hx: - ruptured triad - >back/abdo pain - >pulsatile mass - >hypotension - focused on assessing risk factors - development - >hyperlipidaemia - >connective tissue disease - >COPD - >hypertension - expansion - >cardiac or renal transplant - >severe cardiac disease - >stroke - >older age - rupture - >female sex - >previous cardiac or renal transplant - >hypertension - smoking - >risk factor for development/expansion/rupture - family hx exam - pulsatile and expansile mass - peripheral pulses - >evidence of ischaemia or emboli? - additional aneurysms - eccymoses - >cullens - >grey turners - >fox's (thigh) - >bryants (scrotum) - fevers - >suspicion for infective AAA

Pain (RAPID MEDS) - ruptured viscus - AAA - pancreatitis - infarct (MI) - dissection - mesenteric ischaemia - embolism - diverticulitis - stones Mass for AAA - lymphoma - lymph nodes - >lymphadenopathy - >mets - abscess - hernia

ruptured - surgical repair - >endovascular (lower mortality than open) - >open - medical support - >ABCD - >blood products - >ICU symptomatic -requires surgery regardless of size small asymptomatic - no improvement in mortality with immediate surgery - surveillance - >every 6-12 months - medical management - >cease smoking - >cardiovascular risk factor control large asymptomatic - surgery indicated - >greater than 5.5cm in men - >greater than 5cm in women

every reduction reduces events LDL - primary prevention = 2mmol/L - secondary = 1.8 mmol/L HDL -1mmol/L non-HDL -2.5mmol/L Total cholesterol -4mmol/L Triglycerides -2mmol/L

PAALMER - PE (ddx's: EMPPATHIC) - Atrial myxoma - Autoimmune/vasculitis (eg. rheumatoid or scleroderma) - Libmann saccs - >malignancy (lung, colon, pancreatic) - >SLE - >antiphospholipid - MI with mural thrombus - Emboli (cholesterol) - Rheumatic heart disease

Cardio Flashcards by Michael Joubert

risk factors aortic dissection

FAT CASH

family hx
atherosclerosis
takayasu
connective tissue disease
smoking
HTN

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aortic dissection pathophys, path and classification

pathophys

risk factors weaken vessel wall
cystic medial degeneration
> loss of elastic fibres
> loss of extracellular matrix
> increase in GAGs
laplaces law
> wall tension proportionate to radius and pressure
> inversely proportional to wall thickness
> cycle of wall degeneration and increasing stress
intimal tear
> creation of false lumen within laminar plane of media
extension
> retrograde or anterograde
occlusion
> static with obliteration of branching vessel by haematoma on same side
> dynamic during diastole when true lumen collapses and intimal flap closes over ostium on opposite side

path

stanford classification
> A = involves ascending +/- descending and thoracic
> B = does not involve ascending (usually distal to left subclavian)
microscopic
> cystic medial degeneration
> haematoma within laminar planes of media

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aortic dissection investigations

ECG

FBC
-anaemia with haemorrhage
EUCs
-ischaemia = elevated BUN
LFTs
-ischaemia = transaminitis
lactate 
-ischaemia
blood type and cross match
trops
d-dimer
-sensitive but non specific

CXR
-widened medistinum
CTA
-intimal flap

TOE
-if CTA unavailable or in ED

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hx and exam AAA

hx:

ruptured triad
> back/abdo pain
> pulsatile mass
> hypotension
focused on assessing risk factors
development
> hyperlipidaemia
> connective tissue disease
> COPD
> hypertension
expansion
> cardiac or renal transplant
> severe cardiac disease
> stroke
> older age
rupture
> female sex
> previous cardiac or renal transplant
> hypertension
smoking
> risk factor for development/expansion/rupture
family hx

exam

pulsatile and expansile mass
peripheral pulses
> evidence of ischaemia or emboli?
additional aneurysms
eccymoses
> cullens
> grey turners
> fox’s (thigh)
> bryants (scrotum)
fevers
> suspicion for infective AAA

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investigations AAA

ABG
-acidosis

FBC
-anaemia
->haemorrhage
-leukocytosis 
->infective/inflammatory AAA
EUCs
-acidosis
-AKI
LFTS
-shock and end organ damage
Coags
Trops
D-dimer
-associated with aneursym diameter
ESR
-infective/inflammatory AAA

