Cardiovascular Flashcards
(26 cards)
Diagnosis of stable angina?
- Assess typicality with clinical assessment;
Anginal pain is:
A - constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
B - precipitated by physical exertion
& C - relieved by rest or GTN within about 5 minutes
Exclude stable angina if pain is non-anginal. Features which make a diagnosis of stable angina unlikely are when the chest pain is:
- continuous or very prolonged (and/or)
- unrelated to activity (and/or)
- brought on by breathing in (and/or)
- associated symptoms: dizziness, palpitations, tingling or difficulty swallowing.
- Blood tests for conditions that may exacerbate angina: Anemia, tachycardia, thyrotoxicosis
- Diagnostic testing: for everyone with chest pain:
- Take ECG ASAP (may see changes consistent with CAD: indication of ischemia or previous infarct) - If clinical assessment indicates typical or atypical angina or ECG finds ST or Q changes:
- Take 64-slice (or above) CT coronary angiography
- This will confirm the diagnosis if significant CAD found.
- If uncertain non-invasive imaging is used: can also confirm diagnosis by finding reversible myocardial ischemia
Non-anginal chest pain suspected after clinical assessment and ECG: what next?
- Consider non-cardiovascular causes (GI, MSKel, respiratory)
- Take CXR if other causes suspected (e.g. weight loss and lung cancer)
If 64 slice CT angiography shows CAD of uncertain significance or isn’t diagnostic: what next?
Non-invasive functional testing:
Myocardial perfusion scintigraphy with single photon emission CT (MPS-SPECT)
Or: Stress echocardiography (using adenosine)
Or: MRI using contrast
If this finds reversible myocardial ischemia: Angina is diagnosed.
What features are you looking for in echocardiograph?
Looks at heart as a coronal section
Thickness of valves
Thickness of walls (Lateral and interventricular, interatrial isn’t often seen)
Synchronicity of walls and septum (contract together?).
To orientate yourself, look at which direction the valves are moving in order to decide which chamber you are in.
Echo is better for looking at the left ventricle than at the right ventricle.
Akinetic/hypokinetic areas = Previous MI
Thinned walls = Previous MI
Valve thickening = Stenosis (calcification)
Chamber size increase = dilated cardiomyopathy or hypertrophic obstructive cardiomyopathy
For diagnosis of NSTEMI/STEMI two things are necessary, one of these is a rise in cardiac troponin, what is the other?
(Multiple options)
Symptoms of myocardial ischemia (ACS signs: chest pain, dyspnoea etc)
New ST segment changes
New T wave changes
New LBBB
New pathological Q waves
Imaging evidence of;
- New loss of viable myocardium (Echo)
- New regional wall motion abnormality (Echo)
- Intracoronary thrombus (Angiography)
Initial investigations for chest pain (CP)?
- Check if they currently have CP
- Resting ECG and Blood Troponin:
If Troponin is raised and relevant ECG changes seen (or signs of myocardial ischemia) go straight to ACS management. - Check for symptoms of ACS:
Either A-D or X
A - Pain in chest and/or adj areas lasting 15minutes
B - Associated; Nausea, Vomiting, Sweating or Dyspnoea
C - CP is associated with haemodynamic instability
D - New onset CP
X - Abrupt deterioration of stable angina with recurrent CP occurring frequently with little/no exertion, that lasts >15 minutes
- Physical examination:
- Haemodynamic status (Pulses, BP, JVP, cyanosis, murmurs)
- Signs of complications
- Signs of non-coronary causes (not the heart)
4. Take ACS-relevant history: Hx of CP Previous investigations of CP CV RF’s Hx of IHD
What is the pathway for diagnosis of hypertension?
Note: cannot be diagnosed based on a single high reading!
