Cardiovascular Flashcards
(119 cards)
1
Q
What is CVD
A
Cardiovascular disease
An umbrella term used to describe all conditions of the heart and blood vessels both congenital diseases and acquired conditions
2
Q
What is ischaemic heart disease
A
Generic designation for a group of syndromes resulting from myocardial ischaemia (an imbalance between demand and supply of oxygenated blood to the heart)
Almost always caused by coronary artery atherosclerosis
Sometimes due to hypertrophy (demand)
3
Q
What are the ischaemic heart disease syndromes
A
Myocardial infarction (duration and severity of ischaemia causes myocardial death)
Angina pectoris (ischaemia is less severe and does not cause myocardial death)
Chronic IHD with heart failure
Sudden cardiac death
4
Q
What are the types of angina
A
Stable angina: typical angina
Prinzmetal angina: variant angina due to vasospasm rather than atherosclerosis
Unstable angina: crescendo angina
5
Q
Where is the prevalence of IHD highest in the UK
A
Northern England and Scotland
6
Q
What are the medical risk factors of IHD
A
High blood pressure High blood cholesterol (high HDL and low TC:HDL ratio) Diabetes Lifestyle: -smoking -obesity
7
Q
What is the pathogenesis of IHD
A
Myocardial ischaemia is a consequence of reduced blood flow in coronary arteries, due to a combination of fixed vessel narrowing and abnormal vascular tone as a result of atherosclerosis and endothelial dysfunction. This leads to an imbalance between myocardial oxygen supply and demand
8
Q
What is myocardial infarction and what are the types
A
Death of cardiac muscle from prolonged ischaemia
Transmural vs subendocardial
9
Q
What are the complications of myocardial infarction
A
Arrhythmias - either directly or by limited perfusion to the conduction system structures
Congestive cardiac failure - contractility dysfunction or by papillary muscle infarct sever myocardial rupture
Thromboembolism
Pericarditis
Ventricular aneurism
Cardiac tamponade
Cardiogenic shock
10
Q
What is hypertension
A
A sustained diastolic pressure greater than 90mm Hg or sustained systolic pressure greater than 140 mm Hg
11
Q
What causes primary hypertension
A
Majority unknown cause (90%)
Multifactorial:
-Genetics (insulin resistance- metabolic syndrome)
-Environmental (Obesity, alcohol, smoking, stress, Na+ intake)
12
Q
How is blood pressure calculated
A
BP= cardiac output x peripheral resistance
13
Q
What is malignant hypertension
A
BP> 180/120mmHg
Clinically signs and symptoms of organ damage
-acute hypertensive encephalopathy
-and/or nephropathy
-with retinal haemorrhages/ papilloedema
Requires urgent treatment to preserve organ function
14
Q
What are potential hypertension complications
A
Hypertensive renal disease
Hypertensive cerebrovascular disease
15
Q
What is systemic (left-sided) hypertensive heart disease
A
Hypertrophy of the heart is an adaptive response to pressure overload that can lead to myocardial dilation, congestive heart failure and sudden death
Left ventricular concentric hypertrophy
History or pathological evidence for hypertension
16
Q
What is Cor Pulmonale
A
Pulmonary (right sided) hypertensive heart disease
Right ventricular hypertrophy, dilation and potentially heart failure secondary to pulmonary artery hypertension caused by disorders of the lung or pulmonary vasculature
Right ventricular hypertrophy secondary to diseases of the left side and congenital causes are generally excluded in the definition; but pulmonary venous hypertension that follows left sided diseases is quite common
17
Q
What are aneurysms
A
A localised abnormal dilation of a blood vessel or the wall of the heart
True aneurysm - when bounded by arterial wall components or the attenuated wall of the heart
False aneurysm - (pseudoaneurysm) is a breach in the vascular wall leading to an extravascular haematoma that freely communicates with the intravascular space (pulsating haematoma)
Can rupture
18
Q
What is an arterial dissection
A
