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Phase 2a NEW > Cardiology > Flashcards

Cardiology Flashcards

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1
Q

Atherosclerosis

A

Plaque rupture
Thrombus formation
Partial/complete arterial blockage
Heart attack, stroke or gangrene

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2
Q

RFs for atherosclerosis

A 
Increasing age
Smoking
Raised cholesterol
Obesity 
Diabetes
Hptn
Fx
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3
Q

Distribution of atherosclerotic plaques

A

Peripheral and coronary arteries
Focal distribution along artery length
Distribution governed by haemodynamic factors - Changes in blood flow/turbulence (such as bifurcations) cause the artery to alter endothelial cell function

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4
Q

Structure of an atherosclerotic plaque

A

Lipid
Necrotic core
Connective tissue
Fibrous cap

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5
Q

Plaque

A

Occlusion - Angina

Rupture - Thrombus formation (and death)

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6
Q

Causes of inflammation in arterial wall

A

LDL - Accumulates in arterial wall

Endothelial dysfunction due to injury

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7
Q

Stimulus for adhesion of leukocytes

A

Once inflammation is initiated, chemoattractants (chemicals that attract leukocytes) are released from endothelium and send signals to leukocytes
Chemoattractants are released from site of injury and a conc grad is produced
Stimulus = Chemoattractants

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8
Q

Inflammatory cytokines found in plaques

A

IL-1,6,8
IFN Gamma
CRP

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9
Q

Leukocyte recruitment to vessel walls

A

Mediated by selectins, integrins and chemoattractants

Cause leukocytes to roll, adhere and transmigrate

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10
Q

Progression of atherosclerosis - Stage 1

A

Fatty streaks - earliest lesion of AS

Early ages - less than 10 y.o

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11
Q

Progression of atherosclerosis - Stage 2

A

Intermediate lesions
Composed of foam cells (lipid laden macrophages), vascular smooth muscle cells, T lymphocytes, adhesion and aggregation of platelets to vessel wall, isolated pools of extracellular lipid

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12
Q

Progression of atherosclerosis - Stage 3

A

Advanced lesion - Fibrous plaque
Impedes blood flow
Prone to rupture
Dense fibrous cap made of collagen (strength) and elastin (flexibility) laid down by smooth muscle cells
May be calcified
Contains smooth muscle cells, macrophages, foam cells and T lymphocytes

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13
Q

Progression of atherosclerosis - Stage 4

A

Plaque rupture
Plaque is constantly growing and receding (resorbed and redeposited)
Cap becomes weak and plaque ruptures
Thrombus formation and vessel occlusion

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14
Q

Progression of atherosclerosis - Stage 5

A

Plaque erosion
Lesions tend to be early lesions
Fibrous cap thick may

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15
Q

Treating coronary artery disease

A

PCI - Percutaneous coronary intervention

Stent implantation

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16
Q

Restenosis

A

Narrowing/blocking of vessel lumen after surgical correction

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17
Q

Drug elution

A

Anti-proliferative and inhibits healing

Reduce restenosis

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18
Q

Useful drugs in atherosclerosis

A

Aspirin
Clopidogrel
Statins

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19
Q

ECG and drug toxicity

A

Digoxin prolong the QT interval

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20
Q

Depolarisation

A

Contraction of a muscle

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21
Q

Pacemakers of the heart

A

SAN (Dominant) - 60-100bpm
AVN (Back-up) - 40-60bpm
Ventricular cells (Back-up) - 20-45bpm

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22
Q

Standard calibration of an ECG

A

25mm/s (speed)

0.1mV/mm (voltage)

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23
Q

Impulse conduction

A 
SAN
AVN
Bundle of his
Bundle branches
Purkinje fibres
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24
Q

PQRST

A

P - Atrial depolarisation
QRS - Ventricular depolarisation
T - Ventricular repolarisation
PR interval - allows time for atria to contract before ventricles

