Cardio Flashcards
(162 cards)
1
Q
Stroke volume eqn
A
EDV- ESV
2
Q
CO eqn
A
HR xSV
3
Q
BP eqn
A
CO x TPR
4
Q
PP eqn
A
SP - DP
5
Q
MAP eqn
A
DP + 1/3PP
6
Q
Ejection fraction eqn
A
SV/EDV
7
Q
Ohm’s Law
A
F = Pressure difference/R
8
Q
Poiseuille law
A
Q = Pi(Pressure difference) r^4 /8nl
9
Q
Preload
A
Volume of blood in ventricles before they contract
10
Q
Afterload
A
Force against which the ventricles must contract to expel blood out of ventricles
11
Q
Contractility
A
Inherent strength and vigor of the heart’s contraction during systole
12
Q
Elasticity
A
Ability of heart to return to its normal shape after stretching by recoiling once the force is removed
13
Q
Compliance
A
How easily the heart will stretch when filled with a volume of blood
14
Q
Resistance
A
Force that must be overcome to push blood through the circulatory system
15
Q
Atherosclerosis
A
Deposition of fatty deposits in the artery walls and hardening/stiffening of blood vessel walls
16
Q
Where does atherosclerosis affect
A
Medium and large arteries
,mainly affecting Cx, LAD, RCA
17
Q
Structure of atherosclerotic plaque
A
Lipid
Necrotic Core
Connective tissue
Fibrous Cap
18
Q
Atherosclerosis formation
A
- Endothelial dysfunction
- High levels of LDL in blood
- Inflammation
- Macrophages take up oxidised LDLs, to form foam cells
- Foam cells promote migration of SMC from tunica media to intima. When they die, lipid content released causing plaque growth
- Formation of fatty streak in intimal layer
- Activated macrophages release cytokines and growth factors
- Smooth muscle proliferation around lipid core, leading to formation of fibrous cap
19
Q
Three main things atherosclerosis causes
A
Stiffening -> HTN
Stenosis -> Ischaemia -> angina
Plaque rupture -> thrombus -> ischaemia -> ACS
20
Q
Hypertrophic Cardiomyopathy?
A
Marked ventricular hypertrophy in the absence of abnormal loading conditions such as hypertension and valvular disease
21
Q
Hypertrophic Cardiomyopathy
A
Second most common cardiomyopathy after dilated
Most common cause of sudden cardiac death in young
22
Q
Inheritance pattern Hypertrophic Cardiomyopathy
A
Autosomal dominant
23
Q
Pathophysiology hypertrophic cardiomyopathy
A
Caused by sarcomeric gene mutations
They hypertrophic, non compliant ventricles impair diastolic filling causing reduced SV and CO
Disarray of cardiomyocytes so conduction is affected
24
Q
Hypertrophic Cardiomyopathy presentation
A
Asymptomatic
SOB, Angina, Syncope
25
Hypertrophic Cardiomyopathy investigation
ECG (LVH hypertrophy- Progressive T wave inversion and deep Q waves)
ECHO and MRI show ventricular hypertrophy, MRI shows fibrosis
Genetic Analysis
26
Hypertrophic Cardiomyopathy management
Amiodarone (risk of arrhythmia)
| B blockers, verapamil (Chestpain dyspnoea)
27
Hypertrophic Cardiomyopathy complications
Sudden death, cardiac arrhythmias, thromboembolisms, infective endocarditis, heart failure
28
Dilated Cardiomyopathy
Dilated left ventricle that contracts poorly
29
Dilated Cardiomyopathy epidemiology
Most common cardiomyopathy
30
Inheritance pattern dilated cardiomyopathy
Autosomal dominant
31
Dilated Cardiomyopathy causes
Genetic
Alcohol
Ischaemia
Thyroid Disorder
32
Dilated Cardiomyopathy pathophysiology
Cytoskeleton gene mutations
| Poorly generated contractile force leads to progressive dilation of heart with some diffuse interstitial fibrosis
33
Dilated Cardiomyopathy presentation
SOB
Fatigue
Heart Failure
Embolism from mural thrombus
34
Dilated Cardiomyopathy investigations
CXR - Cardiac enlargement
ECG - Arrhythmia, t wave flattening
Echo - Dilated ventricles
35
Dilated Cardiomyopathy management
HF and AF treated in conventional way
36
Restricted Cardiomyopathy
condition where the chambers of the heart become stiff over time.
