Cardiology Flashcards
What is atherosclerosis, what vessels does it affect and what causes it ?
A combination of atheromas (fatty deposits in artery walls) and sclerosis (the process of hardening or stiffening of the blood vessel walls). Atherosclerosis affects medium and large arteries. It is caused by chronic inflammation and activation of the immune system in the artery wall. This causes deposition of lipids in the artery wall followed by the development of fibrous atheromatous plaques.
What do atheromatous plaques cause (three things) ?
- Stiffening of the artery walls leading to HTN and strain on the heart trying to pump blood against resistance
- Stenosis of the artery leading to reduced blood flow (e.g. in angina)
- Plaque rupture results in a thrombus that can block a distal vessel and cause ischaemia (e.g. a coronary syndrome where a coronary artery becomes blocked).
Name 3 non-modifiable RF’s of atherosclerosis ?
Age
Family History
Male sex
Name 7 modifiable RF’s of atherosclerosis ?
Smoking Alcohol consumption Poor diet (high sugar and trans-fat low in fruit and veg and omega 3) Low exercise Obesity Poor sleep Stress
Name 5 co-morbidities that increase risk of atherosclerosis ?
Diabetes HTN CKD Inflammatory conditions such as RA Atypical antipsychotic medications
Name 6 end results of atherosclerosis
Angina MI TIA Strokes PVD Chronic mesenteric ischaemia
What is the difference between primary and secondary prevention of CVD?
Primary - for patients that have never had a CV event
Secondary - for patients that have developed angina, MI, TIA, stroke or PVD already.
What is meant by optimising modifiable risk factors in terms of preventing CVD (four points) ?
Advice on diet, exercise and weight loss
Stop smoking
Stop drinking alcohol
Optimise treatment of co-morbidites
As part of primary prevention a QRISK3 score should be performed. What is that?
Calculates the % risk that a pt will have a MI or stroke in the next ten years.
In regards to the QRISK3 score when should a statin be started? + What statin/dose?
When they have more than a 10% risk.
Atorvastatin 20mg at night.
NICE recommend that lipids are measured at 3 months incase the dose needs to be increased (aim of greater than 40% reduction in non-HDL cholesterol).
NICE also recommend that LFTS are checked at 3 and 12 months as they can cause a raise in AST and ALT (They don’t usually need to be stopped unless the rise is more than 3 times the upper normal limit).
What should patients with CKD or type 1 diabetes for more than 10 years be offered?
Atorvastatin 20mg OD
What are the four A’s of secondary prevention of CVD?
Aspirin (plus a second antiplatelet such as clopidogrel for 12 months). Atorvastatin 80mg. Atenolol (or other B blocker - commonly bisoprolol) titrated to maximum tolerated dose. ACE inhibitor (commonly ramipril) titrated to maximum tolerated dose.
Name 3 notable side effects of statins?
Myopathy (check creatine kinase in patients with muscle pain or weakness)
Type 2 diabetes
Haemorrhagic stroke (very rarely)
What is angina?
The narrowing of the coronary arteries resulting in reduced blood flow to the myocardium. During times of high demand e.g. exercise, there is an insufficient supply blood to meet the demand. This causes the symptoms of angina, typically constricting chest pain +- radiation to the jaw or arms.
What is the difference between stable and unstable angina?
Stable - when symptoms are always relieved by rest or GTN spray
Unstable - when the symptoms come on randomly whilst at rest. It is a type of ACS.
What is the gold standard investigation for diagnosing angina?
CT coronary angiography
What 8 baseline investigations should patients with angina have ?
Physical exam (heart sounds, signs of heart failure, BMI) ECG FBC (check for anaemia) U&Es (prior to starting an ACEi and other medications) LFTs (prior to starting statins) Lipid profile TFTs HbA1C and fasting glucose (for diabetes)
What are the four principles of angina management ?
RAMP
Refer to cardiology (urgently if unstable)
Advise them about the diagnosis, management and when to call an ambulance
Medical treatment
Procedural or surgical interventions
What are the 3 aims to the medical management of angina ?
Immediate symptomatic relief
Long term symptomatic relief
Secondary prevention of CVD
Discuss the immediate symptomatic relief of angina ?
