CVS Diseases

CVS Disease

Hypertension

Chronically elevated BP

Presentation

Usually asymptomatic (except malignant HTN)

Cardiac enlargement

Features of underlying causes, eg: radiofemoral delay, palpable kidney

Causes

Primary/Essential/Idiopathic -95%

Secondary

1. Renal

• Intrinsic renal disease(75%)- glomerulonephritis, PAN, systemic scelosis, chronic pyelonephritis, PKD
• Renovascular disease(25%) –atheromatous,  fibromascular dysplasia
• Renin producing tumour

2. Endocrine

• Thyroid disease – hyperparathyroidism
• Adrenal – Cushing, Conn (Primary aldosternism), Phaechromocytoma

3. Others

• Coarctation of aorta, pregnancy, sleep apnea, stress, drugs(alcohol, cocaine)

Investigation

U&E

Creatinine

cholesterol

glucose

ECG

urine analysis

Specific: (exlclude secondary cause)

• renal US
• renal arteriography
• 24h ambulatory BP monitoring (always lower, add-on 12/7 mmHg)

Hypertensive retinopathy

I   Tortuous arteries with thick shiny walls (silver or copper wiring)

II  A-V nipping (narrowing where arteries cross veins)

III Flame haemorrhages and cotton wool spots

IV Papillodema

Management

Category	Systolic (mmHg)	Diastolic (mmHg)
Normal	<120	<80	-
Pre-hypertension	120-139	80-89	Reassess in 5 years, advice on healthy lifestyle
Stage 1	140-159	90-99	CHD+stroke risk
Stage 2	>160	>100
isolated systolic hypertension	>140	<90

Heart Failure

Problem with the structure or function of the heart impairs its ability to supply sufficient blood flow to meet the body's needs.

Presentation

	Left ventricular failure	Right ventricular failure
Symptoms	Exertional dyspnoea orthopnoea PND nocturnal cough + pink frothy sputum tachypnoea (Cheyn-Stokes Crackles at lung bases (Pulmonary oedema) +ve abdominojugular test S3, apex displaced lateral to mid-clavicular line	Peripheral oedema abd. distention(ascites) anorexia nausea JVP ↑ Hepatomegaly

New York Classification of HF

Class I  asymptomatic

Class II symptoms at routine activity

Class III symptoms at less than routine activity

Class IV symptoms at rest

Causes

Heart disease with anaemia or pregannacy

hyperthyroidism

Paget’s disease

atreoalvenous malformation

Risk Factor

Previous MI

Hx of arrhythmia, valvular/ vascular disease

HTN

Family hx of cardiomyopathy

DM

Obesity

Prior exposure to cardiotoxic agents

Investigation

FBC

U&E

B-type Natriuretic Peptide(BNP)

• secreted by the heart in response to excessive stretching of heart muscle cells
• 100pg/ml, HF likely, sensitivity = 90%, specificity = 76%
• ↓ aldosterone, endothelin-1 (vasoconstrictor)&  noradrenaline, ↑diuresis, lusitropic, anti-fibrotic, anti-remodelling
• Caveats: lower with ↑ BMI, affected by renal fn, ↓ by ACEi, diuretics,

ECG –usually shows abnormality (causes) – MI

If ECG and BNP are normal, heart failure is unlikely

Echocardiography – not diagnostic, indicate the causes (MI, valvular disease, LV dysfunction), performed if BNP ↑. Findings:

Ejection fraction: EDV-ESV > 50% + 5%

valvular disease

Diastolic dysfunction - ↑ wall thickness, LA dimension

CXR- eg: features in LVF:

• Alveolar oedema – perihilar bat’s wing shadowing
• Kerley B lines (interstitial oedema)
• Cardiomegaly -cardiothoracic ratio >50%
• Dilated prominent upper lobe vessels
• Pleural Effusion

Cardiac CT, MRI

Coronary angiogram

Management

Acute HF (emergency)

Chronic HF

ABC Sit pt upright O2 100% if no lung disease IV access and monitor ECG, treat any arrhythmia. Investigation while treating Diamorphine 2.5-5mg IV slowly, caution in lover failure and COPD Furosemide 40-80mg IV slowly, larger doses in AKI GTN spray 2 puffs SL, don’t give if systolic BP < 90mmHg Necessary investigation, hx and exam if systolic BP > 100mmHg, start a nitrate infusion, isosorbide dinitrate 2-10mg/h IVI, keep systolic BP >90mmHg If worsens, further dose of furosemide 40-8-mg. Consider ventilation, eg. CPAP, get help If systolic BP< 100mmHg, treat as cardiogenic shock, ie. consider a Swan-Ganz catheter and inotropic support

Treat the cause, eg. valve disease Treat exacerbating factors, eg thyroid disease, infection, HTN Avoid exacerbating factors- NSAIDs, verapamil Stop smoking, eat less salt, maintain weight Drugs: Diuretics, ACEi, B-Blocker, Spirinolactone, Digoxin, vasodilators Intractiblable HF - reassess the cause, compliance - bed rest - metolazone,frusemide, opiates, nitrates - DVT prophylaxis: heparin and TED - consider heart transplant. Jarvik thumb-sized titanium axial flow impeller pump.

