myocardial damage is shown by a rise in serum troponin.

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19
Q

What are the differences between a STEMI and NSTEMI?

A
  • STEMI has ST elevation, NSTEMI has ST depression
  • STEMI is complete occlusion of a major artery, NSTEMI is partial occlusion or occlusion of only a minor artery
  • STEMI causes full-thickness damage, NSTEMI only partial thickness damage
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20
Q

What are the similarities between STEMI and NSTEMI?

A
  • Occlusion of a coronary artery typically due to acute thrombosis on a atherosclerotic plaque
  • Can lead to pathological Q waves
  • Causes increased troponin levels
  • Same symptoms
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21
Q

What is angina?

A

Chest pain or discomfort accompanied by breathlessness as a result of reversible myocardial ischaemia

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22
Q

Why does angina occur?

A

Due to narrowing of one or more of the coronary arteries.
Imbalance between the heart’s oxygen demand and supply, usually from an increase in demand accompanied by a limitation of supply.

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23
Q

What causes impaired blood flow (and so angina)?

A
  • Proximal arterial stenosis
  • Increased distal resistance
  • Reduced oxygen-carrying capacity eg anaemia
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24
Q

How much occlusion is needed to cause angina?

A

70% occluion of the blood vessel

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25
Where does angina pain radiate?
* One or both arms * The neck * The jaw * The teeth
26
What are other symptoms of angina?
* Dyspnoea (laboured breathing) * Nausea * Sweatiness * Faintness
27
What actually causes the sensation of pain in angina?
Ischaemic metabolites including adenosine stimulate nerve endings and produce pain.
28
Types of angina
* Stable angina * Unstable angina * Microvascular angina * Prinzmetal's angina
29
Describe stable angina
Comes during exercise, and is relieved by rest
30
Describe Prinzmetal's angina
Caused by coronary artery spasm Rare
31
Describe microvascular angina
Due to narrowing only in small arteries
32
Describe unstable angina
Angina of recent onset (less than 24 hours) or deterioration in previously stable angina Cardiac chest pain at rest, following a crescendo pattern of worsening
33
How is unstable angina diagnosed?
Diagnosed with troponin test, will have no significant rise
34
Predisposing factors for angina
* Age * Cigarette smoking * Family history - cardiovascular events under around 65 in parents, siblings * Diabetes mellitus * Hyperlipidemia * Hypertension * Obesity * Physical inactivity (sedentary) * Stress * Male sex
35
Reasons for imperfect blood supply to the heart
* Anaemia * Atherosclerosis * Thrombosis * Thromboemboli * Artery spasm * Hypoxemia * Polycythemia (high rbc count) * Hypothermia * Hypovolaemia * Hypervolaemia
36
Causes of increased heart demand
* Hypertension * Tachyarrhythmia * Valvular heart disease * Hyperthyroidism * Hypertrophic cardiomyopathy
37
Environmental factors which can exacerbate angina
* Cold weather * Heavy meals * Emotional stress
38
Differential diagnoses for angina
* Pericarditis/ myocarditis * Pulmonary embolism * Chest infection * Dissection of the aorta * Gastro-oesophageal * Musculoskeletal * Psychological
39
Testing for angina
ECG - often normal, may have some ST depression, and flat or inverted T waves CT coronary angiography - uses a contrast dye given by IV to identify narrowing or blockages Myoview scan - radio-labelled tracer is injected, and the light and dark shows well and poorly perfused myocardium
40
Non-medical treatment for angina
Reassurance - MI is still unlikely Advice for emergency: ring 999 Lifestyle changes: * Stop smoking * Weight loss * Exercise * Diet
41
Medication for angina
* Beta blockers * Glyceryl trinitrate (GTN) spray * Calcium channel blockers * Statins * Antiplatelets * ACE inhibitors
42
Describe beta blockers
* First-line antianginal * Negatively chronotropic (decrease HR) and negatively ionotropic (decrease contractility) * Act on beta 1 receptors in the heart as part of the adrenergic sympathetic pathway
