Cardiac Pathology Flashcards
(257 cards)
1
Q
HOW CAN ISCHAEMIC HEART DISEASE OCCUR?
A
- Reduced blood flow to the heart muscle (clot or atheroma)
- Increased distal resistance (LV hypertrophy)
- Reduced O2 carrying capacity (anaemia) or availability (hypoxia)
2
Q
What are some risk factors for IHD?
Modifaible and non-modifiable?
A
MODIFIABLE
Smoking.
Diabetes
Hypertension.
Hypercholesterolaemia.
Sedentary lifestyle
Non-modifiable
Gender.
Family history.
Personal history.
Age.
3
Q
WHAT IS ANGINA?
A
Chest pain brought on either:
By exertion which resloves with rest
Or at rest
4
Q
What are the different types of angina?
A
Stable angina
Unstable angina
Decubitus angina (precipitated by lying flat)
Variant (Prinzmetal’s) angina: caused by coronary artery spasm.
5
Q
What are the causes of angina?
A
Atheroma
Anaemia
Spasm
Tachycardia
6
Q
What are the symptoms of angina?
A
Chest pain/discomfort.
Heavy, central, tight, radiation to arms, jaw, neck.
Precipitated by exertion.
Relieved by rest or GTN within 5 mins
7
Q
What are the tests for stable angina?
A
ECG
Pathological Q waves in particular, LBBB, and ST-segment and T wave abnormalities (for example, flattening or inversion).
Bloods
May show anaemia
CXR
May show increased heart size and pulmonary vessels
Angiogram
Gold standard, shows luminal narrowing
8
Q
What are the management options for stable angina pectoralis?
A
Drugs
Glyceryl Trinitrate (SL) (GTN Spray)
Aspirin to prevent clots
Statin to lower cholesterol
BB (atenolol)/CCB (verapamil/diltiazem)
BB + CCB (nifedipine), OR monotherapy + long-acting nitrate/ivabradine/nicorandil/ranolazine
Can use BB + CCB + 3rd Drug whilst waiting for PCI/CABG
Percutaneous Intervention (PCI)
Coronary Artery Bypass Graft (CABG)
9
Q
WHAT IS ACUTE CORONARY SYNDROME PATHOLOGY?
A
Plaque rupture, thrombosis, and inflammation.
10
Q
What are the different acute coronary syndomes?
A
Unstable angina
(NSTEMI) Non-Q wave infarction, ST depression and T wave inversion
(STEMI) Q wave infarction, ST elevation
11
Q
What are the different ECG changes for ACS?
A
STEMI
ST elevation and tall T waves, may be a new LBBB in larger MIs (STEMI)
NSTEMI
A retrospective diagnosis, will see ST depression
Ischaemia
ST depression and T wave flattening
12
Q
WHAT IS UNSTABLE ANGINA?
A
An acute coronary syndrome (ACS) that is defined by the absence of biochemical evidence of myocardial damage
13
Q
What is the clinical classification of unstable angina?
A
Cardiac chest pain at rest.
Cardiac chest pain with crescendo pattern.
New onset angina.
14
Q
What are the test for unstable angina?
A
FBC
Anaemia aggravates it
Cardiac enzymes
Excludes infarction
ECG
When in pain shows ST depression
Coronary angiography
15
Q
What is the treatment for unstable angina?
A
Anti-platelet agents e.g. Clopidogrel
Anti-coagulants e.g. Heparin, Warfarin
Break up any clots and stop new ones from forming.
Nitrates
B-blockers
Calcium antagonists (if B-blocker contraindicated)
CABG and PCI
16
Q
WHAT IS A MYOCARDINAL INFARCTION?
A
Plaque rupture leads to a clot forming which then occludes one of the coronary arteries causing myocardial cell death and inflammation.
17
Q
What are the symptoms of a myocardial infarction?
How long does it need to last to be an MI?
A
Acute central chest pain radiating to jaw or shoulder
Lasting >20 mins
Nausea
SOB
Palpitations
18
Q
What are the signs of a myocardial infarction?
A
Clammy and pale
4th heart sound
Pansystolic murmur
May later develop peripheral oedema
19
Q
What are the tests for a MI?
A
ECG: Classically, hyperacute (tall) T waves, ST elevation or new LBBB occur within hours of transmural infarction.
T wave inversion and development of pathological Q waves follow over hours to days.
CXR:
Cardiomegaly, pulmonary oedema, or a widened mediastinum
Blood
FBC, U&E, glucose, lipids.
Cardiac enzymes
Troponin
Creatine kinase
Myoglobin
20
Q
What is the initial management for a MI?
A
Morphine
Oxygen
Nitrates
Aspirin (or Clopidogrel if aspirin is contraindicted)
21
Q
What is the management after a MI?
For ST evelation and non ST elevation?
A
ST elevation MI
If within 2 hours and ST elevation on ECG then PCI is preferred option.
Beta blocker IV.
ACE inhibitor
Clopidogrel.
Non ST elevation MI
Beta blocker IV.
Antithrombotic; fondaparinux.
High risk of bleeding; angiography, clopidogrel and aspirin
Low risk of bleeding; ticagralor, clopidogrel.
22
Q
What are the complications of MI?
A
- Cardiac arrest; cardiogenic shock; LVF.
- Unstable angina
- Bradycardias or heart block.
- Tachyarrhythmias
- Pericarditis
- DVT & PE
- Systemic embolism
- Cardiac tamponade
- Mitral regurgitation
- Ventricular septal defec
23
Q
What is Dressler’s syndrome?
A
Recurrent pericarditis
pleural effusions
fever
anaemia and ESR increase
1–3 wks post-MI
24
Q
WHAT IS SHOCK?
A
Circulatory failure resulting in inadequate organ perfusion
25
What is shock defined as?
Low BP
Evidence of tissue hypoperfusion.
26
What does a patient in shock look like?
Skin is pale, cold, sweaty and vasoconstricted
Pulse is weak and rapid
Pulse pressure reduced, MAP may be maintained
Urine output reduced
Confusion, weakness, collapse, coma
27
What is the main cause of injury from shock?
Prolonged hypotension can lead to life threatening organ failure
28
What are the different types of shock?
