PHASE 3A/4 > CARDIO > Flashcards

CARDIO Flashcards

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1
Q

types of HF (ejection fraction)

A
  1. heart failure with reduced ejection fraction (HF-rEF) - LVEF <35-40%
  2. heart failure with preserved ejection fraction - LVEF >50%
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2
Q

what is high output HF? list some causes

A

where the ‘normal’ heart is unable to pump enough blood to meet the metabolic needs of the body

pregnancy, anaemia, thyrotoxicosis

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3
Q

NYHA classification of heart failure

A

I - no limitation on activity

II - comfortable at rest but symptomatic with ordinary activities

III - comfortable at rest but symptomatic with less than ordinary activity

IV - symptomatic at rest

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4
Q

causes of HF (5)

A
  1. ischaemic heart disease (most common)
  2. valvular heart disease e.g. aortic stenosis
  3. HTN
  4. arrhythmias
  5. cardiomyopathy
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5
Q

brief pathophysiology of HF

A

compensations of HF which eventually become overwhelmed:

  1. salt and water retention - reduced CO > diminished BP > RAAS stimulated
  2. increased preload due to fluid retention > stretches myocardium
  3. increased afterload due to vasoconstriction from RAAS
  4. myocardial remodelling in response to above - hypertrophy, loss of myocytes. contributes to progressive pump failure, CO decreases and back to step 1
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6
Q

signs and symptoms of heart failure

A

symptoms
- paroxysmal nocturnal dyspnoea
- cardinal = SOB, fatigue, ankle oedema
- orthopnea

signs
- tachycardia
- tachypnoea
- bilateral basal crackles (pul oedema)
- raised JVP
- peripheral oedema

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7
Q

what heart sound will be heard on auscultation in HF?

A

3rd heart sound

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8
Q

investigations for HF
a) 1st line
b) other
c) gold standard

A

a) NTproBNP
b) ECG, bloods e.g. U&Es, LFTs, FBC
c) ECHO/CXR

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9
Q

NTproBNP - what to do if result is
a) 400-2000ng/litre
b) >2000ng/litre

A

a) seen by specialist within 6 weeks for ECHO
b) seen by specialist within 2 weeks for ECHO

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10
Q

CXR findings in HF

A

ABCDE
Alveolar oedema (bat wing opacities)
kerly B lines
Cardiomegaly
Dilated upper lobe vessels
Effusion

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11
Q

HF medical management
a) 1st line
b) 2nd line
c) 3rd line

A

a) ACEi e.g. ramipril
b blocker e.g. bisoprolol

b) aldosterone antagonist e.g. spironolactone
SGLT-2 inhibitors e.g. dapagliflozins

c) digoxin, ivabradine

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12
Q

if HF patient has valvular heart disease, what should be used instead of an ACEi?

A

ARB e.g. candesartan

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13
Q

what needs to be monitored in HF patients? why?

A

U&Es - diuretics, ACEi and aldosterone antagonists all cause electrolyte disturbance

ACEi and aldosterone antagonists both cause hyperkalaemia!!

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14
Q

surgical procedure for severe HF (LVEF <35%)

A

cardiac resynchronisation therapy - biventricular pacemakers

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15
Q

ECG changes and correlating coronary artery territories

a) V1-V4
b) II, III, aVF
c) I, V5-6

A

a) LAD
b) RCA
c) L circumflex

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16
Q

features of ACS on ECG/biomarkers
a) STEMI
b) NSTEMI
c) unstable angina

A

a) ST elevation and raised troponin

b) ECG changes but no ST elevation, raised troponin

c) ischaemic sx, no troponin elevation, with/without ECG changes

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17
Q

what is an aortic dissection?

A

tear in the tunica intima (inner layer) of the aorta

blood flows into new false channel between inner and outer layers of tunica media (middle layer of aortic wall)

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18
Q

type A vs type B aortic dissection

A

type A - ascending aorta (2/3)

type B - descending aorta

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19
Q

RFs for aortic dissection - which is most significant?

A

HYPERTENSION

other -
trauma
Marfan’s/Ehlers-Danlos Turner’s and Noonan’s Pregnancy
Syphilis
Bicuspid valve

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20
Q

presentation of aortic dissection

A
  1. chest/back pain - severe, tearing, maximum pain at onset
  2. pulse deficit - weak/absent carotid, brachial or femoral. variation (>20) in systolic BP between arms
  3. aortic regurg
  4. HTN
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21
Q

gold standard ix for aortic dissection (in stable pts)

A

CT angiography of chest, abdomen, pelvis

will show false lumen

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22
Q

other ix for aortic dissection (3)

A

ECG - often normal
cardiac enzymes - rule out MI
CXR

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23
Q

what will be seen on CXR in aortic dissection?

