Cardiovascular Disease Flashcards
(421 cards)
1
Q
What are 6 types of CVD?
A
- Hypertension
- Stroke
- Heart Failure
- Peripheral vascular discease
- Valvular heart disease
- Congenital Heart Disease
2
Q
Ischaemic Heart Disease (IHD) shares the same disease processes as what other heart disease?
A
Coronary Artery Disceas (CAD)
3
Q
Fill in the blank: The _______ valve may require repair or replacement in patients with valvular heart disease.
A
Mitral
4
Q
What is the abbreviation for Percutaneous Coronary Intervention?
A
PCI
5
Q
Name two types of myocardial infarction.
A
- ST elevation myocardial infarction (STEMI)
- Non-ST elevation myocardial infarction (NSTEMI)
6
Q
What does the term ‘Angina Pectoris’ refer to?
A
A type of chest pain caused by reduced blood flow to the heart
It is a symptom of coronary artery disease.
7
Q
What is the function of the Sinoatrial node?
A
It acts as the natural pacemaker of the heart.
8
Q
List two imaging techniques used for diagnosing CAD.
A
- Echocardiogram
- Myocardial perfusion scan
9
Q
What does the abbreviation TAVI stand for?
A
Transcatheter aortic valve implantation
10
Q
True or False: Atrial fibrillation is represented by the abbreviation AF.
A
True
11
Q
What does the abbreviation BNP stand for?
A
Brain Natriuretic Peptide
12
Q
Fill in the blank: _______ is the most common presentation of coronary artery disease.
A
Angina Pectoris
13
Q
What is the most common symptom of angina?
A
Chest pain
14
Q
What are the less common symptoms of angina?
A
- Chest: tightness & burning
- Arm: pain or heaviness
- Throat, jaw, abdomen or back discomfort or pain
- Breathlessness (can occur on it’s own)
- Fatigue
- More typically in L arm. 3. caused by an increase in sympathetic activity
15
Q
What is the abbreviation for Left Anterior Descending artery?
A
LAD
16
Q
What does the term ‘ischaemia’ mean?
A
diminished blood supply
It specifically refers to reduced blood flow to a tissue.
17
Q
What is atherosclerosis?
A
narrowing of blood vessels due to atheroma formation
It can affect coronary arteries, arteries supplying blood to the brain, and peripheral circulation.
18
Q
What is the difference between atherosclerosis and arteriosclerosis?
A
Atherosclerosis involves atheroma formation, while arteriosclerosis refers to the hardening of arteries due to calcium deposition
The terms are often used interchangeably, but they denote different processes.
19
Q
What occurs when the endothelial cells are damaged?
A
LDL cholesterol attaches and moves through the endothelium into the intima
This process leads to the attraction of monocytes.
20
Q
What happens to monocytes that engulf LDL cholesterol?
A
They become stuck in the intima and develop into foam cells
This results in the formation of fatty plaques.
21
Q
What is the role of foam cells in atherosclerosis?
A
They die and release lipids, stimulating smooth muscle cells to migrate to the intima
This contributes to plaque growth.
22
Q
Fill in the blank: Atherosclerosis is characterized by the development of _______ in the blood vessels.
A
atheroma
Atheroma formation leads to the narrowing of blood vessels.
23
Q
What is formed as foam cells die and release substances during atherosclerosis?
A
A fibrous cap
The fibrous cap helps contain the atherosclerotic plaque.
24
Q
True or False: Atherosclerosis can lead to coronary artery disease, stroke, and peripheral arterial disease.
A
True
Atherosclerosis affects various blood vessels, leading to these conditions.
25
What is atherosclerosis?
A progressive, localised inflammatory process due to injury of the endothelial surface of medium and large arteries
## Footnote
Atherosclerosis involves the growth of plaque or lesions within the intima of arteries.
26
What results from the inflammatory response in atherosclerosis?
The plaque or a lesion (interchangable terms) grows to narrow the lumen (stenosis) which results in reduced blood flow
27
What does plaque in arteries impair?
Endothelial Function: This impairment includes reduced vasodilation and an increased likelihood of clot formation.
28
What are five factors that can causes injury to the endothelium in atherosclerosis?
1. Shear stress
2. Nicotine
3. Elevated glucose levels
4. Oxidised low-density lipoprotein cholesterol
5. Chronic inflammatory conditions
## Footnote
These factors contribute to endothelial damage and subsequent plaque formation.
29
Where are lesions commonly found in coronary artery disease (CAD)?
In one or more of the three primary coronary arteries or their larger branches
## Footnote
These lesions can significantly affect blood flow and heart function.
30
What are proximal lesions?
Lesions near the origin of an artery
## Footnote
Proximal lesions are considered more serious than distal lesions due to the risk of ischemia in downstream tissue.
31
True or False: Proximal lesions are less serious than distal lesions.
False
## Footnote
Proximal lesions are more serious because they can cause ischemia in downstream tissues.
32
What typically causes myocardial ischaemia?
Myocardial ischaemia is usually caused by atheromatous narrowing of the coronary arteries.
33
What are two less common causes of myocardial ischaemia?
* Vessel spasm constricting the artery lumen
* Aortic valve disease causing diminished blood flow
## Footnote
VS: can be without atheroma in smokers or cocain (& other illicit drug) users
34
What is the difference between a sign and a symptom of disease?
A 'sign' is observed in a patient, while a 'symptom' is experienced by the patient.
35
What is silent ischaemia?
Silent ischaemia is when individuals, particularly those with diabetes, do not experience chest pain despite having myocardial ischaemia.
36
What can be the first indication of coronary artery disease in individuals with silent ischaemia?
The first indication may be an acute event such as myocardial infarction.
37
What are the four main triggers of angina that start with the letter 'E'?
* Exercise
* Emotional stress
* Extremely cold environment
* Eating a main meal
38
Give 3 examples of isometric activities that cause the BP to rise with the potential to cause an angina attack
1. Pushing a garden mower
2. Hanging curtains
3. Shifting furniture
39
How does exercise trigger angina?
Exercise increases myocardial workload due to increases in
1. heart rate
2. blood pressure
3. sympathetic nervous system activity.
40
How does emotional stress trigger angina?
Emotional stress increases myocardial workload due to increases in heart rate and blood pressure.
41
What effect does a cold environment have on angina?
A cold environment causes vasoconstriction, increasing blood pressure and reducing coronary blood flow.
42
What is 'post-prandial' angina?
Post-prandial angina occurs when myocardial workload increases after eating due to increased cardiac output.
## Footnote
Heart rate and stroke volume increase
43
How much blood volume is redirected to the stomach and small intestine during digestion?
About 20% of blood volume is redirected to the stomach and small intestine.
44
Fill in the blank: Angina is most commonly induced by an increase in _______.
[physical exertion]
45
What characterizes stable angina in terms of exertion?
It follows a pattern of 'exertion-pain' and 'rest-relief'
## Footnote
Stable angina is predictable based on similar situations that induce chest pain.
46
What are the four
predictable aspects of stable angina?
1. Onset (similar situations bring it on)
2. severity
3. relief methods (rest or GTN)
4. reproducibility
## Footnote
Stable angina is characterized by its consistent nature regarding when it occurs and how it can be alleviated.
47
How is the diagnosis of stable angina primarily made?
Based on a patient's history and symptoms
## Footnote
Symptoms include chest pain on exertion, which leads to referrals for further evaluation.
48
What is the purpose of a Rapid Access Chest Pain Clinic (RACPC)?
To provide prompt assessment for individuals with new angina symptoms
## Footnote
Patients are seen more quickly than through standard outpatient referrals.
49
Which 5 factors are assessed to estimate the risk of coronary artery disease at the RACPC?
1. Nature of chest discomfort,
2. triggers
3. duration of pain
4. relief methods
5. risk factors for CAD
## Footnote
These factors help determine the necessary investigations for the patient.
50
What is performed as a baseline test for all patients at the RACPC?
A resting electrocardiogram (ECG)
## Footnote
The ECG typically does not show ischaemia unless taken during an angina episode.
51
What does an electrocardiogram (ECG) record?
Electrical events during the cardiac cycle
## Footnote
Leads placed on the chest and limbs provide different views of the heart's electrical activity.
52
What 9 key pieces of information can an ECG provide?
* Rhythm (regular or irregular)
* Heart rate (fast or slow)
* Normal atrial electrical activity
* Coordination between atrial and ventricular activity
* Normal ventricular electrical activity
* Adequacy of blood flow to heart muscle (ST depression represents ischaemia)
* Diagnosis of acute infarction (ST Elevation MI)
* Site of infarction
* Disturbances in electrical activity (arrhythmias)
## Footnote
Each lead offers a unique perspective on the heart's electrical performance.
53
Fill in the blank: The presence of ischaemia is seen as (what) in an ECG.
ST depression
## Footnote
ST depression indicates inadequate blood flow to the heart muscle.
54
True or False: An ECG can diagnose previous infarcts.
True
## Footnote
ECGs can identify signs of past heart attacks based on electrical activity.
55
What is the estimated risk percentage range for CAD that qualifies a patient for CT calcium scoring?