Valve Disease
 

	Mitral Stenosis	Mitral Regurgitation	Aortic stenosis	Aortic regurgitation
Causes	Rheumatic, congenital parachute valve- all chordate insert into 1 papillary muscle., mucopolysacharide	Functional (LV dilatation) annular calcification, Rheumatic, IE, HOCM	senile calcification, bicuspid valve, William’s syndrome	congenital, rheumatic fever, IE, RA, aortic root disease
Symptoms	dyspnoea, PND, haemoptysis (ruptured bronchial vein), ascites	dyspnoea, fatigue	Exertional chest pain/dyspnoea/ syncope	Exertional dyspnoea, angina, palpitation
General	tachypnoea, mitral stenosis	tachypnoea	-	Marfan, ankylosin.  spondilytis
Pulse, BP	normal/↓	normal/ sharp upstroke	Pulse: Plateu/ anacrotic/ late peaking/ small volume	Pulse :collapsing, water hammer/ bisfirens Corrigan sign
Palpation	tapping apex beat (palpable S1	displaced apex beat, pansystolic thrill, parasternal impulse	apex beat hyperdynaamic, slightly displaced	apex beat displaced & hyperkinetic
Auscultation	Loud S1, mid-diastolic murmur over mitral area using bell, louder with isometric handgrib and left lateral position	Soft/ no S1 pansystolic murmur maximal at the apex and radiating to the axilla, louder with isometric handgrib and left lateral position	narrowly  split/ reversed S2 Ejection systolic murmur, radiates to carotid arteries, louder when pt squats rapidly from standing position	Soft S1 Early diastolic murmur, maximal at the left sternal border with diaphragm and pt leans forward in full expiration
Severe	valve area<1cm. longer murmur, early opening snap, soft S1	larger left ventricle, loud S3	valve area<1cm, valve gradient >50mmHg,delayed carotid upstroke,late peaking murmur	collapsing pulse, wide pulse pressure, soft A2, Austin Flint murmur, systolic 80mmHg > than diatolic BP
Complication	Pulm. HTN, emboli, pressure effct
Test	ECG(AF, P-mitrale if in sinus rhytm, RVH) CXR(large left atrial, pulm edema, valve calcification), Echo. Indication for cardiac catheter: prev. valvotomy, other valve disease, angina, severe pulm HTN	ECG(AF, P-mitrale if in sinus rhytm, RVH) CXR(large LA & LV), Echo, Doppler echo, cardiac catheterisation	ECG(P-mitrale, LVH, LAD, LBBB), CXR(LVH, calcified aortic valve), Echo: (dx, measure valve gradient) Cardiac cathter: LV function	ECG:(LVH), CXR; (cardiomegaly), Echo, cardiac catheter
Management	control AF, warfarin, diuretics. if fail:balloon valvuloplasty, open valvulotomy/valve replacement, penicillin for recurrent rheumatic fever if <30 Indication for surgey LVEF >60%, LVESD <45mm		symptomatic: Prompt valve replacement, except for unfit: percutaneous valvuloplasty. Asymptomatic: regular monitor Poor prognosis: 2-3y if angina,	Valve replacement

MYOCARDIAL INFARCTION

Pathophysiology

90% caused by artherosclerosis

nonatherosclerotic c in younger patients: infected cardiac valve through a patent foramen ovale (PFO), coronary occlusion secondary to vasculitis, primary coronary vasospasm (variant angina), cocaine use, or other factors leading to mismatch of oxygen supply and demand, as may occur with a significant gastrointestinal bleed.

Epidemiology

• 5/1000 per year for ST segment elevation

• African American, Hispanic, and white populations in the United States.

• male, age 70 years when the sexes converge to equal incidence.
• Premenopausal women appear to be somewhat protected from atherosclerosis, possibly owing to the effects of estrogen.

• Incidence increases with age.
• Most patients who develop an acute myocardial infarction are older than 60 years. Elderly people also tend to have higher rates of morbidity and mortality from their infarcts.

