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Cardiovascular Flashcards

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1
Q

Supraventricular Tachycardia: Definition (3)

A

HR > 100, QRS <120ms, narrow complexes
E.g. Atrial fibrillation, AV Re-entry Tachycardia (AVRT), AV Nodal Re-entry Tachycardia (AVNRT)

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2
Q

Supraventricular Tachycardia: Pathophysiology

A

Re-entry circuit is established at or above the AV node

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3
Q

Supraventricular Tachycardia: Atrioventricular nodal re-entry tachycardia (AVNRT) Definition (3)

A

Re-entry pathway exists in AV node, not re-rentry, stable rhythm

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4
Q

Supraventricular Tachycardia: Atrioventricular re-entry tachycardia (AVRT) (3)

A

Extra-accessory pathway/tissue separate to AV node exists, Re-rentry pathway, Unstable rhythm

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5
Q

Supraventricular Tachycardia: General Symptoms (3)

A

Palpitation, SOB, Chest pain

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6
Q

Supraventricular Tachycardia: AVNRT specific symptoms

A

Pre-syncope

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7
Q

Supraventricular Tachycardia: AVNRT prognosis

A

Generally safe rhythm

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8
Q

Supraventricular Tachycardia: AVRT symptoms

A

Syncope

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9
Q

Supraventricular Tachycardia: AVRT cause of mortality

A

Rhythms conducted much faster than normal cardiac tissue.
If AF occurs on top, can be conducted 1:1 without AV block which can be fatal.

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10
Q

Supraventricular Tachycardia: AVNRT ECG Signs (3)

A

Lead V1: Variable p-wave, >300ms, can be hidden in QRS complex

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11
Q

Supraventricular Tachycardia: AVRT Signs on ECG (3)

A

Lead V1: Sinus ECG, Delta wave, short PR interval

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12
Q

Supraventricular Tachycardia: Investigations (4)

A
  1. ECG
  2. EP study
  3. 24 Hour ambulatory ECG
  4. Echo
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13
Q

Supraventricular Tachycardia: Echo Results (2)

A

LV failure or cardiomyopathy

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14
Q

Supraventricular Tachycardia: Management (AVNRT) (2)

A
  1. Vagal manœuvres (carotid sinus massage or valsalva manœuvre)
  2. Adenosine
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15
Q

Supraventricular Tachycardia: Management (AVRT)

A

Treat as Atrial Fibrillation
1. DC cardioversion (if Haemodynamic Instability)
2. Anticoagulation with rate/rhythm control (If no Haemodynamic instability)

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16
Q

Supraventricular Tachycardia: Prophylaxis

A
  1. Beta-blockers
  2. Pace and ablate re-entry pathway
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17
Q

Aortic Regurgitation: Definition

A

Blood flow across the aortic valve in diastole from the aorta into the left ventricle, due to incompetence of the valve.

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18
Q

Aortic Regurgitation: Epidemiology

A

More common in men than women

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19
Q

Acute causes of Aortic Regurgitation (4)

A
  1. Infective endocarditis (valve destruction and leaflet perforation)
  2. Iatrogenic
  3. Traumatic rupture
  4. Aortic Dissection
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20
Q

Chronic causes of Aortic Regurgitation (3)

A

Most common are:
1. Congenital heart disease (bicuspid aortic valve)
2. Rheumatic fever
3. Aortic root dilatation

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21
Q

Aortic Regurgitation: Causes of aortic root dilatation (3)

A
  1. Genetic syndromes like Marfans or Ehlers-Danlos
  2. Systemic vasculitis
  3. Congenital bicuspid valve disease
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22
Q

Aortic Regurgitation: Pathophysiology of Aortic Root Dilatation

A

Dilatation stretches the annulus the cusps are attactched to, so the valves are unable to meet/close

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23
Q

Aortic Regurgitation: Pathophysiology

A

Inadequate closure - back flow of blood and decrease in aortic diastolic pressure - pressure in LA and Vasc - increased wall tension , enlargement and hypertrophy - congestive heart failure

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24
Q

Aortic Regurgitation: Pathophysiology of wide pulse pressure

A

Increased systolic volume but rapid fall of aortic pressure as blood flows back during systole.