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25
1st degree heart block
Long PR interval
26
QRS abnormalities
Ventricular enlargement | Conduction blocks
27
Angina types
Prinzmetal's angina (coronary spasm) Microvascular angina Crescendo angina Unstable angina (Critical ischaemia - plaques severely occluding artery)
28
IHD history
``` Personal details Presenting complaint Past med history Drug history, allergies Fx (only first degree relatives) Social history (smoking) Systematic enquiry ```
29
Cardiac symptoms
``` Chest pain Breathlessness Fluid retention (HF) Palpitation Syncope or pre-syncope ```
30
Pain
``` OPQRST Onset Position (site) Quality (nature/character) Relationship (exertion, posture, meals, breathing, etc) Radiation (Throat, arm, upper body) Relieving/aggravating factors Severity Timing Treatment (does it work immediately) ```
31
Chest pain - Differential diagnosis
``` MI Pericarditis/myocarditis Pulmonary embolism/pleurisy Chest infection/pleurisy Dissection of aorta Gastro-oesophageal (reflux, ulceration, spasm) MSK - Arthritis Psychological - Anxiety ```
32
Treatment
Lifestyle - Smoking, weight, exercise, diet Advice for an emergency - 999 Medication Revascularisation
33
NICE guidelines for angina - GP
History - typical/atypical angina? Exam - exacerbating causes Investigations - Routine bloods, lipids, ECG Angina? - Refer to cardio Treat - Smoking cessation, aspirin, BB, statin, GTN spray
34
NICE guidelines for angina - Cardiologist
Diagnostic test - CTCA (CT coronary angiogram) | High risk/CTCA shows stenoses - Refer to cath lab
35
Exercise testing
The patient runs on treadmill whilst ECG records
36
Myoview scan
Perfusion scan
37
Stress echo
Echocardiogram
38
Perfusion MRI scan
Gold standard | Indicates the structure and function of the heart - any ischaemic areas are highlighted
39
Invasive coronary angiography
Through radial artery | Not diagnostic, more about treatment planning (what interventions are appropriate)
40
Angina - 1st line drug - BB
BB - Lowers HR, Lowers LV contractility which together lower cardiac output and demand SEs of BB - Tiredness, bradycardia, cold hands and feet, erectile dysfunction CIs of BB - Asthma patients
41
Angina - 2nd line drug - Nitrates
Dilate vessels and reduce preload on the heart Dilate coronary vessels SE - Headache
42
Angina - 3rd line drug - CCB
Reduce afterload on the heart Dilate arterial vessels SE - Flushing, swollen ankles, postural hypotension
43
Angina - 4th line drug - Aspirin
Antiplatelet and anti-inflammatory Cyclo-oxygenase inhibitor SE - Gastric
44
Angina - 5th line drug - Statins
HMG CoA reductase inhibitors
45
Angina - 6th line drug - ACEi
Ramipril
46
Revascularisation
PCI/CABG | MDT meeting
47
Coronary angioplasty/Stenting -
PCI - Percutaneous coronary intervention | Risks - stent thrombosis, restenosis
48
CABG
If a stent is not appropriate then bypass is next step Coronary artery bypass graft Risks - v invasive, stroke risk, chest bleeding risk
49
PCI and CABG use
STEMI - PCI NSTEMI - PCI>CABG Stable angina - PCI/CABG
50
Unstable angina
Cardiac chest pain at rest | Diagnosis - Troponin level is not increased
51
Acute MI
ST elevation | Non ST elevation - retrospective diagnosis
52
MI - ECG features
ST elevation - can be inverse which confirm MI Q waves - broad and deep indicate pathology Poor R wave progression Biphasic T wave
53
MI
Cardiac chest pain - persistent, severe but can be mild, occurs at rest, sweating, breathlessness, N/V Causes permanent heart muscle damage Higher risk - higher age, diabetes, renal failure, left ventricular systolic dysfunction
54
MI - Initial management
999 If ST elevated - transfer to PCI Aspirin immediately Pain relief
55
MI - hospital management
Oxygen therapy - if hypoxic Pain relief - Narcotics/nitrates Antiplatelets - Aspirin +/- P2Y12 inhibitor BB Coronary angiography - If troponin elevated
56
MI - Causes
Atherogenesis/atherothrombosis
57
Troponin
Protein complex regulates actin/myosin contraction Highly sensitive marker for cardiac muscle injury Not specific for ACS
58
Antiplatelet drugs
Aspirin | Streptokinase
59
P2Y12 inhibitors
Clopidogrel Used in combo with aspirin to manage ACS (Dual antiplatelet therapy) Clopidogrel is a prodrug - activated by CYP450 enzymes Drug interactions - Omeprazole Tricagelor (rapid onset and offset) is preferred over clopidogrel (much more irreversibly bound to CYP450 which makes offset delayed) Adverse effects - Bleeding (GI), haematuria, rash
