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drugs and misc Flashcards

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1
Q

What does regurgitation cause?

A

Insufficiency + proximal chamber dilation -loss of structural chamber integrity and strength

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2
Q

What does stenosis cause?

A

Increase in upstream pressure + proximal chamber dilation+hypertrophy - heart becomes huge and rigid; poorly compliant

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3
Q

Main valve disorders?

A

Aortic regurgitation and stenosis Mitral regurgitation and stenosis

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4
Q

What do the main valve disorders cause?

A

Murmers

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5
Q

How are murmers best heard?

A

Using RILE Right side defects (tricuspid /pulmonary) heard on Inspiration Left sided defects (mitral\aortic) heard on Expiration

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6
Q

Normal size of mitral bicuspid lumen and after undergoing stenosis?

A

Mitral bicuspid lumen = 4-6cm2 Symptoms of stenosis start at <2cm

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7
Q

Causes of mitral stenosis

A

Most common = rheumatic fever (Post strep pyogenes infection) Also valve calcification in older patients + infective endocarditis

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8
Q

Pathophysiology of mitral stenosis

A

RHD causes mitral reactive inflammation, after years exacerbated with calcification => LA hypertrophy and chamber dilation

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9
Q

Symptoms and signs of mitral stenosis

A

-malar cheek flush (due to CO2 retention) - association with Atrial Fibrillation (due to stasis in LA and hypertrophy of LA) -dyspnoea - A wave on JVP

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10
Q

Mitral stenosis murmur?

A

Low pitched Mid diastolic murmer Loudest at apex Best heard on expiration with patient lying on left hand side

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11
Q

Investigations to diagnose mitral stenosis

A

CXR (LA enlarged) EVG (AFib, P mitrale= bifid “m” shale P waves when LA enlarged) ECHO -assess valve area, gradient, mobility (gold standard)

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12
Q

Treatment for mitral stenosis

A

Surgical Percutaneous balloon valvotomy (stent open mitral valve opening) Mitral valve replacement

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13
Q

Why is mitral stenosis more atrial fibrillation associated?

A

Mitral stenosis causes left atrium hypertrophy - more chances of embolisation as blood actively pumped harder

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14
Q

Causes of mitral regurgitation

A

Myxomatous mitral valve (most common valve disease) = mass of cells in valve connective tissue makes leaflets heavier + prolapse

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15
Q

What is mitral regurgitation

A

Heart valve disease in which the valve between the left heart chambers doesn’t close completely, allowing blood to leak backward across the valve

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16
Q

Risk factors for mitral regurgitation

A

Females Older Decreased BMI Prior MI Connective tissue disorder (marfan, ehlers danos)

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17
Q

Symptoms of mitral regurgitation

A

Exertion dyspnoea (due to pulmonary hypertension from back logging of blood)

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18
Q

Mitral regurgitation murmer?

A

Pan systolic blowing murmur radiating to axila (at apex) soft S1, prominent S3 in heart failure (severe cases)

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19
Q

Investigations for diagnosing mitral regurgitation

A

ECG CXR ECHO (gold standard) - check left atrium size and left ventricle function analysis Also assess valve structure to decide treatment

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20
Q

Treatment for mitral regurgitation

A

ACEi, Bb + serial ECHO monitoring If severe - (symptoms at rest) = valve repair\replacement

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21
Q

What is aortic stenosis

A

Pathological narrowing or aortic valve -decrease in flow Normal area 3-4cm Symptoms at 1/4 lumen size Most common valve disorder- results in LV dilation + hypertrophy

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22
Q

Symptoms of aortic stenosis

A

SAD Syncope (exertional) Angina Dyspnoea (relates to heart failure)

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23
Q

Aortic stenosis murmur

A

Ejection systolic crescendo decrescendo, radiating to carotids heard at right sternal border, second IC space -prominent S4 seen in LVH - narrow pulse pressure + slow rising pulse (not collapsing corrigan’s pulse)