GTN spray is used prn
Causes vasodilation
Instruct patient to take GTN when symptoms start, then repeat after 5 mins if required. If there is still pain 5 minutes after the repeat dose - call an ambulance.
Long term symptomatic relief of angina ?
Use either or both if symptoms are not controlled on one:
- B blocker (e.g. bisoprolol 5mg OD)
- CCB (e.g. amlodipine 5mg OD)
What other options for the long term symptomatic relief of angina may be considered by a specialist ?
Long acting nitrates e.g. isosorbide mononitrate
Ivabradine
Nicorandil
Ranolazine
4 A’s of secondary prevention of angina ?
Aspirin (i.e. 75mg OD)
Atorvastatin 80mg OD
ACEi
Already on B blocker for symptomatic relief
What are the two main procedural/ surgical interventions of angina ?
PCI with coronary angioplasty
CABG
What is PCI with coronary angioplasty ?
PCI with coronary angioplasty is offered to all patients with proximal or extensive disease on CT coronary angiography. A catheter is inserted into the brachial or femoral artery which is fed up into the coronary arteries under X ray guidance. Contrast is used to see the areas of stenosis. This can be treated with balloon dilation followed by the insertion of a stent
What is a CABG ?
The chest is opened along the sternum. A graft vein is taken from the pts leg (usually great saphenous vein) and sewing it onto the affected coronary artery to bypass the stenosis.
What four areas does the RCA supply ?
Right atrium
Right ventricle
Inferior aspect of left ventricle
Posterior septal area
What two areas does the circumflex artery supply?
Left atrium
Posterior aspect of left ventricle
What two areas does the LAD artery supply?
Anterior aspect of left ventricle
Anterior aspect of the septum
When a pt presents with possible ACS symptoms what should you do ?
Perform an ECG
What two ECG changes would indicate a STEMI ?
ST elevation in leads consistent with an area of ischaemia
or
New left BBB
What three ECG changes could indicate a NSTEMI ?
T wave inversion in a specific region
Pathological Q waves
ST depression - This suggests a deep infarct and is a late sign
If there are no ECG changes in someone with suspected ACS what else should you check
Troponin
Name six symptoms of ACS ?
N+V Sweating and clamminess Feelings of impending doom Shortness of breath Palpitations Pain radiating to the jaw or arms
If someone has ACS how long should symptoms last for ?
Symptoms should continue at rest for more than 20 minutes. If they settle with rest consider angina.
What type of patients may not experience typical chest pain during an acute coronary syndrome ?
Diabetic patients. They can experience a “silent MI”
Left coronary artery - heart area and leads?
Anterolateral
I, aVL, V3-6
LAD - heart area and leads?
Anterior
V1-4
Circumflex artery - heart area and leads?
Lateral
I, aVL, V5-6
RCA - heart area and leads?
Inferior
II, III, aVF
What are troponins ?
Proteins found in cardiac muscle
A diagnosis of ACS typically requires what ?
Serial troponins e.g. at baseline and 6 or 12 hours after the onset of symptoms
Why is a rise in troponin consistent with myocardial ischaemia ?
As troponin is released from ischaemic heart muscle
What is meant by troponins are non specific in relation to ACS ?
Raised troponin does not automatically mean ACS
Name five causes of raised troponins besides ACS ?
Chronic renal failure Sepsis Myocarditis PE Aortic dissection
In the event of an ACS you should perform all the normal investigations you would normally arrange for stable angina plus what three other investigations and why ?
Chest Xray - to investigate for pulmonary oedema and other causes of chest pain
Echocardiogram - after the event to assess the functional damage to the heart
CT coronary angiogram - to assess for coronary artery disease
Patients with a STEMI presenting within 12 hours of onset should be discussed urgently with the local cardiac centre for what two procedures?
+
Other management of STEMI and NSTEMI ?
Primary PCI (if available within 2 hours of presentation) Thrombolysis (if PCI not available within 2 hours)
- Immediate dual antiplatelet therapy (DAPT; aspirin plus Ticagrelor, Prasugrel, or Clopidogrel) and pain relief. Paramedics usually give the Aspirin and opiates. Oxygen should be avoided and nitrates are useless for MI.