60
Anticoagulants
Target thrombin Inhibit fibrin formation and platelet activation Heparin used during PCI/CABG
61
ACS - Order of medication
``` Initial pain relief - Morphine/nitrates Antiplatelet - Aspirin + clopidogrel Anticoag - Heparin BB, CCB Statins, ACEi ```
62
Heart weight
Heavier in males than females
63
Heart is composed of these proteins
Sarcomere proteins | Protein conformational change = contraction
64
Heart contraction
2 stage electrical generated contraction | Contractioon initiated by depolarisation and changes to calcium conc
65
Heart relaxation
Removal of calcium mediates relaxation
66
Types of cardiac myocytes
AV conduction system (fast conduction) | General cardiac myocyte
67
Heart failure
Failure to transport blood out of heart | Cardiogenic shock - severe failure
68
Myocardial hypertrophy
Athletes | Pregnancy
69
Diabetic complications
``` Stroke CVD (leading cause of mortality) Peripheral vascular disease Diabetic retinopathy, Blindness Diabetic neuropathy ```
70
Diabetic neuropathy - Consequences
Pain - burning, paraesthesia, nocturnal exacerbation, sharp and shoots up legs Autonomic - Diarrhoea, urinary incontinence, erectile dysfunction Insensitivity - Foot ulceration, infection, falls (lead to amputation)
71
Diabetic peripheral neuropathy
Typical 'glove and stocking' sensory loss
72
DN - Risk factors
Hptn Smoking Hba1c
73
DN - Treatment
Glycaemic control SSRIs Anticonvulsants - Carbamezapine, gabapentin) Opioids - Tramadol, oxycodone
74
Diabetic foot ulceration
15% of people with DM
75
Diabetic amputation - pathophysiology
``` Neuropathy or vascular cause Trauma Ulcer Failure to heal Infection Amputation ```
76
Neuropathy
Painless nature of diabetic foot disease
77
DN - Complications
Motor nerve damage Localised callus (hard skin) Autonomic nerve damage - dry skin which leads to cracks/fissures and makes feet susceptible to infection. Treat by moisturising twice a day
78
DPN - Screening tests
Test sensation - Monofilament, neurotip, tuning fork
79
Peripheral vascular disease
Decreased perfusion due to macrovascaular disease More distal sites Ischaemia in legs High rates of amputation
80
PVD - Symptoms
Intermittent claudication - pain and cramping (ischaemic legs)
81
PVD - Signs
Absent pedal pulses Coolness of deet Poor skin and nails
82
PVD - Investigation
Doppler | Duplex arterial imaging
83
PVD - Treatment
Smoking cessation Surgery MDT foot clinic (for ulcers) Pressure-relieving footwear, podiatry
84
Diabetic retinopathy
The commonest cause of blindness in adults
85
DR - RFs
Diabetes (chronic) Poor glycaemic control - Hba1c raised Hptn Pregnancy
86
DR - Eye screening
Retinal photographs
87
DR - Pathogenesis
Leakage of blood vessels Occlusion of blood vessels Micro-aneurysms - Pericyte loss and smooth muscle cell loss Basement membrane thickens Reduces junctional contact with endothelial cells Glial cells grow down capillaries - Ischaemia and occlusion due to proliferation These lead to changes in the retina and then blindness occurs as a result
88
DR - Treatment
Laser therapy - burns off abnormal blood vessels to prevent leakage etc Not curative, just stabilises disease to prevent progression to blindness Photocoagulation - burns as much of retina as possible, which unfortunately leads to tunnel vision with only central vision surviving
89
Diabetic nephropathy
Diabetes is main cause of end stage renal disease
90
Diabetic nephropathy
Hallmark is proteinuria Progressive decline in renal function RFs - Poor BP and BG control Major RF for CVD
91
Diabetic nephropathy - Pathogenesis
Glomerulus changes - Thickening of BM Glomerular injury Filtration of proteins DN occurs
92
End-stage renal disease
Stage 5 CKD
93
Nephropathy in T1DM and T2DM
T1DM - Microalbuminuria develops 5-10 years after diagnosis | T2DM - Microalbuminuria present at time of diagnosis
94
Diabetic nephropathy - Treatment
ACEi | Statins - Cholesterol control
95
Diabetes screening
Urine dip - Albumin:Creatinine ratio Retinal photography Foot exam (10g monofilament)
96
T2DM meds - Insulin sensitisers (first line)
Metformin | Pioglitazone
97
T2DM meds - Increase beta-cell function (second line)
Sulphonylureas DDP4i GLP1 receptor agonists
98
Diabetes lab tests
