Week 2 Flashcards
What is cardiovascular disease?
General term for diseases of the heart and blood vessels
Give some examples of CVD.
Angina
MI
TIA, CVA
PVD
Chronic mesenteric ischaemia
Does severe mental illness increase risk of CVD?
Yes
What co-morbidities increase risk of CVD?
HTN
High or abnormal cholesterol
Irregular heartbeat (AF)
Hyperglycaemia
Diabetes
CKD
Inflammatory conditions e.g. RA
What statin is recommended for people with high risk of CVD initially?
Atorvastatin
Why is anticoagulation recommended in AF patients?
Reduce stroke risk
What increase in BP causes mortality risk to double?
20/10
If clinic BP is normal and ambulatory BP is high what type of HTN is this?
Masked HTN
What tests should be offered for all with HTN?
Urine for protein presence
Blood tests - Glucose, electrolytes, creatinine, estimated glomerular filtration rate, cholesterol
ECG
Fundi
What are the grades of hypertensive retinopathy?
I to IV
What are some common causes of secondary HTN?
Renal disease
Obstructive sleep apnoea
Aldosterinism
Reno-vascular disease
What are some uncommon causes of secondary HTN?
Cushing’s
Pheochromacytoma
Hyperparathyroidism
Intracranial tumour
What is fibromuscular dysplasia?
Corkscrew type dysplasia of the renal artery common in young women
When should lipids be measured?
MI
CVA
Other vascular disease
Acute pancreatitis
Family hx
Clinical signs
What are the clinical symptoms of hyperlipidemia?
Xanthomata
Xanthelasma
Corneal arcus
Milky blood/ serum
What should high HDL indicate?
Cardioprotection
Which lipid measurement is affected by fasting?
Triglycerides
What affect do statins have?
Stop cholesterol synthesis and have other impacts on atherosclerosis formation
Give some examples of statins.
Atorvastatin
Simvastatin
Rosuvastatin
Fluvastatin
Pravastatin
When does fluvastatin tend to be prescribed?
Safety grounds as least potent
Name some PCSK9 inhibitors
Alirocumab
Evolocumab
Inclisiran
What increases acute pancreatitis risk?
Triglyceride concentration
How much weight loss correlates to a BP reduction of 1mmHg?
1kg
What type of tablet can increase mortality in HTN?
Salty tablets
What diet is recommended for HTN?
DASH diet
Low or no salt diet
What drug groups can be used in HTN treatment?
Thiazide diuretics
ACEi/ARBs
Ca channel blockers
Beta blockers
Spironolactone
What HTN drugs are given to young women with caution?
ACEi or ARBs
What diet type can help in resistant HTN?
Low salt
What drug tends to be added to treatment in resistant HTN?
Spironolactone
In IHD what is a prolonged QT interval associated with?
Sudden cardiac death
What tools may be used to diagnose angina?
Exercise Testing
Perfusion Scanning
CT angiography
Angiography
What is a type 2 NSTEMI?
Troponin release during another illness, no evidence of recent plaque rupture
If a patient has raised troponin but a no MI symptoms and a normal ECG what is this likely to be classed as?
Myocardial injury
What patient group tend to have type 2 NSTEMIs?
Older patients with more comorbidities
What GI issues could lead to chest pain?
Reflux
Peptic ulcer pain
Oesophageal spasm
Biliary colic
How might pericarditis be differentiated from an MI?
Posture related pain
How is stable angina likely to present?
Visceral pain, hard to describe
Risk factors present
Radiating to arm(s), back, neck, jaw
Pain brough on by exertion, stress, cold, after meals
Relieved by rest within 5 minutes or GTN
What are the components of drug management in angina?
Antiplatelet - Usually aspirin
Beta blockers - Slow HR and reduce oxygen demand
Statins
ACEi
Nitrates
What are the main drugs used for secondary prevention in PVD?
Antiplatelet
High dose statin
What conditions are seen within PVD?
Intermittent Claudication
Chronic Limb Threatening Ischaemia
What is intermittent claudication and how will it present?
Muscle ischaemia on exercise
Pain on walking in muscle groups distal to occlusion
No pain at night/ rest
Does treatment of intermittent claudication prevent development of chronic limb threatening ischaemia?
No
What is chronic limb threatening ischaemia?
Insufficient blood reaching a limb or part of a limb to maintain limb viability
How might chronic limb threatening ischaemia present?