43
Side effects of beta blockers
* Tiredness * Bradycardia - dizziness * Erectile dysfunction * Cold hands and feet
44
Contraindications for beta blockers
* Severe athsma: binds to beta 2 receptors * Hypotension * Bradyarrhythmias
45
Describe GTN spray
* Dilates coronary arteries to reduce blood pressure * Dilates veins to reduce preload * Thus reduces work of the heart and the oxygen demand
46
Main side effect of GTN spray
Causes headache, as blood vessels around the brain dilate
47
Describe calcium channel blockers
* Cause dilation of the systemic arteries, resulting in a drop in blood pressure * Reduces afterload (pressure needed to eject blood from the ventricles) on the heart * Thus less energy is required to produce the same cardiac output
48
Describe statins
* Inhibits the enzyme which causes synthesis of cholesterol by the liver * Lowers low-density lipoprotein by 50% * Anti-atherosclerotic
49
Describe antiplatelets
* Inhibits cyclo-oxygenase and prostaglandins * Reduces platelet aggregation in coronary arteries, thereby avoiding platelet thrombosis
50
Main side effect of antiplatelets
Cause gastric ulceration
51
Describe ACE inhibitors
Reduce blood pressure through the renin-angiotensin-aldosterone system
52
Types of surgical intervention for angina
Percutaneous coronary intervention (PCI) Coronary artery bypass graft (CABG)
53
When is surgical intervention used?
* If the drugs are not effective enough * When a high risk disease is identified Revascularisation restores the coronary artery to become patent and increase its flow reserve
54
Describe PCI
Dilating coronary atheromatous obstructions by inflating a balloon and stent within it The balloon is removed, leaving the stent and patent artery
55
Pros of PCI
* Non-invasive * Convienient * Short recovery * Repeatable
56
Cons of PCI
* Risk of stent thrombosis * Not good for complex disease
57
Describe CABG
* Vein removed from saphenous vein to connect aorta and right atrium * Internal mammary artery swung round to connect to the left atrium to bypasss stenosis in the LAD
58
Pros of CABG
* Good prognosis * Deals with complex disease
59
Cons of CABG
* Invasive * Risk of stroke or bleeding * Need to stay in hospital * Long recovery
60
Tako-Tsubo cardiomyopathy
* Stress-induced cardiomyopathy * May look like MI * Causes transient (short-time) left ventricular systolic dysfunction, ballooning of the left ventricular apex during systole * Recovers over a few days or weeks * Limited or no permanent damage
61
How are acute coronary syndromes managed?
1. Diagnosis: history, ECG, troponin, coronary angiography 1. Pain relief: opiates, nitrates 1. Check no active/ recent life threatening bleeding/ anaemia 1. If ST elevation, arrange PCI 1. Cardiac monitoring for anaemia 1. Antithrombolytic therapy
62
Define congenital heart disease
Faulty embryonic developmentof the heart - misplaced structures or arrest of the progression of normal structure development
63
Describe tetralogy of fallot
* Ventricular septal defect * Pulmonary stenosis * Hypertrophy of the right ventricle * Overriding aorta
64
When does surgery for tetralogy of fallot take place?
First before the age of two years Often again in adult life, for pumonary valve regurgitation
65
Describe ventricular septal defects (VSD)
* Abnormal connection between the two ventricles. * Blood flows from high pressure left ventricle to low pressure right ventricle, increasing blood flow through the lungs. * May close spontaneously during childhood
66
Signs of large ventricular septal defect
* Breathless * Poor feeding * Small, skinny baby * Increased respiratory rate * Tachycardia * Big heart on chest x ray * Murmur * May lead to Eisenmenger's syndrome
67
Signs of a small septal defect
* Loud systolic murmur due to high force through a small hole * Asymptomatic * Well grown * Normal heart rate and size * Risk of endocarditis
68
What is Eisenmenger's syndrome?
* High pressure pulmonary blood flow leads to damage to delicate pulmonary vasculature * Resistance to blood flow through the lungs increases, the right ventricle pressure increases - the shunt direction reverses. * The patient becomes blue in the lips and hands.