Hypovolaemic shock
Cardiogenic shock
**_Distributive shock_**
Septic shock
Analphylactic shock
Neurogenic shock
29
WHAT IS HYPOVALEMIC SHOCK?
Low circulating blood volume
30
What can cause hypovalemic shock?
**_Loss of blood_**
Acute GI bleeding
Trauma
Ruptured AA
**_Loss of fluid_**
Dehydration
Burns
31
How do you treat hypovalaemic shock?
Identify and treat underlying cause.
Raise the legs.
Give fluids
32
WHAT IS CARDIOGENIC SHOCK?
When can it occur?
Cardiogenic shock is a state of inadequate tissue perfusion primarily due to cardiac dysfunction.
May occur suddenly or after progressively worsening heart failure
33
What are some causes of cardiogenic shock?
1. MI
2. Arrhythmias
3. PE
4. Tension pneumothorax
5. Cardiac tamponade
6. Myocarditis
7. Endocarditis
8. Aortic dissection
34
What are the symptoms for cardiogenic shock?
Low BP
High HR
High RR
Confusion
Pallor
Clammy
Pale peripheries
Reduced urine output
35
What are the investigations for cardiogenic shock?
**_ECG_**
Tachycardic
**_Blood pressure_**
Low
**_JVP pressure_**
RAISED
U&E, troponins/cardiac enzymes,
ABG
CXR
Echocardiogram
36
What is the management of cardiogenic shock?
What do you need to monitor?
Treat the cause
Oxygen
Diamorphine IV for pain and anxiety
Correct arrhythmias, U&E abnormalities or acid–base disturbance
Monitor CVP, BP, ABG, ECG, urine
37
WHAT IS SEPSIS?
Sepsis exists when a systemic inflammatory response is associated with an infection
38
What is septic shock?
Septic shock exists when sepsis is complicated by persistent hypotension unresponsive to fluid resuscitation
39
What are the risk factors for septic shock?
Age
Diabetes mellituis (DM)
Immunocompromised
Alcoholics
Burns
IVDU
Pregnancy
Catheter
40
What are the symptoms for septic shock?
Low BP
High HR
Low sats (O2)
High resp rate (RR)
Lactate \>2
Unresponsive
41
What are the investigations for septic shock?
Cultures (2 peripheral blood, plus urine/sputum/CSF)
LACTATE
ABG and BP
42
What is the treatment for septic shock?
OXYGEN
FLUIDS (check BP and ABG)
IV ANTIBIOTICS
(Tacozin and gentamicin, and vancomycin)
43
WHAT IS ANAPHYLATIC SHOCK?
Intense allergic reaction.
Massive release of histamine and other vasoactive mediators causing haemodynamic collapse.
44
What type of hypersensitivity is anaphylatic shock?
Type-I IgE-mediated hypersensitivity reaction.
45
What are some causes of anaphylatic shock?
1. Drugs, eg penicillin, and contrast media in radiology
2. Latex
3. Stings, eggs, fish, peanuts, strawberries, semen (rare)
46
What are the signs and symptoms of anaphylatic shock?
1. Itching
2. Sweating
3. Diarrhoea and vomiting
4. Erythem
5. Urticaria
6. Oedema
7. Wheeze
8. Laryngeal obstruction
9. Cyanosis
10. Tachycardia
11. Hypotension
47
What is the management of anaphylatic shock?
1. Oxygen
2. Remove the cause
3. Adrenaline IM - 500 micrograms - 1 in 1000
Repeated every 5 minutes if necessary
48
WHAT IS NEUROGENIC SHOCK?
Distributive
Disruption of the autonomic pathways within the spinal cord
49
What can cause neurogenic shock?
Spinal cord injury
Epidural
Spinal anaesthesia
50
What are the investigations for neurogenic shock?
Cold and clammy suggests cardiogenic shock or fluid loss.
Warm and well perfused, with bounding pulse points to septic shock.
Any features suggestive of anaphylaxis—history, urticaria, angio-oedema, wheeze?
CVS: usually tachycardic and hypotensive.
JVP or central venous pressure: If raised, cardiogenic shock likely.
Check abdomen: Any signs of trauma, or aneurysm? Any evidence of GI bleed?
51
What are the treatment options for neurogenic shock?
Dopamine and vasopressin (ADH).
Atropine is administered for slowed heart rate.
52
What organs are at risk of shock?
Kidneys - Acute tubular necrosis
Lung – Acute Respiratory Distress Syndrome (ARDS) (or “shock lung”)
Heart – myocardial ischaemia and infarction
Brain – confusion, irritability, coma
53
WHAT IS ACUTE RESPIRATORY DISTRESS SYNDROME?
1. Increase in alveolar permeability
2. Fluid accumilation in the alveoli
3. Not associated with cardiac causes
4. Impaired oxygenation
54
What are some causes of ARDS?
1. Infection: sepsis, pneumonia
2. Massive blood transfusion
3. Trauma
4. Smoke inhalation
5. Acute pancreatitis
6. Cardio-pulmonary bypass
55
What are the clinical features of ARDS?
1. Dyspnoea
2. Elevated respiratory rate
3. Bilateral lung crackles
4. Low oxygen saturations
56
What are the investigations for ARDS?
1. Chest x-ray
2. ABG
57
What is the management for ARDS?
1. ITU - Oxygenation/ventilation to treat the hypoxaemia
2. General organ support e.g. vasopressors as needed
3. Treatment of the underlying cause e.g. antibiotics for sepsis
4. Certain strategies such as prone positioning and muscle relaxation have been shown to improve outcome in ARDS
58
WHAT DOES CARDIOMYOPATHY REFER TO?
Primary heart muscle disease – often genetic.
Three types.
59
WHAT IS HYPERTROPHIC CARDIOMYOPATHY?
https://www.youtube.com/watch?v=8RnkKB8xvwA
Heart muscle becomes thick, heavy and hypercontactile.
60
What is Hypertrophic cardiomyopathy (HCM) caused by?
What inheritance is it?
Sarcomeric protein gene mutations.
Autosomal dominant inheritance.
61
What is the epidemology of HCM?
Leading cause of death in the young
62
What is the pathology HCM?
Asymmetric septal hypertrophy
Intervenricular septum more than free wall
Take up more room so less filling
More stiff and less compliant
Stroke volume goes down
Heart failure
LV outflow tract (LVOT) obstruction
63
What type of heart failure if HCM?
