Diseases of the Cardiovascular System Flashcards Preview

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Flashcards in Diseases of the Cardiovascular System Deck (207):
1

What is ischaemic heart disease

inadequate blood supply to the myocardium

2

Incidence of CHD

10% in women, 16% in men

3

Causes of Ischaemic Heart Disease

Almost always atheroma +/- thrombosis
Myocardial hypertrophy - usually occurs in conjunction
Vasculitis or amyloid deposition

4

When does auto regulation of coronary blood flow break down

Over 70% occlusion
If over 90% occlusion insufficient at rest

5

Which area of the heart has the lowest perfusion levels

Sub-endocardial

6

3 types of angina

Stable/typical - predicatable
unstable/crescendo - unpredictable - coronary artery spasms treat with calcium channel blockers
Variant/Prizemental - RED FLAG SYMTPOM, getting worse often due to plaque disruption

7

What is acute coronary syndrome

Actue MI and crescendo angina

8

What usually causes sudden cardiac death

Arrhythmias

9

What does chronic ischaemic heart disease cause

Hypertrophied heart

10

What is acute ischaemia

atheroma + acute thrombosis/haemorrhage
Get transmural MI
Usually due to atheroma plays rupturing

11

Describe the MI Morphology stages

1)

12

When can a subendocardial MI occur

Can infarct without any coronary artery occlusion if:
Stable atheromatous occlusion of coronary artery
Acute hypotensive episode

13

5 Markers of cardiac myocyte damage

Troponin
CKMB
LDH1
Aspartate Transaminases
Myoglobin

14

Troponin in MI's

Peaks 12/24 hours
Detectable for 7 days
Also raised post PE, heart failure and my carditis

15

CKMB in MIs

Peaks 10-24 hours
Detectable for 3 days
3 types of CK, CKMM, CKBB, CKMB

16

LDH1

Peaks at 3 days
Detectable for 14 days

17

Myoglobin

Peaks at 2 hours
Also detecable in skeletal muscle damage

18

Aspartate transaminases

Also present in liver so less useful

19

MI Complications

Mural thrombosis/emboli can cause stroke (due to altered flow)
Autoimmune pericarditis (dressler;s syndrome)
LV Failure
Ischaemic pain
Arrythmias
Myocardial rupture --> tamponade

20

How is familial hypercholesterolaemia inherited

mutation in LDL receptor gene or apolipoprotein B
Autosomal dominant

21

What do heterozygotes for familiar hypercholesterolaemia get

Early atherosclerosis
Tendon Xanthoma
Corneus Arcus

Treat with statinsQ

22

What are statins

Hydroxymethylglutamyl Co A Reductase inhibitos

23

What is abnormal bp

140/90

24

Secondary hypertension causes

Renal, endocrine, CV, neurological

25

All inherited and acquired hypertension share

Increased net salt balance

26

Primary hypertension causes

cardiac baroreceptors
RAS
Kenin-kallikrein defeciency
naturetic peptides
adrenergic receptros
ANS
autrocrine factors released by blood vessels

27

Where is renin synthesised and stored

in the juxtaglomerular apparatus in the afferent arteriole of the kidney

28

What does angiotensinogen II do

short half life
causes vasoconstriction
Causes renal cortex to secrete aldoesterone

29

What secretes aldosterone

the zone glomerulosa cells of the adrenal cortex

30

What can cause increased aldosterone production

Renal artery stenosis
Coarctation of the aorta

31

How do we detect coarctation of the aorta

differences in leg/arm bp
characteristic chest x-ray

32

What is conn's syndrome

Excessive aldosterone production but low renin

33

Causes of conn's syndrome

Mostly due to adrenocortical adenoma
Some due to nodular hyperplasia

34

Effects of Conns Syndrome

High bp due to aldosterone
Potassium loss - muscle weakness, cardiac arrythmias, paraesthesis, metabolic alkalosis

35

Diagnosing conns syndrome

CT of adrenas

36

What is phaemochromacytoma

Tumour of the adrenal medulla -> causes an increased secretion of catecholamines (adrenaline/noradrenaline)