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25
Aortic Regurgitation: Pathophysiology of acute regurgitation
End-diastolic pressure in LV increases sharply - HR increases - this fails to maintain stroke volume - cariogenic shock
26
Aortic Regurgitation: Acute symptoms (5)
1. Sudden cardiovascular collapse 2. Pulmonary oedema 3. Pallor 4. Sweating 5. Peripheral vasoconstriction
27
Aortic Regurgitation: Primary Chronic Symptoms (3)
1. Exertional Dyspnoea 2. Orthopnea 3. Paroxysmal nocturnal dyspnoea
28
Aortic Regurgitation: Secondary Chronic Symptoms (3)
1. Syncope 2. Palpitations 3. Angina
29
Aortic Regurgitation: Clinical Findings (3)
1. War-hammer - collapsing pulse 2. Wide-pulse pressure 3. Displaced, hyperdynamic apex-beat
30
Aortic Regurgitation: Corrigan's sign
Large volume, collapsing pulse in the carotid arteries
31
Aortic Regurgitation: De Musset's sign
Bobbing of the head in synchrony with the beating of the heart
32
Aortic Regurgitation: Quincke's sign
Pulsation of the nail beds
33
Aortic Regurgitation: Traube's sign
"Pistol shot" like bruit heard on auscultation of the femoral pulse
34
Aortic Regurgitation: Duroziez sign
Diastolic femoral murmur
35
Aortic Regurgitation: Müller's sign
Pulsation or bobbing of the uvula
36
Aortic Regurgitation: Auscultation Finding
High pitched early diastolic murmur (heard best when patient is leant forward and on exhalation)
37
Aortic Regurgitation: Investigations (4)
1. ECG 2. CXR 3. Echo 4. Cardiac Catheterisation
38
Aortic Regurgitation: ECG findings (1)
LVH (left axis deviation)
39
Aortic Regurgitation: CXR findings (3)
1. Cardiomegaly 2. Dilated ascending aorta 3. Pulmonary Oedema
40
Aortic Regurgitation: Cardiac Catheterisation findings (4)
1. Severity of AR 2. Valve movement 3. LV size, function and pressures 4. Aortic Root dimensions
41
Aortic Regurgitation: Moderate AR (2)
1. ACEi to reduce systolic hypertension 2. Follow up with serial echocardiography
42
Aortic Regurgitation: Indications for surgery (5)
1. Severe AR 2. Increasing symptoms 3. Declining LV function or enlarging LV 4. Enlarged ascending aorta 5. Infective endocarditis refractory to treatment
43
Aortic Regurgitation: Surgical Intervention (2)
Aortic valve replacement (tissue or mechanical) Aortic root/ascending aorta surgery
44
Aortic Regurgitation: Management of acute AR
1. ABCDE 2. Positive ionotropes (dopamine) and vasodilator (sodium nitroprusside) for haemodynamic support
45
Infective Endocarditis: When to suspect IE? (2)
Fever + New Murmur Temperature >1 week in the at-risk patient
46
Infective Endocarditis: Acute infective endocarditis presentation and where does it occur? (3)
Occurs on Normal valves Acute heart failure Emboli
47
Infective Endocarditis: Most common cause of acute IE
Staph. Aureus
48
Infective Endocarditis: Acute IE risk factors (3)
1. Skin Breach (IV lines, wounds) 2. Renal failure 3. Immunosuppression
49
Infective Endocarditis: Where does subacute IE present?
Abnormal valves
50
Infective Endocarditis: Risk factors for IE
1. Valve disease (aortic mitral) 2. IV drug users (tricuspid) 3. Coarctation or PDA
51
Infective Endocarditis: Most common cause of prosthetic valve IE
Staph. Epidermis
52
Infective Endocarditis: Most common organisms (3)
1. Strep viridans 2. Staph Aureus 3. Strep Bovis
53
Infective Endocarditis: Rare Gram Negative causes
HACEK 1. Haemophilus 2. Actinobacilus 3. Cardiobacterium 4. Eikenella 5. Kingella
54
Infective Endocarditis: Most common fungal causes
1. Candida 2. Aspergillus 3. Histoplasma
55
Infective Endocarditis: Systemic septic signs (4)
1. Fever 2. Night sweats 3. Rigors 4. Weight loss
56
Infective Endocarditis: Septic signs on examination (3)
Anaemia Splenomegaly Clubbing
57
Infective Endocarditis: Facial stigmata (1)
Roth spots
58
Infective Endocarditis: Hand stigmata (3)