37
Restricted Cardiomyopathy causes
Amyloidosis
Idiopathic
Sarcoidosis
End-myocardial fibrosis
38
Restricted Cardiomyopathy pathophysiology
Normal/decreased ventricular volume with bi-atrial enlargement, normal wall thickness, normal cardiac valves and impaired ventricular filling
Restrictive physiology
Poor dilation of the heart restricts the ability of the heart to pump blood to the rest of the body
39
Restricted Cardiomyopathy presentation
SOB
Fatigue
Embolic symptoms
40
Restricted Cardiomyopathy investigations
CXR
Echo (abnormal but non-specific)
Cardiac Catheterisation
41
Restricted Cardiomyopathy management
None, poor prognosis
42
Arrhythmogenic right ventricular cardiomyopathy
progressive fatty and fibrous replacement of ventricular myocardium
43
Arrhythmogenic right ventricular cardiomyopathy inheritance pattern
Autosomal dominant with incomplete penetrance but can be recessive
44
Arrhythmogenic right ventricular cardiomyopathy presentations
Arrhythmia
Syncope
RHF
45
Arrhythmogenic right ventricular cardiomyopathy investigation
ECG (T wave inversion)
Echo (normal/right ventricular dilation)
Genetic testing
46
Arrhythmogenic right ventricular cardiomyopathy management
Beta blockers
Amiodarone
Cardiac transplant
47
Atherosclerosis Risk factors
Older age
FHx
Male
```
Smoking
Alcohol
poor diet (reduced veg, omega 3, high salt)
Low exercise
obesity
Poor sleep
Stress
```
48
Medical co-morbidities increasing risk of atherosclerosis
```
Diabetes
HTN
CKD
Inflammatory conditions i.e. RA
Atypical antipsychotics
```
49
End results of Atherosclerosis
```
Angina
MI
TIA
Stroke
PVD
MI
```
50
Primary Prevention Cardiovascular disease
Do a Q risk score
If more than 10%, offer a statin, 20mg at night
All patients with CKD/T1DM for >10 years should be offered too
51
Secondary prevention Cardiovascular disease
Aspirin (and second antiplatelet (clopidogrel)
Atorvastatin (80mg)
Atenolol (100mg once daily) /other B-blockers (5-10mg once daily)
ACE inhibitor (Ramipril 1.25mg once daily)
52
Side effects of statin
myopathy
T2DM
Haemorrhagic strokes
53
Primary cause of IHD
atherosclerosis
54
IHD epidemiology
Largest cause of death in UK
55
IHD RF
Age, Gender, FHx
Smoking, HTN, Obesity, DM, Sedentary lifestyle, High Fat, low antioxidant, stress, alcohol, high coagulation factors
56
Angina presentation and classifications
1. Constricting discomfort in chest, neck, shoulder, jaw
2. Precipitated by exertion
3. Relieved by rest/GTN
all 3= typical angina
2 = atypical angina
1/0 = non-anginal pain
57
IHD investigations
```
ECG (normal-
Lipid profile (may be increased)
FBC (exclude anaemia)
HBA1C (exclude DM)
CT coronary angiography (may show narrowed/blocked areas on vessel)
```
58
IHD treatment
Antiplatelet (aspirin/clopidogrel)
Statin
HTN control
Angina control
GTN spray
Beta blockers
```
Secondary
Aspirin
Atorvastatin
ACEi
PCI/CABG if extensive
```
59
Angina DDx
```
Pericarditis
PE
Chest Infection
Dissection of aorta
GORD
```
60
Angina features
```
Central, retrosternal pain
Crushing
Radiates to arms and neck
Exacerbated by cold, exertion, large meal
Relieved with rest
```
61
Causes of Prinzmetal's angina
Coronary artery spasm
62
Cardiac syndrome X?
patients with symptoms of angina, positive exercise test but normal coronary arteries
63
Angina investigations
```
ECG (possible ST depression, T wave flattening/incersion)
Exercise ECG positive
FBC (exclude anaemia)
U+E (prior to ACEi)
LFT (prior to statin)
Lipid profile
TFT (check hypo/hyper)
HBA1C (exclude diabetes)
CT coronary angiography
```
64
Angina Management
RAMP
Refer to cardiology if unstable
Advise about diagnosis, management and when to call ambulance
Medical treatment
Procedural/surgical intervention
65
Medical management Angina
GTN (immediate symptomatic relief)
```
Beta blocker (long term symptomatic relief)
CCB
```
```
Secondary prevention
Aspirin
Atorvastatin
ACEi
Already on Beta blocker
```
66
Surgical interventions Angina
PIC
| CABG
67
ACS DDx
```
Angina
Pericarditis
Aortic Dissection
Pulmonary Embolism
GORD
```
68
RCA supply
Right atrium
Right ventricle
Inferior aspect of left ventricle
Posterior septal area
69
Cx supply
Left atrium
| Posterior aspect of left ventricle
70
LAD supply
Anterior aspect of left ventricle
| Anterior aspect of septum
71
Types of ACS
Unstable angina
STEMI
NSTEMI
72
If there is a new left bundle branch block and suspected ACS diagnosis?