37

Presentation of phaemochromacytoma

Pallor, headaches, nervous, hypertension

38

Diagnosis of phaemochromacytoma

24 hours urine collection
Surgery to treat

39

What is cushing disease

Overproduction of cortisol

40

What produces cortisol

The zone fasiculata cells of the adrenal cortex

41

Causes of cushing's disease

Pituitary adenoma (80%)
Paraeoplastic effects of other cancers --> particularly small cell lung cancer as it secretes adrenocorticotrophic horome

42

Effects of Cushings

Aldosterone like effect on kidney
Increased sympathetic nervous system activation

43

Hypertension effects

Hypertensive heart disease
Renal
Cerebrovascular

44

What is hypertensive heart disease

Systemic heart disease causes LV hypertrophy --> Initially without dilation
Later get dilation and LV failure
Cause of Sudden cardiac death

45

Renal effects of hypertension

Vascular changes:
Hyaline arteriosclerosis
Arterial intimal fibroelastosis

Gradual decline in renal function causing chronic renal failure

46

Cerebrovascular effects of hypertension

Hypertensive encephalopathy
Increased risk of rupture: Atheromatous (intracranial haemorrhage), circle of willis (SAH)

47

What is a hypertensive crisis

bp 180/120
Hypertensive encephalopathy
Retinal haemorrhage
Renal failure

48

What is hypertensive encephalopathy

Confusion, vomiting, convulsions, coma and death

Diffuse cerebral dysfunction

Rapidly treat to reduce raised ICP

49

Risk assessment of CVD

Framinghams, SCORE and QRISK

50

Cardiac disease in low risk individuals

Coronary atheromas due to familial hypercholesterolaemias
Cardiomyopathyies e.g. hypertrophic heart
Channel-opathies causing cardiac arryhytmias e.g. Long-QT and Brugada syndrome

51

Causes of pulmonary hypertension

Loss of pulmonary vasculature
Secondary to LVF
Systemic to pulm. artery shunting
Primary/idiopathic

52

What does RV failure cause

systemic oedema

53

what is heart failure

an insufficiency of cardiac output to meet metabolic demand

54

What are the main causes of heart failure

1) MI
2) Hypertension
3) Valvular

55

Describe what happens in heart failure

Increased cardiac work, increased wall stretch, increased cell stretch, hypertrophy, dilation, cardiac failure

56

Is preload proportional to contractile power?

Yes - but if volume overload causes disruption in blood flow patterns --> regurgitation and decreased contraction etc.

57

Causes of Left sided heart failure? (congestion)

Pre-renal azotemia

58

What is pre-renal azotemia?

Poor perfusion to kidneys causes high urea in blood
Kidneys secrete renin - activates RAS
Naturietc peptides secreted
Causes salt and water retention

59

Where are naturetic peptides produced?

Produced by the atrium when its dilated to cause salt and water retention

60

Features of pulmonary congestion

Oedema and heart failure
Blood tingled sputum
Dyspnoae, paraoxysmal nocturnal dyspnoea
Cyanosis
Elevated WEDGE pressure

61

Main cause of RH Failure

Pulmonary hypertension - usually secondary to left sided heart failure

62

Signs of Rh Failure

Liver/Spleen Enlargement: Due to passive congestion and NUTMEG LIVER
Kidneys effected
Pericardial and pleural effusion
Systemic Oedema

63

Autopsy of findings in congestive heart failure

Box Car Nuclei
Cardiomegaly
Dilated chambers
Hypertrophy of myocardial fibres

64

What causes valvular heart disease

Due to opening problems (stenosis) or regurgitation (closing problems)

65

Causes of aortic stenosis

Rheumatic fever
Calcification of valve

66

Cause of mitral valve stenosis

Rheumatic Fever

67

Why does rheumatic fever cause valve problems?

Group A Streptcoccci haemolytic infection
Antibodies produced against
Cross reacts with tissue glycoproteins
Can occur in heart --> causes vegetations

68

acute features of rheumatic fever

Inflammation
Aschoff Bodies
Atischkow bodies - macrophages in the cell
Pancarditis
Vegetations --> on the chordae tendinae and leaflet junctions

69

chronic features of rheumatic fever

Thickened valves
Commissural fusion
Thick, short chordae tendinae

70

Aortic stenosis

Left ventricular hypertrophy but no hypertension

Get ischaemia, cardiac decompression, angina and CHF

71

What is mitral annular calcification

Calcification of the mitral skeleton
Usually get regurgitation but stenosis possible

72

Who is mitral annular calcification more common in

women

73

Causes of aortic regurgitation

Rheumatic Fever
Infection
Aortic dilation - syphilis, rheumatoid arthritis and Marfans

74

Causes of mitral regurgitations

Mitral valve prolapse

75

Causes of mitral valve prolapse - degeneration of the mitral valve

Infection
Fen-Phen (reaction to anti-obesity drug)
Chrodae tendinae and papillary muscle problems
Calcification of the mitral ring (annulus)

76

What is mitral valve prolapse associated with?