A

widened mediastinum

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24
Q

management of aortic dissection
a) type A
b) type B

A

a) surgery

b) IV labetalol to reduce BP, conservative, bed rest

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25
what is the most common valvular pathology?
aortic stenosis
26
what is aortic stenosis?
narrowing of the root of the aorta, leading to obstructed LV emptying
27
causes of aortic stenosis (3)
1. congenital bicuspid valve 2. age-related calcification (elderly) 3. rheumatic heart disease
28
why do you get LV hypertrophy in aortic stenosis?
aortic valve narrow > obstructed LV emptying > LV working harder > compensatory hypertrophy
29
aortic stenosis presentation inc. murmurs
symptoms - chest pain, dyspnoea, syncope narrow pulse pressure, slow rising pulse murmur - ejection systolic, radiating to carotids
30
gold std ix for valvular disease
echocardiography
31
ECHO findings in aortic stenosis
LV hypertrophy
32
management of aortic stenosis a) asymptomatic b) symptomatic
a) observe b) valve replacement
33
what is aortic regurgitation?
incomplete closure of aortic valve leaflets >> blood leaks back into LV during diastole
34
causes of aortic regurgitation a) chronic b) acute
either valve disease or aortic root disease a) valve disease - rheumatic fever, calcification, connective tissue disease, bicuspid valve aortic root disease - bicuspid valve, spondyloarthropathies, syphilis, Marfan's, Ehlers-Danlos b) valve disease - IE aortic root disease - aortic dissection
35
presentation of aortic regurgitation inc. murmur
Quinke's sign - nailbed pulsation De Musset's sign - head bobbing wide pressure, collapsing pulse murmur - early diastolic
36
define cardiac arrest
cessation of the functional circulation due to failure in the heart's pumping action
37
what is cardiac arrest categorised into?
shockable - VF, pulseless VT non-shockable - asystole, pulseless electrical activity (PEA)
38
initial management of all cardiac arrest types
1. attach defib and assess rhythm 2. IV access 3. begin chest compressions and ventilation (30:2)
39
ALS guidelines for management of shockable cardiac arrest
1. single defib shock followed by 2 minutes CPR 2. adrenaline 1mg after shock 3 3. amiodarone 300mg after shock 3 and 5
40
ALS guidelines for management of non-shockable cardiac arrest
1. chest compressions/ventilation 30:2 for 2 minutes 2. adrenaline 1mg as soon as possible 3. assess rhythm with defib after every 2 minutes, repeat CPR
41
unmodifiable and modifiable RFs for MIs
unmodifiable - male, increased age, FHx modifiable - smoking, diabetes, HTN, hypercholesterolaemia, obesity
42
ECG - NSTEMI
may be normal ST depression, reciprocal T wave inversion
43
ECG - STEMI
ST elevation possible LBBB pathological Q waves
44
general immediate management for MI
MONA morphine (if severe pain) oxygen (if <92%) nitrates aspirin 300mg
45
gold std ix for MI
coronary angiography (also guides PCI)
46
investigation/management ladder for NSTEMI
1. aspirin 300mg 2. risk stratification - GRACE if low (<3%) - conservative (dual anti-platelets) if high (>3%) or unstable - coronary angiography immediately if unstable or within 72h if stable 3. give fondapurinux if no immediate angiography planned
47
indications for coronary angiography in NSEMI
1. GRACE score >3% 2. patient is unstable
48
dual antiplatelet choice for conservative NSTEMI management a) patient does not have a bleeding risk b) patient has a bleeding risk
a) aspirin + ticagrelor b) aspirin + clopidogrel
49
investigation/management ladder for STEMI
1. aspirin 300mg + ticagrelor/prasugrel (if about to have PCI) 2. urgent coronary angiography 3. PCI - IF presenting within 12h and can offer within 120 minutes of the time when fibrinolysis can be given 4. if no access to PCI within 120 mins, give fibrinolysis
50
what antiplatelet should be given with PCI?
prasugrel
51
what medication should be given alongside and after fibrinolysis when treating a STEMI?
during - an antithrombin ticagrelor following procedure
52
secondary prevention of MI (5)
1. aspirin 2. second antiplatelet 3. B-blocker 4. ACE-i 5. statin
53
dual antiplatelet therapy following ACS a) post ACS without PCI b) post ACS if patient had PCI how long should the pt take the second antiplatelet for?
a) aspirin + ticagrelor b) aspirin + prasugrel/ticagrelor stop second antiplatelet after 12m