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24
Q

Investigations to diagnose aortic stenosis

A

ECG CXR ECHO = gold standard for LV size and function + aortic valve area

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25
Treatment for Aortic stenosis
General: Fastidious dental care to prevent IE As it is a mechanical problem-drugs are not effective Surgical if symptomatic: - in a healthy patient -> open repair\valve replaced (definitive) - more at risk (eg 75+) ->TAVI (transcutaneous aortic valve implant) less invasive and stents valve open
26
Differential diagnosis for aortic stenosis
Hypertrophic cardiomyopathy may also cause S4 - associated with sudden death in young men
27
What is aortic regurgitation
Leaky aortic valve which makes it insufficient
28
Causes of aortic regurgitation
Congenital bicuspid valve RHD Connective tissue disorders (Marfan/ehlers danos) Infective endocarditis
29
Symptoms and signs of aortic regurgitation
-Collapsing carrigon’s pulse with wide pulse pressure -Quincke’s sign (nailed pulses when pressed) -De Musset sign (head bobbing in time with arterial pulsation)
30
Aortic regurgitation murmur
Early diastolic blowing murmer at right sternal border 2nd intercostal space - Austin fling murmer (severe) - mid diastolic low pitched rumble - heard when regurgitation is so severe blood bounces if mitral valve cusps and makes sound
31
Investigations to diagnose aortic regurgitation
ECG CXR ECHO gold standard, evaluates aortic valve, root, dimensions
32
Treatment for aortic regurgitation
Consider IE prophylaxysis (consider as differential diagnosis) Surgical valve replacement if symptoms
33
Most common congenital heart defect?
Bicuspid aortic valve 1-2% of the population M>F
34
Is the aortic valve bicuspid or tricuspid?
Typically tricuspid
35
Disadvantage of bicuspid aortic valve?
Bicuspid degenerates quicker than normal and will become regurgitative earlier Are also associated with coarction and dilation of ascending aorta Can be severely stenotic in infancy or childhood
36
Another name for atrial septal defect
Patent foramen ovale
37
Pathophysiology of atrial septal defect
Shunt of blood L->R and therefore not cyanotic (blue skin inducing) - increased flow to right side of heart and lungs - may overload RHS circulation causing RVH
38
Investigations to diagnose an atrial septal defect
Using an ECHO
39
Treatment for atrial septal defect
Sometimes there is spontaneous closure Otherwise treatment is surgical Percutaneous (key hole technique)
40
What is a ventricular septal defect
L->R non cyanotic shunt (not blue) Blood flows from high pressure to low pressure chamber Increased blood flow through the lungs (more in larger defects) Risk of Eisenmengers syndrome and RVH later
41
Symptoms of small ventricular septal defect
Typically asymptomatic Normal heart rate/size Loud systolic murmur
42
Symptoms of a large ventricular septal defect
Exercise intolerance Failure to thrive Murmur varies in instensity Tachycardia + increased respiratory rate Small skinny breathless baby :(
43
Investigation used to diagnose ventricular septal defect?
ECHO
44
Treatment for ventricular septal defect
Spontaneous or surgical closure in infancy if big No need for intervention if small and asymptomatic
45
What is an atrioventricular septal defect?
Essentially a hole down the middle of heart (no atrial or IV septum!) Can be complete or partial
46
What is atrioventricular septal defect associated with
Massively associated with Downs Syndrome
47
Symptoms of atrioventricular septal defect
Dyspnoea Exercise intolerance Complete defect: - breathless new pats with poor weight gain and feeding and needs repair wishing is surgically challenging Partial defect: Can present late in adulthood band can be left alone if no right heart dilation
48
Prognosis of atrioventricular septal defect
Progresses to eventually Eisenmenger’s and hard to treat
49
What is patent ductus arteriosus
When ductus arteriosus fails to close post birth = unusual
50
Pathophysiology of patent ductus arteriosus
Blood shunt from aorta to pulmonary trunk -risk of pulmonary overload and Eisenmengar’s
51
Symptoms of patent ductus arteriosus