- Measure BP in both arms:
- If difference is >20 mmhg, repeat readings
- If difference persists, measure from arm with higher BP
-140/90 mmhg is the threshold for suspecting HTN-
- If BP is >140/90, take 2nd measurement
- If 1st BP = 2nd BP, that is the clinical measurement
- If substantially different, take third measurement
- Use lowest measurement of 2nd and 3rd as the clinical measurement
-Confirmation of HTN diagnosis-
- Ambulatory BP measurements
- To confirm: average of >14 measurements recorded between 8am and 10pm (Done within 24 hours)
Or; 3. Home BP measurements
- Two recordings per day (each measured twice one min apart)
- Measured for 4-7 days, averaged over the recordings
What is QRISK2?
A risk calculator for stroke and MI over the next 10 years.
If risk score is >10% their cerebrovascular prophylaxis is given priority.
Underestimates risk in: HIV Mental health disorders Patients on antipsychotics - cause dyslipidemia Patients on corticosteroids Patients on immunosuppressants
What are the factors that mean QRISK2 shouldn’t be used?
Age >84
T1 DM
eGFR < 60
Preexisting cardiovascular disease
Familial hypercholesterolaemia
- These all mean that the patient is at high risk of CVD anyway.
Following diagnosis of hypertension, what investigations should be carried out?
Check for target organ damage:
FBC - anemia (kidney disease) U+E’s - nephropathy Urine dip - haematuria (kidney disease) ECG - left ventricular hypertrophy CXR - left ventricular hypertrophy/aortic dissection Retinoscopy
Check QRISK2 score
What are the stages of hypertension?
Grade 1: Mild = 140-159/90-99
Grade 2: Moderate = 160-179/100-109
Grade 3: Severe = >180/>110
At what grade is a murmur easily heard and also has a palpable thrill?
Grade 4
Grading: 1-6
Grade 1 = barely audible, requires listening intently for a period
Grade 2 = faint but heard immediately on auscultation
Grade 3 = easily heard
Grade 4 = easily heard and palpable thrill
Grade 5 =very loud
Grade 6 = heard without stethoscope in contact with precordium
When interpreting B-type natriuretic peptide (BNP) or NT-proBNP levels in the assessment of suspected chronic heart failure:
What circumstances can REDUCE the peptide level?
Obesity - BMI >35 kg/m2
Drugs: Diuretics ACE-I ARB Beta blockers Spironolactone
Any hypertension drugs - since they reduce the normal BP put on the heart
BNP is released mostly in the ventricles (and other places) in response to stretching.
BNP causes renal, vascular, cardiac and adrenal changes that lower blood pressure.
When interpreting B-type natriuretic peptide (BNP) or NT-proBNP levels in the assessment of suspected chronic heart failure:
What circumstances can RAISE the peptide level?
Age >70 years
Female gender
Pathologies: LV Hypertrophy Hypoxia Pulmonary hypertension Pulmonary embolism CKD Sepsis COPD DM Liver cirrhosis
How is NT-proBNP or BNP used in the diagnosis of heart failure?
A negative BNP excludes HF as a diagnosis.
It isn’t diagnostic, but it’s an important positive finding. (Like positive calprotectin in IBD diagnosis).
What are the indications for using the CHA2DS2-VASc score?
CHA2DS2-VASc score is a stroke risk assessment tool. Used in those with arrhythmia or at high risk of arrhythmia.
Indications are for those at high risk of stroke:
1. Atrial fibrillation - any kind
(Paroxysmal, persistent, permanent and asymptomatic)
- Atrial flutter
- Cardioversion to sinus rhythm
When taking an echocardiogram of a suspected heart failure patient, what is the normal physiological range of ejection fraction?
50-70%
What is the grading system used for dyspnoea?
The New York heart association breathlessness grading:
All about how your subjective SOB affects normal physical activities (e.g. walking to shops, jogging, exercise).