``` Fasting plasmaa glucose Hba1c Na, K, Ur, Crt Urine - Alb:Crt ratio LFTs - AST, ALT Lipids - T Chol, HDL, Trig ```
99
Diabetes - Lifestyle interventions
Local education programmes - In sheffield = Desmond and xpert Exercise - 30mins a day Dietician
100
T2DM - Pharmacotherapy regimen
1st line - Metformin (reduces insulin resistance) - Weight neutral/loss 2nd line - Sulphonylurea - Weight gain occurs 3rd line - DPP4i - Prolongs action of GLP1 (no weight change with DPP4i). GLP1 induce weight loss 4th line - SGLT2i (Reduce reabsorption of glucose in kidneys in proximal tubules from going back into the bloodstream) - Weight loss 5th line - Insulin - Weight gain
101
Bariatric surgery
Surgical weight loss in T2DM BMI above 35 Reduce stomach size (gastric bypass) so patients appetite is reduced and weight loss occurs Improves glycaemic control
102
DVT - Symptoms
Pain | Swelling
103
DVT - Signs
Tenderness Swelling Warmth Discolouration
104
Proximal DVT
More problematic | Between hip and knee
105
DVT - Investigations
Ultrasound compression test for proximal veins (popliteal fossa) - if vein squashes flat then no DVT, if can't squash flat then DVT possible D-dimer blood test - Normal result excludes diagnosis, Raised result is not specific for thrombosis (cannot confirm diagnosis) D-dimer is used after ultrasound to confirm diagnosis Infection and inflmmation can raise D-dimer level which is why it's not specific for DVT Raised D-dimer is common
106
Low Hb =
Anaemia
107
DVT - Treatment
1st line - LMW Heparin (anticoag) - minimum 5 days 2nd line - Oral Warfarin (anticoag) - 3-6 months DOAC - Direct-acting oral coag Compression stockings - Decrease swelling and risk of long term post-thrombotic syndrome
108
DVT - Causes
Thrombophilia | Malignancy
109
DVT - RFs
``` Surgery Immbolity Leg fracture Pregnancy (Oestrogen raised) Long haul flights/travel (rare though) Inherited thrombophilia (genetic predisposition) - Caucasians ```
110
DVT - Prevention
``` Compression stockings Early mobilisation Hydration Mechanical foot pumps Chemical thromboprophylaxis - LMW Heparin ```
111
Thromboprophylaxis
Not required in young patients having short duration surgery | Required in high risk, long duration surgery
112
Pulmonary embolism
DVT which has broken off from vein and gone through heart and blocking up pulmonary artery A big clot will block up both./bifurcation of pulmonary aeries and results in death
113
Pulmonary embolism
Hypotension Cyanosis Severe dyspnoea Right heart failure
114
Pulmonary embolism - Removal
Embolectomy | Thrombolysis - mechanical or chemical (tPA)
115
Pulmonary embolism - Presentation
``` Chest pain - pleuritic SOB/breathlessness Haemoptysis - if pulmonary infarct Signs of DVT in legs Signs - Tachycardia, tachypnoea ```
116
PE - Investigations
CXR - Usually normal ECG - May show sinus tachycardia, ECG to rule out cardiac causes D-dimer - raised then do imaging, if normal then no pulmonary embolus (not specific though) CTPA - Spiral CT with contrast, visualise major segmental thrombi - major diagnostic tool Ventilation/perfusion scan - Mismatch defects
117
PE - Treatment
Same as DVT - LMW Heparin then warfarin/Or DOAC (Only in outpatients with minor PE) If cannot anti-coag, consider IVC filter insertion to prevent further PE, however, legs may embolise as a result
118
PE - Prevention
Same as DVT
119
Warfarin
``` Oral Works on liver Prevents synthesis of active factors - 2,7,9,10 (still synthesised but do not work, does this by interfering with VitK pathway) VitK antagonist Long half-life Prolongs prothrombin time Narrow therapeutic range - have to keep monitoring INR Lots of drug interactions ```
120
INR
International normalised ratio | Derived from prothrombin time
121
DOAC
``` New oral anticoag drugs Oral Directly act on factors 2,10 (not via liver, more direct) No blood tests or monitoring required Short half life Not used in pregnancy Used for treatment/thromboprophylaxis Only used for INR target ranges of 2-3 (small targets) ```
122
DVT vs PE mortality
PE kills as opposed to DVT
123
Thrombosis
Blood coag inside a vessel
124
Thrombosis
Arterial - High pressure, platelet-rich - use antiplatelets (aspirin) Venous - Low pressure, fibrin rich - anticoag (DOACs)
125
Arterial thrombosis - Consequences
MI Stroke Gangrene
126
MI diagnosis
ECG | Cardiac enzymes
127
Peripheral vascular disease diagnosis