Pain at rest
Ulcers
Gangrene
Usually wake at night
Cool to touch, absence of peripheral pulses, colour change, venous guttering
What investigations may be carried out in chronic limb threatening ischaemia?
Pulses
ABPI
Duplex
Angiography - MR, CT
What is ABPI and what are the normal values?
Ankle Brachial Pressure Index
Ankle/brachial pressure
>1.0 are normal
<0.9 confirms PAD
What should happen to ABPI after exercise?
Increase
What surgical options are there for PVD?
Angioplasty +/- stent
Open surgery grafting
Amputation
What is an aneurysm?
Permanent, localised dilation of an artery of more than 50% of the normal arterial diameter
What is the normal aortic diameter?
1.2 -2cm
What are the 2 aneurysm types?
True
False
Describe a true aneurysm.
All 3 layers are involved and intact
Describe a false aneurysm.
Defect in the wall of the artery and the surrounding structure (skin, fat, fascia) keep the aneurysm restrained
What are the 2 aneurysm shapes?
Saccular
Fusiform
How are AAAs screened?
Ultrasound
What investigation gives the morphology of an AAA?
Contrast CT
When an AAA ruptures what structure may contain it?
Retroperitoneal
What is the recommended size for asymptomatic AAA repair?
5.5cm diameter
Rapid expansion >1cm/year
What is trashing?
Clot within an aneurysm and bits break off affecting the lower limbs
What are the 2 surgical options for AAA elective repair?
EVAR
Open repair
What occurs in aortic dissection?
Blood propagates within medial layer, creating a flap, true lumen and false lumen
What is a type A aortic dissection?
Always involves aortic arch
What is a type B aortic dissection?
Involves descending aorta distal to left subclavian artery
What type of aortic dissection is an emergency?
Type A
What are the common signs and symptoms of aortic dissection?
Acute excruciating chest or interscapular pain
Chest pain
Back pain
Abdominal pain
Renal ischaemia
Recurrent pain, refractory pain
Name some rare symptoms of aortic aneurysm.
Syncope
Pulse deficits
Hypotension/ shock
Visceral ischaemia
Limb ischaemia
Spinal cord ischaemia
What are the time periods for acute, sub acute and chronic aortic dissection?
Acute < 2 weeks
Sub acute 2 weeks to 90 days
Chronic >3 months
What are the goals of medical management of aortic dissection?
Lower BP
Reduce aortic wall stress
Reduce force of left ventricular ejection
Aim BP 100-120, HR <60
What medication groups are used in medical treatment of aortic dissection?
IV beta blocker
Calcium channel blockers
ACEi
What are the 2 surgical options for aortic dissection repair?
Stent graft
Open thoracic aortic repair
Why is cognitive impairment a potential complication of a CABG?
Cardio-pulmonary bypass used during procedure so can be reduced oxygen supply to the brain
What is PCI
Percutaneous Coronary Intervention
Coronary angioplasty with stenting
What artery tends to be accessed for PCI?
Radial artery
What is the recommended time limit for a STEMI to have PCI?
<30 minutes after arrival
Why is the radial artery used for PCI access?
Hand has dual supply
Superficial
Compressible
No adjacent nerve/ vein
What is the main treatment for 3 vessel or left main coronary artery disease?
CABG
What is VTE?
Venous Thromboembolic Disease
Covers DVT and PE
What are the 2 types of DVT?
Distal: Calves
Proximal: Popliteal or femoral
What syndrome occurs in nearly a third of proximal DVT patients?
Post thrombotic syndrome
How is a DVT diagnosed?
Ultrasound or doppler ultrasound
How is a DVT treated?
Oral anticoagulation
How would a PE present?
Pleuritic pain
Collapse
Haemoptysis
Hypoxia
Tachycardia
What is the gold standard for PE diagnosis?
CTPA
What score can be used in identifying PE likelihood?
WELLS
What can help to identify PE severity?
PESI score
Presentation
How are high risk PE patients treated?
Thrombolysis then oral anticoagulation
How are intermediate or low risk PEs treated?
Oral anticoagulation
What is Virchow’s triad?
Endothelial injury
Circulatory status
Hypercoagulable state
What does a D-Dimer measure?
Breakdown product of cross linked fibrin
What does a D-Dimer help screen for?
VTE
What are the first line anticoagulants for VTE?
