Cardio 2: SOB Flashcards Preview

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Flashcards in Cardio 2: SOB Deck (40):
1

left heart failure aetiology

heart valves
- aortic valve disease
- MR

heart muscle
- ischaemic heart disease
- MI
- cardiomyopathy e.g. hypertrophic, dilated, restrictive
- myocarditis
- arrhythmia e.g. AF

systemic
- hypertension
- amyloidosis

drugs
- alcohol
- cocaine

2

right heart failure aetiology

LEFT HEART FAILURE

heart valves
- TB
- pulmonary valve

lungs
- pulmonary hypertension
- PE
pulmonary valve disease
- chronic lung disease

3

high-output state heart failure aetiology

- Systemic demand- Requires higher CO- Strain on heart

AV malformations (abnormal connection between arteries and veins)
malignancy (multiple myeloma)
endocrine (hyperthyroidism)
pregnancy
nutritional (thiamine/vitamin B1 deficiency (beriberi)
GI/renal (liver cirrhosis)
anaemia
sepsis

4

LHF symptoms

LHF --> fluid congestion in lungs --> respiratory symptoms:

1. Dyspnoea (difficulty breathing)
2. Orthopnoea (SOB when lying flat)
3. Paroxysmal Nocturnal Dyspnoea (attacks of SOB/coughing at night, may wake patient up)
4. Fatigue
5. Nocturnal cough (±pink frothy sputum)
6. Wheeze (cardiac asthma)

5

LHF signs

Heart:
raised HR and RR
Displaced apex beat
Gallop rhythm (S3)
Murmur (AS, MR)

Lungs:
Bibasal crackles

Acute:
Cyanosis
Peripheral shutdown

6

RHF symptoms

RHF --> fluid congestion in system --> peripheral symptoms:

1. swelling- ankles, face, abdomen (ascites)
2. fatigue
3. weight gain (oedema)
4. reduced exercise tolerance
5. anorexia
6. nausea
7. nocturia

7

RHF signs

face/neck:
raised JVP
facial swelling

heart:
parasternal heave
TR murmur

abdomen:
ascites
hepatomegaly

other:
pitting oedema in ankles/sacrum

8

HF investigations

bedside:
history/exam

bloods:
FBC, U&Es, LFTs, TFTs, glucose
normal BNP= not HF
raised BNP= HF

imaging:
echocardiogram
ECG, CXR

Hx of MI- echo
no Hx of MI- BNP --> echo

9

HF echocardiogram findings

Assess ventricular contraction

Systolic dysfunction = LV ejection fraction < 40%

Diastolic dysfunction = decreased compliance of the myocardium leads to restrictive filling defect

10

HF CXR findings

Alveolar shadowing
Kerley B lines
Cardiomegaly
Upper Lobe Diversion
Pleural Effusion

11

chronic HF management

1. TREAT THE UNDERLYING CAUSE!
2. Treat exacerbating factors
3. Lifestyle – diet (salt intake), exercise, weight management, smoking, alcohol
4. Drugs:
ACE-inhibitors
Beta blockers
Diuretics

12

chronic HF drug management

ACE-inhibitors
- e.g. enalapril, perindopril, ramipril
- can use an ARB if cough is an on-going problem, must monitor K+

Beta blockers
- e.g. bisoprolol, carvedilol

Diuretics
- loop e.g. furosemide


Aldosterone antagonists e.g. spironolactone
Hydralazine + nitrate in Afro Caribbean patients
Digoxin – +ve inotrope, does not improve survival
Cardiac resynchronisation therapy

13

acute HF management

Sit patient upright
O2 – 60-100%
IV Diamorphine 2.5-5mg
GTN
IV furosemide 40-80mg to reduce fluid

14

1. A 78-year-old woman is admitted with heart failure. The underlying cause is determined to be aortic stenosis. Which sign is most likely to be present?
A. Pleural effusion on chest x-ray
B. Raised jugular venous pressure (JVP)
C. Bilateral pedal oedema
D. Bibasal crepitations
E. Atrial fibrillation

D. Bibasal crepitations

Aortic stenosis will first result in left ventricular failure as a result of increased ventricular pressure as the ventricle tries to pump blood across a narrowed valve. Initially the pressure load will cause a backlog of blood into the lungs, resulting in pulmonary oedema – the first sign of which will be bibasal crepitations (D) before enough fluid accumulates as pleural effusions visible on chest x-ray (A). Earlier signs of pulmonary oedema include upper lobe blood diversion and Kerley B lines as fluid infiltrates the interstitium. If the backlog continues back into the right heart, eventually signs of right-sided heart failure will be evident including raised JVP (B) and bilateral pedal oedema (C). Atrial fibrillation (E) may coexist with aortic stenosis, however it is more commonly associated as a result of mitral stenosis as the enlarged atrium disrupts the normal electrical pathways.

