Sharon's phase 3b/4 > Cardiovascular > Flashcards

Cardiovascular Flashcards

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1
Q

Arrhythmias - look at notes on onenote, includes pictures

ECGs: https://zerotofinals.com/medicine/cardiology/arrhythmias/

A

Abnormal heart rhythms

  • Cardiac arrest rhythms
  • Narrow complex tachycardia
  • Broad complex tachycardia
  • Atrial flutter
  • Prolonged QT interval
  • Ventricular ectopics
  • Heart block
  • Bradycardias
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2
Q

Arrhythmia: Narrow Complex Tachycardia

A

Fast heart with QRS complex < 0.12s (3 small squares).

4 main differentials: sinus tachy, supraventricular tachy, AF, atrial flutter

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3
Q

Arrhythmias: sinus tachycardia

A

Normal P waves, QRS complex and T waves

Not an arrhythmia but a response to underlying cause e.g. pain/sepsis

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4
Q

Arrhythmia: supraventricular tachycardia (tachyarrhythmia originating above bundle of his)

A
  • QRS complex followed by T wave, P waves are buried in T waves
  • Causes: idiopathic, atrial fibrillation, AV nodal re-entrant tachycardia (functional re-entrant circuit in AV node), AV re-entrant tachycardia, atrial tachycardia, WPWS (delta wave, slurred upslope before QRS)
  • Tx = vagal manoeuvres and IV adenosine 6mg > 12mg > 18mg, verapamil or beta blocker, synchronised DC cadioversion
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5
Q

Management of SVT

A

Acute:

  • Continuous ECG monitoring
  • Step 1: Vagal manoeuvres
  • Step 2: Adenosine 6mg > 12mg > 18mg
  • Step 3: Verapamil or a beta blocker
  • Step 4: Synchronised DC cardioversion (immediately if life-threatening e.g. syncope, myocardial ischaemia, shock, HF) under sedation or GA
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6
Q

Arrhythmia: atrial fibrillation

A
  • Absent P waves and irregularly irregular ventricular rhythms
  • Treat with rate and rhym control
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7
Q

Arrhythmia: Atrial flutter

A
  • Atrial rate of ~300 beats per minute, saw tooth pattern, usually two atrial contractions for every one ventricular contraction
  • Due to re-entrant pathway and rhythm in either atrium resulting in self-peretuating loop
    • Treat with rate and rhythm control e.g. anticoagulation based on CHA2DSVASc and radiofrequency ablation
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8
Q

Arrhythmias: Broad Complex Tachycardia

A

Fast heart rate with QRS complex duration > 0.12s

  • Ventricular tachycardia (tx IV amiodarone)
  • Polymorphic ventricular tachycardia, such as torsades de pointes (tx IV magnesium)
  • AF with BBB (tx as AF)
  • Supraventricular tachycardia with BBB (tx as SVT)
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9
Q

Arrhythmia: prolonged QT interval

A
  • Start of QRS complex to end of T wave
  • > 440 ms in men
  • > 460ms in women

Tx: stop causative meds, correct electrolytes, beta blocker (not sotalol), pacemaker

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10
Q

miss jasmine

Causes of prolonged QT

A
  • Long QT syndrome
  • Meds e.g. antipsychotics, citalopram, amidarone
  • Electrolyte imbalances e.g. hypokalaemia, hypomagnesaemia and hypocalaemia
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11
Q

Arrhythmia: ventricular ectopics

A

Premature ventricular beats caused by random electrical discharges outside the atria

Appears as isolated, random, abnormal, broad QRS complexes on an otherwise normal ECG

Bigeminy = every other beat is a ventricular ectopic

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12
Q

Mx of ventricular ectopics

A
  • Healthy and infrequent = reassurance
  • Specialist advice if underlying heart disease, frequent/concerning symptoms, FHx of sudden death/heart disease
  • Beta blockers
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13
Q

Arrhythmia: Heart block (look at one note for ECG + more detail)

A
  • First-degree heart block = delayed conduction through the AV node
  • Second-degree heart block = Mobitz type 1 and 2
  • Third-degree = complete heart block, no relationship between P waves and QRS complexes, significant asystole risk
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14
Q

Asystole

A

Absence of electrical activity in the heart = cardiac arrest

Mx of asystole risk

  • IV atropine (1st line) - inhibits parasympathetic nervous system
  • Intotropes (e.g. adrenaline)
  • Temp cardiac pacing e.g. transcutaneous or transvenous
  • Pacemaker
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15
Q

Chronic heart failure

A

When heart function is impaired, the LV is not as effective in pumping blood out of the heart and around the body > increased fluid in left atrium, pulmonary veins and lungs > pulmonary oedema

  • HF with preserved ejection fraction > 50% = diastolic dysfunction with impaired LV filling
  • HF with reduced ejection fraction < 50%
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16
Q

