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Flashcards in Cardio Deck (74):
1

What is the most common classification for Heart Failure

NYHA Classification

2

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

3

What is the scoring system for AF and how does it work?

CHA2DS2-VASc Scoring

C-Congestive Heart Failure
H-Hypertension
A-Age >75 (2 Points)
D-Diabetes Mellitus
S-Stroke/TIA/Thromboembolism (2 Points)
V-Vascular Disease
A-Age (65-74)
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

4

What Scoring System is used to assess the risk of a major bleed in patients on Anticoag for AF?

HAS-BLED score

H-Hypertension
A-Abnormal Renal / Liver function (1 Point Each)
S-Stroke
B-Bleeding history (anaemia, PMH)
L-Liable INR
E-Elderly >65
D-Drugs (NSAIDs, Antiplatelets) / Alcohol (1 Point Each)

A Score >3 is considered high risk and warfarin should be used cautiously.

5

What is the diagnostic criteria for Congestive Cardiac Failure called and how does it work?

Framingham criteria

Major Criteria
-PND
-Raised JVP
-Hepatojugular Reflux
-Crepitations @ lung bases
-Cardiomegaly on PA CXR
-Acute Pulmonary Oedema
-S3 Heart Sound
-↑ CVP
-Weight Loss > 4.5Kg in 5 days

Minor Criteria
-Bilateral Ankle Oedema
-Nocturnal Cough
-Dyspnoea on ordinary exertion
-Hepatomegaly
-Pleural effusion
-Decreased vital capacity
-Tachycardia
(Only if not attributable to another condition)

Pts must have ≥2 Major or 1 Major and ≥2 Minor Criteria to be diagnosed with CCF.

6

What scoring system is used to assess an NSTEMI and how does it work?

GRACE scoring system based on:
AGE
PMH of MI / CCF
Heart Rate and Blood Pressure
ST depression
Serum Creatinine / Troponin

Splits pts into a high-risk category which you treat as a STEMI and low risk which you manage medically.

7

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

8

What is pericarditis?

Inflammation of the pericardium

9

What are the main causes of pericarditis?

Infectious (Coxsackie, Fungal, TB)
Autoimmune (SLE, Rheumatic fever)
Radiotherapy
Kidney Failure (Uraemia)
Drug induced (isoniazid, cyclosporin)
Ca.
Following MI (Dressler syndrome)
Trauma (Surgery / Stabbing)

10

Signs of pericarditis?

Tachycardia
Fever
Kussmaul Sign (JVP rise on inspiration)
Low BP
Pericardial friction rub (extra heart sound)

11

Symptoms of pericarditis?

Central Chest Pain ( Sharp, Stabbing, Worse on inspiration, relieved by leaning forwards, radiate shoulders/neck)
SOB when lying down
Cough
Palpitations
Fever

12

Differentials for pericarditis and how to rule them out?

Dyspnoea and pleuritic pain:
PE, Pneumonia, Pneumothorax
Cardiac pain:
Angina, MI, Aortic Dissection

Raised Troponin rules out lung causes.
ST elevation, PR depression and Pericardial Rub rule out other cardiac causes.

13

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)

14

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.

15

What is Endocarditis and it's causes

Inflammation of the inner walls of the heart and valves

Infection (Bacteraemia/Septicemia)
SLE
Malignancy

16

What are the RFs for Endocarditis?

Valve replacements (esp. mechanical)
Congenital Heart Defects
Poor Dental Hygiene / Recent dental surgery
IVD user

17

What are the Signs/Symptoms of Endocarditis

Pleuritic Pain (radiating to the back)
Fever, night sweats
Fatigue
Weight loss
Anaemia
Murmur
Splenomegaly
Clubbing /Splinter Haemorrhages / Osler's nodes and Janeway Lesions
Petechiae

18

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)

19

What should Pts with prosthetic valves be given prior to dental surgery?

Prophylactic Abx

20

Differentials for endocarditis?

SLE (Anti-dsDNA)
Pericarditis ( No pleural rub + ECG pattern)
Ischaemic heart disease (different ECG pattern)
Pneumonia (CXR)
PE (d-dimer, HRCT)
Pneumothorax (CXR)
Cardiac neoplasms

21

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)

22

What criteria are used to diagnose endocarditis and how does it work?

Duke's Criteria

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

23

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

24

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.

25

What are the symptoms of Angina?

Central crushing pain (comes on with exercise, relieved by rest, radiates to jaw and L. Arm)
SOB
N+V
Sweating, pallor, clamminess.

26

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)

27

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)

28

Treatment for angina?

GTN spray
Educate about RFs
Aspirin 75mg
β-blockers and/or Ca2+ blockers
Regular nitrates to improve exercise tolerance
Angioplasty / Stent

29

RFs for angina?

Smoking
Alcohol
Diet
Excercise
Diabetes control
Blood pressure
Cholesterol

30

What cardio drug is contraindicated in asthma

1st generation β-blockers
Non-cardioselective meaning they cause bronchoconstriction

31

Different types on Angina?

Stable 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)

32

What is an MI

Infarction of the heart muscles due to ischaemia caused by obstruction of the coronary arteries.

33

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)
SOB (Tachypnoea)

34

I which patients might an MI be painless?

Diabetic patients

35

Differentials for MI?