Dyspnoea Failure to thrive Machine like murmur Risk of infective endocarditis
52
Investigations to diagnose patent ductus arteriosus
CXR ECG ECHO
53
Treatment for patent ductus arteriosus
Prostaglandin inhibitor (indomethacin) may induce closure Otherwise consider surgery by catheters
54
What is tetralogy of fallot
Cyanotic! Ventricular septal defect with right ventricular outflow obstruction - therefore O2 deficient blood is systemically shunted = blue blood passes from RV to LV
55
Most common congenital cyanotic heart disease
Tetralogy of Fallot 10% of all congenital birth defects
56
Four congenital abnormalities present in Tetralogy of Fallot
PROV Pulmonary stenosis: RV outflow obstruction Right ventricular hypertrophy Overriding aorta (over top of VSD) Ventricular septal defect (VSD)
57
Symptoms of tetralogy of fallot
Infants are often seen bringing their knees up to their chest as if squatting which partially occluded femoral arteries, this increases systemic vascular resistance and left ventricular pressure => relives cyanosis by reducing right to left shunt *cyanosis often exacerbated when cring or feeding
58
How to diagnose tetralogy of fallot
ECHO CXR - presents as boot shaped heart
59
Treatment of tetralogy of fallot
Full surgical repair within 2y of life and good prognosis if done Normally at 3-6months👩🏻‍🍼
60
Pathophysiology of coarction of aorta
Aorta narrows at or just distal to ductus arteriosus => blood diverted massively through aortic arch branches = increased perfusion in upper body vs lower body
61
Symptoms of coarction of aorta
Scapular bruits from collateral vessels Hypertension in collaterals (right arm) Murmur
62
Investigations to diagnose coarction of aorta
CXR: “notched ribs” dilated intercostal vessels CT angiogram
63
Treatment of coarction of aorta
Surgical repair or stenting of stenoses segment, even when mild to prevent long term problems
64
Most common congenital heart disease?
Ventricular septal defect 25-30%
65
Prevalence of patent ductus arteriosus
10-20%
66
Prevalence of tetralogy of fallot
4-10%
67
Why treat hypertension?
Important preventable cause of premature morbidity and mortality Major risk factors for: - stroke (ischaemic and haemorrhagic) - myocardial infarction - heart failure - cognitive decline - premature death Increases risk of Atrial fibrillation as well
68
The main indications for ACEi?
Hypertension Heart failure Diabetic neuropathy
69
Examples of ACEi?
Ramipril Enalapril Perindopril Trandolapril (Largely do the same job but vary in price)
70
Main side effects of ACEi?
Due to reduced angiotensin II formation: - hypotension - acute renal failure - hyperkalemia - teratogenic effects in pregnancy Due to increased kinins: - cough - rash - anaphylactoid reactions
71
Main clinical indications for ARBs?
-Hypertenison -Diabetic Neuropathy -Heart failure (when ACEi contraindicated)
72
Examples of ARBs?
Cadersartan (most common) Losartan Val sat tan Irbesartan Telmisartan
73
Main side effects of ARBs?
Symptomatic hypotension Hyperkalemia Potential for renal function Rash Angioedema Generally very well tolerated
74
Contraindication of ARBs?
Pregnancy
75
Main clinical indications of CCBs?
Hypertension ischaemic heart disease - angina Arrrhythmia (tachycardia)
76
Examples of CCBs?
Amlodipine Diltiazem Verapamil Felodipine Lacidipine Nifedipine
77
Dihydropyridines CCBs?
Nifedipine Amlodipine Felodipine Lacidipine Preferentially affect vascular smooth muscle = peripheral arterial vasodilators
78
Phenylyalkylamines CCBs?
Verapamil Main effects in the heart = negatively chronotropic and inotropic
79
Benzothiazepines CCBs?
Diltiazem = immediate heart/peripheral vascular effects
80
Main side effects of peripheral vasodilation? (CCBs)
Flushing Headache Oedema Palpitations
81
Main side effects due to negatively chronotropic effects? (CCBs)
Bradycardia Atrioventricular block
82
Main side effects due to negatively ionotropic effects? (CCBs)
Worsening of cardiac failure
83
Side effect of verapamil?
Constipation
84
Main clinical indications for Bb?
Ischameic heart disease - angina Heart failure Arrhythmia Hypertension
85
Examples of B1 selective Bb?