54
criteria for HTN a) stage 1 b) stage 2 c) stage 3
a) clinic BP >140/90 or HBPM >135/85 b) clinic BP >160/100 or HBPM >150/95 c) clinic systolic >180 or diastolic >120
55
HTN investigations
if comes into clinic with BP >140/90, offer ABPM (24hr BP) or HBPM
56
criteria for treating stage 1 HTN
if < 80 y/o AND: - target organ damage - established CVD - renal disease - diabetes - QRISK >10%
57
management of stage 2 and 3 HTN
2 - start antihypertensives 3 - refer for specialist assessment of end organ damage
58
tx pathway for HTN in a patient with T2DM or <55 and not of black african or african-caribbean origin
1. ACEi or ARB 2. + CCB or thiazide-like diuretic (indapamide) 3. ACEi OR ARB + CCB + thiazide 4. low-dose spironolactone if K+ is <4.5, alpha or beta blocker if K+ is >4.5
59
tx pathway for HTN in a patient >55 and/or of black african or african-caribbean origin
1. CCB 2. CCB + ACEi or ARB or thiazide 3. CCB + thiazide + ACEi or ARB 4. low-dose spironolactone if K+ is <4.5, alpha or beta blocker if K+ is >4.5
60
what is haemochromatosis?
autosomal recessive disorder of iron absorption and metabolism >> iron accumulation
61
what causes haemochromatosis?
inheriting mutations in the HFE gene on both copies of chromosome 6
62
early sx of haemochromatosis
early sx = fatigue, ED, arthralgia bronze skin pigmentation diabetes
63
reversible vs irreversible complications of haemochromatosis
reversible - cardiomyopathy, skin pigmentation irreversible - liver cirrhosis, DM, hypogonadotropic hypogonadism, arthropathy
64
haemochromatosis ix - screening general population what results would make you suspect it?
1. transferrin sats (>55% in men, >50% in women) 2. ferritin (>500ug/l)
65
haemochromatosis ix - for testing family members
genetic testing for HFE mutation
66
what is transferrin?
primary serum iron transporter
67
further ix for haemochromatosis
LFTS, MRI (quantify liver/cardiac iron), liver biopsy if cirrhosis suspected
68
management of haemochromatosis
1st = venesection 2nd = deferoxamine (iron-chelating)
69
which valve is most commonly implicated in IE?
aortic valve
70
most common bacterial cause of IE
staph aureus
71
bacterial causes of IE a) acute presentation/IVDU b) dental infection/post dental surgery c) post prosthetic valve surgery (within 2 months) d) associated with colorectal surgery
a) s.aureus b) strep viridans c) s.epidermis d) strep bovis
72
risk factors for IE (6)
1. IVDU 2. history of IE/rheumatic valve disease 3. poor dental hygiene 4. prosthetic valves 5. surgery 6. congenital heart defects
73
signs/symptoms of IE (FROM JANE)
Fever Roth's spots (retinal haemorrhages) Osler's nodes (tender finger nods) Murmur Janeaway lesions (haemorrhages on hands/feet) Anaemia Nail-bed splinter haemorrhages Emboli (MI, stroke, PVD)
74
modified duke's criteria for IE (4)
1. pathological criteria positive OR 2. 2 major criteria OR 3. 1 major and 3 minor criteria OR 4. 5 minor criteria
75
modified duke's criteria - what is the pathological criteria?
+ve histology/microbiology of pathological material obtained at autopsy/cardiac surgery e.g. valve tissue, vegetation, embolic fragments, intracardiac abscess content
76
modified duke's criteria - what is the major criteria? (2)
1. blood cultures +ve 2. evidence of endocardial involvement e.g. new valve regurg, echo positive
77
modified duke's criteria - what is the minor criteria? (6)
1. predisposing heart condition/injection drug use 2. fever >38 3. vascular - emboli, splenomegaly, clubbing, splinter haemorrhage, Janeaway lesions, petechiae, purpura 4. immunological - glmerulonephritis, osler's nodes, roth spots 5. positive blood culture that doesn't meet major criteria 6. positive echo that doesn't meet major criteria
78
diagnostic investigation for IE and others
transesophageal ECHO (TOE) transthoracic ECHO - noninvasive, safer, lower sensitivity blood cultures
79
initial empirical abx for IE a) native valve b) prosthetic valve
a) amoxicillin b) vancomycin + rifampicin + gentamicin
80
abx for IE caused by staph a) native valve b) prosthetic valve
a) flucloxacillin b) fluclox + rifampicin + gentamicin
81
abx for IE caused by strep
benzylpenicillin +/gentamicin
82
indications for surgery for IE (5)
1. severe valvular incompetence 2. aortic abscess (lengthening PR interval) 3. resistant infection 4. cardiac failure 5. recurrent emboli after abx