Cardiac Causes (ACS, Endocarditis, Pericarditis)
GI Causes (GORD, Perforation, Oesophageal rupture, Pancreatitis)
Aortic dissection
PE

36

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)

37

Medical Management of an MI?

MONA-BASH
(Acute)
M-Morphine (upto 5mg IV)
O-O2 (Stats > 94% (88% in COPD))
N-Nitrates (IV BP>100mmHg)
A-Aspirin (300mg) + Clopidogrel
(Follow up)
B-β-blockers
A-ACEi
S-Statins
H-Heparin (stop once patient is mobile)

38

Surgical Management of a STEMI?

PCI within 12hrs of onset and within 2hrs of when fibrinolysis could have been given.
Fibrinolysis in other cases

39

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

40

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)
Cardiac Rehab
DVLA informed as pts cant drive for 4 weeks

41

Causes of Cardiac Arrest

5Hs + 5Ts
Hypovolaemia
Hypoxia
H+ ions (infection, ketoacidosis, renal failure)
Hyperkalaemia / Hypokalaemia (K+ sparing diuretics)
Hypothermia

Toxins (Rate control, Antipsychotics, Cocaine, Aspirin, Paracetamol)
Tamponade
Tension pneumothorax (blockage of great vessels due to mediastinal shift)
Thrombosis (MI/PE)
Trauma (Cariac / Subarachnoid Haemorrhage)

42

Signs and Symptoms of Cardiac Arrest

Preceded by weakness, dizziness, chest pain, SOB, vomit
Lack of pulse
Stop breathing
Loss of consciousness

43

Differentials for Cardiac Arrest

Respiratory Arrest (ruled out by pulse)
Shock with loss of consciousness (pulse may be weak but will be present)

44

Treatment for Cardiac Arrest

Call for help
CPR
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

45

How would you treat the following causes of Cardiac Arrest:
MI
Tamponade
Tension pneumothorax
Hypovolaemic shock
Hyperkalaemia
Ischaemic Stroke
PE

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

46

What are the methods of Embolectomy?

Balloon 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

Aspiration embolectomy
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
Surgical embolectomy is the simple surgical removal of a clot following incision into a vessel by open surgery on the artery.

47

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.

48

Who should be screened for HCM

People with a Family history of sudden unexpected death (including drowning as can commonly happen while swimming)

49

What are the symptoms although rare for HCM

Angina
Dyspnoea
Palpitations
Syncope
CCF
Ejection systolic murmur

50

Differentials for HCM

Aortic Stenosis
Atrial Fibrillation
Restrictive cardiomyopathy

51

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

52

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
Implantable defibrillator

53

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

54

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
Exertional dyspnoea
Dizziness
Severe symptoms include (Angina, Syncope and HF)

55

Differentials for aortic stenosis

ACS
Mitral Regurg
HF

56

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

57

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

58

Treatment of asymptomatic aortic stenosis.

Observation with no treatment unless valvular gradient in >40mmHg and LV dysfunction. Then consider surgery as if symptomatic.

59

What are the causes of heart failure

Ischaemic Heart Disease
Non-ischaemic dilated cardiomyopathy
Hypertension
Valvular disease
Increased pulmonary resistance (Pulmonary hypertension, PE)
Congenital heart diseases
Arrhythmias
Hyperdynamic circulation (Anaemia, Thyrotoxicosis, Paget's Disease)
Pericardial disease
Chemotherapy
Alcoholic cardiomyopathy

60

Signs and symptoms of LHF

Fatigue
Dyspnoea and Orthopnea
Displaced apex beat (Cardiomegaly)
Gallop rhythm
Murmur indicating valvular disease
Bilateral coarse crackles at lung bases (pulmonary oedema)
Pitting oedema

61

SIgns and symptoms of RHF

Fatigue, Dyspnoea, Anorexia
Raised JVP
Displaced Apex beat (Cardiomegaly)
Hepatic enlargement and ascites
Hepatojugular reflex
Pitting oedema

62

Differentials for HF

COPD
Cirrhosiss
AKI
Pulmonary fibrosis
Pulmonary embolism
Pneumonia

63

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

64

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

65

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
- Digoxin

Anticoagulation

66

Surgical Managment of Heart Failure

Surgical revascularistation
Biventricular pacemake
Implantable cardioverter defibrillator
Cardiac transplantation

67

General Managment of Heart Failure

Low-level exercise
Low salt diet
Smoking cessation
Education
Vaccination
Fluid Restriction

68

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

69

What are the causes of decompensated heart failure

MI
HTN
Aortic Stenosis, Aortic or mitral regurgitation
Infection can push compensated HF patients over the edge
Anaemia
Hyperthyroidism
Excessive Fluid +/- salt

70

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)

71

Describe the compensatory mechanisms for low BP

SNS activation causing:
- Increase in HR and contractility
- Vasoconstriction
- Na+ and H2O retention

RAAS activation causing:
- Na+ and H2P retention
- Vasoconstriction

72

What is the acute management of decompensated HF

Airway
- Oxygen
Breathing
- CPAP to raise lung pressure forcing fluid back into interstitium
- Morphine (with antiemetic) to ease respiratory distress
Circulation
- 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.

73

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)

74

What are tachyarrhythmias?

Irregular fast heart rates which can compromise heart function by causing abnormal ventricular function