- Anticoagulation for 24-72hrs; Heparin, Fondapariux or similar
- Both STEMI and NSTEMI should have angiography and if possible stenting; STEMI immediately, NSTEMI within 72hrs or sooner if complications
- Secondary prevention; DAPT for a year then Aspirin alone, Statin, Betablocker for a year, ACE inhibitor, and treatment of any complication (heart failure, arrhythmia, etc).
Cardiac rehabilitation; exercise, education, diet, smoking cessation
What is thrombolysis and name some thrombolytic agents ?
It involves injecting a fibrinolytic medication that rapidly dissolves clots.
Examples = alteplase, streptokinase and tenecteplase
What is the treatment for an acute NSTEMI ?
BATMA
Beta blocker - unless contraindicated Aspirin - 300mg stat dose Ticagrelor - 180mg stat dose (clopidogrel 300mg is an alternative) Morphine - titrate to control pain Anticoagulant: LMWH at treatment dose
Give oxygen only if oxygen saturations are dropping (i.e. <95%)
What score is used to assess for PCI in NSTEMI ?
GRACE score
What does a GRACE score show ?
6 month risk of death or repeat MI after having an NSTEMI
<5% = low risk
5-10% = medium risk
>10% = high risk
If the patient is medium or high risk they are considered for early PCI (within 4 days of admission) to treat underlying coronary artery disease.
Complications of MI ?
DREAD
Death Rupture of the heart septum or papillary muscles oEdema (heart failure) Arrhythmia and aneurysms Dressler's syndrome
What is dresslers’s syndrome (post-myocardial infarction syndrome) ?
It usually occurs 2-3 wks following an MI. It is caused by a localised immune response and causes pericarditis .
How does dressler’s syndrome present and name two complications ?
Pleuritic chest pain, low grade fever and pericardial rub on auscultation
Pericardial effusion and rarely a pericardial tamponade
How can a diagnosis of dressler’s syndrome be made ?
ECG - global ST elevation and T wave inversion
Echocardiogram - pericardial effusion
Inflammatory markers - CRP, ESR
What is the management of dressler’s syndrome ?
NSAIDS (aspirin, ibuprofen)
In more severe cases - steroids (prednisolone)
Pt may need pericardiocentesis to remove fluid from around the heart
Secondary prevention medical management of MI ?
6 A’s
Aspirin 75mg OD
Another antiplatelet e.g. clopidogrel or ticagrelor for up to 12 months
Atorvastatin 80mg OD
ACEi (e.g. ramipril titrated as tolerated to 10mg OD)
Atenolol (or other B blocker titrated as high as tolerated)
Aldosterone antagonist for those with CHF (i.e. eplerenone titrated to 50mg OD)
Dual antiplatelet therapy duration will vary following PCI procedures depending on the type of stent that was inserted
Secondary prevention lifestyle advice of MI ?
Stop smoking
Reduce alcohol consumption
Mediterranean diet
Cardiac rehabilitation (a specific exercise regime for patients post MI)
Optimise treatment of other medical conditions e.g. HTN, diabetes
What is acute left ventricular failure
When the left ventricle is unable to adequately move blood through the left side of the heart and out into the body.
What does acute LVF cause, how does this happen ?
Pulmonary oedema (when lung tissue and alveoli become full of interstitial fluid)
There is a backlog of blood from the left ventricle that increases the amount of blood in the LA, pulmonary veins and lungs. As the vessels in these areas are engorged with blood due to the increased volume and pressure they leak fluid into the surrounding tissues and are unable to reabsorb it. This interferes with normal gas exchange in the lungs causing shortness of breath, reduced oxygen saturation and the other S+S.
Name four triggers for acute LVF ?
Iatrogenic (e.g. aggressive IV fluids in frail elderly pt with impaired LV function)
Sepsis
MI
Arrhythmias
How does acute LVF present and what type of respiratory failure does it cause ?
Rapid onset breathlessness. This is exacerbated by lying flat and improves on sitting up.
Type 1 respiratory failure
Three symptoms of acute LVF ?
SOB
Looking and feeling unwell
Cough with frothy white or pink sputum
What signs would you see on examination of acute LVF (six) ?
Increased RR
Decreased oxygen sats
Tachycardia
3rd heart sound
Bilateral basal crackles “sounding wet” on auscultation
Hypotension in severe cases (cardiogenic shock)
In someone presenting with acute LVF there may also be S+S relating to the underlying cause, name three examples ?