Causes of chronic heart failure

A
  • IHD
  • Valvular heart disease (e.g. aortic stenosis)
  • HTN
  • Arrhythmia (e.g. AF)
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17
Q

Clinical features of chronic HF

A
  • SOB worse on exertion
  • Cough + frothy white/pink sputum
  • Orthopnoea (how many pillows?)
  • Paroxysmal nocturnal dyspnoea (waking with sudden cough, SOB, wheeze)
  • Peripheral oedema

Signs:

  • Tachycardia + tachypnoea, HTN, murmur (VHD), bilateral basal crackles (wet = pulmonary oedema), raised JVP, peripheral oedema (ankle, legs and sacrum)
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18
Q

Ix chronic heart failure

A
  • Clinical asessment
  • N-terminal pro-B-type natruretic peptide (NT-proBNP) blood test
  • ECG
  • Echo

Refer to cardiology depending NT-proBNP

  • 400 - 2000ng/L = echo within 6 weeks
  • > 2000ng/L = echo within 2 weeks
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19
Q

New York Heart Association Classification for heart failure

A
  • Class I: No limitation on activity
  • Class II: Comfortable at rest but symptomatic with ordinary activities
  • Class III: Comfortable at rest but symptomatic with any activity
  • Class IV: Symptomatic at rest
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20
Q

Management of chronic heart failure

A

ABAL

  • ACEi/ARB (ramipril/candesartan) - renal function, hyperkalaemia
  • Beta blocker (e.g. bisoprolol)
  • Aldosterone antagonist if above ineffective (e.g. spironolactone/eplerenone) - renal function, hyperkalaemia
  • Loop diuretic (e.g. furosemide) - monitor U+Es

Surgery - implantable cardioverter defibrillators

ARB = Angiotensin receptor blocker

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21
Q

Atrial Fibrillation (AF)

A

Condition where the electrical activity in the atria becomes disorganised. Choatic electrial activity in the atria overrides regular, organised electrical activity from SA node.

  • Irreguarly irregular pulse
  • Tachycardia
  • Heart failure due to impaired filling of the ventricles during diastole
  • Increased risk of stroke (x5)
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22
Q

Common causes of AF

A

SMITH

S – Sepsis
M – Mitral valve pathology (stenosis or regurgitation)
I – Ischaemic heart disease
T – Thyrotoxicosis
H – Hypertension

Alcohol and caffeine too

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23
Q

Presentation of AF

A
  • Often asymptomatic, could be dx after stroke
  • Palpitations
  • Shortness of breath
  • Dizziness or syncope (loss of consciousness)
  • Symptoms of associated conditions (e.g., stroke, sepsis or thyrotoxicosis)
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24
Q

Key examination finding in AF

A

Irregularly irregular pulse.

Consider ventricular ectopics as differential - VE disappear above certain HR, normal HR during exerise indicate VE