Diastolic heart failure
64
What does the obstuction of the ventricular outflow tract cause?
Pulling of the mitral valve towards the atrioventricular septum
Venturi effect
65
What kind of heart sound is heard in HCM? Where is it also seen?
Crescendo-decrescendo murmur
Aortic valve stenosis
66
What are the symptoms of HCM?
**_Sudden death._**
Fast arrythmias
Palpitations
Dyspnoea
Dizzy spells or syncope
67
What are the sings of HCM?
Jerky pulse
Double apex beat
Systolic thrill at lower left sternal edge
Harsh ejection systolic murmur
68
What are the tests for HCM?
**_Echo_**
Asymmetrical septal hypertrophy; small LV cavity with hypercontractile posterior wall; midsystolic closure of aortic valve
**_ECG_**
LVH; progressive T wave inversion; deep Q waves, AF
69
What is the treatment for HCM?
Beta-blockers or verapamil for angina + SOB.
Amiodarone for arrhythmias (AF, VT) DIGOXIN IS CONTRAINDICATED
Anticoagulate for paroxysmal AF or systemic emboli.
70
What drug is contraindicated in HCM?
Digoxin
Increase contraction force, increase obstruction
71
WHAT IS DILATED CARDIOMYOPATHY (DCM)?
Causes all four chambers of the heart to enlarge
72
What is Dilated Cardiomyopathy (DCM) often caused by?
1. Alcohol
2. Increased BP
3. Haemochromatosis
4. Viral infection
5. Autoimmune
73
What happens in Dilated cardiomyopathy (DCM)?
What type of heart failure is it?
Large space, thin walls
Weak contraction
Less blood pumped out in each beat
Biventicular congestive heart failure
Systolic heart failure
74
What type of heart sound is heard in DCM?
Holosystolic murmur
S3 sounds also present, blood slamming into wall in diastole
75
What are the symptoms of DCM?
Fatigue
Dyspnoea
Pulmonary oedema
Right ventricular failure
Emboli
Atrial fibrillation
Ventricular tachycardia
76
What are the signs of DCM?
Increased pulse
Decreased blood pressure
Increased JVP
Pleural effusion
Oedema
Jaundice, hepatomegaly, ascites
Displaced diffuse apex beat, S3 gallop
Mitral or tricuspid regurgitation
77
What are the tests for DCM?
**_Blood_**:
Plasma BNP is sensitive and specific in diagnosing heart failure.
**_CXR_**:
Cardiomegaly, pulmonary oedema.
**_ECG_**:
Tachycardia, non-specific T wave changes, poor R wave progression.
**_Echo_**:
Globally dilated hypokinetic heart and low ejection fraction. Look for MR, TR, LV mural thrombus.
78
What is the treatment for DCM?
1. **Stop drinking**
2. **Treatment of cardiac failure**
- ACE inhibitors
- Beta Blockers
- Diuretics + Digoxin
3. **Anti-arrythmic drugs**
Amiodarone
4. **Cardiac transplantation and cardiomyoplasty**
79
WHAT IS RESTRICTIVE CARDIOPATHY?
Heart muscle becomes stiff and less compliant
80
What diseases commonly cause RCM?
Amyloidosis
Familial amyloid cardiomyopathy
Afro-americans
Senile cardiac amyloidosis
Elderly
81
What are the causes of RCM?
Amyloidosis
Sarcoidosis
Collection of immune cells
Haemochromatosis
Radiation
Endocardial fibroelastosis
Loffler endomyocarditis
Eosinophils in lung tissue and heart tissue
82
What happens in amyloidosis?
Proteins that have been misfolded and become insoluble
Deposit in tissue in organs making them become less compliant
83
What is the pathology of RCM?
1. Heart muscle stays same size
2. When blood comes in heart doesn't stretch
3. Less blood
4. Less pumped out
5. = Heart failure
84
What type of heart failure is RCM?
Diastolic heart failure
85
What are the signs of RCM?
These are mainly of right heart failure with increase JVP
Kussmaul’s sign (JVP rising paradoxically with inspiration)
Quiet heart sounds
S3
Diastolic pericardial knock, hepatosplenomegaly, ascites, and oedema.
86
What are the investigations for RCM?
**_ECG_**
Low amplitude QRS
87
What is the treatment for RCM?
Treat underlying cause
Heart transplant
88
What do all cardiomyopathies carry?
An arrhythmic risk.
89
WHAT IS INHERITED ARRHYTHMIA (CHANNELOPATHY) CAUSED BY?
Ion channel protein gene mutations.
90
Which ions are involved with channelopathy?
potassium, sodium or calcium channel.
91
What do channelopathies include?
Long QT, short QT, Brugada and CPVT.
92
What do channelopathies normally present with and what do they have that is normal?
Recurrent syncope and have a structurally normal heart.
93
What is sudden cardiac death in young people normally due to? What disease is it most likely to be?
An inherited condition. Cardiomyopathy or ion channelpathy.
94
What does sudden arrhythmic death syndrome (SADS) usually refer to?
Normal heart/arrhythmia.
95
WHAT IS AN ANEURYSM?
https://www.youtube.com/watch?v=pEOqffiwE7k
Abnormal buldge in vessel
96
What are the risk factors for aneurysms?
Male
Over 60
Hypertension
Smoking
97
What are the typical causes of an anneurysm
Atheroma
Trauma
Infection
Connective tissue disorders
Inflammations
98
What is the pathology of an aneurysm?
Weakness in vessel wall
Ballooning outwards of vessel wall due to pressure
Laplace's law causes positive feedback loop
Gives bigger aneurysm
99
When is an aneurysm official labelled an aneurysm?
When the diameter exceeds 1.5 times the normal size
100
What are the common sites for anneurysms
What are the complications?
Common sites Aorta (infrarenal most common), iliac, femoral and popliteal arteries.
Complications Rupture; thrombosis; embolism; fistulae; pressure on other structures.
101
What are the different types of aneurysms?
**_True aneurysms_**
Abnormal dilatations that involve all layers of the arterial wall.
THEN EITHER
Fusiform
OR
saccular (Berry aneurysms)
**_False aneurysms (pseudoaneurysms_**)
Blood in the outer layer only (adventitia) which communicates with the lumen (eg after trauma).