1. Osler Nodes 2. Jane Way lesions 3. Splinter haemorrhages
59
Infective Endocarditis: Cardiac lesions observed on examination (2)
1. New murmur 2. Regurgitation or valve obstruction
60
Infective Endocarditis: Key ECG findings (2)
3. PR interval prolongation (aortic root abscess) 4. AV block
61
Infective Endocarditis: Co-morbid conditions which increase risk (2)
1. Heart disease 2. (congenital or acquired) Prosthetic valves
62
Infective Endocarditis: Duke's Criteria (Major: Blood Culture positive for IE) (3)
1. Typical culture in 2 separate cultures 2. Persistently positive cultures (3 drawn 12 hours apart) 3. Single positive blood culture for coxiella burnetii
63
Infective Endocarditis: Duke's Criteria (Major: Imaging positive for IE) (3)
1. Echo positive for IE 2. Abnormal activity around site of valve implantation on PET-CT 3. Paravalvular lesions on cardiac CT
64
Infective Endocarditis: Duke's Criteria (Minor) (5)
1. Predisposition (heart pathology, IV drug use) 2. Fever (>38) 3. Vascular phenomena (aneurysm, infarct) 4. Immunological phenomena (glomerulonephritis, Osler's nodes) 5. Positive blood culture not meeting major criteria
65
Infective Endocarditis: Duke's Criteria Interpretation
Definite IE if: 1. 2 major criteria 2. 1 Major and 3 minor 3. All 5 minor criteria
66
Infective Endocarditis: 3 key test
1. Transthoracic/transoesophageal echo echocardiogram 2. CXR 3. Bloods (Tests and cultures)
67
Infective Endocarditis: How to take blood cultures
Take 3 samples from 3 different places at height of fever
68
Infective Endocarditis: Key blood tests (3)
1. Anaemia 2. White cell count 3. Rheumatoid factor
69
Infective Endocarditis: Urinanalysis finding (1)
Microscopic haematuria
70
Infective Endocarditis: CXR findings (2)
1. Cardiomegaly 2. Pulmonary oedema
71
Infective Endocarditis: ECG findings (1)
Heart block
72
Infective Endocarditis: Echo (transoesophageal findings)
1. Mitral lesions 2. Aortic root abscess
73
Infective Endocarditis: CT findings
Emboli
74
Infective Endocarditis: Management
1. Long term IV antibiotics (6 weeks minimum) 2. Potentially surgery (Heart failure, bacteraemia, valve obstruction etc.)
75
Infective Endocarditis: Staphylococcus antibiotics
Flucloxacillin + gentamicin + rifampicin (Vancomycin if allergic)
76
Infective Endocarditis: Streptococcus antibiotics
Benzylpenicillin + gentamicin (Vancomycin if allergic)
77
Infective Endocarditis: ECG sign which is an indication for surgery
PR prolongation - can be caused by aortic root abscess
78
Infective Endocarditis: Hand stigmata
1. Osler Nodes 2. Jane Way lesions 3. Splinter haemorrhages
79
Mitral regurgitation: Definition
Backflow through the mitral valve during systole
80
Mitral regurgitation: Causes
1. Functional (LV dilatation, calcification, prolapse) 2. Infective (rheumatic, endocarditis) 3. Genetic (congenital, connective tissue disorders)
81
Mitral regurgitation: Symptoms (4)
1. Dyspnoea 2. Palpitations 3. Fatigue 4. Symptoms of causative factor
82
Mitral regurgitation: Signs on palpation (2)
Palpitations Displaced hyperdynamic, apex beat
83
Mitral regurgitation: Signs on ECG (3)
AF P-mitrale LVH
84
Mitral regurgitation: Signs on Auscultation (2)
Pansystolic murmur at apex which radiates to axilla Soft (S1) Split (S2) Loud (P2)
85
Mitral regurgitation: Key investigations (4)
ECG CXR Echo Cardiac catheterisation (confirms diagnosis)
86
Mitral regurgitation: CXR findings (3)
Big LA and LV Mitral valve calcification Pulmonary oedema
87
Mitral regurgitation: Use of an Echo (3)
Assess LV function, MR severity and aetiology
88
Mitral regurgitation: Use of cardiac catheterisation
Confirms diagnosis Excludes other valve disease Assesses coronary artery disease
89
Mitral regurgitation: 4 key points of management
1. Rate control (fast AF) 2. Anti-coagulate (if risk) 3. Diuretics (symptoms) 4. Surgery if symptoms deteriorate