10-29%
## Footnote
Patients with this estimated risk will be offered CT calcium scoring as the first line diagnostic investigation.
56
What type of scan is used for CT calcium scoring?
Myocardial Computerised Tomography (CT) Scan
## Footnote
This scan is used to assess the presence of calcium in coronary arteries.
57
What does a CT scan involve in terms of imaging technology?
A sophisticated type of X-ray that provides images of internal organs
## Footnote
It uses a special dye injected into the vein and rotates around the body to capture images.
58
What does the CT coronary calcium score measure?
How much calcium is in the coronary arteries
## Footnote
A higher calcium score indicates a greater risk of coronary artery disease.
59
What does the presence of calcium deposits in a CT scan suggest?
Evidence of atheroma in the coronary arteries
## Footnote
Normal healthy coronary arteries do not contain calcium.
60
What does a zero score in CT coronary calcium scoring indicate?
No atheroma present
## Footnote
The individual would not need further investigation if a zero score is obtained.
61
What is the follow-up procedure if narrowings are detected in the coronary arteries?
Standard coronary angiogram
## Footnote
This is a more invasive procedure to further investigate the condition.
62
Is CT coronary calcium scoring recommended for individuals at low risk of CAD?
Yes
## Footnote
It is now recommended as the first line diagnostic investigation.
63
What is the estimated risk percentage for patients offered functional imaging for CAD?
30-60%
## Footnote
Patients with this risk are offered a myocardial perfusion scan as the first line investigation.
64
What does a myocardial perfusion scan assess?
Adequate oxygen supply to the myocardium at rest and during exercise
## Footnote
It involves capturing radiation emitted from a patient after a radioisotope is administered.
65
What is the purpose of using a radioisotope in myocardial perfusion scanning?
To create an image of the heart by visualizing areas that take up the radioisotope
## Footnote
Thallium is a commonly used radioisotope in this procedure.
66
What happens to cardiac cells that are ischaemic or necrotic during a myocardial perfusion scan?
They do not take up the radioisotope
## Footnote
Viable cardiac cells that are well oxygenated will appear bright on the image.
67
What indicates reversible ischaemia in a myocardial perfusion scan?
Perfusion defects present during exercise but not at rest
## Footnote
These indicate that the tissues are viable but have inadequate blood supply under stress.
68
What is a key benefit of identifying areas of reversible ischaemia?
The patient will benefit from revascularisation procedures
## Footnote
Such procedures include percutaneous coronary intervention and coronary artery bypass graft surgery.
69
When is myocardial perfusion scanning used?
To diagnose coronary artery disease and determine eligibility for revascularisation procedures
## Footnote
It is also used in patients who can only perform minimal exercise or cannot exercise at all.
70
What is the estimated risk percentage for patients who will be offered invasive coronary angiography?
61-90%
## Footnote
These patients are considered to have a high risk of CAD.
71
What does coronary angiography involve?
Passing a catheter into the radial or femoral artery to inject radio-opaque dye.
## Footnote
This allows visualization of the coronary arteries on X-ray.
72
What is the main use of coronary angiography?
To visualize the site and size of stenoses and potential treatment options
## Footnote
It is particularly used for patients with a high likelihood of CAD.
73
What type of anesthesia is used during coronary angiography?
Local anaesthetic
## Footnote
This allows the procedure to be performed with minimal discomfort.
74
True or False: Coronary angiography can determine if a patient is a candidate for percutaneous coronary intervention.
True
## Footnote
This applies to patients with acute coronary syndrome at high risk of further events.
75
Fill in the blank: Patients with a strongly positive _____ can undergo coronary angiography.
ECG ETT
## Footnote
This indicates a high likelihood of coronary artery disease.
76
Give 4 circumstances in which coronary angiography is indicated?
* When stable angina has not responded to medication
* When angina persists after myocardial infarction (residual angina)
* If the diagnosis of angina is uncertain
* Prior to valve replacement surgery to identify whether the patient also has coronary artery disease
## Footnote
Angiography helps in assessing the need for further interventions.
77
What information does the angiogram provide?
The site and severity of blockages (stenoses) in the coronary arteries
* The number of stenoses
* The location of stenoses
* The severity of stenoses
## Footnote
This information is crucial for determining suitable treatment options.
78
What are some treatment options determined by angiogram findings?
* Percutaneous coronary intervention
* Coronary artery bypass graft surgery
* Medical management only (e.g., aspirin, nitrates, beta blockers, statins)
## Footnote
Treatment options depend on the specific findings from the angiogram.
79
What advice is given to patients regarding lifestyle management?
* Advice on smoking, stress management, diet & exercise
* actions to take in the event of chest pain
* Use of glyceryl trinitrate (GTN)
## Footnote
Patients are educated on managing their condition effectively.
80
What is the recommended procedure for the use of GTN in the event of angina symptoms?
Stop activity, sit down and rest
* If no immediate relief, take GTN spray/tablets
* Repeat at 5-minute intervals up to 2 doses
* If no relief after 2nd dose, dial 999
* If symptoms relieved, rest for 5 minutes then rewarm before resuming exercise
## Footnote
Following these steps ensures patient safety during an angina episode.
81
What medications are typically prescribed to patients with coronary artery disease?
* Anti-platelet therapy
* Statins
* PCSK9 Inhibitors
## Footnote
These medications help reduce the risk of heart attack or stroke.
82
Give 4 examples of anti platelet therapy drus that can reduce the liklihood of a cardiac event
1. Aprin
2. Clopidogrel
3. Ticagrelor
4. Prasugrel
83
What is the purpose of anti-platelet drugs in coronary artery disease?
1. To reduce the likelihood of blood clots forming
2. To reduce the risk of arteries becoming completely occluded
## Footnote
Effective in managing partially blocked arteries.
84
True or False: The radial artery is easier to compress than the femoral artery.
True
## Footnote
This characteristic minimizes bleeding during catheterization.
85
Fill in the blank: The entrance into the radial artery is via the _______.
wrist
## Footnote
This method contrasts with the traditional approach that uses the groin.
86
What are Statins?
Statins are drugs that lower cholesterol levels and slow down further atheroma formation by reducing inflammation in the coronary artery.
## Footnote
Statins are commonly prescribed for individuals at high risk of developing coronary artery disease or other vascular diseases.
87
What is the role of PCSK9 in cholesterol metabolism?
PCSK9 is a protein involved in the destruction of LDL receptors in the liver.
## Footnote
PCSK9 inhibitors reduce this destruction, allowing for increased removal of LDL cholesterol from the blood.
88
What is the purpose of medications for angina?
Medications for angina aim to reduce the demand for oxygen by decreasing myocardial work and to increase the supply of oxygen by improving coronary blood flow.
89
Name three types of medication that improve coronary supply by dilation of the coronary arteries.
1. Nitrates
2. calcium channel blockers
3. potassium channel activators.
## Footnote
These medications help to dilate coronary arteries and improve blood flow to the myocardium.
90
How do nitrates affect venous return?
Nitrates cause venodilation, which reduces venous return and preload.
## Footnote
This leads to less tension on the walls of the left ventricle and a less forceful contraction.
91
What effect does arterial vasodilation have on afterload?
Arterial vasodilation reduces arterial resistance and consequently reduces afterload.
## Footnote
This means the left ventricle does not need to contract as forcefully to pump blood.
92
True or False: Reducing sympathetic drive increases heart rate.
False. Reducing sympathetic drive decreases heart rate, blood pressure, and the force of each contraction.
93
Fill in the blank: By reducing sympathetic drive, myocardial work is _______.
reduced.
94
What is the benefit of extended diastole in terms of myocardial perfusion?
Extended diastole improves myocardial perfusion because coronary blood flow is greater during diastole than during systole.
95
What are the effects of dilating veins in the systemic circulation?
Dilation of veins reduces venous return, leading to reduced left ventricular filling and less tension on the left ventricular walls.
96
List three types of medications that can decrease sympathetic drive.
* Beta blockers
* Calcium channel blockers
* Nitrates
97
What is the primary function of beta blockers in cardiovascular treatment?
Increase blood supply by reducing heart rate, thus improving coronary perfusion and reducing workload.
## Footnote
Beta blockers lower heart rate, blood pressure, and contractility of the heart muscle.
98
How do calcium channel blockers improve blood supply to the heart?
By vasodilating coronary arteries and inhibiting smooth-muscle contraction.
## Footnote
They also reduce myocardial workload through more efficient contraction.
99
What is the effect of potassium channel activators on coronary arteries?
They dilate coronary arteries, reducing preload and afterload.
## Footnote
This increases perfusion and reduces workload.
100
What is the mechanism of action of Ivabradine?
Reduces heart rate, thus lengthening diastole and increasing time for coronary perfusion.
## Footnote
This directly improves blood supply to the heart muscle.
101
What is revascularisation in the context of angina treatment?
A procedure that restores blood flow to an ischaemic area.
## Footnote
It may involve PCI or CABG, depending on the patient's condition.
102
What does PCI stand for and what is its purpose?
Percutaneous coronary interventions; restore blood flow by widening the lumen of a narrowed artery.