Risk Factor

• Non modifiable: age, gender, family hisyory
• Modifiable: smoking, hypertension, DM,, hyperlipidaemia, obesity, sedentery lifesyle
• Controversial: stress, type A personality, ↑ of apoprotein A & fibrinogen, hyperinsulinaemia, homocystein, ACE genotype, cocaine

Presentation

• acute central chest pain > 20min ass with sweatiness, nausea, SOB, palpitations.
• Silent infarct in elderly and diabetics- syncope, pulmonary oedema, epigastric pain and vomiting, post-op hypotension, oliguria, acute confusional state, stroke, diabetic hyperglyceamic state
• distress, anxiety, pallor, pulse & BP ↑ or ↓, S4, sign of heart failure (↑  JVP, S3 and basal crepitations) or a pansystolic mumur (papillary muscle dysruption, rupture)
• low grade pyrexia
• later: pericardial rub or peripheral oedema

Diagnostic criteria

WHO criteria: 2 out of 3

1. Typical history of ischaemic type chest pain lasting for more than 20 minutes
2. Changes in serial ECG tracings
3. Rise and fall of serum cardiac biomarkers such as creatine kinase-MB fraction and troponin + typical symptoms, pathological Q waves, ST elevation or depression or coronary intervention are diagnostic of MI.

Investigation

ECG

1. hyperacute (tall) t waves, ST elevation or new LBBB within hours of acute Q wave (transmural infarction). T wave inversion and development of pathological Q wave follows over hours to days.
2. St depressiion, T inversion, non-specific changes, or normal
3. normal in 20% of MI

CXR

Cardiomegaly, pulmonary odema, widened mediastinum (?aorta dissection)

Blood

FBC, U&E, glucose ↑, lipids ↓,

Cardiac enzyme

(CK, AST, LDH, troponin) ↑, CK is found in myocardial and skeletal muscle: ↑ in MI, after trauma, prolonged exercise, myositis, afro-carribeans, hypothermia, hypothyroidism

Check CK-MB isoenzyme levels if there is doubt as to the source (normal CK-MB:CK ratio <5%)

Troponin T better shows MI (peaks at 12-24H, elevated for >1wk) If normal >6h after onset of pain, and ECG mormal, risk of  missing  Mi is tiny (0.3%). peak post MI levels also help risk stratification.

Differential Diagnosis

Angina, pericarditis, myocarditis, aortic dissection, pulmonary embolism, PE, oesophageal reflux

Management

Pre-hosp

Arrange emergency ambulance.aSPIRIN 300MG chewed and GTN sublingual

Analgesia (morphine 5-10mg IV + metoclopramide 10mg IV (not IM- risk of bleeding)

Hospital

Morphine, O2, Aspirin, IVI

check for ST elevetaion

ST-segment elevation

No ST segment elevation

Thrombolysis or primary angioplasty B-blocker eg. atenolol 5mg IV ACEi (eg lisinopril 2.5mg) start in all normotensive pt within 24h of acute MI, especially if thre is clinical evidence of heart failure or echo evoidence of LV dysfunction

B-blocker eg. atenolol 5mg IV LMWH (eg enoxaparin 1mg/kg/12H SC for 2-8d Nitrates High risk pt (persistent or recurrent ischaemia, St depression, diabetes, ↑troponin) require infusion of GPIIb/IIIa antagonist (eg tirofiban) and ideally urgent angiography. Aspirin + copidogrel considered for up to 12 months. Low risk pt (no further pain, flat or inverted T waves, or normal ECG and negative troponin) can be discharged if a repeat troponin is negative. Treat medically and arranged for stress test, angiogram ect.

Subsequent management: bed rest for 48H, continuous ECG monitoring

• Daily examination of heart, lungs anfd legs complications
• Daily 12-lead ECG, U&E, cardiac enzymes for 2-3d
• Prophylaxis against thromboembolism, eg heparin 5000u/12h, until,fully mobile. If large anterior MI, consider warfarin anticoagulation for 3months as prophylaxis against systemic emnolism from LV mural thrombus. Continue daily low-dose aspirin (75-150mg) -reduce vascular events (MI, stroke, vascular death) by 29%
• oral B-blocker (metoprolol 50mg/6h decrease pulse <60, continue for at least 1 year. Long term- reduce mortality by 25% in pt who had previous MI. If CI: verapamil or diltiazem
• ACEi in all pt ↓ 2y mortality by 25-30%
• Statin - ↓ cholesterol for all pt or if total cholesterol >4mmol/L
• discourage smoking, encourage exercise, treat DM, HTN and hyperlipidaemia
• exercise EC: in risk stratification 3-4wk post MI, in non STEMI or troponin rise
• if uncomplicated : discharged after 5-7d.
• Return to work after 2M, x start post MI: airline traffic, divers. Lighter jobs. Diet: oily fish, veg, fibre, low in saturated fat. Exercise. Avoid sex for 1 month, avoid air travel for 2 months
• Review symptoms at 5wks
• Review at 3 months: check fasting lipids