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25
Investigations for AF
ECG: - Absent P waves - Narrow QRS complex tachycardia - Irregularly irregular ventricular rhythm
26
Paroxysmal AF
Episodes of AF that occur spontaneously and resolve back to sinus rhythm - 24-hr ambulatory RCG (Holter monitor) - Cardiac event recorder for 1 - 2 weeks
27
Management of AF
- Rate or rhythm control - Anticoagulation to prevent strokes - Rate control is first-line* - beta blocker 1st line (atenolol or bisoprolol) ## Footnote * Unless reversible cause of AF, new onset (within 48hrs), HF caused by AF, rate control ineffective (rhymth control in cases listed)
28
AF: options for rate control
1st line: beta blockers e.g. bisoprolol 1st line anticoagulation: DOAC (e.g. apixaban), warfarin as alternative | Remember most patients treated with bisprolol and DOAC for anticoag.
29
AF: options for rhythm control
Cadioversion - Immediate (<48hrs, life-threatening haem instability): electrical or pharmacological with flecainide/amiodarone (structual heart disease) - Delayed (>48 hrs, stable): electrical - anticoagulation 3 weeks before. Long-term = 1st line beta-blockers
30
AF: when is ablation considered?
When rate and rhythm control not effective - Left atrial ablation - identifying areas of abnormal signals and destroying them - Atrioventricular node ablation and a permanent pacemaker
31
CHA2DS2-VASC
Stroke risk score for patient with AF, and whether to start anticoagulation. C – Congestive heart failure H – Hypertension A2 – Age above 75 (scores 2) D – Diabetes S2 – Stroke or TIA previously (scores 2) V – Vascular disease A – Age 65 – 74 S – Sex (female) - 0 – no anticoagulation - 1 – consider anticoagulation in men (women automatically score 1) - 2 or more – offer anticoagulation Aspirin alone is not used for stroke prevention in AF.
32
AF: Orbit score
Assesses risk of major bleeding in patients with AF taking anticoagulation: O – Older age (age 75 or above) R – Renal impairment (GFR less than 60) B – Bleeding previously (history of gastrointestinal or intracranial bleeding) I – Iron (low haemoglobin or haematocrit) T – Taking antiplatelet medication ## Footnote Most pts with AF = risk of stroke with no anticoag. > bleeding risk on anticoag.
33
Management of Paroxysmal Atrial Fibrillation
- "Pill-in-pocket" - take flecainide+ when symptoms start - Anticoagulation based on CHA2DS2VASc ## Footnote * Risk of atrial flutter, 1:1 AV conduction to ventricles = high ventricular rate
34
Thoracic Aortic Aneurysms
Dilatation of the thoracic aorta, most commonly ascending aorta (normally < 4.5cm) True aneursym = all three layers (intima, media and adventitia) intact, but dilated False aneurysms: intima and media rupture and blood enters adventitia = dilation
35
Risk factors for thoracic aortic aneurysm
- Men affected when younger and more often than women - Increased age - Smoking - HTN - FHx - Existing CVD - Marfan symdrome
36
Presentation and diagnosis of thoracic aortic aneurysms
Usually asymptomatic, incidental finding on CXR, echo or CT DIagnosis: echo, CT or MRI angiogram
37
Management of thoracic aortic aneurysm
Prevent progression by tx of modifiable RFs: stop smoking, healthy diet + exercise, optimise HTN, diabetes + hyperlipidaemia Depends on size: - Surveillance with regular imaging - Thoracic endovascular aortic repair (TEVAR) - Open surgery (midline sternotomy) Complications: aortic dissection, rupture, aortic regurgitation | TEVAR - stent via catheter via femoral artery to affected area of aorta ## Footnote Open surgery - remove affected section and replace with sythetic graft
38
Rupture of thoracic aortic aneuysms
Bigger = increase risk of rupture Bleeding into the mediastinum, oesophagus (haematemesis), lungs (haemoptysis), pericardial cavity (cardiac tamponade) - Severe chest/back pain - Haemodynamic instability - Collapse - Death (often patients do not reach hospital) Tx = emergency open surgery
39
Abdominal aortic aneurysm (AAA)
- Dilation of abdominal aorta, diameter > 3cm - Often incidential on abdo X-ray/CT and asymptomatic until rupture > bleed into abdo cavity, 80% mortality - Features: non-specifc abdo pain, pulsatile/expanile mass on palpation RFs: male (more often and younger), age, smoking, HTN, FHx, CVD
40
Diagnosis and classifcation of abdominal aortic aneurysm
- 1st line: USS - CT angiogram for detail, guide elective surgical repair Normal: < 3cm Small: 3 - 4.4cm Medium: 4.5 - 5.4cm Large: > 5.5cm
41
Management and prevention of AAA
- One USS screening for males aged 65 - Manage RFs e.g. smoking and optimise HTN, diabetes and hyperlipidaemia - NICE recommends elective repair if: symptomatic, diameter > 1cm yearly, > 5.5cm - Surgery is artifical graft insertion = endovascular repair (EVAR) or open surgery ## Footnote EVAR: stent inserted via femoral arteries
42
Ruptured abdominal aortic aneurysm
- Surgical - experienced seniors, vascular surgeons, anaethetists, theatre teams - DO NOT DELAY SURGERY IF HAEM UNSTABLE - CT angiogram if haem stable - Presents with severe abdo pain +/- radiation to back or groin, haem. instability, pusatile/expansile abdo mass, collapse, LOC - Permissive hypotension to prevent excessive blood loss