Arises when blood enters the wall of an artery, as a haematoma dissecting between its layers
Dissections may, but do not always, arise in aneurysmal arteries
Can rupture
19
Q
What causes aneurysms
A
Atherosclerosis Cystic medial degeneration Trauma Congenital defects Infections (mycotic aneurysms)
20
Q
What are risk factors for abdominal aortic aneurysm
A
Smoking
Male
Hypertension
Advanced age
21
Q
What is heart failure/congestive cardiac failure
A
Inability of the heart to pump enough blood needed to meet the metabolic demands of the tissue
Can occur gradually or suddenly:
-Cumulative effects of chronic workload (hypertension and valve diseases) - Insidious
-Acute haemodynamic stress (fluid overload and large myocardial infarction)- sudden
22
Q
What are the clinical effects of left sided heart failure caused by
A
Low cardiac output and hypo perfusion of tissues
Pulmonary congestion
23
Q
How does pulmonary congestion present
A
Dyspnea Orthopnea PND (paroxysmal nocturnal dyspnea) Blood tinged sputum Cyanosis Elevated pulmonary "WEDGE" pressure (PCWP) (nl=2-15mmHg)
24
Q
How does low cardiac output present
A
Reduced kidney perfusion:
- Pre-renal azotemia
- Renin-angiotensin-aldosterone activation
- -salt and fluid retention ( expansion of interstitial and intravascular fluid volume
Advanced cardiac failure can lead to cerebral hypoxia - irritability, restlessness, stupor and coma
25
What are the symptoms and signs of right sided heart failure
Engorgement of systemic and portal venous systems results in:
- Liver and spleen (portal congestion:
- -Passive congestion (nutmeg liver)
- -Congestive splenomegaly
- -Ascites
- -Congestion and oedema of bowel wall
- Pleura/Pericardium (systemic venous congestion)
- -Pleural and pericardial effusions
- -Transudates
- -Oedema of peripheral and dependent parts of body
26
What causes calcific aortic stenosis
Consequence of age-related wear and tear of either normal valve or congenital bicuspid aortic valve (which undergoes more mechanical stress and so becomes stenotic earlier)
27
What results from aortic stenosis
```
2x gradient pressure
Left ventricular hypertrophy but no hypertension
Ischaemia
Angina
cardiac decompensation
```
28
What is the prognosis for aortic stenosis
50% die in 5 years if angina present
| 50% die in 2 years if congestive heart failure present
29
What is acquired aortic stenosis
Calcification of a deformed (congenitally bicuspid) valve
-senile calcification of anatomically normal aortic valve >70 yo
Rheumatic heart disease
30
What cause acquired mitral stenosis
Rheumatic heart disease
31
What is rheumatic heart disease
```
Follows a group A strep infection, a few weeks later
Acute:
-inflammation
-Aschoff bodies
-Anitschkow cells
-Pancarditis
-Vegetations on chordae tendinae at leaflet junction
Chronic:
-thickened valves
-commisural fusion
-thick, short chordae tendinae
Mitral valves always involved
```
32
What is mitral valve prolapse
Myxomatous degeneration of the mitral valve
Unknown cause but associated with connective tissue disorders (Marfan syndrome)
Floppy valve
Easily seen on echocardiogram
33
What are the clinical features of mitral valve prolapse
Usually asymptomatic
Mid-systolic click
Holosystolic murmur if regurgitation present
Occasional chest pain
Dyspnea
97% no untoward effects
3% infective endocarditis, mitral insufficiency, arrhythmias, sudden death
34
What is mitral annular calcification
Degenerative calcification of the mitral skeleton
Usually no dysfunction
Regurgitation usually but stenosis possible
Arrhythmias and sudden death
Increased risk of infective endocarditis and embolic stork from dislodged overlying thrombi
35
What are congenital heart defects
Abnormalities of the heart and great vessels present from birth (may not be evident until adult life)
Faulty embryogenesis (week 3-8)
Usually Mono- morphic (single lesion)
1% of births
36
What environmental factors can result in congenital hear defects
Rubella (congenital rubella syndrome)
Gestational diabetes
Teratogens
37
What is ASD
Atrial septal defect