Ultrasound | Angiogram
128
Arterial thrombosis - Treatment
``` Aspirin Clopidogrel Prasugrel Tiglacor Anti-platelet ```
129
Venous thrombosis - Causes
Genetic - Antithrombin deficiency, Factor 5 Leiden | Acquired - Anti-phospholipid syndrome (autoimmune)
130
Haemophilia
Lack of clotting factors
131
Heparin
``` Glycoaminoglycan Binds to antithrombin and increases its activity Indirectly inhibits prothrombin Injected Protamine reverses effects of heparin ```
132
LMW Heparin
Smaller molecule | Less variation in dose
133
Aspirin
Inhibits cyclo-oxygenase irreversibility Inhibits thromboxane formation and hence platelet aggregation Used in arterial thrombosis
134
Clopidogrel
Similar to aspirin Irreversible platelet inhibitor Target ADP receptor of platelet
135
Pericarditis
Cause of acute chest pain
136
Cardiac biomarkers
Troponin and CK
137
Pericardial sac
lubricates the heart 50ml of fluid Cardiac tamponade - alteration of fluid level in pericardial sac
138
Acute pericarditis
Inflammation of pericardium With or without pericardial effusion Features - Chest pain, friction rub, ECG changes, pericardial effusion
139
Pericarditis - Causes
``` Infectious) Viral - common - Enteroviruses Bacterial - uncommon - TB Non-infectious) Autoimmune - RA, Sjogrens syndrome Neoplastic - Secondary metastatic tumours Trauma/iatrogenic - Direct injury ```
140
Pericarditis - Presentation
Chest pain - Severe, sharp, pleuritic, rapid onset, radiates to arm//trapezius ridge, relieved by sitting forward, exacerbated by lying down Dyspnoea Cough
141
Pericarditis - Examination
Pericardial rub - crunching snow Sinus tachycardia Fever Effusion (pulsus paradoxus)
142
Pericarditis - Investigations
ECG - Saddle shaped, ST elevation, PR depression, concave ST segment Bloods - Raised ESR/CRP, raised troponin, raised WBC CXR Echocardiogram
143
Cardiac tamponade - Signs
Pulsus paradoxus - Fall in systolic BP of >10mmHg
144
Pericarditis - Management
NSAIDs - Aspirin (high dose)
145
Pericarditis - Complications
Cardiac tamponade
146
Constrictive pericarditis
Calcified pericardium | Treatment - Pericardectomy (surgical removal of pericardium)
147
Pericarditis
Bacterial worse than viral
148
Dresslers syndrome
Secondary pericarditis with or without pericardial effusion, occurs as a result of injury to the heart
149
Cardiomyopathies
Hypertrophic - muscle thickens Dilated - Heart chambers dilated Arrhythmogenic - Structural abnormality leading to rhythm disturbances Diseased desmosomes (adhesion molecules)
150
Hypertrophic cardiomyopathy
Diastolic dysfunction Fibrosis scar tissue ECG abnormality - Repolarisational T wave inversion, ventricular tachycardia
151
Dilated cardiomyopathy
Chamber dilation | Contraction impaired - heart failure
152
Arrhythmogenic cardiomyopathy
``` Arrhythmias Myocyte death - replaced by fibrous fatty tissue Ventricular Epsilon waves Diseased desmosomes (adhesion molecules) ```
153
Naxos disease
Palmar plantar caratiderma (hand and foot skin thickened) Wooly hair Abnormal ECG - Ventricular arrhythmias Recessive disease
154
Ion channels abnormalities
Voltage-gated Protein based Normal heart (asymptomatic) with ECG abnormalities (electrical problem) - Long QT syndrome, brugada syndrome
155
Brugada syndrome
Ion channel abnormality | Ajamline test - diagnostic
156
CPVT
Catecholaminergic polymorphic ventricular tachycardia | Adrenaline driven - Stress, activity
157
Marfan syndrome
Fibrillin disorder Genetic disorder of connective tissue - tall and thin figure, long arms, legs, fingers and toes Aortic aneurysms
158
Familial hypercholesterolemia
``` LDL receptor genetic mutation - not taking up LDL Vascular disease is a complication Heart attack risk increased Lipid deposition in hands, tendons, eyes Raised cholesterol ```
159
Hypertension
Treat to reduce risk, not symptoms Major risk factor for - Stroke, MI, HF, chronic renal disease, AF Asymptomatic by itself 140/90
160
ABPM
Ambulatory blood pressure monitoring | Slightly lower than clinical BP
161
Hypertension - Diagnosis
Stage 1 - 140/90 Stage 2 - 160/100 Severe - 180/110
162
Hptn - Treatment
Lifestyle | Antihypertensive drug therapy
163
Secondary hptn - Underlying causes
Renal | Adrenal
164
Only treat hptn if patient has
Target organ damage CV disease Renal disease Diabetes
165
BP targets
Under 80 years - 140/90 | Over 80 years - 150/90
166