Connective tissue disorders

77

Consequences of mitral valve prolapse

Usually asymptomatic
But get floppy valve - prone to infective endocarditis
Get a mid-systolic 'click' - holosystolic murmur if regurgitation present
Can get occasional chest pain and dyspnoea

78

What causes congenital heart diseases

Problems in embryogenesis in weeks 3-8

79

what % of congenital heart diseases are due to gene abnormalities?

10%

80

What genes are usually involved in congenital heart disease

12, 15, 18, 21 and XO

81

Mutations in which gene cause congenital heart problems?

TBX5 - ASD, VSD
NKX2.5 - VSD

These genes code for transcription factors

82

Which chromosome is important for heart development?

Chromosome 22
Deletions cause conotrucus!

83

Is rubella a teratogen for heart disease?

Yes

84

What is patent foramen ovale

where the septum primum and secundum don't fuse
occurs in 1 in 4

85

Symptoms of PFO

Usually asymptomatic
UNLESS increased pressure on the R side such as pulmonary hypertension

86

Describe the developmet of the aorticopulmonary septum

Septum divides the bulbis cords and truncus and aorta and pulmonary artery
Spirals

87

When does the ductus arteriosus close

Usually at birth due to increase in oxygen and decrease in prostaglandins

88

What happens in patent ductus arteriosus

Oxygenated blood flows back to the heart
Pulmonary hypertension
Ventricular hypertrophy
Heart failure

89

How to treat PDA

Prostaglandin inhibitors

90

3 types of Congential heart Disease2

R->L shunts
L-->R Shunts
Obstructions - of aorta or pulmonary artery

91

What causes L-->R Shunts

1) Atrial Septal Defects
2) Ventricular Septal Defects
3) Patent Ductus Arteriosus
4) Atrioventricular Septal Defect

92

What causes R-->L Shunts

1) Tetralogy of Fallots
2) Transposition of the great vessels
3) Truncus Arteriosus
4) Total anomalous pulmonary venous connection
5) Tricuspid atresia

93

What causes ASD's

90% due to problem in septum secundum
5% due to problem in septum primum
5% due to sinus venosus --> abnormal pulmonary veins draining into the SVC or RA

94

Problems with ASD

Usually asymptomatic until adulthood

95

What causes VSD

90% involve problems in the membranous septum
If muscular septum involved often get multiple holes --> small ones can fix themselves larger ones need surgery

96

Most common congenital heart defect

VSD - 30% occur alone but lots occur with tetralogy of ballots

Can cause pulmonary hypertension

97

What causes atrioventricular septal defects (AVSD)

Defection AV vavles
Can be partial or complete with all 4 chambers freely communicating

98

What do a 1/3 of people AVSD also have

Downs Syndrome

99

Direction of shunt in PDA

Initially L-->R
Then R--> L when it reaches systemic pressure

100

Symptoms of PDA

No cyanosis
Pulmonary hypertension
Significant pulmonary hypertension --> irreversible

101

What is tetralogy of fallots

VSD
Overriding aorta
Pulmonary Stenosis
RV Hypertrophy

102

What causes PINK tetralogy of fallots

if the pulmonic obstruction is small

103

What causes transposition of the great vessels

Abnormal formation of the conotruncal septum --> does not spiral

104

What do you need to survive in the transposition of the great vessels

PDA or PFO
VSD can occur

105

Which ventricle is thicker in transposition of the great vessels

Right Ventricle
Fatal in first few months without surgical switching

106

What causes truncus arteriosus

Developmental failure of seperation of the truncus arteriosus CONOTRUNCAL SEPTUM DOESNT FORM --> pulmonary artery and aorta are not separated

107

What problems are associated with truncus arteriosus

VSD - as the conotruncal septum doesn't form it can't fuse with inter ventricular septum so you get a VSD

108

What does truncus arterioles causes

Systemic cyanosis with increased pulmonary blood flow

109

What is total anomalous venous connection

Pulmonary veins drain into the left innominate vein or the coronary sinus

110

What happens if you get a total anomalous venous connection

Get a hypo plastic left atrium
Need a PFO or an ASD otherwise a fatal condition due to lack of perfusion to the organs!

