Flashcards in Cardio Deck (74):
What is the most common classification for Heart Failure
Describe how the NYHA Classification works?
Class 1-4 based on severity of symptoms
Class A-B based on severity of signs
1/A: No Signs/Symptoms
2/B: Mild Signs/Symptoms
3/C: Moderate Signs/Symptoms
4/D: Severe Signs/Symptoms
What is the scoring system for AF and how does it work?
C-Congestive Heart Failure
A-Age >75 (2 Points)
S-Stroke/TIA/Thromboembolism (2 Points)
Sc-Sex = Female
Offer anticoagulation treatment to all people with a CHA2DS2VASc score of 2 or above, and consider offering it to men with a CHA2DS2VASc score of 1
What Scoring System is used to assess the risk of a major bleed in patients on Anticoag for AF?
A-Abnormal Renal / Liver function (1 Point Each)
B-Bleeding history (anaemia, PMH)
D-Drugs (NSAIDs, Antiplatelets) / Alcohol (1 Point Each)
A Score >3 is considered high risk and warfarin should be used cautiously.
What is the diagnostic criteria for Congestive Cardiac Failure called and how does it work?
-Crepitations @ lung bases
-Cardiomegaly on PA CXR
-Acute Pulmonary Oedema
-S3 Heart Sound
-Weight Loss > 4.5Kg in 5 days
-Bilateral Ankle Oedema
-Dyspnoea on ordinary exertion
-Decreased vital capacity
(Only if not attributable to another condition)
Pts must have ≥2 Major or 1 Major and ≥2 Minor Criteria to be diagnosed with CCF.
What scoring system is used to assess an NSTEMI and how does it work?
GRACE scoring system based on:
PMH of MI / CCF
Heart Rate and Blood Pressure
Serum Creatinine / Troponin
Splits pts into a high-risk category which you treat as a STEMI and low risk which you manage medically.
How does the management of NSTEMIs differ depending on the GRACE score?
Offer 300mg loading Aspirin to all patients ASAP
Offer 300mg loading Clopidigrol to patients with a 6/12 mortality >1.5%
Offer PCI to patients with a 6/12 mortality >3%
Assess mortality using GRACE scoring
What is pericarditis?
Inflammation of the pericardium
What are the main causes of pericarditis?
Infectious (Coxsackie, Fungal, TB)
Autoimmune (SLE, Rheumatic fever)
Kidney Failure (Uraemia)
Drug induced (isoniazid, cyclosporin)
Following MI (Dressler syndrome)
Trauma (Surgery / Stabbing)
Signs of pericarditis?
Kussmaul Sign (JVP rise on inspiration)
Pericardial friction rub (extra heart sound)
Symptoms of pericarditis?
Central Chest Pain ( Sharp, Stabbing, Worse on inspiration, relieved by leaning forwards, radiate shoulders/neck)
SOB when lying down
Differentials for pericarditis and how to rule them out?
Dyspnoea and pleuritic pain:
PE, Pneumonia, Pneumothorax
Angina, MI, Aortic Dissection
Raised Troponin rules out lung causes.
ST elevation, PR depression and Pericardial Rub rule out other cardiac causes.
Investigations required for pericarditis?
ECG (Saddle ST elevation and PR depression)
CXR (Pericardial effusion and ≠ pneumonia)
Echo (Pericardial effusion)
CRP, Troponin, U+Es (uraemia causes pericarditis), Bld cultures.
Virology, Rheumatoid Factor, Anti-dsDNA (SLE), Interferon gamma release assay (IGRA) (TB)
Managment for pericarditis?
NSAIDS (PPIs if PMH of GI problems)
If Cardia Tamponade then pericardiocentesis (US guidance, 5/6 intercostal space @ L. Sternal border 45°)
Send pericardiocentesis sample for culuture if infective cause is supsected.
What is Endocarditis and it's causes
Inflammation of the inner walls of the heart and valves
What are the RFs for Endocarditis?
Valve replacements (esp. mechanical)
Congenital Heart Defects
Poor Dental Hygiene / Recent dental surgery
What are the Signs/Symptoms of Endocarditis
Pleuritic Pain (radiating to the back)
Fever, night sweats
Clubbing /Splinter Haemorrhages / Osler's nodes and Janeway Lesions
What are the common organisms in endocarditis and how do you treat them?
