Heart disease and failure

Question 1

Risk factors of CVD

Answer 1

High cholesterol
High blood pressure
Smoking
Obesity
Diabetes
Age
Family history
Previous heart attack

Question 2

Clinical manifestations of IHD

Answer 2

Development of atherosclerosis - fatty streak, lipid deposition, intimal fibrosis
Atherosclerotic plaque leads to an imbalance between myocardial oxygen supply and demand

Question 3

Signs/symptoms

Answer 3

Asymptomatic
Stable angina
Acute coronary syndromes - unstable angina, NSTEMI, STEMI
Long term: HF, arrhythmias, sudden death

Question 4

Typical angina

Answer 4

Substernal chest discomfort
Provoked by exertion
Relieved by rest/nitrates within minutes

Question 5

What is an acute coronary syndrome

Answer 5

Unstable angina
Acute MIs
- you can tell if its MI by rise in troponin on blood test (not elevated in unstable angina)
Characterised by development of a thrombosis at the site of acute disruption

Question 6

STEMI

Answer 6

ST elevation on ECG
Complete coronary occlusion
Need timely diagnosis

Question 7

NSTEMI

Answer 7

ST depression, variable T wave

Incomplete coronary occlusion

Question 8

ACS symptoms

Answer 8

Discomfort that lasts and radiates
Occurs with exertion and at rest
Not relieved by GTN
Breathlessness, nausea/vomiting, sweating/clamminess

Question 9

Immediate assessment

Answer 9

Patient history
ECG
Physical exam
Then risk stratification and blood test (troponin)

Question 10

Management of ACS

Answer 10

Antiplatelet therapy (aspirin, clopidogrel)
Anti-ischaemic therapy (nitrates)
Thrombolysis (if STEMI)
Secondary prevention (statin, ACE inhibitor, beta blocker, lifestyle)

Question 11

Other causes of raised NSTEMI

Answer 11

Pneumonia, PE
Pericarditis, sepsis
Heart failure, uncontrolled tachyarrhythmias

Question 12

High risk ACS patients

Answer 12

Elevated troponin
Renal impairment
Recurrent chest pain
Changes on ECG
Haemodynamic instability
Major arrhythmias, HF
Elderly

Question 13

Cardiac output equation

Answer 13

CO = HR x SV
At rest: 70ml/kg/min
Stroke volume affected by contractility, preload and afterload

Question 14

Low output heart failure

Answer 14

Systolic (iscahemic injury, pressure/volume overload)

Diastolic (hypertrophy, infiltrative disorders, constrictive pericarditis, restrictive cardiomyopathy)

Question 15

High output heart failure

Answer 15

Caused by increased demand on CO
High demand for blood
Causes: anaemia, pregnancy, Pagets disease, sepsis, acromegaly, thyrotoxicosis

Question 16

Cardiomyopathy

Answer 16

Dilated: 50% familial, or toxins, or systemic disease
Hypertrophic: familial
Restrictive - amyloid

Question 17

Pathophysiology of heart failure

Answer 17

Reduced SV and CO -> compensatory mechanisms
Vasoconstriction, increased venous return -> enhanced contractility (starling law)
Results in augmented muscle mass
Activation of neurohormonal system (noradrenaline = increased heart rate; vasoconstriction, ANP, RAAS)

Question 18

RAAS/compensation in heart failure

Answer 18

Vasoconstriction
Na and water retention
Excessive tachycardia

Question 19

What does Left ventricular failure do to the kidneys

Answer 19

Decreased CO
Reduction in renal perfusion
Activation of RAAS
Increased blood volume

Question 20

What does left ventricular failure do to the brain

Answer 20

Hypoxic encephalopathy
Irritability
Loss of attention
Restlessness
Stupor and coma

Question 21

Effects of right sided heart failure

Answer 21

Liver and portal system (hepatomegaly, centrilobular necrosis, cardiac cirrhosis)
Spleen
Abdomen
Subcutaneous tissue (oedema
Pleural and pericardial space (effusions)

Question 22

Biventricular failure

Answer 22

Due to same pathological process on each side of heart

Or left heart failure leads to volume overload and then right heart failure

Question 23

Side effects of left ventricular failure

Answer 23

Pulmonary congestion and oedema

Heavy wet lungs - breathlessness, orthopnoea, paroxysmal nocturnal dyspnoea