Abnormal fixed opening in atrial septum by incomplete tissue formation that allows communication of blood between the left and right atria
Usually asymptomatic until adulthood
Mortality is low following repair
38
How is ASD classified
According to location
Secundum (90%): defective fossa ovalis (near centre of atrial septum
Primum (5%): adjacent to AV valves, mitral cleft
Sinus venosus (5%): near entrance of SVC with anomalous pulmonary veins draining to SVC or RA
39
What is ventricular septal defect
Most common CHD defect
only 30% are isolated
Often with tetralogy of fallot
Classified according to size and location
90% involve the membranous septum (membranous VSD)
10% involve the muscular septum or lie below pulmonary valve (infundibular VSD)
If muscular septum is involved, can have multiple holes (Swiss cheese septum)
Small ones often close spontaneously
Large ones progress to pulmonary hypertension
40
Which defects shunt blood from right to left
```
Tetralogy of Fallot
Transposition of great arteries
Truncus arteriosus
Total anomalous pulmonary venous connection
Tricuspid atresia
```
41
What is tetralogy of Fallot
Large VSD
Obstruction of RV outflow tract (subpulmonary stenosis)
Aorta overrides the VSD
RVH
Due to anterosuperior displacement of the infundibular septum during embryogenesis
Survival depends on severity of subpulmonic stenosis
Classical TOF is cyanotic congenital heart disease
42
What are the types of obstructive CHD
Coarctation of aorta
Pulmonary stenosis/atresia
Aortic stenosis/ atresia
43
What are the two forms of coarctation of aorta
Infantile form:
- Proximal to PDA
- Shunting of deoxygenated blood via PDA produces cyanosis in lower half of body
- Serious
Adult form:
-Closed ductus
-Typically hypertension in the upper extremities and hypotension and weak pulses in lower extremities and features of arterial insufficiency (claudication and coldness)
Development of collateral circulation between pre-coarctation arterial branches and post-coarctation arteries though enlarged intercostal and internal mammary arteries causing visible erosions (notching) of the undersurface of the ribs
Bicuspid aortic valve 50% of the time
44
What is peripheral vascular disease
Atherosclerosis of arteries supplying legs or arms leading to the narrowing of the vessel lumen and restriction of blood flow
45
Who gets peripheral vascular disease
```
Smokers
Obese people
Age>40
Family history
Men or post menopausal women
Those with a PMH:
-Diabetes
-Hypercholesterolaemia
-Hypertension
```
46
What is the process of atherosclerosis
Normal artery -> Endothelial disfunction -> Fatty streak formation -> Stable (fibrous) plaque formation -> Unstable plaque formation
47
How does peripheral vascular disease make a patient ill
Chronic (gradual atherosclerosis) or Acute (plaque rupture or thrombus formation) -> narrows lumen -> Reduced blood flow -> Ischaemia -> Tissue damage/death
48
What does peripheral vascular disease look like
```
6 Ps
Pale
Pulseless
Painful
Paralysed
Paraesthetic
Perishing cold
```
49
What is giant cell arteritis
Also known as temporal arteritis
Type of vasculitis affecting the large arteries in the head
Considered a medical emergency as it can lead to blindness
Most common form of vasculitis
50
Who gets giant cell arteritis
Older individuals, very rare <50 years old
F>M
US/ Europe
PMH of polymyalgia rheumatica
51
How does giant cell arteritis make the patient ill
Chronic granulomatous inflammation -> thickens wall of artery -> Narrows lumen -> Reduced blood flow -> Ischaemia -> tissue damage/ death
52
What are the clinical features of giant cell arteritis
Flu like symptoms:
- Fatigue
- Weight loss
- Fever
Pain:
- Tender superficial temporal artery/ scalp
- Jaw claudication (when eating)
Vision problems:
- Blurred vision
- Blindness
Stroke
53
What is infective endocarditis
Infection and inflammation of the endocardium (lining of the heart) mainly involving the valves
54
What is the epidemiology of infective endocarditis
