Cardio Flashcards
(56 cards)
1
Q
What is angina?
A
Angina is symptomatic reversible myocardial ischaemia
2
Q
Features of angina
A
1 Constricting/heavy discomfort to the chest, jaw, neck, shoulders, or arms.
2 Symptoms brought on by exertion.
3 Symptoms relieved within 5min by rest or GTN.
All 3 features = typical angina; 2 features = atypical angina; 0–1 features = non-anginal chest pain.
3
Q
Precipitants of angina
A
Exertion, emotion, cold weather, and heavy meals.
4
Q
Most common cause of angina
A
Atheroma
5
Q
Stable angina
A
Induced by effort, relieved by rest. Good prognosis.
6
Q
Unstable angina
A
Angina of increasing frequency or severity; occurs on minimal exertion or at rest; associated with increased risk of MI.
7
Q
Basic tests to consider with angina
A
- ECG
- Blood tests:
- FBC, U&E, TFTs, lipids, HbA1c
- Echo
- Chest X-ray
8
Q
Investigations for ischaemic heart disease (IHD) include:
A
- Exercise ECG - assess for ischaemic ECG changes.
- Angiography - either using cardiac CT with contrast, or transcatheter angiography (more invasive but can be combined with stenting)
- Functional imaging - stress echo (echo whilst undergoing exercise or receiving dobutamine), cardiac MRI.
9
Q
Management of angina
A
- Address exacerbating factors
- Secondary prevention of cardiovascular disease:
- 75mg aspirin daily if not contraindicated.
- PRN Symptom pain relief
- Glyceryl trinitrate (GTN) spray or sublingual tabs.
- Anti-anginal medication
- First line: beta blocker and/or calcium channel blocker
- Revascularization
- Percutaneous coronary intervention (PCI)
- CABG
10
Q
Acute coronary syndromes
A
ACS includes unstable angina and myocardial infarctions (MIs)
11
Q
What is the common underlying pathology of acute coronary syndromes?
A
plaque rupture, thrombosis, and inflammation
12
Q
How could you differentiate between MI and unstable angina?
A
MIs have raised troponin, unstable angina does not.
13
Q
Risk factors for acute coronary syndromes
A
- Non-modifiable:
- age,
- male gender,
- family history of IHD (MI in 1st-degree relative <55yrs).
- Modifiable:
- smoking,
- hypertension,
- DM,
- hyperlipidaemia,
- obesity,
- sedentary lifestyle,
- cocaine use
14
Q
Classical presentation of MI
A
Acute central chest pain, lasting >20min, associated with nausea, sweatiness, dyspnoea, palpitations.
15
Q
Revascularistaion of STEMI patients and very high-risk NSTEMI patients
A
should receive immediate angiography ± PCI
16
Q
Medications for MI
A
- Antiplatelets
- Aspirin (75mg OD) and a second anti-platelet agent (eg clopidogrel)
- Anticoagulant
- Beta-blockade reduces myocardial oxygen demand
- ACE-i in patients with LV dysfunction, hypertension, or diabetes unless not tolerated
(consider ARB). Titrate up slowly, monitoring renal function. - High-dose statin, eg atorvastatin 80mg.
17
Q
PCI or CABG
A
Patients with single-vessel coronary artery disease and normal LV function usually undergo PCI, and those with triple-vessel disease and abnormal LV function more often undergo CABG.
18
Q
Definition of heart failure
A
Cardiac output is inadequate for the body’s requirements.
19
Q
Symptoms of left ventricular failure (LVF)
A
- dyspnoea,
- poor exercise tolerance,
- fatigue,
- orthopnoea,
- paroxysmal nocturnal dyspnoea (PND),
- nocturnal cough (±pink frothy sputum),
- wheeze (cardiac ‘asthma’),
- nocturia,
- cold peripheries,
- weight loss.