STEMI
73
If ST elevated suspected ACS dx?
STEMI
74
Raised Troponin with ST depression/T wave inversion/ pathological Q wave dx?
NSTEMI
75
Troponin levels normal, normal ECG ddxs?
Unstable angina, MSK chest pain
76
ACS symptoms
```
Central constricting chest pain
Nausea vomiting
Sweaty, clammy
Feeling of impending doom
SOB
>20 mins
Palpitation
Radiation to jaws, arms
```
77
ACS investigations
ECG
Troponin
CXR (look for oedema)
```
FBC
U+E
LFT
Lipid
TFT
HBA1C
Echo (functional damage assessment)
CT coronary angiogram
```
78
ECG changes in STEMI
ST segment elevation
| New Left Bundle Branch Block
79
ECG changes NSTEMI
ST segment depression
Deep T wave inversion
Pathological Q waves
80
heart area, ECG leads for LCA
Anterolateral
I, aVL, V3-6
81
heart area, ECG leads for LAD
Anterior V1-4
82
heart area, ECG leads for LCx
Lateral
I, aVL, V5-6
83
heart area, ECG leads for RCA
Inferior
II, III, aVF
84
What does a rise in troponin mean and when can it be raised
Proteins released from ischemic muscle
```
Chronic Renal Failure
Sepsis
Myocarditis
Aortic Dissection
Pulmonary Embolism
```
85
ACUTE STEMI treatment
PCI if <2hrs of presentation
Thrombolysis if PCI not available within 2hrs
Advice on aspirin and ticagrelor
86
Acute NSTEMI management
```
Betablockers
Aspirin (300mg stat)
Ticagrelor (180mg stat)
Morphine
Anticoagulant (Fondaparinux unless high risk bleeding)
Nitrates
```
87
How to assess PCI in NSTEMI
GRACE Score
88
GRACE score for NSTEMI
5% low risk
5-10& medium
>10% high
```
Low = ticagrelor aspirin
Medium/high = angiography + PCI + Prasugrel and aspirin
```
89
Complications of MI
```
Death
Rupture of heart septum and papillary muscles
Edema (HF)
Arrhythmia and Aneurysm
Dressler's Syndrome
```
90
Dressler's Syndrome onset
Usually 2-3 weeks after MI
91
What is the cause of Dressler's and what does it cause
Localised immune response, causes pericarditis
92
Dressler's syndrome presentation
Pleuritic chest pain
Low grade fever
Pericardial rub on auscultation
Possibly Pericardial effusion
Rarely Pericardial tamponade
93
Dressler's syndrome diagnosis?
ECG (ST elevation, T wave inversion)
Echo (pericardial effusion)
Raised ESR, CRP
94
Dressler's syndrome management
NSAIDs
SEVERE: Steroids,
May need pericardiocentesis
95
ACS Secondary prevention
Aspirin (75mg OD)
Another antiplatelet (clopidogrel,ticagrelor)
Atorvastatin (80mg)
ACEi
Atenolol/other BB
Aldosterone antagonist (for those with clinical heart failure)
96
Differential diagnosis MI (4)
Angina
Pneumonia
Pneumothorax
GORD
97
MI pathophysiology
Rupture of vulnerable fibrous plaque cap. Results in arterial occlusion resulting in myocardial necrosis.
98
MI presentation (7)
```
Pale, Grey, Sweaty
Nausea, vomiting
Brady/tachycardia
Central Chest pain (radiates to arm, jaw, neck)
Hypotension
Pulmonary oedema
Arrythmias
SOB
```
99
MI investigations (5)
Clinical history
STEMI on ECG (ST elevation, Tall T waves, LBBB, T wave inversion and pathological Q waves follows)
NSTEMI - ST depression
Troponin
CXR
Bloods (FBC, U+E, Glucose, Lipids)
100
Management MI acute (5)
MONAC
101
LVF triggers (4)
Iatrogenic (aggressive IV fluids in frail elderly)
Sepsis
MI
Arrythmia
102
Presentation LVF (9)
SOB
Cough (frothy white/ pink sputum)
Tachycardia
Tachypneic
Chest pain in ACS
Fever in Sepsis
Palpitations in arrhythmias
If with RHF
Peripheral oedema
Raised JVP
103
Clinical signs LVF (8)
```
Tachypneic
Tachycardia
Reduced O2 sats
3rd Heart Sound
Bilateral basal crackles
Hypotension in severe cases
```
IF with RHF
Raised JVP
Peripheral oedema
104
LVF investigations (8)
```
History
Clinical examination
ECG (look for ischemia, arrhythmia)
ABG
CXR (ABCDE)
Bloods
BNP
Echocardiography ( ejection fraction should be >50% in normal)
```
105
Cardiomegaly definition
Cardiothoracic ration of > 0.5
106
LVF management
POUR SOD
Pour/remove IV fluids
Sit Up
Oxygen (if falling <95%)
Diuretics (IV 40 mg stat)
Monitor fluid balance
107
Why sit patients up if LVF
When lying flat the fluid in the lungs spreads to a larger area. When upright gravity takes it to the bases leaving the upper lungs clear for better gas exchange
108
Cor pulmonale?
