Flashcards in CLINICAL- CARDIOVASCULAR Deck (52):
What condition are people left with when they've had a heart attack??
People are left with heart failure after they have had a heart attack as muscle dies and hearts function deteriorates
___% of people die within their first year of having heart failure/ congestive cardiac failure (CCF)
What does prevalence of heart failure increase with??
1 in 15 have it aged 75-84
1 in 7 have it aged over 85
What is the NYHA (New York heart association) classification of heart failure CLASS 1?
Class 1: No limitations on physical activity
What is the NYHA (New York heart association) classification of heart failure CLASS 2?
Class 2: slight limitation: comfort at rest but ordinary physical activity leads to symptoms
What is the NYHA (New York heart association) classification of heart failure CLASS 3?
Class 3: marked limitation of activity. Comfort at rest but less than ordinary activity will cause symptoms e.g. Walking from one room to another
What is the NYHA (New York heart association) classification of heart failure CLASS 4?
Symptoms even at rest. Unable to carry out any physical activity at all without discomfort.
What's the problem with loosing heart muscle e.g. After a heart attack where some of the heart muscle dies??
Heart muscle is responsible for the pumping mechanism of the heart. If we loose this, the heart struggles to pump blood to all areas of the body that need it, so oxygen isn't carried round the body which is why we feel tired and breathless with Heart failure.
The thing we need to remember with Heart failure is that it is NOT a disease by itself, it often occurs as a CONSEQUENCE of some other disease process. What heart related diseases can it be caused by??
Coronary Heart Disease (coronary artery disease)- most common cause!!
Acute Coronary syndromes (angina, STEMI, NSTEMI) but these can also be caused by HF themselves.
Cardiomyopathy (viral infection)
What none-heart related risk factors can cause HF?
SMOKING- most common factor
Diabetes (as it's associated with obesity)
Drugs/ toxins (alcohol, cocaine, cytotoxics)
Cholesterol- but fine if they're put on a Statin
Endocrine e.g. Thyroid, adrenal sufficiency, cushings
ECG is one of the diagnostic tools used in heart disease, what does it show?
It can show the rate and rhythm of the heart
Most common cause of abnormal rhythm = atrial fibrillation
It can also help to show us signs of a previous heart attack
Echocardiography is a KEY diagnostic tool used to look at the heart, what is it?
It's an ultrasound exam of the heart
Ultrasound machine combined with Doppler
Used to look specifically at heart function
We can look at a 2D image of the heart in real time using this tool: it allows us to look at particular valves and heart muscle
What is cardiac catheterisation?
Takes x ray pictures of the hearts arteries using coronary angiography. Considered to be the best method to diagnose coronary heart disease.
A tube called a catheter is inserted into a blood vessel in groin or arm, and x ray images guide the tip of the catheter to the heart and coronary arteries. INVASIVE
What is a CXR?
Chest X ray
Can be used to look at size of heart compared to the lungs, can show PE in lungs, but it's very inaccurate for heart diagnostics!
Can we use a stethoscope to help diagnose diseases of the heart?
No! It won't work as it's not accurate
What four things can an echocardiogram show to diagnose heart failure?
Ejection fraction (volume of the left ventricle that gets extracted when the heart beats)
Size of the chambers especially the left ventricle
(If the left ventricle starts to fail it gets bigger and bigger as it's lost it's elasticity: think of a balloon being blown up several times)
Regional wall abnormalities
Mild, moderate or severe left ventricular systolic dysfunction: this tends to get graded by the person doing the echocardiogram
What is specialist nurse intervention?
Aims to improve patient outcomes for patients with chronic heart failure
It can improve patient compliance with their medicines
It can keep patients out of hospital
It can improve quality of life
Why do high dose ACE inhibitors work in heart failure??
They block the action of angiotensin which is a powerful vasoconstrictor in the body. This means they result in vasodilation, improving blood flow, this helps to decrease the work the heart has to do. Not only do they open blood vessels, but they also reduce blood pressure.