Ultrasound

high sensitivity and specificity
thresholds
> diameter 1.5x normal
> 3cm

Consider

MRA/CTA
> surgical planning

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AAA/dissection ddx

Pain (RAPID MEDS)

ruptured viscus
AAA
pancreatitis
infarct (MI)
dissection
mesenteric ischaemia
embolism
diverticulitis
stones

Mass for AAA

lymphoma
lymph nodes
> lymphadenopathy
> mets
abscess
hernia

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AAA treatment

ruptured

surgical repair
> endovascular (lower mortality than open)
> open
medical support
> ABCD
> blood products
> ICU

symptomatic
-requires surgery regardless of size

small asymptomatic

no improvement in mortality with immediate surgery
surveillance
> every 6-12 months
medical management
> cease smoking
> cardiovascular risk factor control

large asymptomatic

surgery indicated
> greater than 5.5cm in men
> greater than 5cm in women

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lipid targets

*every reduction reduces events

LDL

primary prevention = 2mmol/L
secondary = 1.8 mmol/L

HDL
-1mmol/L

non-HDL
-2.5mmol/L

Total cholesterol
-4mmol/L

Triglycerides
-2mmol/L

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investigations APO

ECG
-arrhythmias
ABG
-hypoxia
-acid/base
-electrolytes
PEFR
-ddx cardiac vs pulmonary
Ultrasound
-B lines

FBC
-anaemia
-leukocytosis
EUC
-eGFR
-electrolytes
CMP
-arrhythmia 
BNP/NT-BNP
-elevated in exacerbation CCF
-specific and sensitive
Troponins
-subendocardial ischaemia with LV pressure
TSH
D-dimer
-strong negative predictive value

CXR

cardiomegaly
butterfly
air bronchogram
effusion
ddx’s

Echo

LV size and wall thickness
LV function
estimate EF and pulmonary wedge pressure

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ddx APO

Exacerbation of CCF (A Reduction In Cardiac Output)
arrhythmias
-AF
regurgitation 
-mitral (endocarditis, myxoma, papillary rupture)
-aortic (endocarditis, dissection)
infarct/ischaemia
crisis (hypertensive crisis)
overload (renal, drugs, fluids)

Dyspnoea (DICTAATE)

reconditioning
infection/inflammatory (pneumonia, bronchiectasis, bronchitis, ILD)
COPD/asthma
tumour (effusion)
anaemia
ascities
thyroid dysfunction
embolism (pulmonary)

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dukes modified criteria

Pathologic:

pathologic lesions (on histology)
> vegetation
> intracardiac abscess

Clinical:

Definite
> two major
> one major + three minor
> five minor
Rejected
> symptoms resolve <4 with antibiotics
> no histo in surgery or autopsy <4 of antibiotics

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major clinical dukes criteria

Positive culture
> typical organisms from 2 seperate blood cultures
> persistently positive blood culture
1) 2 cultures taken >12 hrs apart for typical or
2) 3/3 or 2-3/4 cultures for skin flora
3) single positive culture for Coxiella or
4) positive Q fever IgG antibody titre
Evidence of endocardial involvement
> positive echo
1) oscillating intracardiac mass
2) abscess
3) new partial dehiscence of prosthetic valve
> new valvular regurg

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minor criteria dukes

1) predisposition
- typical heart condition
- IVD

2) fever

3) vascular phenomena
- major emboli
- septic pulmonary infarcts
- mycotic aneurysm
- intracranial haemorrhage
- conjunctival petechiae
- Janeway lesions

4) immunologic phenomena
- GNP
- oslers nodes
- roths spots
- rheumatoid factor

5) microbio evidence
- positive culture not meeting major criteria
- serologic evidence of typical organism infection

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IE ddx

PAALMER

PE (ddx’s: EMPPATHIC)
Atrial myxoma
Autoimmune/vasculitis (eg. rheumatoid or scleroderma)
Libmann saccs
> malignancy (lung, colon, pancreatic)
> SLE
> antiphospholipid
MI with mural thrombus
Emboli (cholesterol)
Rheumatic heart disease

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CXR findings IE

PE signs 
-hamptoms hump
-westermark sign
Septic emboli
-cavitating nodules
CCF
-cardiomegaly
-batwing/butterfly
-airbronchogram
-effusion
DDx's

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investigations IE

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ECG
-heart block
Urinalysis
-GNP