102
What happens when an aneurysm explodes?
Blood spurts out of the hole
Less blood goes downstream
Ischaemia of downstream cells
103
What are the symptoms and signs of an abdominal aortic aneurysm?
Severe left flank pain
Abdomen
Chest
Lower back
Groin
Pulsating mass with heartbeat
Hypotension
104
What are the diagnosis options for an aneurysm?
Often incidental finding
Ultrasound
CT
MRI
105
What are the options for a unruptured anneurysm?
Elective surgery
Stenting
106
WHAT IS AORTIC DISSECTION?
https://www.youtube.com/watch?v=AZElPJtyxck
Tear in tunica intima, causes blood to pool between intima and media
107
What can cause aortic dissection?
**_Chronic hypetension_**
Stress
increase blood volume
Coarctation
**_Weakened aortic wall_**
Marfan's
Ehlers-Danlos syndrome
Decrease blood flow to vasa vasorums
**_Aneurysms_**
108
Where does aortic dissection normally occur?
Within the first 10cm of aorta
109
What can a aortic dissection cause?
**_Blood back up into pericardial space causing_**
Pericardial temponade
**_Blood goes out intima and comes back into blood vessel through and hole_**
**_Blood flows does the aorta inbetween the layers and puts compression on other arteries_**
Renal artery
Subclavian artery
110
What are the different types of aortic dissection?
Type A (70%) dissections involve the ascending aorta, irrespective of site of the tear,
Whilst if the ascending aorta is not involved it is called type B (30%)
111
What are the symptoms of aortic dissection?
Sharp chest pain radiating to back
Weak pulse in downstream artery
Difference in BP between left and right arms
Hypotension
Shock
112
What are the investigations for aortic dissection?
**_CXR_**
Widend aorta
**_Transoesophageal echo_**
True lumen and flase aorta
**_Angiogram_**
113
What is the management of aortic dissection?
**_Surgery_**
Removal of dissected aorta
Blocks entry of blood into wall of aorta
Wall reconstructed with synthetic graft
Stent
**_Blood pressure meds_**
Beta Blockers
114
HOW MANY LAYERS IS THE PERICARDIUM? WHAT IS THE STRUCTURE?
Two.
Visceral single cell layer adherent to epicardium
Fibrous parietal layer
2mm thick
Acellular collagen and elastin fibres
50ml of serous fluid.
115
What is contained within the pericardium? What is outside?
Great vessels lie within the pericardium
Two layers are continuous
Left atrium is mainly outside the pericardium
Parietal layer has fibrous attachments to fix the heart in the thorax.
116
Why is the pericardium important? What is important about the small reserve volume?
Restrains the filling volume of the heart.
If the volume is exceeded the pressure is translated to the cardiac chambers.
117
WHAT IS CARDIAC TAMPONADE?
Fluid builds up in the pericardium and results in compression of the heart.
118
What is the cause of cardiac tamponade?
Any pericarditis
Aortic dissection
MI
Trauma
Trans-septal puncture at cardiac catheterization
Cancer
119
What are the signs of cardiac tamponade?
Pulse increase
BP decerease
Pulsus paradoxus
JVP increase
Kussmaul’s sign
Muffled S1 and S2.
120
What is Beck's triad?
Falling BP
Rising JVP
Muffled heart sounds.
121
What are the investigations for cardiac tamponade?
**_Beck’s triad_**
Falling BP; rising JVP; muffled heart sounds.
**_CXR_**
Big globular heart (if \>250mL fluid).
**_ECG_**
Low voltage QRS ± electrical alternans.
**_Echo is diagnostic_**
Echo-free zone around the heart ± diastolic collapse of right atrium and right ventricle.
122
What is the management of cardiac temponade?
The pericardial effusion needs urgent drainage
123
What does chronic pericardial effusion have that is unique?
Pericardium slowly adapts to the increasing fluid and therefore reduces the effect on diastolic filling of the chambers.
124
WHAT IS PERICARDIAL EFFUSION?
Accumulation of fluid in the pericardial sac.
125
What are the causes of pericardial effusion?
Any cause of pericarditis.
126
What are the symptoms of pericardial effusion?
1. Dyspnoea
2. Raised JVP
3. Bronchial breathing at left base
4. Look for signs of cardiac tamponade
127
What are the investigations for pericardial effusion?
**_CXR_**
Enlarged, globular heart.
**_ECG_**
Low-voltage QRS complexes and alternating QRS morphologies (electrical alternans).
**_Echo_**
Shows an echo-free zone surrounding the heart.
128
What are the management options for pericardial effusion?
Treat the cause.
Pericardiocentesis may be diagnostic (suspected bacterial pericarditis) or therapeutic (cardiac tamponade).
129
WHAT IS ACUTE PERICARDITIS?
https://www.youtube.com/watch?v=jqClJsqnFFA
Inflammatory pericardial syndrome with or without effusion.
130
What are the causes of pericarditis?
1. Idiopathic.
2. **Viral**
Enteroviruses
Coxsackie B viruse
Herpesviruses (EBV, CMV, HHV-6),
3. **Dresseler's syndrome**
Happens after heart attack
When an MI happens lots of necrosis
This also affects the pericardium
4. **Autoimmune**
Rheumatoid arthritis
Scleraderma
SLE
131
What is the patholgy of pericarditis?
Fluid and immune cells move from tiny blood cells into the fibrous pericardium
132
What is the clinical presentation of somebody with pericarditis?
**_Fever_**
**_Chest pain_**
Worse with heavy breathing
Better with sitting up and leaning forward
133
What can a clinical diagnosis of acute pericarditis be diagnosed from?
**2 of 4 of:**
1. Chest pain.
2. Friction rub.
3. ECG changes.
4. Pericardial effusion.
134
What tests can you do to check if somebody has pericarditis?
1. **Clinical examination**
Pericardial rub
Sinus tachycardia
Signs of effusion (pulsus paradoxus, Kussmauls sign)
2. **ECG**
3. **Bloods**
FBC
Modest increase in WCC, mild lympocytosis
ESR & CRP
High ESR may suggest aetiology
ANA in young females - SLE
Troponin
Elevations suggest myopericarditis
4. **CXR**
Silouette
5. **Echocardiogram**
135
What does an ECG look like with a patient who has pericarditis?