111

What happens if you get tricuspid atresia

Hypoplastic RV

112

What do you need to survive if you have a tricuspid atresia

PDA or ASD defect needed to fill the Left atrium with blood
VSD needed to pump blood into the pulmonary arteries

Left ventricle supplies both the aorta and pulmonary artery! Heart unable to pump oxygenated blood properly

113

Who is coarctation of the aorta more common in

Males and XO's

114

Which form of aorta coarctation happens in infants that is serious

Proximal to the PDA

115

What occurs with coarctation of the aorta 50% of the time

Bicuspid aortic valve

116

What happens with 100% artretic pulmonary stenosis

Hypoplastic RV with ASD

117

What happens if you get severe aortic stenosis/vavlular

If severe can cause hypo plastic LV which is fatal

118

3 types of aortic stenosis

Valvular
Sub-valvular
Supra-valvular

119

What is endocarditis

inflammation of the endocardium of the heart

120

What are the 2 main forms of endocarditis?

1) Infective
2) Non-infective: e.g. NonBacterial Thrombotic Endocarditis (NBTE) or endocarditis of SLE (Libman Sacks)

121

What is the main cause of infective endocarditis

Bacteria, then fungi then virus

122

What are the vegetations in infective endocarditis

Mixture of thrombotic debris and organism --> destroyed the underlying cardiac tissue

123

Describe acute infective endocarditis

Infects normal heart valves
Highly virulent organisms
Necrotizing, ulcerative, destructive lesions
Difficult to cure with antibiotics and usually require surgery
Death frequent

124

Describe sub-acute infective endocarditis

Less virulent organisms
Usually infects formed valves
Wax and wane of flu like symptoms
Cured by antibiotics

125

Risk factors for endocarditis

Cardiac/valvular abnormalities i.e. rheumatic fever
Dental wrok
Structural abnormalities of the heart

126

Bacteria causing endocarditis from mouth

Strep viridans

127

Bacteria causing endocarditis from skin

Staph aureus, especially in IVDU

128

Bacteria causing endocarditis that indicates bowel cancer

Strep. bovis

129

What bacteria commonly infects prosthetic heart valves

Coagulase negative staphylococci e.g. S. Epidermidis

130

What are the vegetation of acute infective endocarditis like

Bulky, friable, potentially destructive
Can cause abscesses
Emboli contain large numbers of virulent organsisms

Usually affects AV, MV and right hear (especially in IVDU)

131

Clinical features of infective endocarditis

Fever, flu-like symptoms, weight loss, murmurs (in 90% of those with left sided infective endocarditis)

132

Clinical Signs of Infective Endocarditis

F-fever
R-Roth spots (retinal haemorrhages)
O-Oslers Nodes (subcutaneous lesions in the pulp of digits)
M-Murmur
J-Janeway lesion
A-Anaemia
N-Nail (splinter) haemorrhages
E-Emboli (septic)

133

Complication of infective endocarditis

Immunological mediated conditions e.g. glomerulonephritis

134

Who does NBTE infect

Often debilitated patients often with hypercoaguble state
e.g. DVT, PE, Cancer, pro-coagulant effect of tumour-derived mucin or tissue factor

Can occur part of trousseau syndrome of migratory thrombophlebitis

135

What predisposes you to NBTE

endocardial trauma and indwelling catheter

136

What is NBTE (Libman Sacks) associated with

SLE
usually asymptomatic apart from the SLE symptoms

137

What are the vegetations in Libamn Sacks like

AV vealves affects
Small, pink, sterile, and warty

138

What are aschoff bodies

Distinctive in cardiac lesions i.e. rheumatic fever
Foci of T cell, plasma cell and macrophages