## Footnote
PCI often includes stent insertion.
103
What is the role of Drug Eluting Stents (DES) in PCI?
To prevent re-stenosis over time through slow-releasing drugs.
## Footnote
DES are now commonly used in PCI procedures.
104
What does CABG stand for and when is it usually favored?
Coronary artery bypass graft surgery; favored for widespread coronary artery disease.
## Footnote
It bypasses blocked arteries using veins or arteries from other body parts.
105
What are the three manifestations of acute coronary syndrome?
1. Unstable angina
2. NSTEMI
3. STEMI.
## Footnote
Each involves acute chest pain and symptoms of myocardial ischaemia.
106
What characterizes NSTEMI in an ECG?
The ST segment is normal or depressed.
## Footnote
This is a classification of myocardial infarction.
107
What characterizes STEMI in an ECG?
The ST segment is raised.
## Footnote
This indicates a more severe type of myocardial infarction.
108
What are the two common tests for diagnosing acute coronary syndrome?
Resting ECG and blood tests for cardiac markers.
## Footnote
These tests help assess the severity of ischaemia and myocardial damage.
109
What is the most sensitive marker of myocardial damage?
Troponin.
## Footnote
Troponin is released by ischaemic cardiac cells.
110
How soon can troponins be detected after myocardial damage?
As early as 3 - 4 hours.
## Footnote
Modern assays allow for early detection of troponins.
111
What is the significance of elevated troponin levels at baseline?
Indicates worse outcomes compared to those with elevated levels at 8 hours.
## Footnote
Normal serial troponin values can effectively rule out acute myocardial ischaemia.
112
What is unstable angina?
Unstable angina is thought to be the result of plaque disruption that results in the formation of a platelet plug that temporarily occludes the artery but dissolves spontaneously.
113
What is the significance of transient occlusion in unstable angina?
Because the occlusion is transient, no irreversible damage or death of myocardial cells occurs.
## Footnote
The platelet plug disolves spontaneously
114
Who is at risk for developing unstable angina?
Individuals with a history of stable angina can develop unstable plaque and may then present with unstable angina.
115
What percentage of unstable angina cases progress to myocardial infarction?
5-15% of unstable angina cases progress to a myocardial infarction.
116
What are the three main presentations of unstable angina?
* New onset angina is considered 'unstable' for one month
* Angina at rest
* Increases in angina indicating a change in previous pattern (increased frequency, increased severity and occuring at lower levels of exertion than previously)
117
What is a key characteristic of resting ECG in unstable angina?
The resting electrocardiogram may be normal but could show abnormalities like ST depression, especially if recorded during symptoms.
118
What is the expected result of a blood test for troponin in unstable angina?
There will not be a significant rise in troponin levels, indicating that myocardial cells did not die (because the occlusion was transient).
119
What is myocardial infarction commonly referred to as?
Heart attack.
120
What causes myocardial infarction?
Myocardial infarction is caused by the death (necrosis) of myocardial tissue as a result of prolonged ischemia.
121
What happens to myocardial cells during myocardial infarction?
Irreversible damage occurs within 6-8 hours due to deprivation of oxygen.
## Footnote
Large plaque is disrupted. Large complex thrombus occludes the artery lumen as a result.
122
What is the timeline for scar formation after a myocardial infarction?
Within a few days, dead cells disappear, and by 6-8 weeks, scar formation is complete.
123
What are common signs and symptoms of myocardial infarction?
* Intense pain or pressure in the chest
* Radiating pain to the throat, jaw, or arms
* Mild discomfort similar to indigestion
* Discomfort in the abdomen or back
124
What has a bearing on the severity of the damage to the heart tissue?
The size and site of the infarct
125
What is a critical action for BACPR instructors regarding myocardial infarction?
Recognize signs and symptoms of myocardial infarction to ensure individuals receive timely medical attention.
126
What complications can lead to death from myocardial infarction?
Death from MI usually occurs from complications such as arrhythmia or heart failure.
127
Fill in the blank: Myocardial infarction is characterized by the formation of a _______.
[large complex thrombus]
128
What are the symptoms of an MI
1. Intense chest pain (or pressure)
2. Radiating pain to throat, jaw and arm (heaviness in one or both). Bt can be simply mild discomfort in one of these areas
3. Indigestion or discomfort in abdomen
4. Back discomfort
5. Breathlessness
6. Nausea / Vomitting
7. Pale, cold and clammy
8. Agitation
9. Fear of impending doom
10. Weakness and collapse
## Footnote
Crushing, band-like sqeezing
129
How can GTN be used to distinguish between angina and myocardial infarction?
GTN provides symptom relief in angina but not in myocardial infarction. Prolonged pain lasting more than 10 minutes must be treated as myocardial infarction.
## Footnote
GTN stands for glyceryl trinitrate.
130
What should a person do if they suspect they are having a heart attack?
Chew an adult aspirin tablet (300 mg), unless allergic to aspirin.
## Footnote
This recommendation is based on recent British Heart Foundation guidelines.
131
What are 'silent infarctions'?
Myocardial infarctions that occur without obvious symptoms, detected later via ECG showing heart muscle damage.
## Footnote
Silent infarctions may reveal a Q wave on the ECG.
132
What does ST elevation on an ECG indicate?
It is a classic sign of myocardial infarction, indicating greater myocardial damage.
## Footnote
ST elevation is associated with STEMI (ST-Elevation Myocardial Infarction).
133
What are the common sites for myocardial infarctions?
Anterior and inferior regions of the left ventricle.
## Footnote
Other terms include septal, lateral, and posterior.
134
What is the prognosis for anterior infarcts compared to other types?
Anterior infarcts tend to be larger and are often associated with greater impairment of left ventricular function and a poorer prognosis.
## Footnote
Left ventricular function refers to the heart's ability to pump blood.
135
What blood test is used to diagnose NSTEMI or STEMI?
A blood test to measure troponin levels.
## Footnote
Elevated troponin levels indicate cell death (infarction).
136
What does the peak troponin level indicate?
The size of the infarction and the severity of myocardial damage.
## Footnote
Higher values generally correlate with a larger infarct.
137
What does it indicate if troponin levels are elevated at baseline?
Patients tend to have worse outcomes than those whose troponin levels are elevated at 6 hours.
## Footnote
Baseline refers to the initial measurement before any treatment.
138
Is it possible to provide specific troponin levels for infarction diagnosis?
No, different laboratories use different assays, and there are many variables involved.
## Footnote
There are no specific levels that can determine size or risk correlation for use by cardiovascular rehabilitation professionals.
139
What is the management approach for acute coronary syndrome (ACS)?
Always treated as an emergency to establish diagnosis and commence appropriate treatment as soon as possible.
140
What medication is given for strong pain relief in suspected ACS?
Morphine.
141
What is the advantage of administering morphine in ACS?
Dampens down the level of circulating catecholamines (adrenaline and noradrenaline).
142
What are the risks associated with unstable angina and non-ST segment elevation myocardial infarction (NSTEMI)?
Significant risk of further adverse events.
143
What is a priority once the diagnosis of NSTEMI is confirmed?
Accurate predictions of a patient's likelihood of further infarction or death.
144
What may differentiate treatment for patients with the same diagnosis of NSTEMI?
Using established risk assessment scoring systems.
145
What is a potential treatment for a patient with unstable angina?
Revascularisation.
146
When might a patient with STEMI not benefit from revascularisation?
If the damage to the myocardium is very extensive.
147
What investigation should patients with myocardial infarction undergo while in hospital?
An echocardiogram.
148
What does an echocardiogram determine in myocardial infarction patients?
The extent to which the event may have affected left ventricular function.
149
Fill in the blank: The presence of persistent ST elevation indicates _______ myocardial infarction.
STEMI
150
What is indicated by no persistent ST elevation but other changes?
Non-STEMI myocardial infarction.
151
In hospital, MI patients might have two types of non invasive investigations. What are they?
1. An echocardiogram (determines how much L Ventricular Function is affected)
2. Stress Echocardiogram (assessment during exercise to assess ischaemia)
152
If a patient cannot exercise, what stress echo is done instead?
Dobutamine Stress Echo
## Footnote
The drug is given IV to mimic the effect of exercise on the myocardium
153
How does the reliability of a stress echo compare to an ECG ETT?
More reliable as a diagnostic tool and less likely to produce false positives or negatives
## Footnote
It assesses heart performance rather than just ECG and BP response.
154
What is a myocardial perfusion scan used for?
To identify areas of myocardium that may benefit from revascularisation
## Footnote
This scan provides insights into potential treatment needs for myocardial areas.
155
What does coronary angiography determine?
The site and severity of the disease within the artery
156
What does a magnetic resonance imaging (MRI) scan provide?
§§§
1Higher resolution and clearer three-dimensional images of the heart
## Footnote
MRI is excellent for showing heart structure, blood vessels, and blood flow.
157
What is the preferred reperfusion treatment for STEMI patients near hospitals?
Primary Percutaneous Coronary Intervention (PPCI)
## Footnote
This involves immediate balloon angioplasty without thrombolytics and improves prognosis when done soon after symptoms occur.