43
Aortic dissection
Break or tear in the intima of the aorta, allowing blood to pool in between the intima and media = false lumen
44
Risk factors for aortic dissection
Same as PAD - Increasing age - Smoking - HTN (weight lifting, coacine, primary) - major RF! - Poor diet - Male - Sedentary lifestyle Conditions/surgery: bicuspid aortic valve, coarctation of aorta, aortic valve replacement, Marfan's
45
Presentation of aortic dissection
- Often missed, typically old man with PMHx of HTN with sudden "tearing" or "ripping" chest pain if ascending aorta or back if descending aorta - Pain migrates, some pts don't have chest pain - DIfference in BP of arms (>20mmHg) - Radial pulse deficit - Collapse - Hypotension as dissection progresses - Focal neuro deficits (e.g. limb weakness)
46
DIagnosis of aortic dissection
ECG and CXR to exclude differentials e.g. MI CT angiogram = 1st line to confirm dx
47
Management of aortic dissection
- Surgrical emergency with experienced seniors, vascular surgeons, anaesthetists, ICU team, high mortality - Analgesia e.g. morphine - Control BP and HR = beta blockers - Surgical intervention: type A = open surgery, replace damaged area with synthetic graft, Type B = TEVAR - catheter via femoral artery to insert stent graft into decending aorta ## Footnote Passmed: Type A: control BP (IV labetalol) + surgery Type B: control BP (IV labetalol) - no surgery (I guess if pt haem stable?)
48
Classification of aortic dissection
Standford classification: - Type A = affects ascending aorta before brachiocephalic artery - Type B = descending aorta after left subclavian artery Debakey: - Type I - ascending aorta + aortic arch or more - Type II - isolated to ascending aorta - Type IIIa - descending aorta, only above diaphragm - Type IIIb - descending aorta, below diaphragm
49
Complications of aortic dissection
- Myocardial infarction - Stroke - Paraplegia (motor or sensory impairment in the legs) - Cardiac tamponade - Aortic valve regurgitation - Death
50
Aortic stenosis
- Narrowing of aortic valve - Most common valve pathology + replacement - Ejection-systolic, high-pitched murmur, crescendo-decrescendo - Other signs: exertional syncope, narrow pulse pressure (diff between systolic and diastolic), slow rising pulse - Causes LVH (pump harder to overcome narrowing) - Causes: idiopathic age-related calcification (MC), bicuspid aortic valve
51
Management of aortic stenosis
- Asymptomatic: watch + wait - Symptomatic or valvular gradient > 40mmHg: aortic valve replacement (AVR) - Surgical AVR: young, low/medium oprerative risk patients - Transcatheter AVR for high operative risk patients ## Footnote Valvular gradient: pressure difference on two sides of valve
52
Aortic regurgitation
- Incompentent aortic valve, allowing blood to flow back from aorta into LV - Causes: age-related, biscuspid, Marfans or Ehlers-Danlos, infective endocarditis - Early diastolic, soft murmur or Austin-Flint murmur, "rumbling" at apex - Collapsing/Water hammer pulse (forcefully appearing then disappearing radial pulse) - Other signs: thrill, wide pulse pressure, HF and pulmonary oedema Mx: - Medical mx of associated HF - Aortic valve replacement if severe AR, or asymptomatic with severe AR and LV systolic dysfunction
53
Arterial ulcers
Due to insufficient blood supply to skin due to PAD Features (to distinguish it from venous ulcer): - DIstal, affecting the toes or dorsum of the foot - Associated with PAD, with absent pulses, pallor and intermittent claudication - Smaller than venous ulcers - Deeper than venous ulcers - Well defined borders - “punched-out” appearance - Pale colour due to poor blood supply - Less likely to bleed - Painful - Pain worse at night (when lying horizontally) - Pain worse on elevating and improved by lowering the leg (gravity helps the circulation)
54
Venous ulcer
- Gaiter area (between ankle to mid-calf) - Are associated with chronic venous changes, such as hyperpigmentation, venous eczema and lipodermatosclerosis - After minor injury to the leg - Larger than arterial ulcers - More superficial than arterial ulcers - Irregular, gently sloping border - More likely to bleed - Less painful than arterial ulcers - Pain relieved by elevation and worse on lowering the leg
55
Investigations for arterial/venous ulcers
- Ankle-brachial pressure index (ABPI) - Bloods (FBC (infection/anaemia), CRP, - HbA1c, Albumin (malnutrition)) - Charcoal swab (infection) - Skin biopsy, 2WW to dermatology if skin cancer suspected
56
Management of arterial ulcers
- Same as PAD, urgent vascular sugery referral to consider surgical revascularisation - If tx effective, ulcer should heal quickly
57
Management of venous ulcers
NICE CKS Might need referral for: - Vascular surgery if mixed/arterial ulcers suspected - Tissue viability / specialist leg ulcer clinics in complex or non-healing ulcers - Dermatology if skin cancer suspected - Pain clinics if the pain is difficult to manage - Diabetic ulcer services (for patients with diabetic ulcers) - Wound care by experienced nurses: clean, debridment, dress - Compression therapy with compression bandage over affected area - Abx for infection - Analgesia (not NSAIDs)