69
Describe atrial septal defects (ASD)
* Abnormal connection between the two atria. * Shunt is left to right, increasing flow into right heart and the lungs. * Common, often the patient will present in adulthood.
70
Effects of large atrial septal defect
* Significant increased flow through the right heart and lungs in childhood * Right heart dilatation * Shortness of breath on exertion * Increased chest infections
71
Effects of small atrial septal defect
* Small increase in flow * No right heart dilatation * No symptoms * Leave alone * Increases in size with age
72
Heart sounds and x-ray of small atrial septal defect
* Heart sounds: pulmonary flow murmur, split second heart sound (due to delayed closure of pulmonary valve due to increased right heart blood flow) * X ray: big pulmonary arteries and big heart
73
Describe atrio-ventricular septal defect
* Hole in the very centre of the heart, involving the ventricular septum, the atrial septum, the mitral valve, and tricuspid valve. * Instead of two separate atrioventrcular valves there is one large malformed one * Often seen in down syndrome patients
74
Complete atrio-ventricular septal defect signs
* Breathless neonate * Poor weight gain * Poor feeding * Extremely high pulmonary blood flow
75
Partial atrio-ventricular septal defect signs
* Can present in late adulthood * Presents like a small VSD
76
How are atrio-ventricular septal defects treated?
* Complete defect: Needs repair or pulmonary artery band in infancy - repair is surgically challenging * Partial defect: May be left alone if there is no right heart dilatation
77
Describe a patent ductus arteriosus
Failure of the ductus arteriosus (between pulmonary artery and aorta) to close during the first breath. High pressure, high blood flow into the pulmonary vasculature.
78
Signs of a large patent ductus arteriosus
* Continuous 'machinery' murmur * Big heart * Breathless, poor feeding, failure to thrive * Eisenmenger's syndome
79
Signs of a small patent ductus arteriosus
* Usually asymptomatic * Murmur found incidentally * Endocarditis risk
80
How is a patent ductus arteriosus treated?
Surgically or percutaneously
81
Describe coarctation of the aorta
Narrowing of the aorta at the site of insertion of the ductus arteriosus
82
Severe coarctation of the aorta symptoms
* Complete or almost complete obstruction of aortic flow * Collapse with heart failure * Needs urgent repair
83
Mild coarctation of the aorta symptoms
* Presents with hypertension * Incidental murmur finding * Should be repaired to prevent long-term problems
84
Signs of coarctation of the aorta
Right arm hypertension Bruit (buzzing) over the scapulae and back from collateral vessels Murmur
85
How is coarctation of the aorta repaired?
Surgical or percutaneous repair.
86
Long-term complications of coarctation of the aorta
- Hypertension - Early coronary artery disease - Early strokes - Subarachnoid haemorrhage - Re-coarctation requiring repeat intervention - Aneurysm formation at the site of repair
87
Describe bicuspid aortic valves
Can have only two flaps, or two of the flaps are fused.
88
Effects of bicuspid aortic valves
* Can be severely stenotic in infancy or childhood * Degenerate quicker than normal valves. * Become regurgitant earlier than normal valves
89
Describe pulmonary stenosis
Narrowing of the outflow of the right ventricle
90
Effects of severe pulmonary stenosis
* Right ventricular failure as a neonate * Collapse * Poor pulmonary blood flow * Right ventricle hypertrophy * Tricuspid regurgutation
91
Mild pulmonary stenosis effects
* Well-tolerated for many years * Right ventricular hypertrophy
92
Treatment of pulmonary stenosis
* Balloon valvuloplasty (balloon opens it up) * Open valvotomy * Open trans-annular patch to enlarge * Shunt to bypass the blockage
93
Describe univentricular hearts
* Singular ventricle * Number of congenital heart defects which result in the lack of two fully developed ventricles.
94
Surgical treatment for univentricular hearts
Fontan circulation: passive connection of vena cava to the pulmonary artery. This surgery has long-term complications and risks.

Phase 2a (7 decks)

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