158
What treatment is offered to patients in rural areas for STEMI?
Thrombolysis
## Footnote
Thrombolytics like Tenecteplase are used to dissolve blood clots in occluded arteries.
159
What is the function of thrombolytics?
To disperse the blood clot in the occluded artery and restore oxygen to the myocardium
## Footnote
'Thrombus' refers to a clot, and 'lyse' means to dissolve.
160
What does an echocardiogram involve?
Non-invasive technique using ultrasound to create a moving image of the heart
## Footnote
The chest is covered with gel, and ultrasound pulses are applied to reflect back images.
161
What 6 pieces of information does the echocardiogram provide?
1. Ejection fraction and LV function
2. size of heart's chambers
3. thickness of atrial and ventricular walls
4. motion of walls
5. valve competence
6. presence of abnormalities such as thrombus
## Footnote
See Section 4.3 for more on the diagnosis of heart failure.
162
When is an echocardiogram used?
* Post-myocardial infarction
* in left ventricular dysfunction and heart failure
* in valve disease.
163
What does an MRI involve?
A scan using strong magnetic fields and radio waves to produce detailed images of the body.
164
Describe the MRI scanner.
A large tube 'tunnel' that contains powerful magnets.
165
What do short bursts of magnetic fields and radio waves allow in MRI?
Creation of images of the heart.
166
Can MRI be used in patients with large implanted metallic devices?
No, except for some MRI compatible pacing devices.
167
What can modern mechanical heart valves and coronary artery stents do during an MRI?
Be imaged safely.
168
What are the uses of MRI scans?
Plan treatments, diagnose conditions, assess treatment effectiveness.
169
What types of images does an MRI create?
Both still and moving pictures of the heart and major blood vessels.
170
What detailed information does an MRI provide?
Information about cardiac anatomy and function.
171
What are the main clinical uses of cardiac MRI in cardiovascular disease?
To determine the:
* size of the heart's chambers
* thickness of the atrial and ventricular walls
* motion of the atrial and ventricular walls
* ejection fraction
* competence of the valves
* presence of abnormalities such as a thrombus within the ventricles
## Footnote
Cardiac MRI can also assess myocardial viability, identify stress-induced myocardial ischaemia, and differentiate forms of cardiomyopathies.
172
What is the purpose of the ECG ETT?
An incremental test designed to induce ischaemia with or without symptoms during exercise.
## Footnote
It continuously records the electrocardiogram and measures blood pressure response.
173
What protocols are used during the ECG ETT?
The Modified Bruce and Full Bruce Protocols.
## Footnote
These protocols increase the rate and incline of the treadmill every 3 minutes.
174
What symptoms are recorded during the ECG ETT?
Symptoms such as chest pain.
## Footnote
The ECG is monitored closely for evidence of ST segment depression, which denotes evidence of ischaemia.
175
What information does the ECG ETT provide regarding ischaemia?
It determines whether there is any persisting ischaemia and provides information regarding long-term prognosis.
## Footnote
The lower the intensity at which symptoms are provoked, the poorer the prognosis.
176
What additional information can the ECG ETT provide?
It provides information to:
* establish the extent and severity of the disease in someone with established symptoms
* confirm residual (persisting) ischaemia in patients post-myocardial infarction or post-surgery
* assess the effectiveness of treatment
## Footnote
This includes evaluations before and after surgery or after a cardiovascular prevention and rehabilitation programme, although this is not common.
177
What does a positive ECG ETT result indicate?
Presence of disease signs including:
* Chest pain during exercise
* ST segment depression (> 2 mm)
* Drop in BP indicating poor left ventricular function or severe coronary disease
* Serious arrhythmias like ventricular tachycardia
## Footnote
The lower the level of work at which these signs appear, the greater the likelihood of severe disease.
178
What conditions can lead to the termination of an ECG ETT?
Termination can occur if:
* Patient reaches age-adjusted maximal heart rate
* Patient is very fatigued or experiences excessive breathlessness
## Footnote
Especially at low workloads, excessive breathlessness may indicate serious problems such as heart failure.
179
What characterizes a negative ECG ETT result?
No signs or symptoms of disease provoked by the time the patient reaches age-adjusted maximal heart rate despite incremental workload.
## Footnote
Indicates good functional capacity.
180
What is the typical duration of patient admission to the coronary care unit following acute coronary syndrome?
24 hours
## Footnote
This is the most critical time in their recovery for monitoring abnormal rhythms.
181
What happens after a patient is stable in the coronary care unit?
They are transferred to a step-down unit to begin gentle mobilizing activities.
## Footnote
A cardiovascular rehabilitation nurse usually visits at this time to start the first phase of rehabilitation.
182
What is the typical hospital discharge timeframe for patients without complications after acute coronary syndrome?
3-5 days
## Footnote
If further infarction is likely, early revascularization will be considered.
183
What are revascularisation procedures?
Interventions that restore blood flow to jeopardized myocardial areas, including:
* Percutaneous coronary intervention (PCI)
* Coronary artery bypass graft (CABG)
## Footnote
These procedures are critical in managing coronary artery disease.
184
What is primary PCI (PPCI)?
Urgent restoration of coronary blood flow in patients diagnosed with ST segment elevation myocardial infarction.
## Footnote
It limits heart damage if reperfusion occurs soon after diagnosis.
185
What is staged PCI?
Elective PCI performed at a later date for other arterial blockages after the most urgent blockage is treated.
## Footnote
Ensures comprehensive management of coronary artery disease.
186
What is elective PCI?
Planned angioplasty with or without stenting for patients whose symptoms are not adequately controlled.
## Footnote
Suitable for patients with numerous lesions in other arteries.
187
What is a common postoperative issue following PCI?
Recurrence of angina due to re-stenosis.
## Footnote
Most patients require only an overnight hospital stay.
188
What does percutaneous coronary intervention involve?
1. Introduction of a 'balloon' catheter into an artery.
2. Inflation of the balloon compresses atherosclerotic plaque and widens the artery.
3. Insertion of a stent in at least 97% of cases to hold the artery open.
4. Many stents are drug-eluting stents that release medication to prevent re-narrowing.
## Footnote
A stent is a small metal or mesh coil that supports the artery after widening.
189
What is the purpose of drug-eluting stents?
To retard the tendency of the intima to grow through the stent and re-narrow the lumen.
## Footnote
Drug-eluting stents are coated with medication that helps prevent restenosis.
190
What is coronary artery bypass graft surgery (CABG)?
An invasive surgery used for revascularization in patients with severe coronary artery disease when PCI is not suitable.
## Footnote
CABG is often indicated when multiple arteries are affected or when the patient has poor left ventricular function.
191
When is CABG undertaken?
* When angina is disabling and not amenable to PCI
* When lesions affect large areas of the myocardium
* When there are two or more stenosed coronary arteries with poor left ventricular function
* When PCI fails
## Footnote
Patients must consent to bypass surgery before undergoing angioplasty due to the risk of myocardial infarction.
192
What is a vein graft?
A surgical procedure using a vein to bypass obstructed coronary arteries
## Footnote
Commonly used in coronary artery bypass graft surgery.
193
What is the left internal mammary artery used for in heart surgery?
It is commonly used as a graft to bypass the left anterior descending artery
## Footnote
Known for its effectiveness in coronary artery bypass graft surgery.
194
What does coronary artery bypass graft surgery involve?
Obstructed coronary arteries are bypassed using an internal mammary artery, a radial artery, or a saphenous vein
## Footnote
The procedure is performed under general anaesthetic.
195
What type of anaesthesia is used for coronary artery bypass graft surgery?
General anaesthetic
## Footnote
Ensures the patient is unconscious during the procedure.
196
How is the surgery typically performed?
Through an incision in the sternum
## Footnote
This approach provides access to the heart for the bypass procedure.
197
What is the significance of the heart-lung bypass machine during surgery?
It allows the surgery to be performed while the heart is stopped
## Footnote
Some operations may be performed with the heart still beating.
198
What is the typical hospital stay after coronary artery bypass graft surgery?
Several days in hospital and a short time in Intensive Care
## Footnote
Recovery duration is longer compared to less invasive procedures.
199
What is the recovery time frame for core (Phase II) cardiovascular rehabilitation after surgery?
Usually starts at 2-4 weeks post-surgery
## Footnote
Aimed at improving cardiovascular health and recovery.
200
True or False: Most coronary artery bypass graft surgeries are performed with the heart still beating.
False
## Footnote
Most surgeries are performed with the heart stopped.
201
Fill in the blank: The _______ artery is commonly used as a graft to bypass the left anterior descending artery.
left internal mammary
## Footnote
This graft is preferred for its long-term patency.
202
What are common short-term complications of heart surgery?
Pain and/or numbness around the chest wall, upper back (thoracic) pain, atrial fibrillation
## Footnote
Atrial fibrillation occurs in 20-30% of all patients 2-5 days post-surgery.
203
What can cause upper back pain after heart surgery?
Adopting a round-shouldered posture to minimise chest wound discomfort
## Footnote
This posture may lead to thoracic pain.
204
How common is atrial fibrillation in patients 2 - 5 days post surgery?