20
Q
Causes of left ventricular failure
A
- IHD
- MI
- cardiomyopathy
- ventricular hypertrophy
- constrictive pericarditis
- tamponade
21
Q
Causes of right ventricular failure
A
- LVF,
- pulmonary stenosis,
- cor pulmonale
22
Q
RVF symptoms
A
- peripheral oedema (up to thighs, sacrum, abdomi- nal wall),
- ascites,
- nausea,
- anorexia,
- facial engorgement,
- epistaxis.
23
Q
Causes of low output cardiac failure
A
- Excessive preload: eg mitral regurgitation or fluid overload (eg renal failure or too
rapid IV infusions, particularly in the elderly and those with established HF). - Pump failure: systolic and/or diastolic HF, decreased heart rate (eg beta blockers, heart block, post MI), negatively inotropic drugs (eg most antiarrhythmic agents).
- Chronic excessive afterload: eg aortic stenosis, hypertension.
24
Q
High output heart failure
A
- This is rare. Here, output is normal or increased in the face of increased needs.
- Causes: anaemia, pregnancy, hyperthyroidism
25
How is a diagnosis of heart failure made?
Requires symptoms of failure and objective evidence of car- diac dysfunction at rest
26
What criteria is used for congestive cardiac failure?
Framingham criteria
27
Signs of heart failure
* cyanosis,
* decreased BP,
* narrow pulse pressure,
* pulsus al- ternans,
* displaced apex (LV dilatation),
* RV heave (pulmonary hypertension),
* signs of valve diseases.
* Severity can be graded using the New York classification
28
Investigations for heart failure
* ECG and B-type natriuretic peptide
* If either is abnormal, then echocardiography is required.
29
Drugs used to manage heart failure
* Loop diuretics to relieve symptoms, eg furosemide 40mg/24h
* ACE-inihibitor - Consider in all those with left ventricular systolic dysfunction (LVSD); improves symptoms and prolongs life. If cough is a problem, an angiotensin receptor blocker (ARB) may be substituted
* Beta-blockers decrease mortality in heart failure
* Mineralocorticoid receptor antagonists: Spironolactone (25mg/24h PO) decreases mortality by 30% when added to conventional therapy
* Digoxin helps symptoms
30
How is a diagnosis of hypertension diagnosed?
Confirm with 24hr ambulatory BP monitoring (ABPM); or a week of home readings.
NB: the diagnostic threshold is lower ~135/85mmHg.
31
Essential Hypertension
Cause unknown
~95% of cases
32
Causes of secondary hypertension
* Renal disease
* glomerulonephritis, chronic pyelonephritis, or polycystic kidneys
* Endocrine disease
* Cushing’s, pheochromocytoma, acromegaly, hyperparathyroidism
* Other
* Coarctation, pregnancy
* Drugs: steroids, MAOIs, oral contraceptive pill, cocaine, amphetamines
33
Lifestyle changes to treat hypertension
* stop smoking;
* low-fat diet.
* Reduce alcohol and salt intake;
* increase exercise;
* reduce weight if obese.
34
Hypertension drug treatment if ≥55yrs, and in black patients of any age
1st choice is a Ca2+ channel antagonist or thiazide
35
Hypertension drug treatment if \<55
ACE inhibitor or ARB
Consider beta blockers in younger people
36
Mitral regurgitation (MR)
Backflow through the mitral valve during systole.
37
Causes of mitral regurgitation
* Functional (LV dilatation);
* annular calcification (elderly);
* rheumatic fever;
* infective endocarditis;
* mitral valve prolapse;
* ruptured chordae tendinae;
* papillary muscle dysfunction/rupture (eg post-MI)
38
Symptoms of mitral regurgitation
* Dyspnoea;
* fatigue;
* palpitations;
* symptoms of causative factor (eg fever).
39
Signs of mitral regurgitation
* AF;
* displaced, hyperdynamic apex;
* pansystolic murmur at apex radiating to axilla;
40
Mitral regurgitation investigations
* ECG:
* AF; LVH.
* CXR:
* big LA & LV; mitral valve calcification; pulmonary oedema.
41
Mitral regurgitation management
* Control rate if fast AF.
