Non Ischaemic CV disease Flashcards
what is cardiomyopathy?
any disease of the cardiac muscle
often results in changes in the size of the heart chambers and thickness of the heart
describe the classification of cardiomyopathy
dilated
hypertrophic
restrictive
arrhythmogenic right ventricular dysplasia
what is dilated cardiomyopathy?
a big heart
heart is flabby and floppy
histology features are non specific
what causes dilated cardiomyopathy?
genetics (50%) AD, AR, X-linked, mitochondrial genes that encode heart muscle proteins desmin, dystrophin toxins alcohol doxorubicin- chemotherapy agents rare causes- cardiac infection and pregnancy
what are the clinical features of dilated myopathy?
general picture of heart failure
SoB, poor exercise tolerance
low ejection fraction = low CO
what is hypertrophic cardiomyopathy?
big solid hearts
hypertrophic and strong contraction
diastolic dysfunction only which eventually causes outflow obstruction
what are the causes of hypertrophic cardiomyopathy?
mostly genetic
beta myosin heavy chain
myosin binding protein C
alpha tropomyosin
what happens to the myofibrils in HCM?
they are disorganised creating swirls
what is restrictive cardiomyopathy?
stiff heart which causes a lack of compliance
doesn’t fill well so diastolic dysfunction
can look normal
biatrial dilation as a result of back pressure
what are the causes of restrictive cardiomyopathy?
deposition of something into the myocardium
metabolic byproducts- iron
amyloid
sarcoid- multi system granulomatous disorder
tumours
fibrosis.. following radiation
what is amyloid?
abnormal deposition of an abnormal protein
tendency to form beta pleated sheets
body cant get rid of them
describe the classifications of amyloids
AA AL haemodialysis associated familial forms diabetes alzheimers
what are AA amyloids?
they relate to chronic diseases like rheumatoid
what are AL amyloids?
light chains, abnormal immunoglobulin
what are haemodialysis associated amyloids?
beta 2 microglobulin
what is a familial form of amyloid?
transthyretin
describe the histology of amyloid
waxy pink material
stains positively for ‘congo red’
exhibits green birefringence
what is arrhythmogenic right ventricular dysplasia?
a genetic disease- autosomal dominant with low penetrance
syncope and funny turns
arrhythmia
can cause sudden death
non specific features so difficult to diagnose
what happens in ARVD?
right ventricles becomes largely replaced by fat
big and floppy
what is myocarditis?
inflammation of the heart
can be infectious or non infectious but is normally infectious
what are the infectious causes of myocarditis?
viral bacterial fungal protozoal helminthic
what are the viral causes of myocarditis?
coxsackie A and B ECHO virus Chaga's disease borrelia burgdorferi- lyme's disease HIV
what is the pathology of infectious myocarditis?
thickened beefy myocardium
what causes non infectious myocarditis?
immune mediated hypersensitivity reactions
hypersensitivity to infection
hypersensitivity to drugs
systemic lupus erythematosus
what happens in rheumatic fever?
mitral stenosis with thickening and fusion of valves leaflets
short thick chordae tendinae
myocardium also patchily inflamed
what is pericarditis?
inflammation of the pericardial layers
what are the causes of pericarditis?
infection immune mediated idiopathic uraemic post MI connective tissue disease
what are the infectious causes of pericarditis?
viruses
bacteria
fungi
TB
describe viral pericarditis
viruses especially ECHO produce serious effusions
describe bacterial pericarditis
extension from elsewhere
pneumonia
produce purulent effusions
describe fungi pericarditis
immunosupressed patients
post transplant
produce purulent effusions
describe TB pericarditis
caseous material in sac
describe pericarditis post MI
dressler’s syndrome
many weeks post
assumed to be immune mediated
damaged heart muscle releases previously un-encountered material that stimulates an immune response
what are the complications of pericarditis?
pericardial effusion tamponade constrictive pericarditis cardiac failure death
what is endocarditis?
affects heart lining but generally refers to inflammation of the valves
may be infectious or non infecious
what causes infectious endocarditis?
can occur on normal valves
usually requires a very virulent organism may be bacterial or fungal
IV drug abuse and septicaemia
which patient groups are predisposed to infectious endocarditis?