20 - 30%
205
What are potential complications related to wound healing after heart surgery?
Wound infections and healing problems, especially in diabetics
## Footnote
Diabetics are particularly slow to heal.
206
What is a possible complication related to the sternum after heart surgery?
'Clicking' sternum or unstable sternum
| Poor/slow healing of the sternal bone can cause a 'clicking' sound.
## Footnote
Take care with upper body strength training
207
What is brachial palsy and how can it occur after heart surgery?
Brachial palsy due to nerve compression during surgery
## Footnote
This usually manifests as slight numbness in some fingers and may last up to 6 months.
208
What emotional or psychological side effects may occur post-surgery?
Loss of appetite and constipation, emotional and psychological side effects
## Footnote
These effects also occur in a significant number of patients following myocardial infarction.
209
What is standard drug therapy for acute coronary syndromes at discharge?
1. Anti-platelet therapy
2. Statins
3. GTN spray
3. Beta blockers
4. ACE inhibitors
## Footnote
Patients with ACS are prescribed aspirin and often a second anti-platelet drug.
210
What is the purpose of prescribing aspirin to patients with acute coronary syndromes?
To reduce the likelihood of blood clots forming
## Footnote
This helps to reduce the risk of a further event.
211
Give 3 examples of additional anti-platelet drugs which may be prescribed after an acute myocardial infarction?
Clopidogrel, prasugrel, ticagrelor
## Footnote
These are prescribed in combination with aspirin for a period of time.
212
What are the roles of beta blockers post-myocardial infarction?
Reduce the risk of further myocardial infarction and sudden cardiac death
## Footnote
Clinical research trials support their effectiveness in reducing adverse events.
213
Under what condition might beta blockers not be prescribed?
If their use is contraindicated, such as in asthma
## Footnote
Beta blockade may exacerbate wheeziness in asthma.
214
What is the benefit of ACE inhibitors after a myocardial infarction?
Reduce the risk of future adverse events and deterioration of left ventricular function
## Footnote
ACE inhibitors help prevent the onset of chronic heart failure.
215
Which patients are likely to be prescribed ACE inhibitors?
Most patients following ST segment elevation myocardial infarction and non-ST segment elevation myocardial infarction
## Footnote
This is due to their proven benefits post-myocardial infarction.
216
What are the three common complications following acute coronary syndrome?
* Residual angina
* Left ventricular dysfunction and chronic heart failure
* Arrhythmias and sudden cardiac death
## Footnote
Residual angina indicates persistent angina and ischaemia after the cardiac event.
217
What is residual angina?
It means that angina and ischaemia has persisted after the cardiac event.
## Footnote
Treatment involves drug management and/or interventions like percutaneous coronary intervention or coronary artery bypass graft surgery.
218
What factors increase the likelihood of complications after acute coronary syndrome?
1. Site of the infarction is anterior
2. Size of the infarction is large
## Footnote
Anterior infarctions tend to be more serious and are associated with a poor prognosis.
219
What does an ECG inform about in the context of myocardial infarction?
It informs which site the infarction has occurred in.
## Footnote
It can diagnose MI and determine if there is ST elevation or depression.
220
What blood test helps to establish the size of the infarction?
Troponin test
## Footnote
A large anterior infarct is often associated with a poor prognosis.
221
What are some investigations used to diagnose cardiovascular disease?
* ECG
* ETT
* Myocardial CT scans
* Myocardial Perfusion Scans
* Echocardiography
* Stress Echocardiogram
* Cardiac MRI scans
* Angiogram
## Footnote
These investigations provide various information critical for diagnosing CVD.
222
True or False: Acute coronary syndrome complications are solely related to the syndrome itself.
False
## Footnote
Conditions like left ventricular dysfunction, chronic heart failure, and arrhythmias can have other causes.
223
Fill in the blank: A large anterior infarct is often associated with a _______.
poor prognosis
224
What does the calcium score in coronary arteries indicate?
Likelihood of coronary artery disease (CAD)
## Footnote
This score helps in assessing the risk of CAD.
225
What is the purpose of myocardial perfusion scans?
To identify reversible or irreversible ischaemia
## Footnote
These scans help in determining the viability of myocardial tissue.
226
What can differentiate forms of cardiomyopathies?
Cardiac MRI scans
227
What does an angiogram identify?
Stenoses in coronary arteries and location and degree of blockage
## Footnote
This information is crucial for deciding on appropriate treatment options.
228
What can an echocardiogram measure regarding left ventricular function?
Ejection fraction and determining LV function
## Footnote
It assesses how well the left ventricle pumps blood.
229
What is the most common cause of left ventricular dysfunction?
Myocardial infarction
## Footnote
It is characterized by a reduction in ejection fraction to less than 50% of the end diastolic volume.
230
List some other causes of left ventricular dysfunction.
* Chronic hypertension
* Atrial fibrillation
* Valve disease
* Alcohol and illicit drug abuse
* Cardiomyopathy (heart muscle disorder)
* Hypertrophic cardiomyopathy
* Dilated cardiomyopathy
## Footnote
Hypertrophic cardiomyopathy involves enlargement of the heart, while dilated cardiomyopathy features a large thin-walled left ventricle.
231
What happens to stroke volume following myocardial infarction?
It is reduced due to impairment of both the filling and emptying phases of the left ventricle
## Footnote
Impairment occurs because of damage to the left ventricle and loss of cardiac muscle mass.
232
Why is filling impaired in left ventricular dysfunction?
Damage makes the left ventricle less compliant ('stiffer), reducing its ability to accommodate the same volume of blood
## Footnote
This results in reduced preload.
233
What contributes to the impairment of emptying in left ventricular dysfunction?
Loss of cardiac muscle mass reduces contractility
## Footnote
Consequently, a lower percentage of blood is ejected compared to a healthy left ventricle.
234
What compensatory mechanism occurs in significant left ventricular dysfunction?
Increase in sympathetic activity
## Footnote
This improves the frequency and force of contraction to maintain cardiac output despite reduced stroke volume.
235
What is the process known as remodelling in left ventricular dysfunction?
The left ventricle becomes bigger and thicker after an extensive myocardial infarction
## Footnote
This initially helps maintain cardiac output.
236
What happens when compensatory mechanisms cease to be effective?
Left ventricular dysfunction progresses to symptoms of heart failure becoming apparent
## Footnote
These mechanisms can increase the work of the heart over time.
237
What is heart failure?
It occurs when the left ventricle cannot maintain adequate cardiac output to meet the body's oxygen demands
## Footnote
It is clinically characterized by symptoms like breathlessness, fatigue, and ankle swelling.
238
What are common symptoms of heart failure?
* Breathlessness
* Fatigue
* Ankle swelling
* Objective evidence of cardiac dysfunction
## Footnote
Symptoms may occur at rest or during exertion.
239
What occurs in right-sided heart failure?
Reduced ejection fraction causes blood to back up into the systemic circulation
## Footnote
This results in increased pressure in systemic capillaries, leading to fluid leakage into tissues.
240
What is 'pitting oedema'?
Swollen tissue in which indentations can be made, usually seen as bilateral swollen ankles
## Footnote
It is a result of fluid leaking from the circulation in right-sided heart failure.
241
What occurs in left-sided heart failure?
Reduced ejection fraction causes blood to back up into the pulmonary circulation
## Footnote
This increases pressure in pulmonary capillaries, leading to pulmonary oedema.
242
What are the symptoms associated with pulmonary oedema?
Shortness of breath, particularly on exertion
## Footnote
This hinders gaseous exchange at the alveolar level.
243
What is the New York Heart Association classification used for?
To classify the severity of heart failure symptoms
## Footnote
It helps assess the effectiveness of treatment, although symptom severity does not always correlate with ventricular impairment.
244
List some signs and symptoms of heart failure.
* Shortness of breath
* Fatigue
* Pitting oedema in the feet, ankles, and sacrum
* Reduced exercise capacity
## Footnote
These symptoms can vary in severity among patients.
245
What is Class I in the New York Heart Association classification of heart failure?
No limitations. Ordinary physical activity does not cause undue fatigue, dyspnoea or palpitation.
## Footnote
Asymptomatic left ventricular dysfunction
246
What characterizes Class II heart failure?
Slight limitation of physical activity. Patients are comfortable at rest but ordinary physical activity results in fatigue, dyspnoea or angina.
## Footnote
Symptomatically mild heart failure
247
What is the definition of Class III heart failure?
Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity leads to symptoms.
## Footnote
Symptomatically moderate heart failure
248
What defines Class IV heart failure?
Inability to carry on any physical activity without discomfort. Symptoms present even at rest.
## Footnote
Symptomatically severe heart failure
249
What are the key components of heart failure diagnosis?
Assessment by a skilled practitioner including:
* Medical history and symptoms
* Diagnostic tests such as:
* Resting electrocardiogram
* Echocardiography
* Chest X-ray
* Blood tests
## Footnote
Diagnostic tests help determine the type and severity of heart failure
250
What does a resting electrocardiogram indicate in heart failure?
It may indicate left ventricular hypertrophy, previous myocardial infarction, or arrhythmias such as atrial fibrillation.