They relieve symptoms such as fluid build up and swelling
Who should not take ACE inhibitors?
Those intolerant: dry cough
Those with high potassium levels: ACEi's can raise this
Those with v low blood pressure
Renovascular disease: ACEi's can make renal function worse
Beta blockers are indicated in heart disease. Which beta blocker is cardio selective? Can you think when they would be contra-indicated?
In diabetics: mask hypos
What is eplerenone??
An aldosterone antagonist.
It's given for symptomatic Left Ventricular Dysfunction, a type of Heart failure after a heart attack
They have a diuretic type effect to add to that of the other drugs used in heart failure.
They weekly increase water excretion and therefore they reduce oedema and cardiac workload
What is ivabradine??
A Sinoatrial node blocker.
Helps to regulate pace maker activity: it slows the heart rate which allows more time for blood to flow to the myocardium and therefore allows more blood to be pumped out the heart
In what circumstances does NICE approve the use of Ivabradine?
Stable heart failure
Pulse over 75 beats per minute
Beta blockers not tolerated (e.g. In asthma, diabetes)
Ejection fraction under 35%
Initiated by a specialist
What can Spironolactone (a potassium sparing diuretic) cause?
Can cause high potassium levels: monitor potassium
Can cause problems with heart rhythm
Can cause man boobs (gynecomastia)!
Which is more common, left ventricular heart failure or right ventricular heart failure??
Right ventricular is usually a result of pulmonary hypertension which is much less common
When we are talking about heart failure which are we more commonly referring to: left ventricular systolic dysfunction or left ventricular diastolic dysfunction??
Left ventricular systolic dysfunction
Diastolic dysfunction is less of a significant condition. Symptoms are more likely to come from COPD, obesity and lack of fitness or angina.
What are the signs and symptoms of heart failure?
Symptoms: fatigue, breathlessness, general malaise
Clinical signs: fluid retention (congestive HF) : sacral oedema / pitted oedema : finger sinks into oedema.
Pulmonary oedema: you'll hear crackling sounds in stethoscope.
The term Acute Coronoray Syndrome describes the clinical presentation of ischeamic heart disease. What does this then get classed as?
To determine which of these it is, we look at ECG changes and laboratory test results- allows classification of the diagnosis
What are the initial presenting symptoms of Acute coronary syndromes?
Raised cardiac markers in blood
If a person is admitted with chest pain, the working diagnosis is Acute Coronary Syndrome. How do we then determine whether it's STEMI, NSTEMI or unstable angina??
Do an ECG
If we see persistent ST-elevation-----> STEMI
We then look at troponin levels:
If there is a rise/ fall------> NSTEMI
If troponin is normal------> Angina
Remember troponin is only released when heart muscle is damaged. Heart muscle will only be damaged in STEMI or NSTEMI.
What kind of thrombus does Unstable angina and NSTEMI Usually result from??
A partially occlusive thrombus (one that doesn't completely block the vessel)
What kind of thrombus does a STEMI Usually result from??
An occlusive thrombus
This blocks off the whole thrombus and is more likely to cause death
Why do thrombus causing the various ACS's usually form??
There will be atherosclerotic plaque built up on the inside of the vessel which can become disrupted. This disruption can be healed resulting in further narrowing of the lumen.
Or platelets can aggregate at the disruption which ends up in a thrombus forming.
This can either by a thrombus that partially blocks the lumen (known as a partially occlusive thrombus) which causes NSTEMI and unstable angina.
Or it can be a thrombus that completely blocks the lumen known as an occlusive thrombus. This causes a STEMI
What are the two cardiac markers we can use in myocardial infarctions!?
Cardiac troponin (TnT, TNL): sensitive and specific for myocardial damage
Creatinine Kinase (CK, CK-MB): this ones not selective for myocardial damage, also found in skeletal muscle
When should cardiac troponin levels be taken to determine the type of ACS?