90
Mitral valve prolapse: Epidemiology
Most common valvular abnormality
91
Mitral valve prolapse: Aetiology (2)
Occurs alone or with congenital conditions (ASD, PDA, Marfan's, Turner's)
92
Mitral valve prolapse: Symptoms (4)
Usually asymptomatic *May develop:* Chest pain Palpitations Autonomic dysfunction
93
Mitral valve prolapse: Complications (4)
MR Cerebral emboli Arrythmias Sudden death
94
Mitral valve prolapse: Signs on auscultation (2)
Mid-systolic click and/or late systolic murmur
95
Mitral valve prolapse: Tests (2)
1. Echo for diagnosis 2. ECG
96
Mitral valve prolapse: ECG findings (1)
May show inferior T-wave inversion
97
Mitral valve prolapse: Two steps of treatment
1. Beta-blockers (palpitations, chest pain) 2. Surgery if severe
98
Mitral Stenosis: Causes (3)
Rheumatic Fever Congenital Mucopolysaccharidosis
99
Mitral Stenosis: When do symptoms begin?
When mitral orifice becomes <2cm2
100
Mitral Stenosis: Two key causes of symptoms
Pulmonary Hypertension Pressure from large left atrium on local structures
101
Mitral Stenosis: Effects of pulmonary hypertension (3)
Dyspnoea Haemoptysis Chronic bronchitis picture
102
Mitral Stenosis: ECG findings (4)
AF (enlarged LA) P-mitrale RVH Progressive right axis deviation
103
Mitral Stenosis: Effects of large left atrium (3)
Hoarseness (RLN) Dysphagia (Oesophagus) Bronchial obstruction
104
Mitral Stenosis: Signs on general examination (2)
Malar flush on cheeks (Low CO) Low-volume pulse
105
Mitral Stenosis: Signs on palpation (2)
Non-displaced apex beat RV heave
106
Mitral Stenosis: Signs on auscultation (4)
1. Loud S1 2. Opening snap (pliable valve) 3. Rumbling mid-diastolic murmur *Graham Steel murmur may occur*
107
Mitral Stenosis: When is best to hear this murmur?
In expiration with patient on their side
108
Mitral Stenosis: Signs denoting severity (2)
Longer diastolic murmur And closer the opening snap is to S2
109
Mitral Stenosis: Investigations (4)
1. ECG 2. CXR 3. Echo 4. Potential cardiac catheterisation
110
Mitral Stenosis: CXR findings (3)
Left atrial enlargement Pulmonary oedema Mitral valve calcification
111
Mitral Stenosis: Echo interpretation - When is significant stenosis diagnosed? (2)
1. This is diagnostic 2. Significant stenosis occurs if valve is <1cm2
112
Mitral Stenosis: Management if initial 3 stages fail
1. Balloon valvuloplasty 2. Valve replacement
113
Mitral Stenosis: 3 steps of management
1. Rate control and anticoagulation if AF 2. Diuretics (reduce pre-load and venous congestion)
114
Heart Failure: Definition
Cardiac output is inadequate for heart's requirements
115
Heart failure: Prevalence amongst the elderly population
10%
116
Heart failure: Systolic failure pathophysiology
Ventricules unable to contract normally - decreased cardiac output
117
Heart failure: Systolic failure Ejection fraction
<40%
118
Heart failure: Causes of systolic failure (3)
IHD MI Cardiomyopathy
119
Heart failure: Diastolic failure pathophysiology
Inability of ventricles to relax and fill properly - increased filling pressures (Also known as heart failure with preserved ejection fraction, *HEFpEF*)
120
Heart failure: Diastolic failure ejection fraction
>50%
121
Heart failure: Diastolic failure causes (4)
Ventricular hypertrophy Constrictive pericarditis Tamponade Obesity
122
Heart failure: Left Ventricular Failure (LVF) Symptoms
1. Shortness of Breath (Dyspnoea, poor exercise tolerance, Orthopnea, PND) 2. Cardiac asthma (Wheeze, nocturnal cough) 3. Systemic (Cold peripheries, weight loss)
123
Heart failure: Right Ventricular Failure (LVF) symptoms
1. Fluid retention (Peripheral oedema, ascites, facial engorgement) 2. Systemic (Nausea, anorexia)
124
Heart failure: Right Ventricular Failure (RVF) causes (3)
1. LVF 2. Pulmonary stenosis 3. Lung Disease (Cor pulmonale)
124