## Footnote
Useful for assessing heart function
251
What does echocardiography measure in heart failure diagnosis?
It measures left ventricular function and establishes the ejection fraction (EF).
## Footnote
It is a non-invasive ultrasound test
252
What does EF > 50% indicate?
Good left ventricular function.
## Footnote
Ejection fraction is a key indicator of heart function
253
What does EF between 35% and 49% indicate?
Moderate left ventricular function.
## Footnote
Important for assessing treatment options
254
What is indicated by EF < 35%?
Poor left ventricular function.
## Footnote
Critical for understanding severity of heart failure
255
Why would a doctor X-ray the heart if s/he suspected heart failure?
Because he heart may be enlarged and there may be evidence of pulmonary congestion
256
What hormone that acts to stimulate salt and water excretion might be elevated on the blood test of a patient with Heart Failure?
Brain Natriuretic Peptide (BNP)
257
What is the purpose of dividing heart failure into HFrEF and HFpEF?
To help determine the best treatment as drug treatments that improve prognosis are only effective in patients with HFrEF.
## Footnote
HFrEF refers to reduced ejection fraction, while HFpEF includes all other forms
258
What is the mean age of patients with heart failure?
78 years.
## Footnote
This reflects the increasing prevalence of heart failure
259
How does the degree of left ventricular impairment affect survival in heart failure?
The worse the impairment, the lower the survival.
## Footnote
Important for prognosis and treatment planning
260
What are the survival rates for heart failure patients in the UK after 1 year?
Mortality rate of 29.8%.
## Footnote
This is an improvement from the previous year's rate of 31.6%
261
What factors contribute to improved survival rates in heart failure patients?
Factors include:
* Admission to a cardiology ward
* Seen by specialist doctors
* Followed up by heart failure nurses
* Prescribed optimum medications and treatments
* Referred to cardiac rehabilitation inpatient programmes after discharge
## Footnote
NHFA recommendations, 2020 highlight these factors
262
What are the aims of medical treatment for heart failure?
To relieve symptoms, improve quality of life, and improve survival rates for those with HFrEF.
263
What treatment may benefit patients with heart failure caused by valve disease?
Surgery.
264
What are the main aims of medications for patients with low ejection fraction?
* Reduce myocardial workload
* Remove excess fluid
* Reduce remodelling
265
For which patients are ACE inhibitors indicated?
Patients with impaired left ventricle based on echocardiographic evidence, even if asymptomatic.
266
What is one effect of ACE inhibitors on arteries?
They vasodilate arteries, reducing afterload.
267
How do ACE inhibitors affect venous return?
They dilate veins, which reduces venous return and thereby preload.
268
What action do ACE inhibitors have on salt and fluid retention?
They counteract salt and fluid retention.
269
What is the role of ACE inhibitors in remodelling?
They slow down remodelling.
270
What do angiotensin receptor blockers do?
They directly block angiotensin II receptors, preventing vasoconstriction.
271
What is the purpose of neprilysin inhibitors?
To improve ejection fraction and induce vasodilation in heart failure.
272
What is valsartan classified as?
An angiotensin receptor inhibitor (blocker).
273
What is the effect of sacubitril?
It induces vasodilation.
274
What is the function of diuretics in heart failure treatment?
To reduce afterload by decreasing the volume of fluid in the central circulation.
275
What are beta blockers used for in heart failure?
Beta blockers are used to reduce heightened sympathetic activity in stable patients under supervision.
## Footnote
Beta blockers depress heart rate and myocardial contraction, making their use in heart failure seem counterintuitive.
276
What is the first line treatment in heart failure?
ACE inhibitors and diuretics.
## Footnote
These medications are essential for managing heart failure symptoms.
277
What is the role of diuretics in heart failure?
To reduce salt and fluid retention, thereby reducing preload and afterload.
## Footnote
This helps alleviate the workload on the heart.
278
What effect do ACE inhibitors have on the cardiovascular system?
Vasodilate veins to reduce venous return and preload.
## Footnote
This action helps lower blood pressure and improve heart function.
279
What is sinus rhythm?
The normal rhythm initiated by the sinoatrial node, characterized by a P, Q, R, S, T complex.
## Footnote
In a resting adult, the normal heart rate ranges from 60-100 bpm.
280
What is the mechanism of action of dapagliflozin in diabetes?
Helps the kidneys lower blood glucose levels as a sodium-glucose co-transporter-2 (SGLT2) inhibitor.
## Footnote
This mechanism improves glycemic control in diabetic patients.
281
What is an arrhythmia?
An umbrella term for all types of heart rhythms that are not sinus rhythm or are outside the normal resting range.
## Footnote
Arrhythmias can arise from issues with the natural pacemaker or other points in the conduction system.
282
What are the three broad groups of arrhythmias?
Tachycardias, bradycardias, and irregular rhythms.
## Footnote
These are the most common types encountered in clinical practice.
283
How does dapagliflozin benefit patients with heart failure?
Reduces preload and afterload, which decreases myocardial workload and slows renal failure.
## Footnote
This is especially useful in patients with reduced ejection fraction (HFrEF).
284
What is the effect of neprilysin inhibitors in heart failure?
They contribute to improving heart function alongside other medications.
## Footnote
Neprilysin inhibitors are part of the standard therapy for left ventricular dysfunction.
285
Fill in the blank: ACE inhibitors and ARBs are used to _______ the activity of the sympathetic nervous system.
reduce.
## Footnote
This helps in managing heart failure and hypertension.
286
What is the purpose of a continuous electrocardiogram?
To diagnose intermittent symptoms such as blackout, runs of tachycardia, or palpitations
## Footnote
It allows for recording of the electrocardiogram throughout periods of rest and activity.
287
How long are ambulatory electrocardiograms typically recorded?
24 to 48 hours
## Footnote
This allows for monitoring heart activity during daily activities.
288
What is tachycardia defined as?
A heart rate above 100 bpm
## Footnote
'Tachy' means fast, and 'cardia' means heart.
289
What is supraventricular tachycardia?
Tachycardia that originates in the atria
## Footnote
'Supra' means above.
290
Is supraventricular tachycardia usually life-threatening?
No, it is not usually life-threatening
## Footnote
However, it may cause faintness or collapse.
291
What are some normal physiological responses that can cause heart rates to exceed 100 bpm?
* Exercise
* Anxiety
* Pain
* Fear
* Fever
## Footnote
Stimulants like caffeine and alcohol can also increase heart rate.
292
What should be considered abnormal in terms of resting tachycardia?
A rate > 100 bpm that persists after 10-15 minutes of seated rest
## Footnote
This should always be investigated further.
293
What sensation do some people experience with supraventricular tachycardia?
Palpitations
## Footnote
This is the uncomfortable sensation of rapid beats.
294
What is the initial approach to diagnosing supraventricular tachycardia?
A detailed history of when the tachycardia occurs and in what circumstances
## Footnote
This helps determine if it is a normal response or requires further investigation.
295
What is the common treatment for supraventricular tachycardia?
An anti-arrhythmic medication
## Footnote
Treatment varies according to the underlying cause.
296
What is the most common cause of ventricular tachycardia and ventricular fibrillation?
Acute myocardial infarction
## Footnote
Other cardiac conditions can also trigger these arrhythmias.
297
Why is ventricular tachycardia treated as a medical emergency?
Many patients will not tolerate this abnormal rhythm due to blood pressure loss and it can cause cardiac arrest
## Footnote
Initial symptoms may include palpitations and dizziness.
298
What happens during ventricular fibrillation?
The ventricles quiver and do not contract in a synchronized way
## Footnote
This leads to no cardiac output and potential cardiac arrest.
299
What is defibrillation?
The delivery of a large electrical shock through the chest wall
## Footnote
This may restore normal rhythm by depolarizing the myocardium.
300
What is the role of the sinoatrial node during defibrillation?
To resume the role of pacemaker and restore normal sinus rhythm
## Footnote
This occurs after successful defibrillation.
301
What is the only means of restoring the heart to a normal rhythm in ventricular fibrillation?
Defibrillation
## Footnote
This is also true for ventricular tachycardia where cardiac output is lost.
302
What investigations may survivors of ventricular tachycardia and ventricular fibrillation undergo?
Survivors may undergo:
* resting electrocardiogram
* electrophysiology studies
* echocardiogram
* blood tests for underlying causes
## Footnote
These investigations help assess the electrical system and identify potential causes.
303
What is the immediate treatment for ventricular tachycardia?
Immediate treatment includes:
* direct current cardioversion
* medication (intravenous anti-arrhythmic drugs like amiodarone)
## Footnote
Direct current cardioversion is performed under general anaesthetic.
304
What are the long-term management options for ventricular tachycardia?
Long-term management options include:
* medication (anti-arrhythmic drugs like amiodarone)
* radiofrequency ablation
* Implantable cardioverter defibrillator (ICD)
## Footnote
Radiofrequency ablation targets rogue cells causing arrhythmias.
305
What is an implantable cardioverter defibrillator (ICD)?
An ICD is a battery-driven device that detects and stops life-threatening ventricular arrhythmias by delivering a shock directly to the heart.