**_First few weeks_**
Diffuse ST segment elevation
Decrease PR
**_After that_**
T waves flattened
**_After that_**
ECG returns back to normal
136
What management can help with pericarditis?
**_Sedentary activity_**
**_NSAID_**
Ibuprofen PO or Aspirin PO
**_Treat cause_**
**_Colchicine_**
PO limited by nausea and diarrhoea, reduces recurrence.
137
WHAT IS HEART FAILURE?
A symptomatic condition where breathlessness, fluid retention and fatigue are associated with a cardiac abnormality that reduces cardiac output
A state where the heart is unable to pump enough blood to satisfy the needs of metabolising tissues
138
How do you calculate cardiac output?
CO = HR x SV
139
What is the most common cause of heart failure? What does this usually result from? What are some other causes?
Myocardial dysfunction.
IHD.
Hypertension.
Alcohol excess.
Cardiomyopathy.
Valvular.
Endocardial.
Pericardial causes.
140
What is systolic heart failure?
Inability of the ventricle to contract normally, resulting in decreaed cardiac output.
Ejection fraction (EF) is \<40%
141
What are the causes of systolic heart failure?
IHD
MI
Cardiomyopathy.
142
What is diastolic heart failure?
Inability of the ventricle to relax and fill normally
Causing increased filling pressures.
EF is \>50%.
143
What are the causes of diastolic heart failure?
Constrictive pericarditis
Tamponade
Restrictive cardiomyopathy
Hypertension
144
How may left and right sided heart failure occur?
Left ventricular failure (LVF) and right ventricular failure (RVF) may occur independently, or together as congestive cardiac failure (CCF).
145
What are some causes of left sided heart failure?
Hypertension
146
What are the symptoms of left sided heart failure?
Dyspnoea,
Poor exercise tolerance
Fatigue
Orthopnoea
Paroxysmal nocturnal dyspnoea (PND)
Nocturnal cough (±pink frothy sputum)
147
What are some causes of right ventricular failure?
LVF, pulmonary stenosis, lung disease.
148
What are the symptoms of right ventricular heart failure?
Peripheral oedema (up to thighs, sacrum, abdominal wall),
Ascites
Nausea
Anorexia
Facial engorgement
Pulsation in neck and face (tricuspid regurgitation)
Epistaxis.
149
What tests can you do for heart failure?
History and physical examination
**_Blood Tests_**
BNP
LFTS, FBC, U&Es, BNP, TFTs
**_Cardiac enzymes_**
Creatinine kinase, troponin I, troponin T
CXR
ECG.
Echocardiography
150
What would you see on a chest XR for heart failure?
ABCDE
1. **A**lveolar oedema
2. Kerley **B** lines
3. **C**ardiomegaly
4. **D**ilated prominant upper lobe vessels
5. **P**leural Effusion
151
What are the systems involved with protection and survival of the heart?
**_The sympathetic system_**
Increases afterload by causing peripheral vasoconstriction
**_The renin-angiotensin-aldosterone axis_**
Salt and water retention
Increases afterload and preload (^ volume and vasoconstriction)
**_Cardiac changes_**
Ventricular dilatation
Myocytehypertrophy
152
What does an increase in cardiac norepinephrine produce? What happens in the long term?
**_Increased adrenergic activation_**
Direct toxicity to myocytes
Increased HR and contractility causing extra strain on heart
Increased vasocontriction, increased afterload, more strain on heart
153
What does angiotensin 2 produce?
Increase salt and water retention
Increased preload, extra strain on heart
154
What is the treatment for heart failure?
**_Loop diuretics_**
Furosemide
**_ACEi_**
Lisinopril
**_Beta blockers_**
Bisoprolol
**_Aldosterone antagonists_**
Spironolactone
**_Calcium glycoside_**
Digoxin inhibits Na/K
155
WHAT IS TETRALOGY OF FALLOT?
1. Pulmonary stenosis
2. RV hypertrophy
3. Overriding aorta
4. VSD
156
What are the physiology of Tetralogy of Fallot?
The stenosis of the RV outflow leads to the RV being at higher pressure than the left
Therefore blue blood passes from the RV to the LV
The patients are BLUE
Toddlers may squat
157
What is the presentation of infants in tetralogy of Fallot and why?
Infants may be acyanotic at birth
Pulmonary stenosis murmur as the only initial finding.
Cyanotic due to decreasing flow of blood to the lungs as well as right-to-left shunt across the VSD.
Toddlers may squat
Typical of TOF, as it increases peripheral vascular resistance and decreases the degree of right to left shunt.
Adult patients are often asymptomatic
158
What are the tests for tetrology of Fallot?
**_ECG_**
RV hypertrophy with a right bundle-branch block.
**_CXR_**
Boot-shaped heart
**_Echocardiography_**
Can show the anatomy as well as the degree of stenosis.
159
What is the management of tetrology of Fallot?
1. Surgical repair is often undertaken in two parts
2. Cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm
160
WHAT IS VENTRICULAR SEPTAL DEFECTS?
Hole in the connecting venticles
161
What are the different pressures in the ventricles and what is the result in VSD?
High pressure LV
Low pressure RV
Blood flows from high pressure chamber to low pressure chamber
Therefore NOT blue
Increased blood flow through the lungs
162
What are the causes of VSD?
**_Congenital_**
1. Down's syndrome
2. Edward's syndrome
3. Patau syndrome
4. cri-du-chat syndrome
**_Acquired (post-MI)._**
163
What are the ventricular septal defects clinical signs?
**_Large_**
Pan-systloic murmur varies in intensity
Small breathless skinny baby
Increased respiratory rate
Tachycardia
Big heart on chest X ray
**_Small_**
Loud systolic murmur
Thrill (buzzing sensation)
Well grown
Normal heart rate
Normal heart size.
164
What is the treatment for VSD?
**_Large_**
Require fixing in infancy (PA band, complete repair)
**_Small_**
Endocarditis risk
Need no intervention
165
What may VSD lead to?
May lead to Eisenmengers syndrome.
166
What is Eisenmengers syndrome?
1. High pressure pulmonary blood flow
2. Damages to delicate pulmonary vasculature
3. The resistance to blood flow through the lungs increases
4. The RV pressure increases
5. The shunt direction reverses
6. The patient becomes BLUE.
167
WHAT IS ATRIAL SEPTAL DEFECT?