Heart failure: Right Ventricular Failure (LVF) causes (3)
1. LVF 2. Pulmonary stenosis 3. Lung Disease (Cor pulmonale)
125
Heart failure: What is congestive cardiac failure?
Right and left ventricular failure occur together
126
Heart failure: Acute heart failure definition (2)
1. New-onset acute heart failure 2. Decompensation of chronic heart failure
127
Heart failure: Acute heart failure - Key signs of decompensation or chronic heart failure (2)
1. Pulmonary and/or peripheral oedema 2. With/without signs of peripheral hypo perfusion
128
Heart failure: How does chronic heart failure develop?
Develops and progresses slowly
129
Heart failure: 2 key symptoms of chronic heart failure
1. Venous congestion 2. Arterial pressure is maintained until late
130
Low-output heart failure: Definition
Cardiac output is decreased and fails to increases normally with exertion
131
Low-output heart failure: 3 causes
1. Excessive preload 2. Pump failure 3. Chronic excessive after-load
132
Low-output heart failure: causes of excessive preload (2)
Mitral regurgitation or fluid overload
133
Low-output heart failure: Causes of pump failure (3)
Systolic or diastolic HF Decreased HR (beta-blockers) Negatively inotropic drugs
134
Low-output heart failure: Causes of chronic excessive overload (2)
Aortic stenosis or hypertension
135
Low-output Heart failure: Excessive pre-load pathophysiology
Can cause ventricular dilatation - exacerbates pump failure
136
Low-output Heart failure: Excessive after-load pathophysiology
Leads to ventricular hypertrophy - stiff walls - diastolic dysfunction
137
High-output heart failure: Definition
Output is normal or increased in the face of increased needs - failure occurs with a normal heart
138
High-output heart failure: When does this occur?
With a normal heart or earlier if there is heart disease
139
High-output heart failure: Causes (3)
1. Anaemia 2. Pregnancy 3. Hyperthyroidism
140
High-output heart failure: Consequences (2)
1. Initially features of RVF 2. Later LVF becomes evident
141
Heart failure: Clinical signs of fluid overload
1. Ankle oedema 2. Elevated JVP 3. Basal lung crepitations 4. Ascites
142
Heart failure: Auscultation findings (2)
S3 gallop
143
Heart Failure: Major Framingham Criteria (CXR findings) 2
1. Pulmonary Oedema 2. Cardiomegaly
144
Heart Failure: Major Framingham Criteria (Signs on examination) 2
Hepatojugular Reflex Neck Vein distention
145
Heart Failure: Major Framingham Criteria (Signs on auscultation) 3
S3 gallop Rales
146
Heart Failure: Major Framingham Criteria (Symptoms) 2
Paroxysmal nocturnal dyspnoea and/or orthopnoea
147
Heart Failure: Diagnosis of heart failure (3)
1. Symptoms of heart failure 2. Evident of cardiac dysfunction at rest 3. Framingham criteria for CCF
148
Heart Failure: General signs on examination (3)
Cyanosis Decreased BP Signs of valve disease
149
Heart Failure: Signs on palpation of radial pulse (2)
1. Narrow pulse pressure 2. Pulsus alterans
150
Heart Failure: Signs on palpation of chest (2)
Displaced apex (LV dilatation) RV heave (Pulmonary hypertension)
151
Heart Failure: Interpretation of New York classification
Severity of HF
152
Heart Failure: New York Classification (4)
1. Heart disease present, no SOB during ordinary activities 2. Comfortable at rest, SOB during ordinary activities 3. Less than ordinary actives cause SOB 4. SOB at rest, all activities cause discomfort
153
Heart Failure: 3 Key investigations
ECG Beta Natiuretic Peptide (BNP) Echo if these are abnormal
154
Heart Failure: What does an ECG show (2)
Structural heart disease 1. Q waves (previous MI) 2. AF or LBB
155
Heart Failure: Echo findings
1. LV dysfunction 2. Cause of HF (MI, Valvular heart disease)
156
Heart Failure: Prognosis
25-50% die within 5 years of prognosis
157
Heart Failure: ABCDE CXR findings