Blood cultures
-before antibiotics
-3 sets
-3 sites
-first and last >1hr apart
FBC
EUC
RF
Complement
ESR

Echo (TTE/TOE)
-oscillating mass
-abscess
-partial dehiscence of prosthetic valve
-new regurg
CXR
-septic emboli
-caviating infiltrate
-cardiomegaly
CT chest/abdo/pelvis
-systemic emboli
->infarct
->abscess

Consider
-MRI brain

pathophys MI

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Ischaemia effects (atherosclerosis)

metabolism of fatty acids reduced, anaerobic glycolysis increased
decreased production ATP
decreased pH with lactate formation
impaired K/Na pump and membrane integrity leads to increase in K efflux and Na/Ca influx
regional failure of normal relaxation (decreases blood flow further), failed contraction (decreased supply)
relatively poorer perfusion to subendocardium compared to subepicardium
<20 mins = reversible
> 20 mins = permanent necrosis

distribution of STEMI

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LAD = approx 40%
RCA = approx 1/3
circumflex = approx 1/4

Heart rupture in MI

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Left ventricular free wall

1% of MI
most common anterior left ventricle
early (<72 hrs) and late (<2 weeks) presentation
fibrinolytic therapy can accelerate rupture
presents with haemopericardium and tamponade (Beck’s triad: hypotension, muffled heart sounds, elevated neck veins + electrical alternans) –> PEA
mortality rate = 25%

Interventricular septum

less common than free wall
major risk factor is wrap around LAD
hypotension, biventricular heart failure and harsh pan systolic murmur +/- thrill
50%

Papillary rupture

LV
hypotension, pulmonary oedema, LV heave and pan systolic murmur

short and long term complications MI

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Short (BIRD)

bradycardia/block (1st and 2nd) in RCA and complete in LAD
infarct/ischaemia (recurrent)
rupture (free wall, ventricular septum, papillary muscle)
dresslers syndrome (pericarditis)

Long (PACT)

psychological (depression)
arrhythmias (VT, VF)
CCF
thrombosis (mural –> systemic embolism)

management CCF and APO

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CCF:

Non Pharm:
education
-condition
-drugs
daily weights
fluid restriction (1.5L)
salt restriction
exercise
heart failure program
-heart failure nurse
dietician 
-anorexia

Pharm:

ACEI and beta blockers
swap with ARBs or aldosterone antagonists
supplement with loops
monitor and maintain iron

APO:

furosemide IV
high flow oxygen or CPAP
add nitroglycerol
dobutamine
morphine

Blood pressure ranges and targets

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Range

normal = <120 SBP, <80DBP
prehypertension = 130-40 SBP, 80-90 DBP
HTN = >140 SBP, >90 DBP

Effects

linear increase in cardiovascular events
linear increase in mortality above SBP 115

Targets

general = <140/90
high CVD absolute risk + SBP > 130 = SBP <120

non pharm treatment of HTN

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Complement pharm, not replace

Exercise (aerobic)
weight loss
alcohol restriction
salt restriction
healthy diet

pathology in HTN

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Vessels

arterial stiffness is a cause and consequence of HTN
> ion transporter dysfunction (increased Na/H exchange)
> increased Na entry
> increased Na/Ca exchange ->increased contractility
> increased pH -> increased contractility for Ca concen
endothelial vasoactive dynsfuntion
> NO (dilate)
> endothelin (constrict)
enhanced atherosclerosis

Heart

most common cause of death in HTN
LV hypertrophy –> CCF (HFrEF/HFpEF) + arrhythmias + MI
CAD + microvascular disease -> MI

Brain

stroke
> HTN greatest risk factor (direct relation over age 65)
> vascular dementia
beta amyloid deposition
> cognitive impairment
> alzheimers
autoregulation = 50-150mmHg
> hypertensive encecphalopathy