139

What does rheumatic fever cause

Pancarditis
Vegetations are called verucae

140

what are antibodies directed against in Rheumatic fever

Against the M proteins of the streptococci infection

141

How does rheumatic fever damage heart tissue

CD4+ T cells specific for streptococcal peptides react with streptococcal peptides that read with self-proteins in heart, produce cytokines that activate macrophages

Diagnose with Jones Criteria

142

Causes of Pericarditis

Infection - viruses, Coxsackie B
Immunological processes: RHeumatic Fever, SLE, Dresslers etc
Post MI, surgery, neoplasia, trauma etc

143

Describe types acute pericarditis

Serous/serofibrinous/fibrinous
Purulent/supparative
Haemorrhagic
Caseous

144

Describe chronic pericarditis

ADHESIVE, can cause constrictive peridcarditis

145

Causes of serous pericarditis

Generally non-infective --> usually due to inflammation of adjacent structure or sometimes viral (coxsackie or echovirus)

146

Type of inflammation in serous pericarditis

clear, serous fluid accumulation

147

Most common form of pericarditis

Serofibrinous/fibrinous

148

Cause of fibrinous/serofibrinous pericarditis

Post MI
Dresslers
Uraemia
Radiation
Rheumatic fever, SLE,
Trauma and surgery

149

Type of inflammation in fibrinous/serofibrinous

Fibrous --> without fluid, dry and granular surface with more intense inflammatory response
Serious fluid and or fibrinous exudate in the pericardial sac

150

Purulent/supurative pericarditis cause

Infection

151

Type of inflammation in purulent/supparative pericaditis

Red, granular exudate upto 500ml
Can cause restrictive pericarditis
Inflammation can extend causing media-stino pericarditis

152

Haemorrhagic pericarditis inflammation type

Caseous (Cheesy) pericarditis e.g. TB or fungal

153

Causes of hemorrhagic pericarditis

Neoplasic
Infection e.g. TB
Following surgery

154

Clinical features of pericarditis

Sharp central chest pain: worse on inhalation and movement, better on sitting forward
Pericardial friction rub - loudest over diaphragm in left sternal edge
Fever, leucocytosis, lymphocytosis
Can get pericardial effusion/tamponade

155

Types of chronic pericarditis

Adhesive - obliterates pericardial cavity
Adhesive mediastinopericarditis --> follow infections, surgery or radiation. Obliterated pericardial cavity extending to surrounding structures. Causes hypertrophy/dilation
Constrictive pericarditis

156

How to treat constrictive pericarditis

Surgery

157

what is cardiomyopathy

Disorder of the myocardium

158

What are the 4 main of types of cardiomyopathy

1) Dilated
2) Hypertrophic
3) Restrictive
4) Arrythmogenic Right Ventricular

159

What is dilated cardiomyopathy

Progressive dilation
Causes contractile dysfunction and systolic failures
Heart gets enlarged, flabby and heavy

160

Causes of dilated cardiomyopathy

20-50% Genetic - AD Mutations in cytoskeleton Proteins
Rest due to alcohol and toxins e.g. chemo

161

Signs of dilated cardiomyopathy

Congestive heart failure, SOB, dyspnoea, poor exertional acapcity

162

Treatment of dilated cardiomyopathy

Transplant or long-term ventricular assist

163

What is hypertrophic cardiomyopathy

Hypertrophy and poorly compliant left ventricular myocardium
Diastole dysfunction but systolic function preserved --> can't dilate in diastole due to poorly compliant/stiff walls

Main cause of Left Ventricular Hypertrophy

164

Causes of hypertrophic cardiomyopathy

100% genetic - problems in the sarcomeric proteins

165

Signs of hypertrophic cardiomyopathy

Reduced stroke volume and obstruction to LV outflow --> this causes a systolic ejection murmur

Exertional dyspnoea

The anterior mitral leaflet moves towards the inter ventricular septum in systole

166

Main cause of sudden death in young athletes

hypertrophic cardiomyopathy

167

What can hypertrophic cardiomyopathy lead to?