A - Alveolar Oedema B- Kerley B lines (Interstitial oedema) C - Cardiomegaly (cardiothoracic ratio >50% on film) D - Dilated upper lobe veins E - Pleural Effusion
158
Heart Failure: How does acute HF become life-threatening?
It can cause severe pulmonary oedema
159
Heart Failure: 3 key symptoms of severe pulmonary oedema
1. Pink frothy sputum 2. Autonomic (Pale, sweaty, increase pulse and RR) 3. HF symtoms
160
Heart Failure: Acute Heart failure management (4)
1. A-E 2. Diamorphine 3. Furosemide 4. GTN spray
161
Heart Failure: Acute heart failure if systolic BP fails to respond
Nitrate infusion
162
Heart Failure: Mechanical ventilation option in acute heart failure
CPAP
163
Chronic Heart Failure: Non-pharmacological treatment (4)
1. Stop smoking 2. Stop drinking alcohol 3. Eat less salt 4. Optimise weight and nutrition
164
Chronic Heart Failure: Two key drugs which may be exacerbating factors
1. NSAID (fluid retention) 2. Verapamil (Negative ionotrope)
165
Chronic Heart Failure: Two key goals of intervention around CHF
1. Treat cause 2. Treat exacerbating factors
166
Chronic Heart Failure: 6 stages of treatment
1. Diuretics 2. ACE-i 3. Beta-blockers 4. Mineralocorticoid receptor antagonists 5. Digoxin 6. Vasodilators
167
Chronic Heart Failure: Effect of loop diuretics
Symptomatic relief
168
Chronic Heart Failure: Example loop diuretic
Furosemide, Bumetanide
169
Chronic Heart Failure: Loop Diuretic side effects
Hypokalaemia, renal impairment
170
Chronic Heart Failure: What do do if diuretic causes hypokalaemia
Switch to K+ sparing diuretic like spironolactone
171
Chronic Heart Failure: What to do if refractory oedema occurs after prescribing loop diuretic?
Switch to thiazide diuretic
172
Chronic Heart Failure: When to consider ACEi?
Left ventricular systolic dysfunction
173
Chronic Heart Failure: What to do if ACEi causes problematic cough?
ARB may be a substitute
174
Chronic Heart Failure: Effect of beta blockers
Decrease mortality in HF, and are beneficial when used with ACEi in patient with systolic dysfunction
175
Chronic Heart Failure: Effect of spironolactone
Shown to decrease mortality when added to traditional therapies
176
Chronic Heart Failure: When is spironolactone indicated? (2)
1. When patient is still symptomatic despite optimal therapy (ACEi, diuretics and beta-blockers) 2. Post MI patients with LVSD
177
Chronic Heart Failure: Effect of digoxin
Symptomatic relief even in those in sinus rhythm
178
Chronic Heart Failure: When should digoxin be considered? (2)
Patients symptomatic despite standard therapy, and patients with AF
179
Chronic Heart Failure: Why is important with measure K+ with digoxin?
Hypokalaemia risks digoxin toxicity
180
Chronic Heart Failure: Combination of vasodilators which should be used
Hydralazine and isosorbide dinitrate
181
Chronic Heart Failure: When are vasodilators indicated?
If patient is intolerant of ACEi and ARBs
182
Intractable heart failure: Definition
Failure which is apparently resistant to further treatment
183
Intractable heart failure: Diuretics recommendation
Switch furosemide to bumetanide
184
Intractable heart failure: Other steps to consider (3)
1. Na+ and fluid restriction 2. DVT prophylaxis 3. Add thiazide diuretic to spironolactone
185
Intractable heart failure: Example of thiazide diuretic
Metolazone
186
Intractable heart failure: Treatment in extremis
IV inotropes
187
Intractable heart failure: Surgical interventions to consider (3)
1. Cardiac resynchronisation 2. LV assist device 3. Transplant
188
Heart Failure: How does an LVAD work?
A pump forces blood through tubing from the LV to aorta
189
Heart Failure: Signs on LVAD on exam (2)
No pulse (if continuous flow), Mechanical hum heart on auscultation
190
Heart Failure: Where is BNP released?
Ventricular myocardium
191
Heart Failure: What does plasma BNP show?