Kidney

atherosclerosis of afferent arteriole
> ischaemia in glomerulus
> loss of autoregulation -> transmission of high pressure to glomerulus -> hyperfiltration and hypertrophy -> glomerulosclerosis
progresses to ischaemia of tubules and atrophy + focal necrosis of glomerular tuft
> proteinuria

acute management STEMI

Determine pathway - confirm diagnosis (STEMI/NSTEMI) - risk stratify General management - ACCU - 2x IV canula - O2 - Cardiac monitoring + ECG - Routine bloods - CXR - nitroglycerine - beta blocker (atenolol/metoprolol) - morphine ``` STEMI -dual antiplatelet (aspirin + P2Y12 inhibitor) -LMWH or UFH re-perfuse -within 12 hours -PCI reduces mortality/recurrence and stroke compared to fibrinolytic PCI (balloon angioplasty/stenting) -within 90 minutes Fibrinolytic -alteplase or tenecteplase -within 30 mins consider contraindications ``` NSTEMI - aspirin (without P2Y12 until after surgery) - LMWH or UFH - consider GpIIaIIIb inhibitor - high risk -> coronary angiography and revascularisation (stenting/bypass) - evidence supporting early intervention (eg. within 2 hours very high risk)

Complications IE

CAMPER Cardiac - CCF - perivalvular abscess - >heart block - intracardiac fistulae - pericarditis Aneurysm -mycotic aneurysms MSK - septic arthritis - vertebral osteomyelitis Pulmonary - infarct - abscess - effusion - pneumonia - pneumothorax Embolic - brain - >haemorrhage/ischaemic stroke - >abscess - >meningitis - spleen - >infarct - >abscess - peripheries - >paralysis Renal - infarct - abscess - glomerulonephritis - nephrotoxic drugs - AKI

risk factors IE

CARDITIS - congenital heart disease (eg. bicuspid aortic valve) - age >60 - recurrence - degenerative heart disease (rheumatic heart disease, prosthetic valve, mitral valve prolapse) - IV drug use - teeth (dental procedure, poor dentition) - IVC/implantable cardiac device - sex (male)

IE pathophys

Undamaged endothelium is resistant to infection and thrombus formation 1) Direct infection by highly virulent organisms - staph aureus - fibronectin binding protein - >adhesin: binding to fibronectin and fibrinogen - >invasin: facilitates entry into endothelial cells 2) Endothelial injury due to high velocity blood jets or on the low pressure side of valve defect - formation of platelet fibrin thrombus - >acts as nidus - >becomes colonised during transient bacteraemia Growth of vegetation - proliferation of bacterium - >within cells - >within fibronectin matrix - release of tissue factor from endothelium and macrophages - >platelet deposition - >activation of extrinsic pathway Layers of growth - organisms deep in vegetations are metabolically inactive - >resistance to antimicrobials - outer layer is proliferating and shed continuously - >emboli of vegetation fragments (local immune response) - >deposition of immune complexes

hx and exam IE

``` Hx: risk factors fever/chills/malaise/night sweats anorexia/weight loss arthralgia/myalgia/back pain abdo pain chest pain/palpitations dyspnoea/orthopnoea/PND meningism/stroke/headache haematuria/oliguria ``` ``` Exam petechiae (cutaneous/mucosal) splinter haemorrhage janeway polyarthritis osler roth spots dentition focal neuro signs murmur effusion/diminished breath sounds splenomegaly vertebral pain ```

Arrhythmia treatment

Regular and Narrow Tachy - ddx - >sinus tachy/SVT/atrial tachycardia/atrial flutter - sinus tachy - >treat underlying cause - SVT - >DC cardioversion if unstable - >consider vagal maneuvers then adenosine if stable - atrial tachycardia - >DC cardioversion if unstable - >if stable, beta blockers/non dihyrdropyridine CCB - atrial flutter - >treated liked AF Irregular and Narrow Tachy - ddx - >AF/multifocal atrial tachy/atrial flutter variable conduction - AF - >unstable = DC cardioversion - >stable = beta blockers/non dihydropyridine CCB - >consider need for anticoagulation - multifocal atrial tachy/atrial flutter variable conduction - >usually underlying cardiac/pulmonary path - >usually stable - >treatment focused at addressing cause Regular and Wide Tachy - ddx - >VT (until proven otherwise) - VT - >unstable = DC cardioversion - >stable = amiodarone or lidocaine Irregular and Wide Tachy - ddx - >polymorphic VT/VF - polymorphic VT - >unconscious = DC cardioversion - >conscious with baseline long QT (torsades) = magnesium sulfate - >conscious with normal baseline QT (post MI) = cardioversion if unstable, beta blockers if stable - VF - >ALS Bradycardia - only treat if shocked - atropine while preparing for temporary pacing - >atropine = 0.5mg - >pacing = transvenous or transcutaneous - consider dopamine or adrenaline if unsuccessful

Cardio Flashcards

(30 cards)