Mechanisms of BP control - Targets for therapy
Cardiac output and peripheral resistance Interplay between RAAS (angiotensin 2) and sympathetic NS (noradrenaline) Local vascular mediators (constrictors)
167
Vasoconstrictors
Angiotensin 2 | Noradrenaline
168
ACEi
Inhibits ACE, stops production of angiotensin 2 Hptn Ramipril Enalapril Adverse effects - Hypotension, hyperkalaemia, acute renal failure, cough, rash, anaphylaxis CI - Preg
169
CCB
Calcium channel blockers (L type calcium channel blockers) Hptn, arrhythmias Amlodipine (dihydropyridine) - Peripheral arterial vasodilators Verapamil (phenylalkylamines) - Works on heart Diltiazem (benzothiazepines) - peripheral and heart Adverse effects (peripheral) - Flushing, headache, oedema, palpitations Adverse effects (heart) - Bradycardia, AV block
170
BB
Hptn Bisoprolol Propanolol Atenolol Adverse effects - Fatigue, headache, sleep disturbances, bradycardia, hypotension, cold peripheries, erectile dysfunction Worsens conditions such as asthma, COPD, raynaud's
171
Aldosterone antagonist
Spironolactone
172
ARB
Angiotensin 2 receptor blockers (AT1 receptor blocker) Hptn Losartan Valsartan Adverse effects - Hypotension, hyperkalaemia, renal dysfunction, rash CI - Preg
173
Beta adrenoreceptor selectivity
B1 - Heart (bisoprolol) | B2 - Lungs/airways (propanolol)
174
Diuretics
Hptn, HF Thiazides - distal tubule - Bendroflumethiazide Loop diuretics - loop of henle - Furosemide Aldosterone antagonists (Potassium-sparing) - Spironaloctone Adverse effects - Hypovolaemia, hypotension, metabolic disturbances (low levels of Na, K, Mg, Ca), raised uric acid (lead to gout), erectile dysfunction
175
Alpha-1 adrenoceptor blockers
Doxazosin | Treats hptn
176
Hypertension - Treatment order (gold standard)
Under 55 - 1) ACEi, 2) CCB, 3)Thiazide, 4) BB/AB/Spironaloctone Over 55/afro-carib - 1) CCB, 2) ACEi, 3) Thiazide, 4) BB/AB/Spironaloctone
177
Heart failure types
LVSD - Left ventricular systolic dysfunction HFPEP - Diastolic failure Acute/chronic
178
HF
Syndrome of symptoms that suggest impaired efficiency of the heart as a pump Caused by structural or functional abnormalities of the heart Common cause - Coronary artery disease
179
HF - drugs
``` ACEi ARB BB Diuretics (loop) Aldosterone antagonists ```
180
HF - Order of treatment
1) ACEi + BB (Low doses) 2) Aldosterone antagonists - Spironaloctone 3) ARB (if ACEi is not tolerated) 4) ARNI - Sacubitril/Valsartan 5) Digoxin
181
If ACEi is not tolerated then use an
ARB
182
If ACEi + ARB not tolerated then use
Hydralazine
183
Nitrates
Arterial and venous dilators Lower BP Reduce preload+afterload Used for IHD (Angina) and HF GTN spray (short-acting) - SE = Syncopy, headache Isosorbide mononitrate tablets (longer-acting)
184
Chronic stable angina
``` Anginal chest pain Predictable Exertional, goes away when stop/take GTN Infrequent Stable ```
185
Unstable angina/NSTEMI
Unpredictable Can be at rest Frequent Unstable
186
STEMI
``` Complete occlusion of artery Unpredictable Rest pain Persistent Unstable ```
187
Chronic stable angina - Treatment
1st line - BB/CCB (either) 2nd line - BB+CCB (both) 3rd line - Long acting nitrate (Isosorbide mononitrate) Antiplatelets - Aspirin/clopidogrel(if aspirin intolerant) Statins - Simvastatin/atorvastatin
188
NSTEMI/STEMI - Treatment
``` Pain relief - GTN spray, diamorphine Dual antiplatelets - Aspirin+clopidogrel Antithrombin - Fondaparinux Background therapy - BB, ACEi, etc Surgical - Angioplasty, CABG ```
189
Antiarrhythmic drugs
Na, Ca, K channel targets
190
Vaughan Williams classification - Antiarrhythmic drugs
Class 1 - Na channel blockers - Lidocaine Class 2 - BB - Bisoprolol Class 3 - Prolong action potential - Amiodarone Class 4 - CCB - Verapamil
191
Digoxin
``` Cardiac glycoside - Treats HF Antiarrhythmic drug - Most commonly used in AF Inhibits Na/K pump Bradycardia, slows AVN SE - N/V, diarrhoea, confusion ```
192
HF
The inability of the heart to deliver blood (and oxygen) at a rate commensurate with the requirements of the metabolising tissues, despite normal or increased cardiac filling pressures Syndrome of breathlessness, tiredness and fluid overload (systemic/pulmonary oedema) caused by a form of cardiac dysfunction
193
Ejection fraction
Percentage of blood leaving your heart each time it contracts
194
HF - Aetiology
``` MI Hptn Cardiomyopathy Valvular Endocardial ```