Plasma BNP is closely related to left ventricular pressures
192
Heart Failure: How does BNP change in MI or LV dysfunction?
It is released in high quantities
193
Heart Failure: Things apart from MI or HF which lead to BNP secretion (3)
Tachycardia, glucocorticoids, thyroid hormones
194
Heart Failure: What level of BNP diagnoses heart failure?
>100bg/L
195
Heart Failure: What level of BNP rules out HF?
<50ng/L
196
Acute Coronary Syndrome: Pathophysiology
Thrombus from an atherosclerotic plaque blocks a coronary artery (Plaque rupture - thrombosis - inflammation)
197
Acute Coronary Syndrome: What two conditions does it include?
Unstable Angina and MI
198
Acute Coronary Syndrome: 3 rarer causes of ACS
Vasculitis, emboli and coronary spasm
199
Acute Coronary Syndrome: What is a thrombus in a fast flowing artery mainly formed of?
Platelets
200
Acute Coronary Syndrome: What events does Myocardial Infarction mean have occurred?
Cell death has occurred, releasing troponin
201
Acute Coronary Syndrome: What does ischaemia signify?
A lack of blood supply with or without cell death
202
Acute Coronary Syndrome: What vessels does the left coronary artery form?
The circumflex and left anterior descending artery
203
Acute Coronary Syndrome: What does the right coronary artery supply? (4)
Right atrium Right ventricle Inferior aspect of left ventricle Posterior septal area
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Acute Coronary Syndrome: What does the circumflex artery supply? (2)
Left atrium Posterior aspect of left ventricle
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Acute Coronary Syndrome: What does the left anterior descending artery supply? (2)
Anterior aspect of left ventricle Anterior aspect of septum
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Acute Coronary Syndrome: Two types of MI
1. STEMI 2. NSTEMI
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Acute Coronary Syndrome: STEMI definition
ST segment elevation or new left bundle branch block
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Acute Coronary Syndrome: NSTEMI definition
Troponin positive without ST segment elevation
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Acute Coronary Syndrome: Changes associated with posterior STEMI
ST segment elevation in V7-V9
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Acute Coronary Syndrome: ECG changes associated with NSTEMI (4)
ST depression T-wave inversion Pathological Q waves *May be normal*
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Acute Coronary Syndrome: What should be diagnosed if troponin levels are normal and ECG does not show pathological changes?
Unstable angina or musculoskeletal chest pain
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Acute Coronary Syndrome: Non-modifiable risk factors (3)
1. Family history of ILD 2. Male gender 3. Age
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Acute Coronary Syndrome: Modifiable risk factors (3)
1. Smoking 2. Hypertension 3. DM
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Acute Coronary Syndrome: Symptoms (2)
Central constricting chest pain with autonomic symptoms (nausea, vomiting, sweating, dyspnoea, palpitations)
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Acute Coronary Syndrome: Where can pain radiate?
Jaw or arms
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Acute Coronary Syndrome: Where are silent MIs seen?
Silent MI (do not experience typical chest pain) seen in elderly and diabetic patients
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Acute Coronary Syndrome: What is diagnosis based on? (4)
1. Rise in troponin 2. Symptoms of ischaemia 3. ECG changes - ischaemia, Q waves 4. Imaging showing loss or myocardium or wall abnormalities
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Acute Coronary Syndrome: Pulse and blood pressure
