Conditions - HF / Atherosclerosis / Syncope / stroke / shock Flashcards
(108 cards)
1
Q
What is congestive heart failure
A
inability of the heart to maintain adequate cardiac output
Often the end stage of cardiac conditions
2
Q
Categories of HF
A
Acute vs Chronic
Right vs Left
Systolic vs Diastolic
High vs Low output
3
Q
What is chronic heart failure
A
Progressive dysfunction
Can have acute attacks
4
Q
Common causes of acute heart failure
A
Acute MI
Acute cardiac tamponade
Acute valvular tamponade
Acute infective endocarditis
5
Q
Common causes of chronic HF
A
Aortic stenosis
Ischaemic diseases
Cardiomyopathy
arrhythmias
6
Q
Which side HF causes pulmonary congestion and systemic hypotension
A
Left HF (left ventricular failure)
7
Q
What does right Ventricular failure cause
A
Pulmonary hypoperfusion
Systemic congestion
8
Q
Common causes of right sided heart failure
A
secondary to left sided HF
cor pulmonale
congenital disease
pulmonary valve disease
9
Q
What is cor pulmonale
A
Pulmonary hypertension -> increases SVR -> harder for right ventricle to pump blood -> right ventricular hypertrophy and eventually RVF
10
Q
Common causes of Left sided HF
A
cardiomyopathy
valvular disease
congenital diseases
11
Q
What is it called when there is both right and left side heart failure
A
Congestive cardiac failure
12
Q
What does high output HF mean
A
There is sufficient cardiac output but not enough for the body due to increased metabolic demands / reduced SVR / shunting
13
Q
What does systolic HF mean
A
impaired contraction during systole
14
Q
Ejection fraction formula
A
SV / EDV
15
Q
What does ejection fraction measure
A
The proportion of EDV ejected
16
Q
What causes preserved ejection fraction heart failure
A
Diastolic heart failure
17
Q
What causes diastolic HF
A
Cardiomyopathy - stiffness of the heart (cannot stretch to fill)
Cardiac tamponade
Constrictive pericarditis
18
Q
What type of cardiomyopathy cause systolic HF
A
thin, weak heart muscle
19
Q
What conditions cause increase in metabolic demands which in turn causes high output HF
A
Pregnancy
Hyperthyroidism
20
Q
What conditions cause very low SVR which in turn causes high output HF
A
Sepsis - causes vasodilation
Anaemia
thiamine deficiency
21
Q
What are the consequences of left sided heart failure
A
Pulmonary congestion because blood cannot be pumped out so it backs up in pulmonary vessels
Systemic hypotension because blood not pumped out
22
Q
Symptoms of LVF pulmonary congestion
A
Exertional dyspnea
Orthopnea
Paroxysmal nocturnal dyspnea
nocturnal cough
23
Q
Clinical features of LVF pulmonary congestion
A
Pulmonary oedema - fluid in alveoli due to high blood pressure forcing fluid out
Tachycardia
3rd heart sound
Crackles on auscultation
24
Q
Clinical Signs of systemic hypoperfusion
A
Prolonged capillary refill time
cyanosis
Pulsus alterans
25
What is the word for alternating strong and weak pulses
Pulsus alternans
26
How does LVF cause RVF
Pulmonary congestion -> pulmonary hypertension -> cor pulmonale
27
Symptoms of RVF (systemic congestion)
Oedema
weight gain
abdominal distention
28
Clinical signs of RVF
```
Elevated JVP
Ankle / sacral oedema
Ascites
Hepatomegaly
Tricuspid regurgitation - pansystolic murmur
Pleural effusion
```
29
Diagnosis of HF
Blood tests
ECG
Imaging - echocardiogram / CXR
30
What do blood tests for HF measure
FBC - to exclude anaemia
U&Es - to exclude renal failure causing oedema
LFT - to check for hepatomegaly and exclude liver failure causing oedema
TFT - to exclude hyperthyoridism
BNP
31
What does elevated BNP indicate
Highly likely it is heart failure hence refer the patient to get echocardiogram
32
What does echocardiogram see
Any valvular abnormalities / contraction dysfunction
| Measures ejection fraction - to see if EF is preserved or reduced
33
Normal ejection fraction value
50 - 70%
| Below 40% + elevated BNP = HFrEF
34
Features of CXR that may be seen in HF
Cardiomegaly (due to hypertrophy)
Pulmonary oedema
Pleural effusion
Kerley B line
35
What is Kerley b line
It is a line normally at lung bases, extending transversely to touch the pleural margin.