195
HF - Signs and symptoms
Signs - Tachycardia, raised JVP, heart sounds/murmurs, hepatomegaly (pulsatile/tender), peripheral/sacral oedema, ascites Symptoms - SOB, fatigue, ankle swelling
196
NYHA
Class 1-4 | Higher class = Severe symptoms
197
HF - Diagnosis
Raised NTproBNP - important biomarker in cardiac disease | Echocardiography - to assess structural/functional abnormalities
198
Raised NTproBNP - Causes
HF | Plus many other cardiac and non-cardiac conditions
199
Acute HF - Causes
Rhythmic disturbances | Viral stress
200
In patients with HF, increased plasma hormone levels of (RAN)
Renin Noradrenaline Arginine
201
HF with reduced ejection fraction (HFREF) - Gold standard treatments
ACEi (k-sparing) BB - Low dose - Bisoprolol Aldosterone antagonist - Spironaloctone (K-sparing)
202
ACEi
Is not as effective on afro-carib pop as others
203
Blacks with HF - Alternative
Isosorbide dinitrate and hydralazine
204
ACEi vs ARB
ACEi - dry cough, lower mortality | ARB - no dry cough, greater mortality
205
Ivabradine
HF with sinus rhythm
206
NTproBNP - Functions
Dilates blood vessel | Opposes Na diuresis
207
Digoxin
Slows heart
208
Cardiac resynchronisation therapy (CRT)
Multi-site pacing (stimulates ventricles to contract at the same rate) Treats bundle branch blocks
209
Amiodarone
Treats arrhythmias
210
ICD
Implanted defibrillators
211
Raised aldosterone
Retains Na from blood Removes K from blood (hypokalaemic) Commonly due to tumour in adrenals
212
High BP, firstly examine
Eyes
213
White coat effect
The difference in BP measurement between home and clinical environment
214
Stage 1 hptn - Treatment
140 - Only high risk patients | 160 - Low risk patients
215
Hypertension treatment effects
Reduced headaches and migraines | Otherwise, nothing else is improved
216
BP treatment target ranges
140/90
217
Doxazosin
Alpha-blocker
218
Hptn - Lifestyle changes
1) Weight loss - Diet (salt) 2) Smoking 3) Alcohol
219
Drugs which increase BP
SNRI (Selective noradrenaline reuptake inhibitors) NSAIDs Oral contraceptive pills Corticosteroids
220
Stop BP-lowering agents during
Surgery
221
ECG provides information on
Arrhythmias Ischaemia Infarction Electrolyte disturbances
222
Indications for an ECG
Chest pain Palpitations Breathlessness Blackout
223
ECG - Principles
Positive deflection is towards the lead/vector Width of deflection reflects speed of conduction The amplitude of deflection is related to the mass of myocardium
224
Limb leads - 6
1-3 aVR aVL AVF
225
Chest leads - 6
V1-V6 (Anterior-left lateral)
226
Sinus rhythm
``` P wave: Positive) Inferior leads, lead 1 Negative) aVR, biphasic in V1 S wave: Negative S wave in V1 R wave: Positive R wave in V6 ```
227
P wave - Abnormalities
Low amplitude (Hyperkalaemia, atrial fibrosis) High amplitude - Tall (Right atrial enlargement) Wandering pacemaker/focal atrial tachycardia
228
PR interval - Abnormalities
Prolonged in AV node disorders | Shorter in young patients
229
QRS complex - Abnormalities
Broad - BBB Small - Pericardial effusion, obesity Tall - Left ventricular hypertrophy, thin patients
230
QT interval - Abnormalities
Long - Low HR | Short - High HR
231
ST segment - Abnormalities
Elevated - MI, pericarditis
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T wave - Abnormalities
Inversion - MI
233
Tachycardias
``` Atrial fib (Irregularly irregular) Atrial flutter (Rapid, sawtooth atrial pattern) Supraventricular tachy Ventricular tachy Ventricular fib ```
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Ventricular tachy vs ventricular fib
Tachy is broader than fib
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Bradycardia - Causes
Conduction tissue fibrosis Ischaemia Inflammation Drugs
236
AV conduction problems
1st degree AV block - 1:1 AV ratio 2nd degree AV block 2:1 AV ratio 3rd degree AV block 3+:1 AV ratio As degree of AV block increases, intervals become longer
237
LBBB
Broad QRS
238
LBBB vs RBBB
wiLLiam - LBBB | maRRow - RBBB
239
Ischaemia/Infarction
T wave flattening inversion ST depression ST elevation Q waves
240
LAD
Anterior changes - V2,3,4
241
Circumflex
Lateral - 5,6
242
Lateral
2,3,5avf (inFERIOR
243
Electrolyte disturbances
Hyperkalaemia - Tall T waves, flattened P waves, broad QRS Hypokalaemia - Flattened T wave, QT prolongation Hypercalcaemia - Shortened QT Hypocalcaemia - QT prolongation
244