58
Deep vein thrombosis (DVT)
Called venous thromboembolism (VTE) together with pulmonary embolism. Thrombi in the venous system = DVT Heart defect e.g. ASD = clot travels to systemic circulation > stroke Risk factors: hypercoagulability, venous stasis, endothelial injury e.g. immboility, recent surgery, active cancer, pregnanct, HRT, COCP, polycythaemia, lupus, thrombophilia* ## Footnote *Antiphoslipid syndrome ,factor V Leiden etc.
59
DVT presentation
- Unilateral (if B/L think chronic venous insufficency/HF) - Calf/leg swelling - measure below tibial tuberosity, > 3cm difference = significant - Dilated superfical veins - Calf tenderness, particularly ove deep veins - Oedema - Colour changes Consider and exclude PE
60
Wells score
Predicts risk of DVT or PE - Active cancer (tx within 6m) - Bedridden > 3 days, major surgery < 12 weeks - Calf swelling > 3cm compared to other leg - Collateral (non-varicose) superficial veins present - Entire leg swollen - Localised tenderness along the deep venous system - Pitting oedema in affected leg - Paralysis - Previous DVT - Alternative dx to DVT likely
61
Diagnosis of DVT
Wells score used to inform next steps: - Likely: perform a leg vein ultrasound - Unlikely: perform a d-dimer, and if positive, perform a leg vein ultrasound - D-dimer is sensitive (95%) but not speific, good for excluding when low suspicion. But can be raised in pneumonia, malignancy, HF, surgery, pregnancy - Diagnostic = doppler USS, repeat in 6-8 days if negative USS but postive D-dimer and high Well's
62
Management of DVT
- Prophylaxis (after surgery): compression stockings, LMWH e.g. enoxaparin/dalteparin - Initial: apixaban/rivaroxaban, catheter-directed thrombolysis if iliofemoral DVT < 14 days Long-term: DOACs, warfarin (antiphospholipid syndrome), LMWH (pregnancy) - 3m if reversible, then review - > 3m if unprovoked or recurrent - 3 - 6m active cancer, then review
63
Investigations for unprovoked DVT
Review medical history, bloods, physical examination for cancer If stopping anticoagulation after 3-6m, consider testing for antiphospholipid syndrome or hereditary thrombophilias (if 1st degree relative affected by DVT/PE)
64
Hypertension
- 90% essential - Secondary causes: ROPED Renal disease, Obesity, Pregnancy-induced or Pre-eclampsia, Endocrine, Drugs (alcohol, steroids, NSAIDs, oestrogen and liquorice)
65
Complications of hypertension
- Ischaemic heart disease - Cerebrovascular accident - Vascular disease (PAD, aortic dissection, aortic aneurysms) - Hypertensive retino/nephropathy - LVH - HF
66
Diagnosis of hypertension
Clinic BP 140/90 to 180/120 = 24-hr ambulatory BP or home readings White coat syndrome: > 20/10 difference in clinic and home readings New HTN dx: - Bloods: HbA1c, renal function and lipids - Fundus examination for hypertensive retinopathy ECG for cardiac abnormalities e.g. LVH - Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria to assess for kidney damage - QRISK > 10% = offer statin (atorvastatin 20mg)
67
Management of essential hypertension
-Lifestyle advice - stop smoking, lose weight, reduce alcohol, exercise Medications: - A – ACE inhibitor (e.g., ramipril) - B – Beta blocker (e.g., bisoprolol) - C – Calcium channel blocker (e.g., amlodipine) - D – Thiazide-like diuretic (e.g., indapamide) - ARB – Angiotensin II receptor blocker (e.g., candesartan)
68
Hypertenstion stepwise medical management
- Step 1: under 55 or type 2 diabetic of any age and any family origin = A. Over 55 = C black = ARB - Step 2: A + C, or A+D, C+D - Step 3: A+C+D - Step 4: A+C+D+4th If K ≤4.5 = K-sparing diuretic e.g. spironolactone, > 4.6 = alpha blocker (doxazosin) or beta blocker (e.g. bisoprolol) Check adherence, specialist mx if uncontrolled
69
Hypertensive emergency/accelerated hypertension/malignant hypertension
> 180/120 with retinal haemorrhages or papiloedema on fundoscopy Same-day referral IV meds in hypertensive emergency (experienced specialist) - sodium nitroprusside, labetalol, glyceryl trinitrate, nicardipine
70
Bowel ischaemia
- Acute mesenteric ischaemia (AMI) - embolism > occlusion small bowel artery (e.g. superior mesenteric artery) > urgent surgery, poor prognosis - Chronic mesenteric ischaemia (CMI) - rare, colickly intermittent abdo pain (non-speicfic) "intestinal angina" - Ischaemic colitis (IC) - acute, transient blood flow distruption to large bowel > inflammation, ulceration + haemorrhage > "thumbprinting" abdo x-ray = oedema/haemorrhage > supportive mx, surgery if peritonitis, perforation or persistant haemorrhage
71
Risk factors for bowel ischaemia
- Age - AF (espeically mesenteric ischaemia) - Endocarditis (emboli) - Malignancy (emboli) - CVD RFs e.g. smoking, HTN, diabetes - Cocaine - consider IC if coacine use
72
Common features of bowel ischaemia + investigation
- Abdo pain - sudden, severe and disportionate to findings in AMI - Rectal bleeding - Diarrhoea - Fever - Bloods = ↑WBC, lactic acidosis - Diagnostic = CT abdo