Staph aureus (Fluclox + Gent normally or Vanc + Gent if pen allergic / MRSA+)
Steptococci viridans (Gent + Benzylpenicillin)
Pseudomonas aeruginosa (Gent?)
Enterococci (Amox + Gent)
What should Pts with prosthetic valves be given prior to dental surgery?
Differentials for endocarditis?
Pericarditis ( No pleural rub + ECG pattern)
Ischaemic heart disease (different ECG pattern)
PE (d-dimer, HRCT)
Investigations for endocarditis?
Blds (CRP, WBC, Troponin)
ECG (≠Pericarditis Saddle ST elevation)
CXR (≠Lung pathology)
Echo (valvular damage and vegetation)
Bld Cultures (diagnosis and abx treatment)
What criteria are used to diagnose endocarditis and how does it work?
Major Criteria (+ve Bld culture, +ve Echo, new murmur)
Minor Criteria (RFs, >38°C, Vascular Sign)
Diagnosis if 2 major or 1 major and 3 minor
Treatment of endocarditis?
Abx (Gent + Benzylpenicillin or Vanc for MRSA)
Educate Pt. about good oral hygiene
Educate Pt. against dirty needles
Be aware of ↑ risk of thromboembolic event
What is angina?
What is the cause?
When does it occur?
Angina is chest pain commonly felt in ischaemic heart disease.
Caused by coronary artery disease and tends to arise during exercise due to increased oxygen demand to the heart and shorted diastolic period.
What are the symptoms of Angina?
Central crushing pain (comes on with exercise, relieved by rest, radiates to jaw and L. Arm)
Sweating, pallor, clamminess.
Differentials for angina?
Acute coronary syndrome (NSTEMI / STEMI / Unstable angina) (Pain is not relieved by rest / GTN)
Pericarditis / Endocarditis (Pain aggravated lying flat, relieved leaning forward)
GORD (Pain aggravated after eating and lying flat)
Pancreatitis (Pt. systemically unwell + jaundiced)
Gallstones (Colicky pain)
Investigations for angina?
ECG (Pathological Q waves, ST depression, T wave inversion)
Troponin + Creatinine Kinase (↑ in ACS but not stable angina)
Angiogram (check location of obstruction with intent to stent/angioplasty)
Treatment for angina?
Educate about RFs
β-blockers and/or Ca2+ blockers
Regular nitrates to improve exercise tolerance
Angioplasty / Stent
RFs for angina?
What cardio drug is contraindicated in asthma
1st generation β-blockers
Non-cardioselective meaning they cause bronchoconstriction
Different types on Angina?
Unstable angina (Pain @ rest, impending MI)
Prinzetal's angina (Caused by coronary artery spasm rather than atherosclerosis)
Microvascular angina (blockage of smaller vessels, no risk of infarct as vessels do not supply enough tissue, treated with GTN)
What is an MI
Infarction of the heart muscles due to ischaemia caused by obstruction of the coronary arteries.
What are the symptoms of an MI
Central Chest Pain (Crushing, Radiating to L. arm and jaw, Extreme pain, not relieved by rest of GTN)
Autonomic system activation (sweating, pallor, tachycardia)
N+V (Vagus nerve stimulation)
I which patients might an MI be painless?
Differentials for MI?
Cardiac Causes (ACS, Endocarditis, Pericarditis)
GI Causes (GORD, Perforation, Oesophageal rupture, Pancreatitis)
Investigations for MI?
ECG (differentiate between NSTEMI and STEMI)
CXR (heart failure assoc. with the MI)
FBC (WBC to ≠ infective causese)
Glucose + Lipids (RFs)
Creatinine Kinase + Troponin (Conformation)
U+Es (If GFR is ↓ then coronary angiograph not possible due to contrast)
Amylase/Lipase (≠ pancreatitis)
Medical Management of an MI?
M-Morphine (upto 5mg IV)
O-O2 (Stats > 94% (88% in COPD))
N-Nitrates (IV BP>100mmHg)
A-Aspirin (300mg) + Clopidogrel
H-Heparin (stop once patient is mobile)
Surgical Management of a STEMI?
PCI within 12hrs of onset and within 2hrs of when fibrinolysis could have been given.