Electrolyte disturbances
Hyperkalaemia - Tall T waves, flattened P waves, broad QRS Hypokalaemia - Flattened T wave, QT prolongation Hypercalcaemia - Shortened QT Hypocalcaemia - QT prolongation
245
Pericarditis
Saddle shaped PR depression | ST elevation
246
Ectopic beats
Extra beats outside of sinus rhythm | Atrial or ventricular
247
AF - Treatment
1st line) BB, CCB, Digoxin | 2nd line) Cardioversion (electrical - DC or pharma - Amiodarone)
248
AF increases
Stroke risk
249
CHADS-VASC score measures
Stroke risk
250
SVT - Treatment
Adenosine | Catheter ablation
251
Accessory pathways
Pre-excitation (delta waves on ECG)
252
VT - Treatment
Catheter ablation
253
BLackout - Treatment
Pacemaker
254
Complete heart block - Treatment
Pacemaker
255
Diabetes and NSTEMI/STEMI
Tend to be without chest pain (silent attack)
256
Biventricular ICD
Resynchronises left and right ventricles | Also treats VT episodes
257
PE - ECG changes
T wave inversion
258
Valvular heart diseases
Aortic stenosis Mitral regurg Aortic regurg Mitral stenosis
259
Aortic stenosis - Types
Supravalvular Subvalvular Valvular
260
Aortic stenosis - Causes
Age-related degenerative calcification Rheumatic heart disease IE
261
Bicuspid aortic valve
Congenital
262
Aortic stenosis - Pathophysiology
Left ventricle becomes exhausted and function declines rapidly
263
Aortic stenosis - Presentation
Syncope (extertional) Angina (increased myocardial oxygen demand - demand/supply mismatch) Dyspnoea - Breathlessness on exertion
264
Aortic stenosis - Signs
Pulsus tardus - slowly rising carotid pulse Pulsus parvus - decreased carotid pulse amplitude Heart sounds - S4 gallop due to LVH Ejection systolic murmur - crescendo-decrescendo character
265
Valvular diseases - Investigations
Echocardiography
266
AS - Management
Dental hygeine/care - Reduce bacteraemia + IE risk, IE prophylaxis Surgical replacement TAVI - Transcatheter aortic valve implantation
267
Mitral regurgitation - Causes
IE Rheumatic heart disease Mitral valve prolapse
268
MR - Causes
Auscultation - Pansystolic murmur
269
MR - Investigations
ECG - AF CXR - LA enlargement Echo -
270
MR - Management
ACEi - vasodilator IE prophylaxis Surgical
271
Systolic vs diastolic murmurs
Systolic murmurs easier to hear than diastolic murmurs
272
Aortic regurg - Causes
Bicuspid aortic valve Rheumatic IE
273
AR - Investigations
Auscultation - Diastolic blowing murmur, | Wide pulse pressure - High systolic pressure, low diastolic pressure
274
Mitral stenosis
V uncommon
275
MS - Causes
Rheumatic IE Age-related calcification
276
MS - Causes
Rheumatic IE Age-related calcification
277
IE
Infection of heart valve or other endocardial lined structures within the heart (septal defects, pacemaker leads, surgical patches)
278
IE - Types
``` Left-sided native - (mitral/aortic) Left-sided prosthetic Right-sided native Device related Prosthetic ```
279
IE - Causes
Blood infection Prosthetic heart valve op Drug abusers (IV)
280
IE - Presentation
Signs of systemic infection - Fever, sweats Embolisation - stroke, pulmonary embolism, MI Valve dysfunction - HF, arrhythmia
281
IE - Diagnosis
``` Modified dukes criteria Major criteria (2) - Blood cultures, echocardiography - endocarditis, valve leaks Minor criteria (5) - Predisposing factors, fever, vascular phenomena, immune phenomena, ambiguous blood cultures ```
282
IE - Peripheral signs
Splinter hemorrhages (nails) Osler's nodes (tender nodules in fingers) Embolic skin lesions on hands (from the heart) Roth spot in eyes
283
IE - Echocardiography
TTE - Transthoracic echo (lower quality, non-invasive) | TOE - Transoesophageal echo (better quality, invasive)
284
IE - Diagnosis
Blood cultures Raised CRP Raised WBC TTE
285
IE = Treatment
IV antimicrobials Surgical - remove large materials before they embolise, to remove infected devices Antibiotic prophylaxis
286
IE - Management
Blood cultures | Echo
287
IE - most common bacterial cause
Strep viridans
288
Right-sided IE - Typical history
IV drug abusers, HIV positive | Staph aureus
289
Tetralogy of Fallot - 4 things
``` Ventricular septal defect Pulmonary artery stenosis Hypertrophy of right ventricle Overriding aorta Stenosis of the RV outflow leads to RV being at a higher pressure than the left Hypoxia episodes can then cause death Treatment - surgical ```

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