73
Ischaemic heart disease
Most commonly caused by atherosclerotic plaque build-up = chronic inflammation of medium and large arteries + immune system activation > lipid plaques > stiffening, stenosis and plaque rupture
74
Risk factors for IHD
Non-modifiable risk factors: - Older age - FHx - Male Modifiable risk factors: - Raised cholesterol - Smoking - Alcohol - Poor diet/sleep - Sedentary - Obesity - Stress - Co-mobidities: diabetes, HTN, CKD, inflammatory conditions e.g. RA, atpyical antipsychotics | Consider + ask RFs when taking Hx from pt with suspected IHD
75
Primary prevention of CVD/IHD
Prevention of CVD for patients that never had a dx of CVD - Diet + exercise - QRISK3 - risk of having stroke or MI in next 10 years, > 10% or CKD (eGFR < 60)/T1DM = atorvastatin 20mg - Review in 3m + 12m, aim >40% ↓ non-HDL cholesterol - LFTs = ↑ALT+↑AST, continue if < 3x upper limit of normal | Statin inhibit HMG CoA reductase = ↓cholesterol production in liver
76
What are some rare but sigificant side effects of statins?
- Myopathy (muscle weakness + pain) - Rhabdomyolysis (CK levels if muscle pain) - T2DM - Macrolide abx inhibit CYP450 enzyme = ↑ statin effects, stop statins during course
77
Secondary prevention of CVD/IHD
4As! - A – Antiplatelet medications (e.g., aspirin, clopidogrel and ticagrelor) - A – Atorvastatin 80mg - A – Atenolol (or bisoprolol)* - A – ACE inhibitor (commonly ramipril)* | * titrated to the maximum tolerated dose
78
Familial hypercholesterolaemia
- Autosomal dominant - Heterozgous - Homozygous = extremely high cholesterol (>13mmol/L), early CVD - Simon Broom/Dutch Lipid Clinic Network Criteria for clinical dx: **FHx (e.g. MI < 60 in 1st degree), very high cholesterol (> 7.5mmol/L), tendon xanthomata** - Mx: specialist for genetic tests + statins
79
Mitral valve disease: mitral stenosis
- Narrowed mitral valve = restricted blood flow from LA > LV - Mid-diastolic, low-pitched "rumbling" MURMUR - Palpable tapping apex beat, malar flush (upper cheeks+nose, due to back pressure of blood in pulmonary system = rise in CO2 + vasodilation), AF - Causes: infective endocarditis, rheumatic fever
80
Mitral valve disease: mitral regurgitation
- Incompetent mitral valve = backflow of blood from LV to LA during systole > reduce EF and backlog waiting to be pumped through left heart > congestive HF - Pan-systolic, high-pitched whistling murmur radiating to left axilla - Thrill in mitral area on palpation - HF+ pulmonary oedema - AF Causes: age-related, IHD, infective endocarditis, rheumatic heart disease, Marfans
81
Myocarditis
Inflammation of myocardium Causes: - Viral: coxsackie B, HIV - Bacteria: diphtheria, clostridia - Spirochaetes: Lyme disease - Protozoa: toxoplasmosis - Autoimmune
82
Presentation + investigations of myocarditis
Usually young patient with acute history, chest pain, dyspnoea and arrhythmias Investigations: bloods: ↑CRP, ↑ cardiac enzymes (e.g. tropinin), ↑ BNP (suggests heart failure) ECGs: tachy +/- ST-segment elevation and T-wave inversion Transthoracic echo useful to detect pericardial effusion
83
Management of myocarditis
Tx of cause e.g. abx, methyprednisolone for autoimmune Supportive for HF or arrhythmia Complications: HF, arrhythmia > sudden death, dilated cardiomyopathy
84
Pericarditis
Inflammation of pericardium. membrane around the heart - two layers (fibrous and serous), < 50ml fluid = lubrication. Potential space: pericardial cavity Causes: idiopathic, infection (TB, HIV, coxsackievirus, EBV), autoimmune (SLE, RA), injury (MI), cancer, methotrexate
85
Key presenting features of pericarditis
- Chest pain: central/anterior sharp, pleuritic (worse on inspiration), wose on lying down, relieved by sitting forward - Low-grade fever - Pericardial friction rub on exam
86
Investigations for pericarditis
- Bloods: ↑inflammatory markers (WCC, CRP, ESR) - ECG changes - Echo diagnostic of pericardial effusion
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Management of pericarditis
- 1st line: NSAIDs (aspirin or ibuprofen - Long-term: colchicine 3m reduce recurrence - 2nd line: steroids in recurrent cases or inflammatory conditions - Tx underlying causes - Pericardiocentesis: remove fluid surrounding heart if pericardial effusion or tamponade
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Pericardial (cardiac) tamponade
In pericarditis, pericardial cavity can fill with fluid = pericardial effusion = pressure on heart, reduce expansion during diastole Tamponade = effusion large enough to ↑intra-pericardial pressure, emergency, drainage of effusion to relieve pressure
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Tricuspid regurgitation
Incompetent tricuspid valve, blood back flow from RV to RA in systole - Pan-systolic murmur loudest in inspiration - Thrill in tricuspid area - Raised JVP with giant C-V waves (Lancisi's sign) - Peripheral oedema - Ascites | +Pulmonary valves close before aortic valves as RV empty faster than LV
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Causes of tricuspid regurgitation