15

2. A 60-year-old man presents to his GP with gradually increasing fatigue and some exertional dyspnoea. Blood pressure is 118/74mmHg and pulse rate is 81/minute. There are no abnormal physical findings and on echocardiography the ejection fraction is 0.47. However, the clinical impression remains one of early heart failure. Which of the following circulating biomarkers would lend support to that conclusion?
A. Atrial natriuretic peptide
B. Brain natriuretic peptide
C. Endothelin
D. Noradrenaline
E. Adrenomedullin

B. Brain natriuretic peptide

Brain natriuretic peptide (B) is considered to have the greatest power as a diagnostic biomarker of the given answer options. In established heart failure, high levels of endothelin (C) and noradernaline (D) in particular are associated with poor prognosis. All of the given answers, including atrial natriuretic peptide (A) and adrenomedullin (E), may be increased in heart failure.

16

3. A 55-year-old male presents with increasing exertional dyspnoea, fatigue, weight loss and bone pain. Blood results reveal elevated calcium levels and normocytic anaemia. He is treated for heart failure. What is the underlying cause for his heart failure?

A. Hyperthyroidism
B. Malignancy
C. Thiamine deficiency
D. Meningitis
E. Paget’s disease of the bone

B. malignancy

Multiple Myeloma: Symptoms and presentation are consistent with malignancy. C – hypercalcaemia, R- renal failure, A-anaemia, B- bone lesions. Hence weight loss, bone pain, anaemia. Hyperthyroidism does cause weight loss but would not explain other symptoms
Thiamine deficiency – no other signs, history of alcoholism, peripheral neuropathy
Menigitis – no signs of infection
Paget’s disease – calcium is unaffected, high ALP

17

list three systolic murmurs and two diastolic murmurs

systolic:
AS, MR, TR

diastolic:
AR, MS

18

systolic murmurs aetiology

1. Age-related calcification (AS)
2. Infection – Infective endocarditis (?IVDU), Rheumatic heart disease
3. Congenital - William’s , bicuspid aortic valve (AS)
4. CTD – Marfan’s, EDS, OI

19

systolic murmur symptoms

1. Dyspnoea (SOB)
2. Syncope (dizziness) on exertion
3. Angina (chest pain)
4. Heart failure signs
5. Palpitations

*Patients may also be asymptomatic*

20

signs of aortic stenosis

1. BP – narrow pulse pressure
2. Pulse – slow-rising
3. Palpation – thrill (palpable heart murmur)

AS - Ejection Systolic Murmur
Radiating to the carotids and apex
*Ask the patient to hold breath on inspiration to accentuate murmur*

21

signs of mitral regurgitation

1. Pulse – normal/irregularly irregular
2. Palpation – laterally displaced apex beat

MR - Pan-Systolic Murmur
Radiating to axilla

22

signs of tricuspid regurgitation

1. Inspection – raised JVP
2. Palpation – parasternal heave
3. Signs of RHF – pleural effusion, hepatomegaly, ascites, pitting oedema

TR - Pan-Systolic Murmur
*Ask the patient to hold breath on inspiration to accentuate murmur*

23

systolic murmur investigations

1. ECG – signs of LV hypertrophy e.g. enlarged R waves, T wave inversion, left axis deviation (AS)
Tall p-wave (TR)

2. CXR
- enlargement of ascending aorta
- aortic valve calcification (AS)
- right sided enlargment (TR)
-cardiomegaly (MR)

24

diastolic murmur aetiology

1. Infection – rheumatic heart disease, infective endocarditis
2. Congenital – bicuspid aortic valve,
3. Dilation of aorta – HTN, aortitis
4. CTD