Apixaban
Rivaroxoban
What is the reversal treatment for a warfarin overdose?
Vitamin K
What treatment is used in patients with a PE and active cancer?
Low weight molecular heparin
What treatment durations are recommended in VTE?
Provoked with reversible factor: 3-6 months
Provoked with irreversible factor: 3-6 months or lifelong
Unprovoked: All men lifelong, women patient based
What scoring tool can help decide treatment duration in women with a VTE?
HERDOO2
What characterises post thrombotic syndrome?
Pain
Oedema
Hyperpigmentation
Eczema
Varicose veins
Venous ulceration
What are thought to be associated with post thrombotic syndrome?
DVT induced damage to valves in the deep vein
Valvular reflex leading to venous HTN
How will thromboembolic pulmonary HTN present?
Progressive dyspnoea and hypoxaemia
Right heart failure frequently occurs
What are the sections of the mediastinum?
Superior
Inferior: Anterior, middle, posterior
What can be found in the anterior mediastinum of a child?
Thymus gland
What is the anterior mediastinum normally full of in an adult?
Fat
What is found in the middle mediastinum?
Pericardium
Heart
Parts of the great vessels that connect with the heart
Where does the trachea bifurcate?
Level of the sternal angle
What is found in the posterior mediastinum?
Trachea
Oesophagus
Vagal trunks
Thoracic aorta
Thoracic duct
Azygous vein
Sympathetic chains and trunks
Sympathetic ganglia
Where does the azygous vein pass?
Up posterior mediastinum then crosses over the root of the lung to superior vena cava
When does the thoracic aorta become the abdominal aorta?
As it passes through the diaphragm
Where do the coronary arteries originate?
At aortic valve
What are the 3 branches of the arch of the aorta?
Brachiocephalic trunk
Left common carotid
Left subclavian
Where does the brachiocephalic trunk supply?
Right side of head and neck and right upper limb
Where does the left common carotid artery supply?
Left side of the head and neck
Where does the left subclavian artery supply?
Left upper limb
How many paired costal arteries are there?
11
What branch from the thoracic aortas anterior surface?
Bronchial arteries
Oesophageal arteries
Mediastinal arteries
Pericardial arteries
Phrenic arteries
Where does the thoracic duct drain lymph into?
Left venous angle
Where is the left venous angle formed?
Between the internal jugular vein and subclavian vein
Where does the right lymphatic duct drain into?
Right venous angle
What lymph nodes are found around the root of the lung?
Bronchopulmonary lymph nodes
What lymph nodes are found at the bifurcation of the trachea?
Tracheobronchial lymph nodes
Where does the thoracic duct originate?
In the abdomen at the cisterna chyli (swollen start)
Where does the thoracic duct travel?
Up posterior mediastinum between the azygous vein and oesophagus
What is CN X?
Vagus nerves
Where does the right vagus nerve travel?
Right lateral border of the trachea
Travels down the side
Passes posterior to the root of the lung
Forms a plexus on the oesophagus
Where does the left vagus nerve travel?
Passes over the surface of the aorta
Posterior to the root of the lung
Forms a plexus on the oesophagus
What is the ligamentous arteriosum?
Connective tissue structure between pulmonary trunk and arch of the aorta
What nerve supplies the larynx?
Recurrent laryngeal branch
Where do the recurrent laryngeal nerves branch from?
Vagus nerves
Which recurrent laryngeal nerve enters the chest?
Left
What are central veins?
Large veins close enough to the heart that the pressure within them is said to approximately reflect the pressure in the right atrium
What are the central veins?
Internal jugular veins
Subclavian veins
Brachiocephalic veins
Superior vena cava
Inferior vena cava
Iliac veins
Femoral veins
Where in the spine do phrenic nerves originate?
C3,4,5
Where do the phrenic nerves supply somatic motor to?
Diaphragm
Where do the phrenic nerves supply somatic sensory to?
Mediastinal parietal pleura
Fibrous pericardium
Diaphragmatic parietal pleura
Diaphragmatic parietal peritoneum
What could refer pain to the diaphragm?
Liver abscess
Inflammation of gall bladder
What is the somatic sensory supplied by CN X?
Palate, laryngopharynx, larynx
What is the somatic motor supplied by CN X?
Pharynx and larynx
What type of nerves does CN X contain for the thoracic and abdominal organs?
Autonomic parasympathetic