NYHA 1 = No symptoms and no limitations on ordinary physical activity
NYHA 2 = Mild symptoms and slight limitations on ordinary physical activity
NYHA 3 = Symptoms cause marked limitations on ordinary physical activity, AND in less than ordinary physical activity (Walking in your house)
NYHA 4 = Symptoms even at rest and severe limitations on ordinary physical activity
What is the diagnostic pathway for acute and chronic heart failure?
- Presence of cardinal symptoms in history: dyspnoea, fatigue or tiredness
- Presence of signs on examination
- SUSPECT HF- - If previous MI, pregnant or given birth in last 6 months: Admission to hospital for echocardiography
- Measure BNP/pro-BNP:
A = more than 400/2000 pg/ml = 2 week referral for Transthoracic echocardiography (TTE)
B = 100-400/400-2000 = 6 week referral for TTE
-ECHO ASSESSES VALVES AND SYSTOLIC/DIASTOLIC FUNCTION: preserved or not-
C = Less than 100/400 - NORMAL: Rules out HF
- ECG
- CONSIDER LOOKING FOR POSSIBLE CAUSE-
6. CXR
7. Bloods: U+E eGFR FBC TFT HbA1c Fasting lipids
- Urine dipstick for bloods/proteins
- Lung function tests - PEFR/Spirometry
What is the diagnostic pathway for infective endocarditis?
- Suspect IE in those with bacteraemia (apyrexial sepsis), murmur or cardiac abnormality
- Presentation may be signs of acute infection or low grade subacute infection (general malaise etc)
- Bloods: FBC (most have anaemia), U+E
- Three blood cultures (one hour apart, from different places)
- ECG
- If high risk and suspicion: Transoesophageal echocardiography
- If low risk and suspicion: Screen with transthoracic echocardiography (TTE)
- Urinanalysis (active infective sediment from infective emboli)
- Diagnosis:
- Duke criteria-
Three options for diagnosis:
- Two major criteria
- One major criteria and 3 minor criteria
- Five minor criteria
Major criteria:
1. Positive blood culture for typical IE organisms in two separate cultures
- Echocardiogram evidence of IE
- Intracardiac mass on valve or supporting structure
- Abscess
- New partial dehiscence of prosthetic valve
- New onset valve regurgitation
Minor criteria:
- IE predisposition - IVDU/Heart condition
- Fever >38
- Vascular phenomena: arterial emboli or janeway lesions
- Immunological phenomena: glomerulonephritis
- Positive blood culture for atypical organism
- PCR showing bacterial DNA for 165 ribosomal unit
- Echocardiogram is consistent with IE but not a major finding
What is the diagnostic pathway for atrial fibrillation?
- Irregular pulse detected during examination
- ECG:
- No P-waves
- Chaotic baseline
- Irregular ventricular rate - If AF undetected but paroxysmal AF suspected:
- Episodes are <24 hours apart = 24 hour Ambulatory ECG
- Episodes are >24 hours apart = event recorder ECG
Diagnosis is based on lack of P-waves on ECG
How should we approach the diagnosis of cardiogenic shock?
- Take history - Previous MI, other cardiac risk factors (e.g. smoking), angina, arrythmias, heart surgery
- Examine - weak irregular pulse, tachycardia, heave, cardiac hypertrophy etc
- ECG - evidence of cardiac issue causing shock
How should we approach the diagnosis of distributive shock?
- Check for signs of systemic vasodilation(due to inflammation) - looks like hypovolaemic shock (tachycardia, hypotension, pale)
- Markers of infection - CRP, Ferritin, WCC, blood/sputum/urine cultures
- Capillary leak (due to inflammation) - diffuse pitting oedema, pulmonary oedema, ascites
What are normal cholesterol, LDL and HDL concentrations?
As a general guide, total cholesterol levels should be:
5mmol/L or less for healthy adults
4mmol/L or less for those at high risk
As a general guide, LDL levels should be:
3mmol/L or less for healthy adults
2mmol/L or less for those at high risk
An ideal level of HDL is above 1mmol/L. A lower level of HDL can increase your risk of heart disease.