Patients with:
- Structurally abnormal valves (rheumatic heart disease, congenital heart disease, age-related valve calcification)
- Foreign material in the heart (ICD, prosthetic valves)
- Immunosuppression (HIV)
- Bacteraemia (IVDU, Long term IV catheter (dialysis), colorectal cancer, dental procedures)
Can occur in healthy patients with normal hearts with virulent organisms (eg s. aureus)
55
What is the aetiology of infective endocarditis
Bacteria (common)
- Streptococcus
- - viridanse (dental procedures)
- - bovis (colorectal cancer)
- Staphylococcus
- - aureus (normal hearts of healthy patients
- - epidermis (prosthetic valves
Fungi (rare)
- Candida
- Aspergillus
56
How does infective endocarditis present clinically
```
Splenic infarct
Splinter haemorrhages
Janeway lesions
Oslers nodes
Roth spots
```
57
What is pericarditis
```
Inflammation of the pericardial sac
Acute:
-serofibrinous
-caseous
-haemorrhagic
-purylent
Chronic:
-constrictive
```
58
What causes pericarditis
Infections:
- Viruses (coxsackie B)
- Bacteria
- TB
- Fungi
- Parasites
Autoimmune:
- Rheumatic fever
- SLE
- Scleroderma
- Drug hypersensitivity
- Post-MI (dressler's syndrome)
Miscellaneous:
- Uraemia
- Radiation
- Neoplasia
- Trauma (including surgery)
59
How does pericarditis present clinically
Central chest pain (exacerbated by breathing in, laying flat)
Pericardial friction rub
Fever
Pericardial effusion (may lead to cardiac tamponade)
Heart failure (with constrictive pericarditis)
60
What is myocarditis
Inflammation of myocardium
61
What causes myocarditis
Infections:
- Viruses (adenovirus 'common cold', coxsackie A and B, ECHO, influenza, HIV, CMV)
- Bacteria (C.diptheriae, N. meningococcus, Borrelia)
- Fungi (candida, histoplasma)
- Protozoa (Trypanosoma Cruzi 'Chagas disease')
- Helminths (trichinosis)
Immune mediated:
- Post group A streptococcus
- SLE/ other autoimmune conditions
- Drugs (methyldopa, sulphonamides)
- Rejection of heart transplant
Other:
-Sarcoidosis
62
How does myocarditis make a patient ill
Inflammation of myocardium -> dysfunctional myocardium -> Electrical dysfunction (arrhythmias/sudden death) or mechanical dysfunction (heart failure)
63
How does myocarditis present clinically
Broad spectrum of changes:
- asymptomatic
- chest pain
- heart failure
- arrhythmias
- sudden death
64
What is rheumatic fever
A rare complication of group A streptococcal pharyngitis that affects the heart (and other parts of the body)
65
Who gets rheumatic fever
Children
Developing countries (rare in UK now)
Often have recent history of a sore throat
66
What causes rheumatic fever
3% of un-treated Group A streptococcus infection (streptococcus pyogenes)
67
How does rheumatic fever make a patient ill
Group a strep infection -> antibodies made against M protein on the surface of the strep pyogenes bacteria -> antibodies also recognise proteins on surface of cells (self antigens) in the:
- heart
- skin
- joints
- CNS
68
How does rheumatic fever present
Heart:
- Endocarditis (mitral valve stenosis 'fish mouth' most common valve lesion, vegetations 'verrucae')
- Myocarditis
- Pericarditis
Skin:
- Subcutaneous nodules
- Erythema marginatum
Joints:
-arthritis
CNS:
-Sydenhams chorea
General symptoms:
- Fever
- malaise
69
What is a cardiomyopathy
Heart muscle disease
70
What are the 4 main types of cardiomyopathy
Dilated
Hypertrophic
Restrictive
Arrhythmogenic right ventricular cardiomyopathy
71
Who gets hypertrophic cardiomyopathy and why
All ages and genders
| Due to genetics
72
How does a patient become sick with hypertrophic cardiomyopathy
Impaired ventricular filling
± left ventricular outflow obstruction (1/3 of cases)
Relative ischaemia
73
What are the clinical features of hypertrophic cardiomyopathy
Heart failure
Arrhythmias and sudden death (especially in young athletes)
Mural thrombus formation ± embolisation
Chest pain (ischaemia)
74
Who gets dilated cardiomyopathy and why
```
Any age but commonly males aged 20-50yo
Cause:
-Often unknown
-Genetic ( ~50% of cases)