It indicates pulmonary oedema
36
First line drug therapy for LVF
```
Diuretics - for relief oedema
- loop (furosemide) is used
- add thiazide if oedema is resistant
ACEi + Beta Blockers
AT inhibitor if ACE is not tolerated
```
37
What conditions contraindicate the use of beta blockers
Asthma
COPD
Bradycardia
38
Second line treatment for LVF
Spironolactone (aldosterone inhibitor)
Digoxin
Ivabradine
Vasodilators - hydralazine + nitrates
39
When can digoxin be used
Second line treatment of HF if patient has atrial fibrillation
40
Third line treatment of HF
Cardiac resynchronisation therapy
| Transplantation
41
When is cardiac resynchronisation therapy used
Last line treatment for HF in patients with prolonged QRS
42
Treatment for acute HF
IV furosemide
IV dopamine
IV diamorphine
43
Drugs to treat angina
```
CCB
Beta blockers
Nitrates
aspirin
statin
```
44
Formation of atherosclerotic plaque
1) initial endothelial injury, increasing permeability of the vessel
2) LDL move into the intima layer. Monocytes move into the intima layer
3) Monocytes become macrophages and release free radicals that oxidise LDL -> OXLDL
4) Macrophage engulf OXLDL -> foam cell -> forms fatty streak
5) OXLDL also amplifies this inflammation process by attracting more macrophages
6) Release of inflammatory mediators causes proliferation of smooth muscle into intima layer
7) Recurrent injury and healing -> fibrosis -> collagen deposit in intima layer
8) Atherosclerotic plaque with fibrous cap and fatty core forms
45
Complications of atherosclerosis (STADEI)
```
Arteriole Stenosis
Arteriole Thrombosis
Aneurysm
Dissection
Embolism
Ischaemia
```
46
Why do aneurysms form
Weakened tunica media layer, causing persistant dilation
47
List the different consequences of atherosclerosis in different arteries
Carotid artery - stroke / TIA
Renal artery - renal hypertension / renal failure
Coronary artery - MI / heart failure
Periphery artery - leg ischaemia / claudication
48
What increases risk of thrombosis
Virchow's triad
- abnormal blood flow
- increased coagulability of blood
- injury to the vessel
49
Consequences of arterial thrombosis
MI
renal infarction
cerebral infarction
Gut infarction
50
What is dissection
Splitting of media layer by flowing blood, creating a false lumen
51
pregnancy and Marfan's syndrome causes an increase in risk of which complication of atherosclerosis
Dissection
52
What are the risk factors for atherosclerosis
```
Obesity
High cholesterol
Smoking
Type 1 diabetes
Physical inactivity
Hypertension
```
53
What is considered as hypertension
Anything above 140/90
54
What is considered as stage I hypertension
above 140/90 or
| Ambulatory BP 135/85
55
What is considered as stage II hypertension
Above 160/100 or
| >150/95 ambulatory BP
56
What is considered as stage III hypertension
Above 180/110 or
| Ambulatory diastolic pressure 110
57
Normal range of pulse pressure
30 - 50
58
Formula for pulse pressure
Systolic BP - Diastolic BP
59
What conditions do hypertension increase the risk for
MI
stroke
Chronic kidney disease
60
What are the classifications of hypertension
primary vs secondary
| benign vs malignant
61
What is defined as a malignant hypertension
When diastolic BP is > 130-140
| Life threatening
62
Why is it important to still treat benign hypertension
Because it can eventually case
- Left ventricular hypertrophy
- HF
- atherosclerosis
- thickening of tunica media
- hypertensive arteriosclerosis
- hypertensive retinopathy
63
What can malignant hypertension cause
acute HF
cerebral haemorrhage (haemorrhagic stroke)
acute renal failure
fibrinoid necrosis in blood vessels
64
What drugs can cause hypertension
NSAID
Glucocorticoids
Oral contraceptives
65
Risk factors for hypertension
```
Age
Family history of hypertension
Obesity
Alcohol
Diabetes
```
66
What are the conditions that can cause secondary hypertension
Excess renin
hyperaldosteronism
Cushing's syndrome
67
How would you diagnose hypertension
Blood tests to exclude secondary causes
Measure BP
Average of 2 ambulatory BP to confirm
Measure ASSIGN risk score
68
Management of hypertension
Stage I - lifestyle advice
| Stage II and III - lifestyle advice + drug therapy
69
When is CCB used in hypertension management
First line if the patient does not have type 2
| diabetes
70
What is the drug therapy for hypertension
First line - ACE inhibitors / CCB
Second line - ACEi + CCB/Diuretics or CCB + ACEi/Diuretics
Third line - ACEi + CCB + Diuretics
71