Arrythmias
Mural thrombosis
Cardiac Failures
AF
Sudde Death

168

What is restrictive cardiomyopathy

Primary decrease in ventricular compliance --> reduces ventricular filling during diastole

169

Causes of restrictive cardiomyopathy

Fibrosis
Amyloidosis
Sarcoidosis
Metastatic tumours
Deposition of metabolites

170

Size of ventricles in restrictive cardiomyopathy

Normal/slightly enlarged.
Myocardium is stiff and non-compliant

171

What is arrythmogenic right ventricular cardiomyopathy

Right ventricular dilation and myocardial thinning

172

Cause of arrythmogenic right ventricular cardiomyopathy

Genetic Disease - autosomal dominant
Problem with desmosomes (for cell-cell adhesion)
cells fall off and die during exercise
Replacement of RV with fibrofatty cells

173

Signs of arrythmogenic right ventricular cardiomyopathy

Can be silent, syncope, cardiac death in the young

174

Causes of myocarditis

Mostly infective: Cocsackie A/B Virus
Chaga's Disease (Trypanosome cruzi protozoa) --> endemic in S. AMerica

175

Symptoms of Myocarditis

Asyomptomatic/heart failures/arrythmias/sudden death
Non-specific symptoms: fatigue, palpitation, precordial deiscomfort, fever

Can mimic an acute MI

176

What can develop from myocarrditis

Dilated cardiomyopathy

177

What do we use to name vasculitis

Chapel Hill Nomenclature

178

What is the most common form of vasculitis

Giant Cell Arteritis (GCA)

179

What arteries does GCA affect?

Large/medium sized

Arteries in head i.e. temporal
Also ophthalmic and vertebral

180

Consequence of GCA in the ophthalmic artery

Can cause permanent blindness --> medical emergency

181

Morphology of GCA

Intimal thickening --> narrows the lumen
Chronic granulomatous inflammaton --> elastic lamina configuration
Multinucleated cells

182

Clinical features of GCA

Facial pain or headache --> particularly superficial temporal artery and jaw claudication
Vague symptoms e.g. fever/weight loss
Rare in under 50s

183

Treatment of GCA

corticosteroids and anti-TNF

184

Diagnosis of GCA

biopsy - take 2-3cm of artery as it is a segmental disease

185

What are aneurysms

localised, permanent dilations of a blood vessel

186

Types of aneursyms

atherosclerotic
dissecting
berry
micro
syphilitic
Mycocytic
False

187

Most common aneurysm

Atherosclerotic aneurysm --> commonly affects AAA

188

Risk of AAA rupture

less than 4cm no risk
4-5cm = 1%
5-6cm = 11%
over 6 cm = 25%

189

How to detect AAA

Ultrasound and then have endovascular repair

190

What is dissecting aneursym

Tear in the vessel wall and blood goes between the intimal and medial layers

191

Where do dissecting aneurysms usually occur

Usually in the thoracic artery secondary to systemic hypertension

192

Signs of thoracic aorta

Tearing pain in chest radiating upper left shoulder
Progressive vascular occlusion and haemopericardium
High mortality if not treated

193

What are berry aneurysms

Secular lesions in the circle of willis --> commonly at medial weakness of arterial bifurcaions

194

Who berry aneurysms usually occur in

Young hypertensive patients

195

Cause of micro aneursyms

Charcot-Bouchard syndrome --> aneurysms in small cerebral capillaries in hypertensive disease --> causes intracerebral haemorrhages

Also retinal aneurysms in diabetes can causes diabetic retinopathy

196

Cause of syphilitc aneurusms

Tertiary syphilis can cause aneurysms in the ascending aorta

197

What is a mycotic aneurysms

Weakening of the arterial wall secondary to bacterial/fungal infections

198

How to organisms enter in mycotic aneurysms

Enter the media via the vasa vasorum

199

Most common underlying infection in mycotic aneursysms

Sub-acute endocarditis

200

Where do mycotic aneurysms commonly occur

The cerebral arteries
If it infects the AAA there is a risk of rupture

201

What are false aneurysms

Blood filled spaces around a vessel following traumatic rupture of perforating injury

Adventitial fibrous tissue contains the haematoma

202

When are false aneurysms classically seen

Femoral artery puncture during angioplasty/angiography

203

What do we give to treat acute coronary artery occlusion

Oxygen, ACEi, GTN, Beta blcokers, Pain relief, Statins

204

Why might you collapse and die after an MI

Likely an arrhythmia

205

What could a systolic murmur indicate

Aortic stenosis

206

How can COPD affect the heart

Causes pulmonary hypertension can cause RH failure

207

When is BNP raised

Raised in myocardial stress