- Pressure to due LHF or pulmonary HTN - Infective endocarditis - Marfan syndrome - Ebstein's anomaly (congenital malformation of the tricuspid valve)
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Pulmonary stenosis
Narrowed pulmonary valve, restricted blood flow from RV to pulmonary arteries - Ejection systolic murmur, widely split second heart sound+, pulmonary area deep inspiration - Thrill - Raised JVP giant A waves - Peripheral oedema - Ascites Congential: tetralogy of Fallot ## Footnote +as the left ventricle empties much faster than the right ventricle.
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Shock
Caused by insufficient tissue perfusion: - Septic - Haemorrhagic - Neurogenic - Cardiogenic - Anaphylactic
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Septic shock
- Occurs in severe sepsis - Immune system activation > extensive cytokine release > inflammation, coagulation and fibrinolytic suppression (DIC) = excessive vasodilation = hypoperfusion > organ failure + refractory hypotension = septic shock
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Management of septic shock
- ABCDE - Empirical broad-spectrum abx + Ix for infection source - Aggressive fluid resus + high-flow O2 non-rebreather mask + tight glycaemic control
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Haemorrhagic/hypovolaemic shock
Fluid loss = fall in circulating blood volume - Haemorrhage (trauma, PPH, GI bleed) most common - Burns, DKA - Aggressive fluid resus, then blood transfusion once circulating volume stabilised (aim Hb 7-8)
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Neurogenic shock
Following a spinal cord transection > distruption of autonomic nervous system > ↓peripheral vascular resistance + vasodilation > hypoperfusion Tx: ABCDE, O2 (< 96%), IV fluids, peripheral vasconstrictor to restore vascular tone (e.g. noradrenaline)
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Cardiogenic shock
Main cause = IHD or MI Tx: ABCDE, O2 (< 96%), IV fluids, IV furosemide if fluid overload, vasodilator (GTN) if pulmonary oedema and SBP >90 (BMJ best practice)
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Anaphylactic shock
- Life-threatening systemic hypersensitivity - Causes: food (e.g. nuts), drugs, venom (wasp) - Tx: IM adrenaline, repeat every 5 mins if needed
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Stable angina
Atherosclerosis > narrowed coronary arteries > reduced blood flow to myocardium > insuffcient blood supply during high demand (e.g. exercise) > constricting chest pain +/- jaw/arm radiation Stable = symptoms only on exertion, always reliveved by rest or glyceryl trinitrate (GTN)
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Investigations for stable angina
Baseline: - Physical exam: heart sounds, BP and BMI - ECG - FBC (anaemia) - U+E (before ACEi) - LFTs (before statins) - Lipid profile - Thyroid function - HbA1C Others: - Cardiac stress testing - CT coronary angiography
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Management of stable angina
Medical: - Immediate = GTN spray, repeat after 5m if needed, 999 if ineffective - Long-term: beta-block (bisprolol) AND/OR CCB (diltiazem or verapamil) - Secondary prevention: 4As (Aspirin 75mg, Atorvastain 80mg, ACEi , Already beta-blocker) - ACEi if if diabetes, HTN, CKD or HF | CCB (except amlodipine) CI in HF with reduced EF
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Surgical procedures for angina if severe or meds ineffective
- Percutaneous coronary intervention (PCI) - Coronary artery bypass graft (CABG)
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Congenital Cardiac Conditions
Acyanotic (L > R shunt) - Ventricular septal defect - Atrial septal defect - Patent ductus arteriosus - Coarctation of aorta - Aortic valve stenosis Cyanotic: - Teralogy of Fallot - Transposition of the great arteries
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Atrial septal defect
Defect in atrial septum: - Patent foramen ovale - Ostium secondum - septum secondum fails to close, hole in central septum - Ostium primum: septum primum fails to close, hole in lower septum > possible AVSD
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Presentation of ASD
- Antenatal scans or newborn exam or present in adulthood - Dyspnoea seocndary to pulmonary HTN and right-side HF - Stroke if embolus from DVT moves from RA > LA > LV > systemic circulation (exam q! pt with DVT > large stroke = ? asymptomatic ASD) - AF - L > R shunt = right heart overload, pulmonary hypertension, RHF - Eventually pulmonary hypertension > Eisenmenger syndrome (pulmonary pressure exceeds systemic pressure) > shunt reversal > cyanosis
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What murmur do you hear with ASD?
- Mid-systolic, crescendo-decrescendo loudest in left sternal border - Fixed (no change inspiration + expiration) split second heart sound
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Management of ASD
- Echo = diagnostic - Paediatric cardiologist - Small, asymptomatic = watch + wait - Surgery: percutaneous transvenous catheter closure or open heart surgery - Anticoagulation e.g. aspirin (antiplatelet), warfarin, DOAC ↓ stroke risk