* Diuretics improve symptoms.
* Surgery for deteriorating symptoms; aim to repair or replace the valve before LV is irreversibly impaired.
42
Causes of mitral stenosis
* Rheumatic fever
* Congenital
* Prosthetic valve
43
Mitral stenosis presentation
* Normal mitral valve orifice area is ~4–6cm2. Symptoms usually begin when the orifice becomes \<2cm2.
* Pulmonary hypertension causes dyspnoea, haemoptysis, chronic bronchitis-like picture;
* pressure from large left atrium on local structures causes hoarseness (recurrent laryngeal nerve), dysphagia (oesophagus), bronchial obstruction;
* also fatigue, palpitations, chest pain, systemic emboli, infective endocarditis (rare).
44
Signs of mitral stenosis
* Malar flush on cheeks (due to decreased cardiac output);
* low-volume pulse;
* AF common (due to enlarged LA);
* tapping, non-displaced, apex beat (palpable S1);
* RV heave.
* On auscultation: rumbling mid-diastolic murmur (heard best in expiration, with patient on left side)
45
Mitral stenosis investigations
* ECG: AF; RVH;
* CXR: left atrial enlargement (double shadow in right cardiac silhouette); pulmonary oedema; mitral valve calcification.
* Echo is diagnostic
46
Mitral stenosis investigations
* If in AF, rate control is crucial; anticoagulate with warfarin
* Diuretics decrease preload and pulmonary venous congestion.
* If this fails to control symptoms, balloon valvuloplasty (if pliable, non-calcified valve), open mitral valvotomy, or valve replacement.
47
Aortic stenosis causes
* Senile calcification is the commonest
* Others:
* congenital (bicuspid valve, Williams syndrome)
* rheumatic heart disease.
48
Presentation of aortic stenosis
* The classic triad includes angina, syncope, and heart failure.
* Also: dyspnoea; dizziness; faints; systemic emboli if infective endocarditis; sudden death.
49
Aortic stenois signs
* Slow rising pulse with narrow pulse pressure;
* heaving, non-displaced apex beat;
* LV heave;
* aortic thrill;
* ejection systolic murmur
50
Aortic stenosis investigations
* ECG
* CXR: LVH; calcified aortic valve; post- stenotic dilatation of ascending aorta
* Echo: diagnostic
51
Managemenet of aortic stenosis
* If symptomatic, prognosis is poor without surgery: 2-3yr survival if
angina/syncope; 1-2yr if cardiac failure.
* Prompt valve replacment
* If the patient is not medically fit for surgery, transcatheter aortic valve implantation may be attempted
52
Causes of aortic regurgitation
* Acute:
* Infective endocarditis,
* ascending aortic dissection,
* chest trauma.
* Chronic:
* Congenital,
* connective tissue disorders (Marfan’s syndrome, Ehlers–Danlos),
* rheumatic fever,
* rheumatoid arthritis,
* SLE,
* hypertension,
* osteogenesis imperfecta.
53
Aortic regurgitation symptoms
* Exertional dyspnoea,
* orthopnoea,
* paroxysmal nocturnal dyspnoea
54
Signs of aortic regurgitation
* Collapsing pulse;
* wide pulse pressure;
* displaced, hyperdynamic apex beat;
* high-pitched early diastolic murmur (heard best in expiration, with patient sat forward)
55
Investigations for aortic regurgitation
* ECG: LVH.
* CXR: cardiomegaly; dilated ascending aorta; pulmonary oedema.
* Echo is diagnostic.
* Cardiac catheterisation to assess: severity of lesion; anatomy of aortic root; LV function; coronary artery disease; other valve disease.
56
Management of aortic regurgitation
* The main goal of medical therapy is to reduce systolic hypertension; ACE-i are helpful.
* Echo every 6–12 months to monitor.
* Indications for surgery: severe AR with enlarged ascending aorta, increasing symptoms, enlarging LV or deteriorating LV function on echo; or infective endocarditis refractory to medical therapy.