## Footnote
It is similar to a pacemaker and is implanted beneath the skin.
306
How does a subcutaneous ICD (SICD) differ from a traditional ICD?
A SICD is inserted under the skin of the chest and does not have leads placed into the heart; instead, the lead is tunnelled under the skin.
## Footnote
This design reduces complications associated with lead placement.
307
What is defined as sudden cardiac death?
Sudden cardiac death is an abrupt loss of unconsciousness and unexpected death due to cardiac causes within one hour of symptom onset.
## Footnote
The most common cause is ischaemic heart disease triggering ventricular arrhythmias.
308
What are the UK survival rates for cardiac arrest outside of a hospital?
Less than 10% survive to hospital discharge.
## Footnote
This statistic highlights the critical nature of timely intervention in cardiac emergencies.
309
Define bradycardia.
Bradycardia is usually defined as a heart rate below 60 bpm.
## Footnote
The term 'brady' means slow, and 'cardia' means heart.
310
Give 6 causes of sinus bradycardia?
Causes may include:
* coronary artery disease
* myocardial infarction
* valve disease or surgery
* electrolyte abnormalities
* abnormalities of the conduction system
* Beta blockers and calcium channel blockers
## Footnote
Some individuals, like endurance-trained athletes, may have a normal slow heart rate.
311
What is sick sinus syndrome?
Sick sinus syndrome is when the sinoatrial node is diseased or damaged, but conduction pathways through the atria and ventricles are normal.
## Footnote
This condition can lead to bradycardia.
312
What is heart block?
Heart block is a condition where the sinoatrial node initiates the electrical impulse, but conduction is impeded or blocked somewhere in the normal pathway.
## Footnote
This can lead to bradycardia and various symptoms.
313
What symptoms may indicate the need for investigation in a patient with bradycardia?
Symptoms that may require investigation include:
* dizziness
* lightheadedness
* fainting
* sudden drop in heart rate
## Footnote
In the absence of symptoms, bradycardia is typically not a concern.
314
What investigations may be included in the diagnosis of bradycardia?
Investigations include:
* resting electrocardiogram
* blood tests for thyroid function
* electrolytes
* cardiac enzymes
* 24-hour electrocardiogram
* echocardiogram
## Footnote
These tests help determine the cause and assess the severity of bradycardia.
315
When is treatment for bradycardia usually not necessary?
Treatment is usually not necessary if the patient is not symptomatic and the heart rate is between 40-60 bpm.
316
What is a pacemaker?
A pacemaker is a pulse generator that is smaller than a matchbox and has one electrode lead placed in the right ventricle or one in the right atrium.
317
How much does a pacemaker typically weigh?
Pacemakers weigh about 1-2 ounces.
318
Where is a pacemaker usually implanted?
A pacemaker is implanted just under the skin, usually below the left collarbone.
319
How are the leads of a pacemaker positioned inside the heart?
The leads are threaded into the heart through a vein near the collarbone and the tips are positioned inside the heart.
320
What powers most pacemakers and how long do the batteries last?
Pacemakers are normally powered by lithium batteries that last 6-10 years depending on usage.
321
What symptoms may indicate the need for a pacemaker?
Symptoms may include blackouts due to pauses in the electrical rhythm of the heart, often referred to as heart block.
322
What is syncope?
Syncope is the experience of dizziness or blackouts due to irregular heart rhythms.
323
What type of pacemaker is used when the atria are beating irregularly and the ventricular rate is slow?
A single chamber pacemaker with just one electrode connected to the right ventricle is used.
324
What type of pacemaker is implanted when the sinoatrial node is not functioning properly?
A single chamber pacemaker with one electrode connected to the right atrium is implanted.
325
What is the function of a dual chamber pacemaker?
A dual chamber pacemaker is implanted when the sinoatrial node initiates an impulse normally, but the conduction pathways in the atria and ventricles are not functioning properly.
326
What is the minimum heart rate setting for most pacemakers?
Most pacemakers are set to a minimum rate of 60-70 beats per minute.
327
What is a biventricular pacemaker?
A biventricular pacemaker is used in patients with heart failure to ensure that the left and right ventricles contract simultaneously.
328
How does a biventricular pacemaker improve cardiac output?
It sends an impulse to the two ventricular leads at the right moment after full atrial contraction to ensure simultaneous contraction.
329
What is cardiac resynchronisation therapy (CRT-P)?
CRT-P is a type of biventricular pacemaker that paces the ventricles with every single beat and is rate responsive.
330
What is CRT-D?
CRT-D is a biventricular pacemaker that also functions as a defibrillator.
331
Do pacemakers affect or are they affected by household appliances?
Pacemakers do not affect and are not affected by normal household appliances.
332
What should be avoided near a pacemaker?
Mobile phones should be kept at least six inches from the pacemaker site and strong magnetic fields should be avoided.
333
What are the two main types of irregular heartbeat?
The two main types of irregular heartbeat are:
* atrial fibrillation
* ectopic beats
## Footnote
These conditions are commonly encountered in clinical settings.
334
What is atrial fibrillation?
Atrial fibrillation is the most common irregular heart rhythm, characterized by extremely rapid, erratic depolarisation throughout the atria, preventing synchronised atrial contraction.
335
What percentage of the UK population has atrial fibrillation?
Nearly 2.4%
336
What role does the atrioventricular node play in atrial fibrillation?
It conducts only some of the electrical impulses through to the ventricles, resulting in irregular ventricular contraction.
337
How does atrial fibrillation affect left ventricular filling?
It decreases left ventricular filling by 20%.
338
When can cardiac output be compromised in atrial fibrillation?
Cardiac output can be compromised except at very high heart rates.
339
What is the main long-term risk of atrial fibrillation?
An increased incidence of stroke.
340
What are the common causes of atrial fibrillation? (List them)
* Hypertension
* CAD
* Valvular heart disease
* Cardiac surgery
* Heart failure
341
What are the typical presentations of atrial fibrillation?
* Palpitations
* Irregularly irregular pulse
* Hypotension (if heart rate is very fast)
342
What happens to blood pressure in atrial fibrillation?
It can drop if cardiac output is compromised.
343
How does atrial fibrillation affect pulse monitors?
It interferes with monitors that rely on consecutive beats, potentially leading to no reading or inaccurate readings.
## Footnote
Count the pulse manually to get an acurate reading
344
What investigations are used to diagnose atrial fibrillation?
* Resting electrocardiogram
* Blood tests for thyroid function
* Echocardiogram to detect underlying cardiac disease
* 24-hour electrocardiogram if intermittent
345
What are the common treatment methods for atrial fibrillation?
* Medication to control ventricular response rate (beta blockers, calcium channel blockers, amiodarone)
* Anticoagulation therapy (warfarin, rivaroxaban, dabigatran, apixaban)
* Direct current cardioversion or ablation therapy
346
What are ectopic beats?
Ectopic beats are beats that occur earlier than expected and are initiated by an impulse generated somewhere other than the sinoatrial node.
347
What can cause ectopic beats?
* Nicotine
* Excessive consumption of caffeine
* Excessive consumption of alcohol
* In heart disease where the myocardium becomes ischaemic
348
What is the risk associated with three or more consecutive ventricular ectopics?
They can lead to life-threatening ventricular arrhythmias.
349
How do people often experience ectopic beats?
Some may feel their heart 'missing' a beat due to a compensatory pause after an early beat.
350
What investigations are used to diagnose ectopic beats?
* History
* Resting electrocardiogram
* Possibly 24-hour electrocardiogram if intermittent
* Blood tests to exclude electrolyte disturbances or thyroid disorder
351
What lifestyle changes are recommended for cardiovascular disease treatment?
Smoking cessation and reduction in caffeine and alcohol intake if excessive
352
What is a common prescription for patients with cardiovascular disease?
Beta blockers
353
What medication is most commonly prescribed to all patients diagnosed with cardiovascular disease?
1. Anti-platelet medication, most commonly aspirin
2. Statins
354
Name alternative anti-platelet medications to aspirin.
* Clopidogrel
* Ticagrelor
* Prasugrel
355
What is the primary purpose of anti-platelet drugs?
Reduce the risk of thrombi forming and occlusion of arteries
356
What condition does hypertension refer to?
Elevated blood pressure above normal healthy levels
357
What physiological effect does high blood pressure have on the heart?
Causes the heart to work harder due to greater back pressure (afterload) from the systemic circulation in order to eject blood into the aorta
358
What are potential long-term consequences of untreated hypertension?
* Enlarged heart
* Less powerfully contracting heart
* Arteriosclerosis
* Atherosclerosis
* Myocardial infarction
* Stroke
* Kidney failure
359
What percentage of hypertension cases are considered primary or essential?
About 90%
## Footnote
The cause is not known in these patients
360
What is secondary hypertension?
Hypertension resulting from another condition, such as pregnancy or renal disease
361
What common lifestyle changes can help manage hypertension?
* Increasing physical activity
* Smoking cessation
* Weight loss
* Dietary modification (reduction in alcohol and salt intake)
362
What is the goal of medication in treating hypertension?