-Alcohol
-Catecholamines
-Pregnancy
-Haemochromatosis
-Infection
-Lots of other causes
```
75
What are the clinical features of dilated cardiomyopathy
Heart failure
Thrombus ± emboli
Arrhythmias and sudden death
76
What is the pathogenesis of dilated cardiomyopathy
Dilated and thin walled ventricular chambers -> impaired ventricular pumping (decreased LVEF)
77
What causes restrictive cardiomyopathy
```
Idiopathic
Secondary:
-amyloidosis
-sarcoidosis
-metastatic tumours
-deposition of metabolites (inborn errors of metabolism)
```
78
Why does restrictive cardiomyopathy make a patient ill
impaired ventricular filling
79
What are the clinical features of restrictive cardiomyopathy
Heart failure
Arrhythmias and sudden death
Mural thrombus formation ± embolisation
80
What causes arrhythmogenic RV cardiomyopathy and in who
Genetics
| Most common in young males
81
How does arrhythmogenic RV cardiomyopathy make a patient ill
RV myocyte adhesion impaired due to mutation in desmosome proteins -> cells detach -> fibrofatty tissue forms in attempt to repair damage -> interferes with muscle contraction and electrical conduction
82
What are the clinical features of arrhythmogenic RV cardiomyopathy
```
Palpitations
Syncope
Heart failure
Thrombus ± emboli
Arrhythmias and sudden cardiac death (often exercise induced)
```
83
What is a vascular infection
There is a source of infection in the heart or vascular system
84
What is bacteraemia
Not a diagnosis but simply means bacteria have been detected in the blood
85
What is a bloodstream infection
Bacteraemia and symptoms/ signs of infection
86
What are the types of bacteraemia
Transient
Intermittent
Continuous
87
When should CRBSI be considered as a diagnosis
Intravascular catheter related bloodstream infection
| In any patient with an intravascular catheter and systemic signs of intection or bacteraemia or fungaemia
88
What is infective endocarditis
Infection of the endocardium or devices within the heart
89
How does infective endocarditis present
```
Non-specific illness (lethargy, malaise, night sweats, anorexia, weight loss)
Heart failure (SOB, orthopnea, PND)
Results of extra-cardiac foci of infection (back pain from HVO, stroke, abdominal pain from splenic infarct)
```
90
How is infective endocarditis diagnosed
Echocardiography (trans thoracic and trans oesophageal)
| 3 sets of blood cultures at different times (2 sets in severe sepsis)
91
What is the non-antimicrobial management of infective endocarditis
Surgery:
- replace or repair damage valves
- remove infection when antimicrobials don't work
- remove infected devices
- Prevent complications (eg stroke)
- Drain purulent collections (eg in spleen or spine)
92
What is the antimicrobial management of infective endocarditis
- Antimicrobial therapy - ideally directed towards pathogens identified by blood cultures
- 4-6 weeks treatment usually IV but some switch to oral
- Example flucloaxacillin 2g 6 hourly IV for S.aureus
93
What is a mycotic aneurysm
Aneurysms resulting from or secondarily infected by microorganisms
94
What is the pathogenesis of mycotic aneurysm
Haematogenous seeding
Trauma to arterial wall and direct contamination
Extension from a contiguous infected focus
Secondary to septic microemboly
95
How does mycotic aneurysm present
Usually systemic symptoms of infection and variable symptoms from aneurysm depending on location:
- No localising symptoms
- Painless swelling
- Symptoms caused by rupture (eg intracerebral haemorrhage, collapse)
96
How is a mycotic aneurysm diagnosed
Imaging and detection of bacteria within tissue
97
How is a mycotic aneurysm managed
Surgical removal, stunting or coiling (depending on location) with antibiotics
98
How does an infected DVT present
Signs and symptoms of DVT and systemic infection and/or respiratory symptoms (when infected thrombus breaks from DVT travels via the venous system to the lungs and results in pulmonary emboli)
99
What is the aetiology of infected DVT