Chest pain in ACS
Fever in sepsis
Palpitations with arrhythmias
If a patient with acute LVF also has right sided HF what might you also find on examination ?
Raised JVP
Peripheral oedema in the ankles, legs and sacrum
Work up for acute LVF ?
History
Clinical exam
ECG - to look for ischaemia and arrhythmias
ABG
CXR
Routine bloods for infection, kidney function, BNP and consider troponin if suspect MI
Echocardiogram
If the clinical presentation is acute LVF then initiate treatment before having the diagnosis confirmed by BNP or echo. Pts can deteriorate quickly.
What is B-type natriuretic peptide (BNP) ?
A hormone that is released from the ventricles when the myocardium is stretched beyond normal range. A high BNP blood test result indicates that the heart is overloaded.
What is the action of BNP ?
It causes the smooth muscle in blood vessels to relax which reduces systemic vascular resistance. It also acts on the kidneys as a diuretic. Both of these effects make it easier for the heart to pump blood around the body.
Name five causes of a high blood BNP level other than HF ?
Tachycardia Sepsis PE Renal impairment COPD
Why is echocardiography useful in investigation acute LVF ?
It assesses the function of the LV and identifies any structural abnormalities in the heart. The mean measure of LV function is the ejection fraction. Above 50% is considered normal.
Cardiomegaly may be seen on the CXR of a pt with acute LVF, how is it defined ?
When the cardiothoracic ratio is more than 0.5 - when the diameter of the widest part of the heart is more than half the diamter of the widest part of the lung fields
Upper lobe venous diversion may also be seen on the CXR of a pt with acute LVF, what is that ?
Normally when stand erect the lower lobe veins contain a lot more blood than the upper lobes which remain relatively small. In LVF the backlog of blood causes the upper lobes to fill up and become engorged. This is visible as increased prominence and diameter of the upper lobe vessels on CXR.
Name 3 other CXR findings as a result of fluid leaking from oedematous lung tissue ?
Bilateral pleural effusions
Fluid in interlobar fissures
Fluid in the septal lines (Kerley lines)
Management of acute LVF ?
Pour SOD
Pour away (stop) their IV fluids
Sit up - sit the patient upright as gravity takes fluid in the lungs to the bases leaving the upper lungs clear for better gas exchange
Oxygen - if the pts sats are falling below 95%
Diuretics - e.g. IV furosemide 40mg stat
Also monitor fluid balance
Other management options to consider in severe acute pulmonary oedema or cardiogenic shock ?
IV opiates - opiates such as morphine act as vasodilators but are not routinely recommended
Non-invasive ventilation - Would try CPAP first. Then if this doesn’t work the pt may need full intubation and ventilation.
Inotropes - For example an infusion of noradrenalin. Inotropes strengthen the force of heart contractions and improve HF however they need close titration and monitoring so by this point you would need to send the pt to a the local coronary unit, high dependency unit or ICU.
What is chronic heart failure ?
Basically just the chronic version of acute heart failure. Is either caused by impaired LV contraction (systolic heart failure) or impaired LV relaxation (diastolic heart failure).
Key features that patients with CHF present with (five) ?
- Breathlessness worsened by exertion
- Cough. They may produce frothy white/ pink sputum.
- Orthopnoea. This s the sensation of SOB when lying flat, relieves by sitting or standing. Ask them how many pillows they use at night.
- Paroxysmal nocturnal dyspnoea
- Peripheral oedema
What is PND ?
A term used to describe the experience that pts have of suddenly waking at night with a severe attack of SOB
Diagnosis of CHF ?
Clinical presentation
BNP blood test specifically the N-terminal pro-B-type natriuretic peptide (NT-proBNP)
Echocardiogram
ECG
Name 4 causes of CHF ?
Ischaemic heart disease
Valvular heart disease (commonly aortic stenosis)
HTN
Arrhythmias (commonly AF)
Overall management of CHF ?
- Refer to specialist (NT-proBNP > 2000ng/litre warrans an urgent referral)
- Careful discussion and explanation of the condition
- Medical management
- Surgical treatment in severe aortic stenosis or mitral regurgitation
- HF specialist nurse input for advice and support
Additional information:
- Yearly flu and pneumococcal vaccine
- Stop smoking
- Optimise treatment of co morbidities
- Exercise as tolerated