R sided HF caused by respiratory disease. The increased pressure and resistance in the pulmonary arteries results in the right ventricle being unable to effectively pump blood out.
109
Respiratory causes of Cor pulmonale (5)
```
COPD
Pulmonary Embolism
Interstitial lung disease
Cystic fibrosis
Primary pulmonary hypertension
```
110
Usual PCs RHF (4)
SOB
Chest pain
Peripheral oedema
Syncope
111
RHF management
Treat symptoms and underlying cause
LTOT usually used
112
HF?
Inability of heart to deliver blood and 02 at a rate that is commensurate with the requirement of metabolizing tissue of the body
113
HF epidemiology
Annual incidence of 10% >65 years
| 50% die in 5 years
114
RF HF (5)
```
>65
African
Obesity
Male
History of MI
```
115
Main Causes of HF (3)
IHD
Cardiomyopathy (dilated)
HTN
116
HF pathophysiology
Activation of sympathetic nervous system: Increased contractility and HR, Constriction of venous capacitance vessels redistribute flow centrally and increase preload, also leads to increase of afterload by arteriolar constriction
Outflow resistance: When there is an increase in afterload there is an increase in EDV and decreased SV and hence CO
RAAS: Reduced CO and increased sympathetic tone leads to diminished renal perfusion thereby activating RAAS and fluid retention.
117
HF presentation (5)
```
Fatigue
SOB
Peripheral oedema
Orthopnoea
Paroxysmal nocturnal dyspnoea
```
118
HF clinical signs (8)
* Tachycardia
* Elevated JVP
* Tender hepatomegaly
* Cardiomegaly
* Displaced Apex beat
* Third & Fourth heart sounds
* Pleural Effusion
* Hypotension
119
HF investigations
Bloods (BNP)
ECG (for underlying cause MI)
CXR (ABDCE)
Echocardiogram (Assess ventricular and systolic functioning)
120
Causes of PND (3)
Firstly, fluid settling across a large surface area of their lungs as they sleep lying flat. As they stand up the fluid sinks to the lung bases and their upper lungs clear and can be used more effectively.
Secondly, during sleep the respiratory centre in the brain becomes less responsive so their respiratory rate and effort does not increase in response to reduced oxygen saturation like it normally would when awake. This allows the person to develop more significant pulmonary congestion and hypoxia before waking up and feeling very unwell.
Thirdly, there is less adrenalin circulating during sleep. Less adrenalin means the myocardium is more relaxed and this worsens reduces the cardiac output.
121
Chronic HF causes (4)
* Ischaemic Heart Disease
* Valvular Heart Disease (commonly aortic stenosis)
* Hypertension
* Arrhythmias (commonly atrial fibrillation)
122
Chronic HF management
Based on NICE guidelines 2018.
Refer to specialist (NT-proBNP > 2000ng/L warrants urgent referral)
Medical management
Surgical treatment (aortic stenosis/mitral regurgitation)
```
Additional management:
• Yearly flu and pneumococcal vaccine
• Stop smoking
• Optimise treatment of co-morbidities
• Exercise at tolerated
```
First Line Medical Treatment (ABAL)
ACE inhibitor (e.g. ramipril titrated as tolerated up to 10mg once daily)
Beta Blocker (e.g. bisoprolol titrated as tolerated up to 10mg once daily)
Aldosterone antagonist when symptoms not controlled with A and B (spironolactone or eplerenone)
Loop diuretics improves symptoms (e.g. furosemide 40mg once daily)
123
HF management considerations
Aldosterone antagonists are used when there is a reduced ejection fraction and symptoms are not controlled with an ACEi and beta blocker.
Patients should have their U&Es monitored closely whilst on diuretics, ACE inhibitors and aldosterone antagonists as all three medications can cause electrolyte disturbances.
124
HTN?