Depends on mechanism but commonly S. aureus, streptococci and anaerobes in IVDU
100
How is infected DVT diagnosed
Multiple (3) blood cultures, confirmation of DVT bolus exclusion of other causes eg IE
101
How is an infected DVT managed
Antibiotics plus anticoagulation
102
What are the types of primary infections of the central nervous system
Meningitis
Encephalitis
Brain abscess
103
What is meningitis
An infection of the protective membranes that surround the brain and spinal cord (meninges)
Medical emergency
Can cause life-threatening septicaemia and result in permanent damage to the brain or nerves
104
What is encephalitis
An uncommon but serious condition in which the brain becomes inflamed (swollen)
105
What is a brain abscess
AKA cerebral abscess
An abscess caused by inflammation and collection of infected material within the brain tissue
A focal suppurative process within the brain parenchyma (pus in the substance of the brain)
106
How is meningitis classified
Acute pyogenic: usually bacterial meningitis
Aseptic: usually viral meningitis, lymphocytic pleocytosis
Chronic: mycobacterium tuberculosis (TBM), spirochetes (neurosyphilis), Cryptococcus neoformans
107
How can infectious agents enter CNS
Haematogenous spread: most common, usually via arterial route, can by retrograde (veins)
Direct implantation: most often is traumatic, iatrogenic (rare), congenital (meningomyelocele)
Local extension: secondary to established infections, most often from mastoid, frontal sinuses, infected tooth etc
Along peripheral nerves: usually viruses (rabies, herpes zoster)
108
What are the clinical features of meningitis
```
Headache
Irritability
Neck stiffness
Photophobia
Fever
Vomiting
Varying levels of consciousness
Rash
```
109
Which groups may have non specific presentations of meningitis
Neonates
Elderly
Immunosuppressed
110
How is meningitis diagnosed in the lab
Blood cultures
Lumbar puncture: CSF for microscopy, gram stain, culture and biochemistry
EDTA blood for PCR
111
How does viral meningitis present
Primarily affects children and young adults
Milder signs and symptoms
May start as respiratory or intestinal infection then viraemia
CSF shows raised lymphocyte count (50-200/cu mm); protein and sugar usually normal
Full recovery expected
112
What causes viral meningitis
```
Enteroviruses (echo, coxsackie A, B)
Paramyxovirus (mumps)
Herpes simplex, varicella zoster virus
Adenoviruses
Other: arboviruses, lymphocytic choriomeningits, HIV
```
113
What are the symptoms of encephalitis
```
Fever
Headache
Behavioural changes
Altered level of consciousness
Focal neurologic deficits
Seizures
```
114
What is the incidence of encephalitis
3.5-7.4 per 100,000 persons per year
115
What are the causes of viral encephalitis
Herpes viruses (HSV-1, HSV-2, Varicella Zoster virus, Cytomegalovirus, Epstein-Barr virus, Human Herpes virus 6)
Adenoviruses
Influenza A
Enteroviruses, Poliovirus
Measles, Mumps and Rubella
Rabies
Arboviruses (Japanese encephalitis; St. Louis encephalitis virus; West Nile encephalitis virus)
116
What is recurrent meningits
>2 episodes meningits
Symptom free intervals
Normal CSF between episodes
Must be differentiated from chronic meningitis
117
How do brain abscesses present clinically
```
Headache (most)
Focal neurological deficit (30-50%)
Fever (<50%)
Nausea, vomiting
Seizures
Neck stiffness
Papilloedema
```
118
How are brain abscesses managed
Drainage is treatment of choice (but small ones can be treated with antibiotics alone):
- Urgently reduces intracranial pressure
- to confirm diagnosis
- to obtain pus for microbiological investigation
- to enhance efficacy of antibiotics
- to avoid spread of infection into ventricles
119
What are the principles in antibiotic treatment of CNS infections
- Physiological properties of blood-brain barrier and blood CSF-barrier are distinct
- Penetration of drugs into CSF and brain tissue differ
- Ampicillin, Penicillin, Cefotaxime, Ceftazidime, and Metronidazole achieve therapeutic concentrations in intracranial pus