Abnormal connection between the two atria (primum, secundum, sinus venosus)
Common
Often present in adulthood.
168
What are the two types of ASD?
Primum: present earlier, may involve AV valves
Secundum: may be asymptomatic until adulthood
169
What is the physiology of atrial septal defects?
Slightly higher pressure in the LA than the RA
Shunt is left to right
Therefore NOT blue
Increased flow into right heart and lungs
170
What is the physiology between large and small atrial septal defects?
**_Large_**
Significant increased flow through the right heart and lungs in childhood
Right heart dilatation
SOBOE
Increased chest infections
If any stretch on the right heart should be closed
**_Small_**
Small increase in flow
No right heart dilatation
No symptoms
Leave alone
NB. The shunt on small to moderate sized defects increases with age
171
What are some complications of ASD?
Reversal of left-to-right shunt, ie Eisenmenger’s complex.
Paradoxical emboli (vein to artery via ASD; rare).
172
What are the clinical signs of atrial septal defects?
Pulmonary flow murmur
Fixed split second heart sound (delayed closure of PV because more blood has to get out)
Big pulmonary arteries on CXR
Big heart on chest X ray
173
What is the treatment of ASD?
In children closure is recommended before age 10yrs.
In adults, transcatheter closure is now more common than surgical.
174
WHAT CAN ATRIA-VENTRICULAR SEPTAL DEFECTS INVOLVE?
Hole in the centre. Can involve the ventricular septum, the atrial septum, the mitral and tricuspid valves.
175
What is the physiology of atria-ventricular septal defect? For a partial and complete defect?
Complete defect –Breathless as neonate –Poor weight gain –Poor feeding –Torrential pulmonary blood flow –Needs repair or PA band in infancy –Repair is surgically challenging
Partial defect –Can present in late adulthood –Presents like a small VSD / ASD –May be left alone if there is no right heart dilatation
176
WHAT IS PATENT DUCTUS ARTERIOSUS?
Failure of ductus arterioles to close.
177
What are the clinical signs of ductus arterioles?
Continuous ‘machinery’ murmur
If large, big heart, breathless
Eisenmenger’s syndrome
–Differential cyanosis (clubbed and blue toes, but pink not clubbed fingers)
178
What is the physiology of patent ductus arterioles with a large and a small?
Large –Torrential flow from the aorta to the pulmonary arteries in infancy –Breathless, poor feeding, failure to thrive –More common in prem babies –Need to be closed (surgically) •Small –Little flow from the aorta to Pas –Usually asymptomatic –Murmur found incidentally –Endocarditis risk
179
How do you close the ductus arterioles?
Surgical or percutaneous.
Local anaesthetic.
Venous approach.
180
WHAT IS COARCTATION OF THE AORTA?
Narrowing of the aorta at the site of insertion of the ductus arterioles.
181
What is the physiology for coarctation of the aorta?
**_Severe_**
Complete or almost complete obstruction to aortic flow
Collapse with heart failure
Needs urgent repair
**_Mild_**
Presents with hypertension
Incidental murmur
Should be repaired to try to prevent problems in the long term
182
What are the clinical signs of coarctation of the aorta?
1. Infancy: heart failure
2. Adult: hypertension
3. Radio-femoral delay
4. Mid systolic murmur, maximal over back
5. Apical click from the aortic valve
6. Notching of the inferior border of the ribs (due to collateral vessels) is not seen in young children
183
What are the long term problems of coarctation of the aorta?
**_Hypertension_**
Early coronary artery disease
Early strokes
Sub arachnoid haemorrhage
Re-coarctation requiring repeat intervention
Aneurysm formation at the site of repair
184
What is the treatment of coarctation of the aorta?
1. Surgery, or balloon dilatation ± stenting.
185
WHAT IS BICUSPID AORTIC VALVE?
Normal AV valves has three cusps.
This has two
186
what are the problems associated with bicuspid AVs?
Can be severely stenotic in infancy or childhood
Degenerate quicker than normal valves
Become regurgitant earlier than normal valves
Are associated with coarctation and dilatation of the ascending aorta
187
How can you treat bicuspid aortic valve?
Surgery
188
WHAT IS PULMONARY STENOSIS?
Narrowing of the outflow of the right ventricle.
Valvar.
Sub valvar.
Supra valvar.
Branch.
189
What are the problems with pulmonary stenosis?
Severe
–Right ventricular failure as neonate
–Collapse
–Poor pulmonary blood flow
–RV hypertrophy
–Tricuspid regurgitation
Moderate / mild
–Well tolerated for many years
–Right ventricular hypertrophy
190
What is the treatment for pulmonary stenosis?
Treatment
–Balloon valvuloplasty
–Open valvotomy
–Open trans-annular patch
–Shunt (to bypass the blockage)
191
WHAT IS HYPERTENSION?
Over 140/90
192
What are the two types of hypertension?
Essential hypertension (primary, cause unknown). ~95% of cases.
Secondary hypertension ~5% of cases.
193
What are some causes of secondary hypertension?
**_Renal_**
CKD
**_Endocrine disease_**
Conn’s syndrome
**_Others_**
Coarctation, pregnancy
194
What are the tests for hypertension?
**_24hr ambulatory BP monitor_**
**_Multiple home BP monitoring_**
**_Fundoscopy–in severe HTN_**
Bilateral retinal haemorrhages
Papilloedema
**_Overall CVD risk_**
Fasting glucose
Cholesterol
**_End Organ Damage_**
12 lead ECG –past MI, LV hypertrophy
Urine analysis –protein, blood
195
What are some lifestyle to lower blood pressure?
Stop smoking
Low-fat diet
Reduce alcohol and salt intake
Increase exercise
Reduce weight if obese
196
What do you give for hypertension if they are over 55 or afro-carribean?
**_Calcium channel blocker_**
Amlodipine
Nifedipine
Verapamil
197
What do you give for hypertension if they are below 55 and not afro-carribean?
**_ACE inhibitor_**
Ramapril
Peridopril
OR
**_Angiotensin receptor blocker_**
Candesartan
Valsartan
198
What do you give them if their drug doesn't work?
The other one
199
What do you give them if all their drugs don't work?