83
poor prognostic factors for IE (4)
1. s.aureus 2. prosthetic valve 3. culture negative 4. low complement
84
causes of intestinal ischaemia a) acute b) chronic
a) arterial occlusion, mesenteric venous thrombosis b) atherosclerosis
85
presentation of intestinal ischaemia a) acute b) chronic
a) abrupt, severe abdo pain b) postprandial discomfort, fear of eating, weight loss
86
investigations for intestinal ischaemia a) acute b) chronic
a) CT angiography b) duplex USS
87
what is mitral regurgitation? who is it common in?
backflow of blood through the mitral valve from the LV to the LA during systole common in otherwise healthy patients
88
mitral regurgitation murmur
pansystolic, high pitched blowing murmur
89
how does mitral regurgitation present?
mainly asymptomatic
90
ECG change in mitral regurg
broad P wave (atrial enlargement)
91
complication of mitral regurg
heart failure
92
what is myocarditis? who should we consider it in?
inflammation of the myocardium (muscle of the heart) young people with chest pain
93
viral and bacterial causes of myocarditis
viral - coxsackie B, HIV bacterial - diphtheria, clostridia
94
presentation of myocarditis
usually young pt, acute - chest pain - dyspnoea - arrhythmias
95
investigations and results for myocarditis
BLOODS - raised inflamm markers, raised cardiac enzymes, raised BNP ECG - tachycardia, arrhythmias, ST elevation/T wave inversion
96
late complication of myocarditis
dilated cardiomyopathy
97
what is the pericardium?
fluid-filled sac surrounding the muscle of the heart and roots of the heart vessels
98
functions of the pericardium
1. fixes heart, limits its motion 2. prevents overfilling 3. reduces friction 4. protection from infection
99
define acute pericarditis
inflammation of the pericardium lasting <4-6 weeks
100
most common 2 causes of acute pericarditis in UK
viral infection and MI
101
infective causes of acute pericarditis
viral e.g. coxsackie TB
102
early vs late post-MI acute pericarditis
early (1-3 days) = fibrinous pericarditis late (weeks-months) = autoimmune pericarditis (Dressler's)
103
presentation of pericarditis
- pleuritic chest pain relieved on sitting forwards - pericardial friction rub on auscultation (like crunching snow) - cough - dyspnoea - flu-like sx e.g. fever
104
what is a key complication of acute pericarditis? what does it present with?
cardiac tamponade beck's triad - hypotension, elevated JVP, quiet heart sounds
105
ECG findings in pericarditis
saddle-shaped ST elevation PR depression think PeRicardiTiS
106
imaging investigation for pericarditis
transthoracic echocardiography
107
patients with pericarditis can be managed as outpatients UNLESS...
fever >38 or high troponin
108
1st line tx for acute idiopathic/viral pericarditis how long is this tx given?
NSAIDs + colchicine given until sx resolution and then taper dose over 2-4 weeks
109
what is constrictive pericarditis?
fibrous and calcification of the pericardium >> loss of elasticity
110
signs of constrictive pericarditis
- dyspnoea - right HF: elevated JVP, ascites, oedema, hepatomegaly - pericardial knock (loud S3) - +ve Kussmaul's sign (rise in JVP on inspiration)
111
key investigation and result for constrictive pericarditis
CXR - pericardial calcification
112
management of constrictive pericarditis (symptom management, definitive)
diuretics for symptoms pericardiectomy is definitive
113
what is pericardial effusion?
accumulation of fluid in the pericardial sac
114
inflammatory cause of pericardial effusion
acute pericarditis
115
signs and symptoms of pericardial effusion
- dull constant ache in L side of chest - accentuated by inspiration, movement and lying flat
116
what will be seen on CXR in pericardial effusion?
enlarged heart
117
what is cardiac tamponade? what is the brief pathophys
life threatening - accumulation of pericardial fluid under pressure compresses heart chambers > decrease in venous return > decreased CO and acute HF
118
what is cardiac tamponade a key complication of?
pericarditis
119
key signs of cardiac tamponade
beck's triad - hypotension, raised JVP, muffled heart sounds pulsus paradoxus (fall in systolic BP of >10mmHg on inspiration)
120
what will show on ECG in cardiac tamponade?
electrical alternans (alternating QRS complex axis)
121
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