Take levels at 4 hours and 12 hours
Levels will fall slowly for 2 weeks following the initial rise
When should creatinine kinase levels be taken?
They rise 6 hours after the infarction and fall over 36 hours
Why may cardiac troponins be present in low levels in patients without ACS??
Due to low levels of stress on the myocardial cells
With Patients who have had a STEMI we want to get them into the cath lab ASAP to get PCI (stent) put in. How long have we got to do this? What happens if we don't get them in within this time?
120 minutes (2 hours) from when they first came in
If we don't manage to get them into a cath lab then we must give them thrombolysis (UFH or LMWH)
What is the difference between Coronary angiography and PCI?
Coronary angiography is directly observing the coronary vessels under x-ray fluoroscopy (Use x-rays to see the dye), we use it to look for narrowing or blockage of coronary arteries.
PCI is the opening up of narrowed or blocked vessels using balloons and small stents
How do stents and balloons work in PCI?
A guide wire is used to carry a deflated balloon with a stent around it (a mesh tube) to the area of the artery that is narrow.
When in place the balloon blows under expands the stent around the inner lumen, compressing the plaque so that it widens the artery.
If we are to thrombolyse patients who can't get in the cath lab what agent do we use?
rt-PA such as alteplase, tenecteplase or Reteplase
This is shown to reduce mortality in the treatment of STEMI but not NSTEMI
The earlier thrombolysis is initiated in STEMI the better.
Ideally given within 1 hour from the onset of symptoms
What are Glycoproteins 2B/3A inhibitors and what are they beneficial for??
Act on one of the final stages of platelet activation
Beneficial In the management of patients who have had NSTEMI or Unstable Angina with a high risk of progression to further infarction
They can also be used during PCI to reduce thrombotic complications due to plaque disruption
Can you name any Glycoproteins 2B/3A inhibitors used in NSTEMI, Unstable angina, or PCI?
When would coronary artery bypass grafting (CABG) be used??
If PCI is contraindicated such as in diabetes or severe multi vessel disease
It's a major surgical procedure- has it's own risks
However it is proven to reduce long-term CV morality in patients with significant coronary disease
Why are oral anti-platelet drugs, usually a dual therapy with aspirin 75mg and ticagrelor for 12 months, give to patients post STEMI after PCI??
Anti-platelets will stop the activation and aggregation of platelets in response to disruption of atherosclerotic plaques.
This will therefore prevent the formation of platelet rich thrombus from forming and therefore blockage and cardiac ischemia.
Dual anti-platelet therapy after a STEMI usually consists of aspirin and ticagrelor. What about with an NSTEMI?
Aspirin 75mg OD
With clopidogrel 75mg for 12 months
Should statins be offered to all patients post MI? What doses we looking at??
Offered to all patients post MI regardless of their starting lipid levels
Acute coronary syndrome patients should be treated with high intensity statins
Simvastatin 40 or Atorvastatin 80 considered reasonable
How do beta blockers work as secondary prevention after MI??
Beta blockers reduce sympathetic stimulation on the heart and CV system.
They reduce the stress the heart is under by reducing contractility and oxygen demand
They reduce blood pressure through vasodilation and prevent sudden strikes in blood pressure from stress of anxiety
They reduce the risk of arrhythmia- irregular heartbeat- following an MI (this was often a worry after MIs)
ACE inhibitors are used in both HF and ACS, as secondary prevention after an MI.
They don't effect contractility of the heart like other vasodilators
ACE inhibitors are particularly important in the presence of _______ impairment whether it's symptomatic or not
Left ventricular impairment
In exam: always look to whether you can increase their ACE inhibitor dose up to a max of 10mg OD (if they can tolerate it!) if they have had a STEMI/ NSTEMI!!
What is the name of the aldosterone antagonist recommended for patients with symptomatic LV impairment/ dysfunction (heart failure patients) post MI?
(Used specifically post STEMI)