May be raised or low
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Acute Coronary Syndrome: Signs on auscultation (2)
1. 4th Heart sound 2. Pan-systolic murmur (Due to VSD, or papillary muscle dysfunction)
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Acute Coronary Syndrome: Systemic signs on examination
1. Signs of heart failure (Raised JVP, 3rd heart sound, basal crepitations) 2. Low grade fever
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Acute Coronary Syndrome: Signs which may develop later
1. Pericardial friction rub 2. Peripheral oedema
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Acute Coronary Syndrome: Does the ECG always look abnormal?
In 20% of MIs, the ECG is normal initially
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Acute Coronary Syndrome: Signs in I, aVL and V3-6
Left coronary artery (Anterolateral area)
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Acute Coronary Syndrome: Signs in V1-4
Left Anterior descending artery (Anterior)
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Acute Coronary Syndrome: Signs in I, aVL, V5-6
Circumflex artery, Lateral
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Acute Coronary Syndrome: Signs in II, III, aVF
Right Coronary Artery, Inferior
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Acute Coronary Syndrome: 3 possible findings on CXR
1. Cardiomegaly 2. Pulmonary Oedema 3. Widened mediastinum
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Acute Coronary Syndrome: How does a diagnosis of ACS require troponin to be measured?
Troponin should be measured serially - this is specific to deanery
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Acute Coronary Syndrome: What does Troponin measure?
Myocardial necrosis
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Acute Coronary Syndrome: Which troponins are most specific to MI?
T and I
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Acute Coronary Syndrome: Other causes of raised troponin (3)
1. Renal failure 2. Infection (Myocarditis, pericarditis) 3. Iatrogenic (following CPR, DC cardioversion)
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Acute Coronary Syndrome: What would an Echo show?
Regional wall abnormalities
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Acute Coronary Syndrome: Acute Treatment of NSTEMI
BATMAN B - Beta-blockers A - Aspirin T - Ticagrelor (Anti-platelet) M - Morphine A - Anti-coagulant (Fondaparinux) N - Nitrates (coronary artery spasm)
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Acute Coronary Syndrome: With which drug are beta-blockers contraindicated?
Verapamil - can precipitate systole
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Acute Coronary Syndrome: Function of GRACE score
Gives 6 month risk of death or repeat MI after an NSTEMI
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Acute Coronary Syndrome: Interpretation of GRACE score
<5% Low Risk 5-10% Medium Risk >10% High Risk
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Acute Coronary Syndrome: Management based on NSTEMI
Medium or high risk refer for early PCI (within 4 days of admission) to treat underlying coronary artery disease.
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Acute Coronary Syndrome: Secondary Prevention Medical Management (6As)
1. Aspirin 75mg once daily 2. Another antiplatelet: e.g. clopidogrel or ticagrelor for up to 12 months 3. Atorvastatin 80mg once daily 4. ACE inhibitors (e.g. ramipril titrated as tolerated to 10mg once daily) 5. Atenolol (or other beta blocker titrated as high as tolerated) 6. Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)
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Acute Coronary Syndrome:

Conditions (4 decks)

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