Fibrinolysis in other cases
How does the management of an NSTEMI differ from a STEMI?
Score pts. on GRACE scoring system
High risk treat as STEMI
Low risk treat with β-blockers (Ca2+ if β-blockers contraindicated), short-term anticoag, ACEi
What is the long-term treatment of an MI
Pts with stents have:
Aspirin for life
Clopidogrel for 1yr
(Lifelong clopidogrel or PPI if GORD)
Pts with an LV clot:
Warfarin for 6months
Can have both treatments simultaneously
Manage RFs (Exercise, Diet, Smoking, Alcohol, DM)
Medication (β-blockers, ACEi, Statins, Aspirin)
DVLA informed as pts cant drive for 4 weeks
Causes of Cardiac Arrest
5Hs + 5Ts
H+ ions (infection, ketoacidosis, renal failure)
Hyperkalaemia / Hypokalaemia (K+ sparing diuretics)
Toxins (Rate control, Antipsychotics, Cocaine, Aspirin, Paracetamol)
Tension pneumothorax (blockage of great vessels due to mediastinal shift)
Trauma (Cariac / Subarachnoid Haemorrhage)
Signs and Symptoms of Cardiac Arrest
Preceded by weakness, dizziness, chest pain, SOB, vomit
Lack of pulse
Loss of consciousness
Differentials for Cardiac Arrest
Respiratory Arrest (ruled out by pulse)
Shock with loss of consciousness (pulse may be weak but will be present)
Treatment for Cardiac Arrest
Call for help
Defib shockable rhythms
Give 1mg Adrenaline IV after 3rd shock (given initially in non-shockable rhythms)
Give amiodarone 300mg IV after 3rd shock
Monitor on ECG and treat underlying cause
How would you treat the following causes of Cardiac Arrest:
MI > PCI
Tamponade > Pericardial Drainage
Tension pneumothorax > Needle decompression (large-bore needle into the 2nd intercostal space in the midclavicular line)
Hypovolaemic shock > IV Fluids/Blood Transfusion
Hyperkalaemia > IV dextrose + insulin, Nebulised salbutamol, Calcium Gluconate
Ischaemic Stroke > Alteplase/Streptokinase
PE > Alteplase/Streptokinase, Embolectomy
What are the methods of Embolectomy?
Typically this is done by inserting a catheter with an inflatable balloon attached to its tip into an artery, passing the catheter tip beyond the clot, inflating the balloon, and removing the clot by withdrawing the catheter. The catheter is called Fogarty
Catheter embolectomy is also used for aspiration embolectomy, where the thrombus is removed by suction rather than pushing with a balloon.It is a rapid and effective way of removing thrombi in thromboembolic occlusions of the limb arteries below the inguinal ligament, as in leg infarction.
Surgical embolectomy is the simple surgical removal of a clot following incision into a vessel by open surgery on the artery.
What is Hypertrophic Cardiomyopathy (HCM)
What did it use to be called and why was it changed?
An autosomal dominant inherited condition causing hypertrophy of the myocardium leading to dysfunction. It has no symptoms before sudden death at a young age generally on exertion.
Hypertrophic Obstructive Cardiomyopathy (HOCM). However, this was changed as in the majority of cases, HCM is not associated with LVOT obstruction.
Who should be screened for HCM
People with a Family history of sudden unexpected death (including drowning as can commonly happen while swimming)
What are the symptoms although rare for HCM
Ejection systolic murmur
Differentials for HCM
Investigations for HCM
ECG - LV Hypertrophy (Tall QRS in V5/V6)
Echo - Asymmetrical septal hypertrophy with small LV
Cardiac Catheterisation - Pressure difference between the aorta and LV if the LVOT is obstructed
Treatment for HCM
β-blockers or Ca2+ channel blockers (verapamil)
Amiodarone if arrhythmias
Anticoag is paroxysmal AF
Surgical septal myectomy in symptomatic patients who do not respond to medication.
Alcohol septal ablation if patient not suitable for open heart surgery
What is Aortic stenosis and who does it commonly affect?
Aortic stenosis is a narrowing of the aortic valve which can lead to multiple heart problems due to the effect on the LV.