High blood pressure
125
Causes of HTN
Renal disease
Obesity disease
Pregnancy induced HTN/ pre-eclampsia
Endocrine *Conns
126
Complications of HTN
IHD
Cerebrovascular accident *stroke/haemorrhage
HTN retinopathy, nephropathy
HF
127
HTN stages
S1: >140/90 - >135/85
S2: >160/100 - >150/95
S3: >180/120
128
HTN investigations
Clinical blood pressure , ambulatory blood pressure
End organ damage
Urine albumin creatinine ration (proteinuria)
Dipstick (haematuria)
Bloods (GFR, Hb)
ECG (LVH/MI)
Echocardiography
Fundus examination
Bloods (HBA1c, renal function, lipids)
129
Which patients receive ACEi/ARB for HTN as first step
HTN with T2DM
| HTN without T2DM but <55 and not of african carribean/black origin
130
What is U+E S/E of thiazide
Causes hypokalaemia
131
BP Target for those < and > 80 years
140/90 and 150/90
132
What causes first heart sound
Closure of AV valves at the start of ventricular systole
133
What causes second heart sound
Closure of SLV once systolic contraction is complete
134
When is the 3rd heart sound heard?
0.1s after 2nd heart sound
135
Causes of 3rd heart sound
Rapid Ventricular filling causing chordae tendinae to pull to their full length
136
What is a 3rd heart sound an indication of?
In young 15-40 normal
| In older patients indicates HF as ventricles and chordae are stiff and weak
137
4th Heart sound?
heard directly before s1, indicates a stiff/hypertrophic ventricle caused by turbulent flow from atria contracting against non-compliant ventricle
138
Where to listen for heart murmurs
Pulmonary: 2nd ICS LSB
Aortic: 2nd ICS RSB
Tricuspid: 5th ICS LSB
Mitral: 5th ICS mid clavicular line
139
Where to listen to S1 and S2
Erb's point, third intercostal space on LSB
140
What does mitral stenosis cause
Left atrial hypertrophy
141
What does Aortic stenosis cause
Left ventricular hypertrophy
142
What does mitral regurgitation and aortic regurgitation cause
Left atrial and ventricular dilatations
143
Mitral stenosis RF
Rheumatic fever
| Untreated Strep infections
144
Murmur for mitral stenosis
Mid-diastolic, low pitched "rumbling" murmur due to low velocity blood
145
Mitral stenosis presentation (6)
```
Progressive SOB
Cough
Haemoptysis
Malar flush
Atrial fibrillation
Pulmonary HTN leading to RHF causing fatigue and lower limb oedema
```
146
Why does mitral stenosis cause AF
struggles in pushing blood through stenotic valve causes strain, electrical disruption resulting in fibrilaltion
147
Mitral stenosis investigations
CXR: enlarged LA, pulmonary oedema
ECG: AF, LA hypertrophy resulting in bidid P wave
Echo: diagnostic, assess severity
148
Mitral stenosis treatment
B blockers HR control
Diuretics for fluid overload
Percutaneous balloon valvotomy to increase size of mitral valve opening
Mitral valve replacement
149
Mitral regurgitation sound
Pan-systolic, high pitched murmur due to high velocity blood flow
150
Mitral regurgitation signs
Pan systolic high pitched murmur
Radiates to left axilla
May hear a third heart sound
151
Mitral regurgitation causes
```
Idiopathic
IHD
IE
RHD
Connective tissue: EDS, MS
```
152
Mitral regurgitation investigations
CXR, ECG (signs of enlarged LA /and LV
Echo
Doppler and colour flow doppler
153
Mitral regurgitation management
Diuretics and ACEi
| Surgical intervention if severe/symptomatic
154
Aortic stenosis sound
Ejection-systolic, high pitched murmur with crescendo-decrescendo character due to speed of blood flow across the valve
155
Aortic stenosis signs
Ejection systolic, high pitched murmur with crescendo-decrescendo character
Murmur radiates to carotids
Slow rising pulse and narrow pulse pressure
156
Aortic stenosis causes
Idiopathic age related calcification
| RHD
157
Aortic stenosis investigations
CXR
ECG
Echo
158
Aortic stenosis management
Aortic valve replacement if symptomatic
| TAVI
159
Aortic regurgitation sound
Early diastolic, soft murmur
Associated with Corrigan's pulse (collapsing pulse)
Austin flint murmur (early diastolic "rumbling" murmur)
160
Aortic regurgitation causes
Idiopathic age related weakness
| Connective tissue disorder (EHS/MS)
161
Atrial fibrillation DDx
Atrial flutter
| Supraventricular tachyarythmias
162
AF pathophysiology
SAN