**_Thiazide like diuretic_**
Chlorothiazide
Hydrocholrothiazide
200
How can renal artery stenosis cause hypertension?
Less blood flow to kidneys
Secretes Renin
More water and salt retention
Higher BP
201
What is a pheochromocytoma? How does it cause hypertension?
Tumour on adrenal glands
Constantly produce catecholamines (e.g. adrenaline)
Increase heart rate and peripheral vascular resistance
Increase BP
202
How does cushing's cuase hypertension?
Enhances adrenalines effect on blood vessels to constrict them
Also can act as a mineralacorticoid (aldosterone)
Increase BP
203
How does Conn's syndrome cause hypertension?
High aldosterone
Increased sodium and water retention
Increased BP
204
WHAT IS AORTIC STENOSIS?
Hardening of the aorta
205
What is the cause of aortic valve stenosis
1. Congenital bicuspid valve
2. Degenerative calcification
3. Rheumatic Heart disease
206
What is rheumatic heart disease?
Fusion of cusps.
207
How does a person with aortic stenosis present?
Syncope
Angina
Dyspnoea
Sudden death
208
What physical signs would you hear on aortic stenosis?
1. **Narrow pulse pressure**
* ****Slow rising carotid pulse (pulsus tardus)
* & decreased pulse amplitude (pulsus parvus)
2. **Heart sounds**
* Soft or absent second heart sound, S4 gallop due to LVH.
3. **Ejection systolic murmur**
* Crescendo-decrescendo character.
209
What tests would you do for someone with aortic stenosis?
Echocardiography
Two measurements obtained are:
Left ventricular size and function: LVH, Dilation, and EF
Doppler derived gradient and valve area (AVA).
ECG
CXR –LVH, calcified aortic valve
210
What is the management for aortic stenosis?
**_General:_**
Fastidious dental hygiene / care
Consider IE prophylaxis in dental procedures
**_Medical_** - limited role since AS is a mechanical problem. Vasodilators are relatively contraindicated in severe AS
**_Surgical Replacement_**: Definitive treatment
**_TAVI_** – Transcatheter Aortic Valve Implantation
211
WHAT IS MITRAL VALVE REGURGITATION?
Definition: Backflow of blood from the LV to the LA during systole
Mild (physiological) MR is seen in 80% of normal individuals.
212
What are the aetiologies of chronic mitral valve regurgitation?
Myxomatous degeneration (MVP)
Ischemic MR
Rheumatic heart disease
Infective Endocarditis.
213
What is the pathophysiology of mitral valve regurgitation?
Pure Volume Overload
Compensatory Mechanisms: Left atrial enlargement, LVH and increased contractility
Progressive left atrial dilation and right ventricular dysfunction due to pulmonary hypertension.
Progressive left ventricular volume overload leads to dilatation
214
What are the symptoms of mitral valve regurgitation?
**Mainly asymptomatic**
Exertion dyspnoea –exercise intolerance
Palpitations
Fatigue
215
What are the signs of mitral valve regurgitation?
Pansystolic murmur at apex radiating to axilla
Soft S1
Displaced hyperdynamic apex
216
What do imaging studies for mitral regurgitation show?
ECG: May show, LA enlargement, atrial fibrillation and LV hypertrophy with severe MR
CXR: LA enlargement, central pulmonary artery enlargement.
ECHO: Estimation of LA, LV size and function. Valve structure assessment TOE v helpful
217
What are the medications/management for MR?
Vasodilator –ACEi, hydralazine
Rate control for AF –BB, CCB, Digoxin
Anticoagulant for AF and flutter
Diuretics –to control symptoms
Surgery for deteriorating symptoms –aim to replace valve
218
What are the indications for surgery of severe MR?
ANY Symptoms at rest or exercise with (repair if feasible)
Asymptomatic:
If EF \<60%, LVESD \>45mm
If new onset atrial fibrillation/raised PAP.
219
WHAT IS AORTIC VALVE REGURGITATION?
Leakage of blood into LV during diastole due to ineffective coaptation of the aortic cusps.
220
What is the cause of AR?
Bicuspid aortic valve
Rheumatic
Infective endocarditis.
221
What is the pathophysiology of AR?
Combined pressure AND volume overload
Compensatory Mechanisms: LV dilation, LVH
Progressive dilation leads to heart failure
222
What are the symptoms of aortic valve regurgitation?
Exertional dyspnoea
Orthopnoea
Paroxysmal nocturnal dyspnoea
223
What are the signs or aortic regurgitation?
Collapsing (water hammer) pulse
Wide pulse pressure
Displaced hyperdynamic apex beat
Early diastolic murmur
**_Notable eponyms_**
Corrigans sign (ear movements)
De Musset’s sign (head movements)
Duroziez’s sign (Femoral artery murmur)
Austin flint murmur (cardiac apex murmur)
Traube’s sign (pistol shot over femoral)
224
What would cardiac tests show you for AR?
**_CXR_**
Cardiomegaly
**_ECHO_**
LV dilation and hypertrophy
225
What is the management for AR?
**_Vasdilators_**
ACEi only if symptomatic or HTN
**_Surgical_**
Replace valve before LV dysfunction
226
WHAT IS MITRAL VALVE STENOSIS?
Obstruction of LV inflow that prevents proper filling during diastole
227
What is the aetiology of mitral valve stenosis?
Rheumatic heart disease
Infective endocarditis
Mitral annular calcification.
228
What is mitral valve stenosis pathophysiology?
LA dilation incerease pulmonary congestion (reduced emptying)
Increased Transmitral Pressures
Leads to left atrial enlargement and atrial fibrillation.
Right heart failure symptoms: due to Pulmonary venous HTN
229
What are the symptoms of mitral valve stenosis?
1. Dyspnoea
2. Fatigue
3. Palpitations
4. Chest pain
230
What are the signs in mitral valve stenosis?
Malar flush on cheeks
Low volume pulse
Tapping, non displaced apex beat
Rumbling mid-diastolic murmur
Loud opening S1
231
What tests can you do on mitral valve stenosis and what will they show?
**_ECG_**
May show atrial fibrillation and LA enlargement
**_CXR_**
LA enlargement and pulmonary congestion
Occasionally calcified
**_MV ECHO_**
The GOLD STANDARD for diagnosis
Asses mitral valve mobility, gradient and mitral valve area
232
How would you manage a patient with mitral valve stenosis?