Reduce blood pressure via reduction in circulating fluid volume and vasodilation
363
What is the 'rule of halves' in relation to hypertension?
Only 50% of those with hypertension are diagnosed; of those, only 50% are treated, and of these, only 50% are treated effectively
364
What does the acronym ABCD represent in hypertension medication?
* ACE inhibitors
* Angiotensin Receptor Blockers
* Alpha-blockers (rare)
* Beta blockers
* Calcium channel blockers
* Diuretics
365
What is a stroke?
Occurs when cerebral tissue is deprived of oxygen and dies
366
What is the most common cause of a stroke?
Cerebral infarction due to thrombus formation from atheromatous plaque
367
What distinguishes ischaemic stroke from haemorrhagic stroke?
Ischaemic stroke is due to occlusion, while haemorrhagic stroke is due to a bleed
368
What is a transient ischaemic attack (TIA)?
Reversible neurological deficits from temporary diminished blood flow to the brain
369
What is the connection between a TIA and Mitral Valvue Disease?
TIA's are often due to emboili that arrise from abnormalities in the heart such as MVD
370
What are common clinical manifestations of a TIA?
* Giddiness
* Nausea
* Jerky movements
* Muscle weakness
* Sudden loss of postural control
371
What should individuals presenting with a TIA do?
Be urgently referred to a TIA clinic for assessment
372
True or False: Transient ischaemic attacks can last longer than 24 hours.
False
373
What does the acrynm FAST stand for?
1. FACIAL weakness. Drooped eye or mouth (can they smile)?
2. ARM weakness. Can they raise both arms?
3. SPEECH problems
4. TIME to call 999
374
What is the significance of calling 999 in the context of stroke?
It is crucial to get help immediately if a person fails any of the stroke tests, as a delay can lead to death or long-term disabilities.
## Footnote
The tests include facial weakness, arm weakness, and speech problems.
375
What is the primary treatment for ischaemic stroke in the acute stage?
Early thrombolytic treatment to dissolve the thrombus, reducing injury to the brain.
## Footnote
This treatment is crucial for improving outcomes in ischaemic stroke.
376
What long-term treatments are recommended for preventing further strokes?
* Anticoagulants or antiplatelets to prevent further clots
* Antihypertensive therapy to control blood pressure
## Footnote
These treatments help manage the risk of future strokes.
377
What is carotid endarterectomy?
A surgical procedure to remove blockage from the carotid artery, the main artery to the brain.
## Footnote
This procedure is important in preventing strokes.
378
What treatments are recommended for haemorrhagic stroke?
* Antihypertensive therapy to control blood pressure
* Surgical intervention to address bleeding (usually an aneurism)
## Footnote
Anticoagulants are not appropriate due to the risk of further bleeding.
379
List some risk factors for stroke that should be modified.
* Hypertension
* Diabetes
* Coronary artery disease
* Blood diseases related to clotting
* Smoking
* Elevated cholesterol
* Obesity
* Physical inactivity
* Medications (e.g., birth control pill, steroids)
* High alcohol intake
* Cocaine and other recreational drugs
## Footnote
Modifying these risk factors is essential for stroke management.
380
What does Peripheral Arterial Disease (PAD) refer to?
Diseases affecting systemic blood vessels, including peripheral arterial disease and peripheral venous disease (e.g., varicose veins).
## Footnote
PAD can lead to serious complications such as aneurysms and limb ischaemia.
381
What is the most common symptom of Peripheral Arterial Disease?
Intermittent claudication.
## Footnote
This symptom occurs due to narrowed arteries, leading to pain during physical activity.
382
What causes intermittent claudication?
Narrowing of the arteries within the peripheral circulation due to atheromatous plaques.
## Footnote
This condition restricts blood supply to the legs during exercise.
383
What is the American College of Sports Medicine's grading for claudication pain?
* Grade 1: Definite discomfort, minimal
* Grade 2: Moderate discomfort, attention can be diverted
* Grade 3: Intense pain, attention cannot be diverted
* Grade 4: Excruciating, unbearable pain
## Footnote
This grading helps assess the severity of claudication pain.
384
True or False?
A person experiencing IC should be encouraged to stop exercising
False
## Footnote
Unlike angina, they should work through the pain since it encouraes the oxidative cpacityh of muscle and will help to improve symptoms
385
What lifestyle changes are recommended for treating intermittent claudication?
* Smoking cessation
* Physical activity that induces ischaemic pain
## Footnote
These changes contribute to improved symptoms and overall health.
386
What medications are used to treat IC?
1. Antiplatelets
2. Statins
387
What treatments are available for severe cases of intermittent claudication?
* Angioplasty
* Bypass surgery
* Amputation in extreme cases
## Footnote
These interventions may be necessary when conservative measures fail.
388
What is an aneurysm?
An aneurysm is a condition where the walls of the main arteries become weakened and stretch, making them prone to rupture.
389
Where do aneurysms most commonly occur?
Aneurysms most commonly occur in the abdominal part of the aorta and behind the knee in the popliteal artery.
390
What is the second most common complication of peripheral arterial disease?
The second most common complication of peripheral arterial disease is aneurysm.
391
What is the risk factor for abdominal aortic aneurysm (AAA) in men?
Men aged over 65 are more likely to have an abdominal aortic aneurysm (AAA).
392
What is the purpose of the NHS AAA Screening Programme?
The NHS AAA Screening Programme invites men for screening to identify those at increased risk of an abdominal aortic aneurysm.
393
What happens during the annual monitoring of diagnosed aneurysms?
Patients will have their blood pressure controlled and monitored annually using ultrasound to determine the need for surgical intervention.
394
Which heart valves are most commonly affected by valvular heart disease?
The mitral and aortic valves are the most commonly affected by valvular heart disease.
395
Define stenosis in the context of heart valves.
Stenosis is the narrowing of a valve that obstructs normal blood flow, requiring extra work from the heart.
396
What does it mean when a heart valvue is said to be incompetant?
The valve is allowing backflow - not doing it's job properly because it isn't closing and therefore regurgitation of blood happens
397
What is the consequence of aortic valve stenosis on the left ventricle?
Aortic valve stenosis causes the left ventricle to increase its mass (hypertrophy) but lose its contractile force.
398
List some symptoms of aortic stenosis.
* Shortness of breath
* Dizziness
* Chest pain
399
What causes pulmonary edema in the case of a stenosed mitral valve?
Blood backs up due to the stenosed mitral valve, causing fluid accumulation in the lungs.
400
What happens in the heart with regurgitant valves?
The heart has to cope with an extra volume load due to backward flow, leading to progressive volume overload.
## Footnote
This leads to ventricular hypertrophy followed by heart failure
401
What is a heart murmur?
A heart murmur is an abnormal sound heard with a stethoscope, indicating turbulent blood flow through a valve.
## Footnote
Also present when there is a hole in the septum
402
What may cause defects in heart valves?
Defects may be congenital or due to infection, such as endocarditis or rheumatic fever.
403
How is valve disease generally managed?
Patients are often managed medically for many years, with surgical intervention needed only if symptoms become unmanageable.
404
What medications may be prescribed for valve disease?
* Antihypertensives
* Heart failure medications
* Anticoagulation therapy if atrial fibrillation is present
* Anti-arrhythmic therapy if in atrial fibrillation
405
What are the two types of valves used in valve replacement surgery?
* Mechanical valve
* Tissue valve
406
What is a key advantage of mechanical valves?
Mechanical valves can last for life but require long-term anticoagulation therapy.
407
What is a disadvantage of tissue valves?
Tissue valves usually last for only 10 to 15 years.
408
What factors influence the choice of valve replacement?
The choice depends on the age and lifestyle of the patient.
409
What is endocarditis?
An infection of the valve and surrounding endocardium, potentially life-threatening.
410
What symptoms may suggest endocarditis in patients with replacement valves?
Flu-like symptoms, unexplained malaise, or fever for longer than 48 hours.
411
What is a complication of valve surgery that may increase the risk for stroke?
Atrial fibrillation.
412
What does TAVI stand for?
Transcatheter aortic valve implantation.
413
Describe the procedure of TAVI.
Inserting a new artificial heart valve inside the old tight valve using a balloon catheter.
414
What materials make up the TAVI valve?
A metal frame (stent) and the outer lining (pericardium) of a cow's heart.
415
What are the two common routes for transcatheter aortic valve insertion?
* Transfemoral: through the femoral artery
* Transapical: through a small cut on the left side of the chest
416
What are the expected benefits of treatment with the new valve in TAVI?
Improved symptoms of aortic stenosis, increased life expectancy, and quality of life.
417
When is TAVI recommended over conventional open heart aortic valve replacement surgery?
When the risks of TAVI surgery are less than those of conventional surgery.
418
What types of drugs are commonly used in the management of heart disease?
Drugs affecting heart rate, blood pressure, and exercise capacity.
419
Why might patients be unclear about their cardiac medications?
Many cardiac medications can treat multiple problems, not always obvious.
420
What is a common use for beta blockers?
Management of angina, hypertension, arrhythmias, or heart failure.
421
What is a standard therapy post-myocardial infarction?
Beta blockers, even in the absence of specific conditions.