What is stroke
Acute onset of neurological symptoms and signs due to disruption of blood supply to the brain
72
Difference between TIA and stroke
TIA is a brief disruption, usually due to small blood clots and will resolve by itself
73
2 types of stroke
Ischaemic stroke
| Haemorrhagic stroke
74
What is ischaemic stroke
Due to blood clot occluding the vessels that supply the brain
Can be due to thrombosis or embolism
75
Which part of the heart most commonly produce blood clots
Left atrium (atrial fibrillation usually occurs here)
76
What are the causes for ischaemic stroke
Thrombosis / atherothrombotic
Embolism
Hypoperfusion due to stenosed artery
77
What is haemorrhagic stroke
Stroke due to bleeding inside or around brain tissue, causing damage
78
Unmodifiable risk factors for stroke
```
Age
family history of stroke
previous history of stroke or TIA
gender
race
```
79
Modifiable risk factors of stroke
```
Hypertension
Hyperlipidaemia
AF
Smoking
Alcohol
Diabetes
HF
```
80
What is FAST score
```
Facial drooping
Arm weakness
Speech difficulties
Time
This helps identify those that need urgent referral to stroke center
```
81
Imaging for stroke
CT is better than MRI because CT is quicker
82
What should not be given to a person with haemorrhagic stroke
Antiplatelets and anticoagulants
83
What is the management of ischaemic stroke
Thrombolysis ror thrombolectomy
| Treat underlying cause
84
4 types of shock
Hypovolaemic
Distributive
Obstructive
Cardiogenic
85
What is defined as shock
Abnormal circulatory system resulting in inadequate tissue perfusion due to low BP and CO
86
What is hypovolaemic shock
Shock due to loss in blood volume which can be haemorrhagic or non-haemorrhagic
87
How does loss in blood volume lead to hypovolaemic shock
Loss in blood volume -> decrease in venous return -> decrease in preload -> decrease in EDV -> decrease in SV hence CO
Loss in blood volume -> decrease in BP -> baroreceptor reflex + RAAS system -> vasoconstriction + tachycardia
88
Why are patients in hypovolaemic shock tachycardic and peripherally cool
Due to sustained decrease in blood volume activating baroreceptor reflex and RAAS
Baroreceptor reflex -> increase in sympathetic stimulation -> vasoconstriciton and increase in heart rate
RAAS -> vasoconstriction
89
Under what circumstances will the compensatory mechanisms fail to maintain BP
When the loss in blood is > 30% of total blood volume
90
What is cardiogenic shock
Shock due to cardiac dysfunction
91
What causes cardiogenic shock
Arrhythmias
Valvular pathologies
MI
92
What is obstructive shock
Shock due to pressure pressing against the heart or occlusion of vessels
93
What causes obstructive shock
Pneumothorax - air pressure pressing against the heart -> decrease in venous return
Cardiac tamponade - fluid pressing against the heart -> decrease in venous return
94
What is distributive shock
Shock due to peripheral vasodilation leading to abnormal distribution
95
What causes distributive shock
Septic shock
Anaphylactic shock
Neurogenic shock - excess parasympathetic stimulation causing vasodilation
96
How to manage septic shock
Septic 6 bundle - start within an hour
3 in - IV fluids / oxygen / antibiotics
3 out - blood culture / serum lactate / urine output
97
What is syncope
Transient loss of consciousness characterized by short duration due to hypotension causing short inadequate cerebral perfusion
98
What is the difference between syncope and stroke
Inadequate perfusion in syncope is only for a short duration
Hypotension in syncope is not sustained
Syncope is self-resolving
99
3 types of syncope
Postural hypotension
Reflex syncope
Cardiac syncope
100
3 types of reflex syncope
Vasovagal
Situational
Carotid sinus
101
What is reflex syncope
Syncope due to reflex response leading to cardioinhibition and vasodepression
102
What triggers vasovagal syncope
Prolonged standing
Heat
Stress
103
Prodromal symptoms + no signficant history is a typical example of
Vasovagal syncope
104
What triggers situational syncope
Coughing
Urination
Swallowing
105
What is carotid sinus syncope
Exaggerated response to carotid baroreceptors due to neck manipulation
106
What is cardiac syncope
An acute cardiac event causing sudden drop in CO and BP
107
What kind of cardiac events can cause cardiac syncope
Arrhythmias
| Structural diseases - aortic stenosis / cardiomyopathy limiting blood flow
108
Why shouldn't aspirin be used in asthmatics
Most people with asthma are allergic to aspirin