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Ventricular septal defects (VSD)
- Hole in ventricular septum, small to entire septum - Associated with Down's or Turner's Syndrome - Possible after MI - L to R shunt (as ASD) > right-sided overload > right HF > ↑flow pulmonary vessels > pulmonary HTN > pulmonay pressure exceed systemic pressure > R to L shunt > cyanosis (Eisenmenger syndrome)
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Presentation of VSD
- Often asymptomatic, present in adulthood - Picked up on antenatal scans or murmur in newborn check - Pan-systolic murmur loudest at left lower sternal border 3rd/4th ICS + thrill ## Footnote DDx for pan-systolic murmur if asked: VSD, mitral and tricuspid regurgitation
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Management of VSD
- Transvenous catheter closure or open-heart surgery - Abx prophylaxis before surgery as infective endocarditis risk
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Coarctation of the aorta
- Narrowing of aortic arch, usually around ductus arteriosus (connects pulmonary artery to aorta in fetus) - Mild > severe - Associated with Turner's syndrome - ↑pressure to areas proximal to narrowing e.g. heart + three branches of aorta arch (brachicephalic, left common carotid, left subclavian artery) - ↓pressure distal areas
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Presentation of Coarctation of Aorta
- Can reccur after being treated in childhood - If undiagnosed until adulthood, first present as HTN - Systolic murmur in left infraclavicular area and below left scapula - Four limb BP = high BP in limbs supplied before narrowing, lower BP supplied after narrowing
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Management of coarctation of aorta
- Mild, symptom-free until adulthood then surgery - Severe = emergency surgery shortly after birth Surgery: - Percutaneous ballon angioplasty +/- stent - Open surgical repair
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Syncope
Temporary loss of consciousness due to disruption of blood flow to the brain (vasovagal episodes or fainting) Vasovagal episode: vagus nerve stimulation (emotional, pain) = PNS stimulation = ↓cerebral BP = hypoperfusion = faint
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Clinical features of syncope
- Prodrome: hot, clammy, sweaty, dizzy, blurred vision, headache - Collateral hx: sudden LOC + fall to ground, unconscious seconds - 1min, may be twitching, shaking or convulsion (confused with seizure) - After: groggy but different to seizure postictal period - May be incontinence
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Causes of syncope
Key history to cover: Simple? Otherwise fit and well? Secondary cause? Primary syncope (simple fainting): - Dehydration - Missed meals - Extended standing in a warm environment - A vasovagal response to a stimuli Secondary causes: - Hypoglycaemia - Dehydration - Anaemia - Infection - Anaphylaxis - Arrhythmias - Valvular heart disease - Hypertrophic obstructive cardiomyopathy
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History in syncope to identify possible underlying cause and differentiate from seizure
- Collateral history important - After exercise? Syncope during exercise = likely underlying condition (e.g. arrhythmia) - Triggers? - Concurrent illness? Fever? Infection? - Head injury from syncope? - CV symptoms: palpitations or chest pain? - Neuro symptoms? - Seizure activity? - Family history, particularly cardiac problems or sudden death?
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Examination in syncope
- Physical injury due to faint? - Concurrent illness? Gastroenteritis or infection? - Neuro exam - Cardiac exam (pulse, HR, rhythm, murmurs) - Lying and standing BP
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Investigation for syncope
- ECG: arrhythmia, long QT - 24hr ECG if paroxysmal arrhythmia - Echo if structual heart disease - Bloods: FBC (anaemia), electrolytes (arrhythmia/seizures) and BM (diabetes))
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Management of syncope
- Common in children, teen girls, usually resolve by adulthood. - Important to make confident dx and exclude other pathology - Ressurance and advice: Avoid dehydration, missed meals, standing still for long time, sit/lie down if prodromal symptoms
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Coronary arteries supply to heart and ECG territories
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Blood supply to the heart
Right coronary artery (RCA) Left coronary artery (LCA) RCA supplies: - Right atrium - Right ventricle - Inferior aspect of the left ventricle - Posterior septal area LCA becomes: - Circumflex artery - Left anterior descending (LAD) Circumflex supplies: - Left atrium - Posterior aspect of the left ventricle LAD supplies - Anterior aspect of the left ventricle - Anterior aspect of the septum
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Sharon's phase 3b/4
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