If in AF, rate control
Anticoagulatewith warfarin
Diuretics
Percutaneous mitral balloon valvotomy
233
WHAT IS INFECTIVE ENDOCARDITIS?
Infection of heart valve/s or other endocardial lined structures within the heart.
234
What is the most causative organism in infective endocarditis?
Staph aureus - MOST COMMON and in IVDU or prosthetic valves
Strep viridans
Staph epidermis - prosthetic valves
235
What are the different types of infective endocarditis?
Left sided native IE (mitral or aortic) Left sided prosthetic IE Right sided IE (rarely prosthetic as rare to have PV or TV replaced) Device related IE (pacemakers, defibrillators, with or without valve IE Prosthetic; can be Early (within year) or Late (after a year) post op Each type can have different presentations, pathogens and outcomes.
236
How do you catch infective endocarditis?
Have an abnormal valve; regurgitant or prosthetic valves are most likely to get infected. Introduce infectious material into the blood stream or directly onto the heart during surgery Have had IE previously
237
Who does infective endocarditis affect?
the elderly (in an ageing population) the young i.v. drug abusers the young with congenital heart disease. Anyone with prosthetic heart valves.
238
What is the clinical presentation of infective endocarditis?
Depends on site, organism, etc Signs of systemic infection (fever, sweats, etc) Embolisation; stroke, pulmonary embolus, bone infections, kidney dysfunction, myocardial infarction Valve dysfunction; heart failure, arrythmia
239
How do you diagnose somebody with infective endocarditis?
2 Major Criteria Bugs grown from blood cultures evidence of endocarditis on echo, or new valve leak 5 Minor Criteria Predisposing factors Fever Vascular phenomena Immune phenomena Equivocal blood cultures. Definite IE 2 major, 1 major+3 minor, 5 minor Possible IE 1 major, 1 major+3 minor, 5 minor.
240
What test can you do for infective endocarditis?
ECG (ischemia or infarction, new appearance of heart block) Transthoracic echo (TTE). Safe, non-invasive, no discomfort, often poor images so lower sensitivity. Transoesophageal (TOE/TEE). Excellent pictures as long as you don’t mind having a big tube pushed down your throat. Patients rarely want to have a second TOE. Generally safe but risk of perforation or aspiration. Easiest if ventilated (but never ventilate just for TOE)
241
What are some peripheral stigmata of infective endocarditis?
1. Petechiae 10 to 15%
2. Splinter hemorrhages
3. Osler’s nodes (small, tender, purple, erythematous subcutaneous nodules are usually found on the pulp of the digits)
4. Janeway lesions are erythematous, macular, nontender lesions on the fingers, palm, or sole
5. Roth spots on fundoscopy.
242
How can you diagnose infective endocarditis?
1. Blood cultures
2. Echo
3. Urine - microscopic haematuria and proteinuria are common
243
How can you treat infective endocarditis?
**Native valve endocarditis (NVE):**
1. IV amoxicillin + gentamicin
2. If penicillin allergic: IV vancomycin
**Prosthetic valve endocarditis:**
1. IV vancomycin, gentamicin + rifampacin
244
When do you operate on somebody with infective endocarditis?
the infection cannot be cured with antibiotics (ie recurs after treatment, or CRP doesn’t fall) complications (aortic root abscess, severe valve damage to remove infected devices (always needed) to replace valve after infection cured (may be weeks/months/years later To remove large vegetations before they embolise
245
WHAT IS PERIPHERAL VASCULAR DISEASE?
https://www.youtube.com/watch?v=rTbIazck7rk&t=229s
Blood vessels outside of your heart and brain to narrow, block, or spasm.
246
What are the three patterns of disease seen in PVD?
1. Intermittent cludication
2. Critical limb ischaemia
3. Acute limb-threatening ischaemia
247
What is the classification of PVD called?
What do the numbers mean?
**_Fontaine_**
1 Asymptomatic
2 Intermittent claudication
3 Ischaemic rest pain
4 Ulceration/gangrene (critical ischaemia)
248
What is claudication?
Intermittent claudication is a cramp-like, muscular pain in the calf, brought on by exercise and relieved only by rest.
249
What are the symptoms of claudication?
Intermittent claudication: aching or burning in the leg muscles following walking
Patients can typically walk for a predictable distance before the symptoms start
Usually relieved within minutes of stopping
Not present at rest
250
What are the investigations for claudication?
**ABPI**
Normal is 1-1.2; PAD is 0.5-0.9 gangene\<0.5
**Colour Duplex USS**
Quick and non-invasive, can show vessels and blood flow within them
**MR/CT angiography**
Identify stenosesand quality of vessels.
**Blood tests**
Raised CK-MM, shows muscle damage
251
What is the management for claudication?
**Medications**
1st line - Clopidogrel
**Risk factor modification**
Quit smoking, treat HTN, lower cholesterol, improve DM control, lower fat diet.
**Exercise programmes**
Reduce claudication by improving blood flow.
**PTA or surgery if severely stenosed**
252
WHAT IS CRITICAL LIMB ISCAHEMIA?
Critical limb ischaemia results from severe peripheral arterial disease
253
What are the symptoms of critical limb ischaemia?
Pale
Pulseless
Painful
Paralysed
Paraesthetic
'Perishing with cold'
254
What are the investigations for ctitical limb ischaemia?
Handheld arterial Doppler examination.
If Doppler signals are present, an ankle-brachial pressure index (ABI) should also be obtained.
255
What is the management for critical limb ischaemia?
**Initial management**
* ABC approach
* Analgesia: IV opioids are often used
* IV unfractionated heparin is usually given to prevent thrombus propagation
* Vascular review
**Definitive management:**
* Intra-arterial thrombolysis
* Surgical embolectomy
* Angioplasty
* Bypass surgery
* Amputation: for patients with irreversible ischaemia
256
What is critical limb ischaemia due to?
May be due to a thrombosis (in ‘vasculopaths’), emboli, graft occlusion or trauma
257
What drugs cuase prolongation of QT interval?
Amiodarone
Tricyclic antidepressants, selective serotonin reuptake inhibitors (especially citalopram)
Methadone
Erythromycin
Haloperidol
Ondanestron