Metoprolol Bisoprolol
86
An example of a less selective B1 Bb?
Atenolol
87
B1/B2 (non-selective) Bb examples?
Propranolol Nadolol Carvedilol
88
Are beta 1 selective blockers absolute?
Selectivity is relative rather than absolute
89
What percentage of beta adrenoreceptors in the heart are actually B1?
Only 60% 40% are B2 =hence you can’t use the term cardioselective to describe B1 selective beta blockers
90
Main side effects of Bb?
Fatigue Headache Sleep disturbance/ night mares Bradycardia Hypotension Cold peripheries Erectile dysfunction
91
Contraindications of Bb?
Worsening of : - asthma (can be severe) or COPD - PVD - claudication or raynauds - Heart failure - if given in standard dose or acutely
92
Main clinical indications of Diuretics?
Hypertension Heart failure
93
4 classes of diuretics?
1) thiazides and related drugs (distal tubule) 2) loop diuretics (loop of henle) 3) potassium-sparing diuretics 4) aldosterone antagonists
94
Examples of thuazide and related diuretics?
Bendroflumethiazide Hydroclorothiazide Chlorthalidone
95
Examples of loop diuretics?
Furosemide Bumetanide
96
Examples of potassium-sparing diuretics
Spironalactone Eplerenone Amiloride Triamterine
97
Main side effects of loop diuretics
Hypovolemia Hypotension
98
General side effects of diuretics?
Hypokalemia Hyponatremia Hypomagnesaemia Hypocalcemia Hyperuricaemia- gout
99
Side effects of thiazides?
Erectile dysfunction Impaired glucose tolerance
100
Other anti hypertensives?
A-1 adrenoceptor blockers (Doxazosin) Centrally acting anti-hypersensitive (Moxonidine + methyldopa) Direct renin inhibitor (Aliskeren)
101
What do nitrates do?
Arterial and venous dilators Reduction of preload and afterload Lower BP
102
Main clinical indications for nitrates?
Ischeamic heart disease - angina Heart failure
103
Main examples of nitrates
Isorbide mononitrate GTN spray GTN infusion
104
Main side effects of nitrates
Headache due to GTN syncope (spray)
105
Drug for antiplatelet therapy in angina if aspirin intolerant?
Clopidogrel
106
Example of an antiarrhythmic drug?
Digoxin
107
Drug class and mechanism of Digoxin?
Class: Cardiac glycoside Inhibits Na/K pump and causes: - bradycardia - slows AVN conduction - increased ectopic activity - increased force of contraction
108
Side effects of digoxin?
Narrow therapeutic range Nausea Vomiting Diarrhoea Confusion
109
Main clinical indication of Digoxin?
Atrial fibrillation to reduce ventricular rate response Severe heart failure as +vly ionotropic
110
Eisenmenger’s syndrome?
High pressure pulmonary flow Damages to delicate pulmonary vasculature The resistance to blood flow through lungs increases RV pressure increases Shunt direction reverses Patient becomes BLUE
111
Clinical signs of atrial septal defects
Pulmonary flow murmur Big pulmonary arteries on CXR Big heart on chest x ray Risk of infective endocarditis
112
Long term problems of coarction
-Re coarction requiring repeat intervention -Aneurysm formation at the site of repair Hypertension leads to: - early coronary artery disease/stroke - sun arachnoid haemorrhage
113
What is pulmonary stenosis?
Narrowing of the outflow of the right ventricle can occur in different locations: - Valvar - Sub valvar - Supra valvar - in branches
114
Severe pulmonary stenosis?
-Right ventricular failure as A neonate -Collapse -Poor pulmonary blood flow -RV hypertrophy -Tricuspid regurgitation
115
Moderate/mild pulmonary stenosis?
-well tolerated for many years -Right ventricular hypertrophy
116
Treatment of pulmonary stenosis?
Balloon valvuloplasty Open valvotomy Open trans-annular patch Shunt (to bypass blockage)
117
Pathophysiology of aortic stenosis
-A pressure gradient develops between left ventricle and aorta - LV function initially maintained by compensatory pressure hypertrophy - when compensatory mechanism exhausted, LV function declines
118
Systolic murmurs?
ASMR Aortic Stenosis Mitral Regurgitation
119
Diastolic Murmer?
ARMS Aortic regurgitation Mitral stenosis
120
What is coarction of the aorta associated with?
Turner’s syndrome and Berry aneurysms of the brain

2a cardio (6 decks)

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