prosthetic valves congenital defects bicuspid valves MV prolapse calcific disease
describe the microbiology of endocarditis
HACEK haemophilus actinobacillus cardiobacteria eikenella kingella
describe the microbiology of endocarditis in IV drug users
candida
staph aureus
right sided vales
describe the microbiology of endocarditis in people with prostehtic valves
s. epidermis
describe the pathology of infectious endocarditis
aggregates of organisms on heart valves called vegetations
bacteria excite acute inflammation and bacterial and inflammatory cell products digest the valve leaflets
vegetations are also friable and can cause emboli
describe the complications of endocarditis
acute vavular incompetence
high output cardiac failure
abscess, fistula, pericarditis
describe the systemic manifestations of endocarditis
oslers nodes janeway lesions roth spots splinter haemorrhages septicaemia systemic septic emboli mycotic aneurysms
what causes non infectious endocarditis
rheumatic fever
SLE
non bacterial thrombotic endocarditis
carcinoid heart disease
describe non-bacterial thrombotic endocarditis
non invasive doesnt destroy valves small and multiple vegetations can cause embolic disease assoc. with cancer frequently assoc. with mucinous adnocarsinomas hypercoaguable states
describe lupus endocarditis
small sterile emboli
often undersurfaces of the valves or on chords
range of changes- often small asymptomatic deposits or significant valvulitis
what is carcinoid heart disease?
causes carcinoid tumours which you can see in the mucosa
neuroendocrine component- released hormone
produces right sides cardiac valve disease
what are carcinoid tumours?
neoplasms of neuroendocrine cells
what causes carcinoid heart disease?
excess 5HIAA, serotonin, histamine, bradykinin etc by tumour
what are the symptoms of carcinoid heart disease?
flushing of skin
nausea
vomiting
diarrhoea
describe tumours of the heart
primary tumours are rare
atrial myxoma is the commonest
secondary tumours may occur; metastatic malignant melanoma, direct invasion of carcinoma of lung, oesophagus
describe atrial myxoma
can cause ball/ valve obstruction
may cause tumour emboli
may develop endocarditis
associated with systemic fever and malaise
what are the pros of exercise testing?
cheap
reproducible
risk stratification
what are the cons of exercise testing?
poor diagnostic accuracy in important sub-groups
submaximal tests
what are the pros of perfusion imaging?
non invasive
pharmacological stress in less mobile patients
more precision than ETT
risk stratification
what are the cons of perfusion imaging?
radiation
false positives and negatives
what are the pros of CT angiographys?
non invasive
anatomical data and risk stratification
what are the cons of CT angiography?
radiation
less precise than angiography, particularly when calcium present
cost
what happens during an angiography?
sheath inserted into artery
catheter advanced from wrist/ groin to coronary ostium
xray contrast agent injected to outline coronaries
video fluoroscopy recorded images in multiple views
what are the pros of angiography?
‘gold standard’
anatomical and risk stratification
follow on angioplasty
what are the cons of angiography?
risk of death from stroke
radiation
contrast: renal dysfunction, rash, nausea
what theorem is used to determine how likely a patient is to have IHD?
reverend bayes theorem
describe the surgical technique of coronary artery bypass
median sernotomy long saphenous vein internal mammary artery cardio-pulmonary bypass cardioplegia
what are the complications of CABG?
death stroke MI atrial fibrillation infection cognitive impairment sternal malunion renal failure failure to recover
what are the complications of PCI?
death stroke MI renal failure bleeding vascular complications stent thrombosis stent restenosis
describe the PCI teachnique
vascular access anti-platelet drugs, anticoagulation catheter to ostium of coronary guide wire down vessel balloons threaded over wire stent(s) implanted balloon, catheter, wires removed
what are the indications for angiography?
severe symptoms
high risk
what is the suitability for revascularisation?
multi-vessel diease, diffuse or focal
left main disease
diabetes
co-morbidities
describe radial artery access pros
dual supply to hand
superficial
compressible
no adjacent nerve/vein
describe radial artery access cons
smaller
prone to spasm
asymptomatic occlusion can occur
what is the treatment for a STEMI?
primary PCI
what is the treatment for acute coronary syndrome?
angiography with a view to revascularisation
what is the treatment for chronic stable angina?
revascularisation for severe symptoms or high risk
CABG vs PCI should be determined by discussion