25

diastolic murmur symptoms

1. Dyspnoea (SOB)
2. Syncope (dizziness) on exertion
3. Angina (chest pain)
4. Heart failure signs
5. Palpitations
6. Orthopnoea

*Patients may also be asymptomatic*

26

signs of aortic regurgitation

1. BP – wide pulse pressure
2. Pulse – collapsing/’water hammer’/Corrigan’s pulse
3. Palpation – displaced apex beat

AR - Early Diastolic Murmur
Radiating to the carotids and apex
*Ask the patient to sit forward, hold breath on expiration*

27

signs of mitral stenosis

1. Face – malar flush
2. Pulse – ‘thready’ or irregularly irregular
3. Palpation – tapping apex, parasternal heave

MS - Mid diastolic murmur
Loud 1st HS with opening snap
Bell of stethoscope
Austin Flint MDM: low, rumbling, associated with severe AR

28

diastolic murmur investigations

Investigations:
1. ECG – signs of LV hypertrophy e.g. enlarged R waves, T wave inversion, left axis deviation
MS – broad bifid p wave, AF

2. CXR
- dilation of ascending aorta
- cardiomegaly

29

4. A 49-year-old woman presents with increasing shortness of breath on exertion developing over the past three months. She has no chest pain or cough, and has noticed no ankle swelling. On examination, blood pressure is 158/61mmHg, pulse is regular at 88 beats per minute and there are crackles at both lung bases. There is a decrescendo diastolic murmur at the left sternal edge. What is the most likely diagnosis?

A. Aortic regurgitation
B. Aortic stenosis
C. Mitral regurgitation
D. Mitral stenosis
E. Tricuspid regurgitation

A. Aortic regurgitation

This is a typical clinical scenario for an aortic regurgitation (A), with early cardiac failure. Note the wide pulse pressure, and it is also usual for the pulse to be rapidly collapsing. The only lesion producing a diastolic murmur, among those listed, is of course mitral stenosis (D). No other valve abnormality (B), (C) or (E) produces a wide pulse pressure as seen here, but remember that in older people, almost always over the age of 60, similarly wide or even wider pulse pressures may be noted. This would be due to isolated systolic hypertension, i.e. systolic pressure >140 mmHg and diastolic ≤90 mmHg.

30

5. You see a 57-year-old woman who presents with worsening shortness of breath coupled with decreased exercise tolerance. She had rheumatic fever in her adolescence and suffers from essential hypertension. On examination, she has a mid-diastolic murmur heard loudest over the mitral area. Which of the following is not a clinical sign associated with this particular diagnosis?

A Malar flush
B. Atrial fibrillation
C. Pan-systolic murmur which radiates to axilla
D. Tapping, undisplaced apex beat
E. Right ventricular heave

C. Pan-systolic murmur which radiates to axilla

Diagnosis is mitral stenosis. Malar flush (A), atrial fibrillation (B), a tapping apex beat (D) and right ventricular heave (E), which occurs secondary to pulmonary hypertension, are all clinical signs associated with mitral stenosis. On auscultation of the praecordium, a mid-diastolic murmur (±opening snap, representing a mobile valve) is heard rather than a pan-systolic murmur (C) which is usually heard in mitral regurgitation, tricuspid regurgitation and ventricular septal defects.

31

6. An 8 year old boy comes to the GP with his mother for a check-up. You find the child to be extremely sociable and friendly, with some mild learning difficulties. You also note distinct facial features including broad forehead, short nose and full cheeks. On auscultation of his chest, you detect a murmur in the right 2nd intercostal space, loudest on inspiration. What is the most likely diagnosis?

A. Hypertrophic Obstructive Cardiomyopathy
B. Infective endocarditis
C. Aortic stenosis
D. Aortic regurgitation
E. Mitral stenosis

C. Aortic stenosis

32

what is the difference between hypertension and malignant hypertension?