Common in older patients due to senile calcification
What are the signs and symptoms of Aortic stenosis
Ejection systolic murmur over right sternal border and radiating to the carotids
Slow rising pulse with a narrow pulse pressure
Chest pain worse on exertion
Severe symptoms include (Angina, Syncope and HF)
Differentials for aortic stenosis
Investigations for aortic stenosis
CXR - calcification of the aortic valve and LV hypertrophy
Echo - Reduction in valve area. Increase in pressure gradient and ejection speed across the valve.
Cardiac catheter - assess valve gradient and LV function
ECG - LV hypertrophy with Left axis deviation
Treatment of symptomatic aortic stenosis
Valve replacement in severe disease
-Mechanical valve for lifelong replacement with lifelong warfarinisation
-Tissue valve for 15yrs in older patients or for whom warfarinisation is contraindicated.
-Transcatheter Aortic Valve Implantation for patients who are contraindicated for open heart surgery
Treatment of asymptomatic aortic stenosis.
Observation with no treatment unless valvular gradient in >40mmHg and LV dysfunction. Then consider surgery as if symptomatic.
What are the causes of heart failure
Ischaemic Heart Disease
Non-ischaemic dilated cardiomyopathy
Increased pulmonary resistance (Pulmonary hypertension, PE)
Congenital heart diseases
Hyperdynamic circulation (Anaemia, Thyrotoxicosis, Paget's Disease)
Signs and symptoms of LHF
Dyspnoea and Orthopnea
Displaced apex beat (Cardiomegaly)
Murmur indicating valvular disease
Bilateral coarse crackles at lung bases (pulmonary oedema)
SIgns and symptoms of RHF
Fatigue, Dyspnoea, Anorexia
Displaced Apex beat (Cardiomegaly)
Hepatic enlargement and ascites
Differentials for HF
Investigations for HF
CXR - Cardiomegaly (need PA) + Rule out lung pathologies
FBC - Rule out anaemia or pneumonia
U+Es - rule out renal failure
LFTs - rule out cirrhosis and low albumin
BNP - marker for HF
Echo - assess severity of ventricular dysfunction + find valvular or congenital cause
How does HF appear on a CXR?
A - Alveolar oedema
B - Kerley B lines
C- Cardiomegaly (need PA, >50% cardiothoracic)
D - Upper lobe diversion
E - Effusion with blunting of costophrenic angle
Medical Treatment for HF?
1 - ACEi + β-blocker
-Replace ACEi with Angiotensin 2 receptor blocker (ARB) if ACEi not tolerated
2 - Aldosterone antagonist, ARB, Hydralazine + nitrate
3 - Surgical Options
Diuretics in overloaded patients
- Loop diuretics
- Add in a Thiazide diuretic
- Monitor U+Es for hypokalaemia and AKI
IV inotropes in hypotensive patients with poor LV function
- Dopamine and dobutamine
Surgical Managment of Heart Failure
Implantable cardioverter defibrillator
General Managment of Heart Failure
Low salt diet
What is decompensated heart failure (Acute LV failure)
The heart is unable to output enough blood to meet the demands of the body and the compensatory mechanisms are failing or have reached their compensatory limit
What are the causes of decompensated heart failure
Aortic Stenosis, Aortic or mitral regurgitation
Infection can push compensated HF patients over the edge
Excessive Fluid +/- salt
Signs and symptoms of decompensated HF
Acute pulmonary oedema
- Acute dyspnoea and Orthopnoea
- Syncope, arrest and cardiogenic shock due to low BP
- Pale and sweaty
- Bilateral crepitations
- Gallop rhythm (3rd heart sound)
Describe the compensatory mechanisms for low BP
SNS activation causing:
- Increase in HR and contractility
- Na+ and H2O retention
RAAS activation causing:
- Na+ and H2P retention
What is the acute management of decompensated HF
- CPAP to raise lung pressure forcing fluid back into interstitium
- Morphine (with antiemetic) to ease respiratory distress
- Dobutamine + Dopamine to increase inotropy.
- BP > 100mmHg then give nitrates to improve circ.
- Avoid fluids as may cause fluid overload
- Furosemide to remove excess fluid and reduce preload.
What investigations what you order with uncompensated HF?
Troponin + Creatine Kinase (MI as cause of HF)
U+Es (Renal Failure 2° to HF)
FBCs (Infection as cause of HF)
Echo (Assess LV function and ejection fraction)