Abnormally high blood pressure
Systolic BP > 140 mmHg OR
Diastolic BP > 85 mmHg
Measured on 3 separate

Malignant HTN = BP > 200/130 mmHg

33

hypertension aetiology

>90% of cases are primary/essential/idiopathic

secondary causes:
RENAL:
- Renal artery stenosis
- Chronic glomerulonephritis, pyelonephritis
- Polycystic kidney disease
- Renal failure

CARDIO:
- coarctation of the aorta
- increased intravascular volume

ENDO:
Diabetes, hyperthyroidism, Cushing’s, Conn’s, hyperparathyroidism, phaeochromocytoma, Congenital Adrenal Hyperplasia, Acromegaly

PREGNANCY:
- pre-eclampsia

DRUGS:
- Sympathomimetics, corticosteroids, oral contraceptives

34

hypertension symptoms

Most patients are asymptomatic (primary)

If secondary, may show symptoms of underlying cause:
- Endocrine, Renal, Cardio, Pregnancy

If untreated, may show symptoms of complications:
- heart failure, coronary artery disease/MI, CVA/stroke, peripheral vascular disease, emboli, retinopathy…

Malignant hypertension:
- visual field loss (scotoma), blurred vision, headaches, seizures, nausea, vomiting,

35

signs of hypertension

Measure BP
Auscultation: may hear loud S2, S4

Examine for root cause:
Coarctation of the aorta?
Renal artery stenosis?

36

HTN investigations

bedside:
- history
- exam

bloods:
- U&Es, glucose, lipids

urine dip:
- blood and protein

ambulatory BP:
-white coat syndrome

37

HNT management

Person <55 with hypertension
Step 1
ACE inhibitor or ATII receptor blocker

Person > 55 years or black person of African or Caribbean family origin of any age with hypertension
Step 1
Calcium channel blocker


Step 2
ACE inhibitor or ATII receptor blocker + Calcium channel blocker

Step 3
ACE inhibitor or ATII receptor blocker + Calcium channel blocker + thiazide-like diuretic

Step 4
Resistant HTN: treat with low-dose spironolactone/higher-dose thiazide-like diuretics
Alpha blockers



38

7. A 48-year-old woman has been diagnosed with essential hypertension and was commenced on treatment three months ago. She presents to you with a dry cough which has not been getting better despite taking cough linctus and antibiotics. You assess the patient’s medication history. Which of the following antihypertensive medications is responsible for the patient’s symptoms?
A. Amlodipine
B. Lisinopril
C. Bendroflumethiazide
D. Furosemide
E. Atenolol

B. Lisinopril

ACE inhibitors (e.g. lisinopril (B)) commonly cause a dry cough in some patients. If this occurs, patients are usually taken off the ACEI and started on either an ARB (e.g. irbesartan, losartan, telmisartan) or different class of antihypertensive. Amlodipine (A), bendroflumethiazide (C), frusemide (D) and atenolol (E) do not commonly cause a dry cough as a side effect.

39

8. A 57-year-old man is reviewed in a hypertension clinic, where it is found that his blood pressure is 165/105 mmHg despite standard doses of amlodipine, perindopril, doxazosin and bendroflumethiazide. Electrolytes and physical examination have been, and remain, normal. Which of the following would be your next stage in his management?

A. Arrange for his medication to be given under direct observation
B. Add spironolactone to his medication
C. Arrange urinary catecholamine assays
D. Request an adrenal CT scan
E. Add verapamil to his medication

A. Arrange for his medication to be given under direct observation

Poor adherence to therapy (A) is probably the most common cause of apparent resistance to hypertensive therapy. In cases where this occurs despite good adherence, spironolactone (B) is often highly effective, although it is not clear why. Verapamil (E) is very occasionally added to a dihydropyridine in severe hypertension. If he is already a patient of the hypertension clinic, one can presume that he has been screened for possible secondary causes (C and D), so this is very likely to be primary hypertension.

40

9. A 47-year-old woman presents to clinic after being referred from her GP for consistently elevated blood pressure. Her last reading was 147/93. The female does not report any symptoms but recently lost her job and attributes the elevated reading to stress. Her blood tests are as follows:
Sodium = 146 (135-145 mmol/L)
Potassium = 3.4 (3.5-5 mmol/L)
Random glucose= 7.7 (4.4-7.8mmol/L)
Urea = 4 (2.5-7.8 mmol/L)

The next most appropriate investigation is:
A. CT scan
B. 24-hour ambulatory blood pressure
C. Abdominal ultrasound scan
D. Aldosterone-renin ratio
E. Glucose tolerance test

24-hour ambulatory blood pressure