Complications

Cardiac arrest

Unstable angina

bradycardia or heart block

Tachyarryhtmias

LVF/RVF

Pericarditis

DVT, PE, systemic embolism

Cardai tamponade

Mitral regurgitation, VSD

Late malignant ventricular arryhtmias

Dressler's syndrome – recurrent pericarditis

Left ventricular aneurysm

Mortality

50% deaths occur within 2h onset of symptom

ATRIAL FIBRILLATION

supraventricular tachyarrhythmia characterized by disorganized atrial electrical activity and progressive deterioration of atrial electromechanical function. absence of P waves; rapid oscillations (or fibrillatory [f] waves)

Epidemiology

5% of the population older than 69 years, 8% of persons older than 80 years.

stroke risk 2.5%

Causes

Heart failure/ischaemia, HTN, MI, mitral valve disease, PE, pneumonia

hyperthyroidism, alcohol, post-op, K+ and Mg+ ↓

rare: Cardiomyopathy, constrictive pericarditis, sick sinus syndrome, lung cancer, atrial myxoma, endocarditis, haemochromatosis, sarcoid, Lone AF= no cause found

Presentations

may be asymptomatic

chest pain, palpitations, SOB,or faintness

irregularly irregular pulse, the apical pulse rate is greater than the rate

variable S1 intensity

sign of LVF

Investigation

ECG – absent p waves, irregular QRS complex

Blood: U&E, cardiac enzyme, TFT

Echo to look for left atrial enlargement, mitral valve disease, poor LV function

Management

Acute AF (<AF)

Chronic AF

Treat associated illnesses (eg. MI, pneumonia) control ventricular rate heparin 5000-10000U IV to keep options for cardioversion even if the 48h timelimit is running out. If the 48h has elapsed, cardioversion without anticoagulation is OK if TTE shows no intracardiac thrombus. Cardioversion regimen: O2 → ITU/CCU → GA or IV sedation → 200J → 360J → 360J (monophasic; if 100J is tried 1st, it only works in 20%) relapses back into AF are common, and drug cardioversion is often preferred: amiodarone IVI . Alternative (if stable and no known IHD or WPW), flecainide (negative inotropes). Monitor ECG Controlling ventricular rate: diltiazem/ verapamil/metoprolol digoxin, amiodarone

Control rate.=as good as rhythm control in ↓morbidity +mortality Consider rhythm control if 1st episode or younger patient Warfarin (INR 2-3), CI: bleeding diathesis, platelets < 50x109/L, BP>160/90 (consistently): compliance issues, pt choice Aspirin if CI to warfarin or at  low risk of emboli Controlling ventricular rate: B-blocker or rate limiting CCB if fail, add Digoxin (monotherapy only ok in sedentary pt), then consider amiodarone

Paroxysmal AF

Pill-in-the-pocket

If not,try B-blocker

If fails and no LV dysfunction, sotalol 40mg/12h. S/E:↑QT interval, so monitor QT

If LV sydfunction: amiodarone

INFECTIVE ENDOCARDITIS

Classifications

50% endocarditis occurs in normal valve. It follows acute course -present with heart failure

endocarditis occurs in abnormal valve → subacute course

Causes

• Bacteraemia – dentistry, UTI, urinary catheterization, cystoscopy, resp infection, endoscopy
• Colon cancer, gall bladder disease, skin disease, IV cannulation, surgery, abortion, fractures.
• Streps viridans commonest(35-50%), enterococci, staph aureus/ epidermidis, diphteroids, HACEK group, Coxiella burnetti, chlamydia
• Candida, aspergillus, Histoplasma
• SLE (libman-Sacks endocarditis), malignancy

Presentations

• septic signs: fever, rigors, night sweats, malaise, weight loss, anaemia, splennomegaly, clubbing
• cardiac lesions: any new murmur, or change in the nature of pre-existing murmur
• vegetation may cause valve destruction, and severe regurgitation, or valve obstruction.
• An aortic root abscess causes prolongation of the P-R interval, and may lead to complete AV
• Immune complex deposition: vasculitis may affect any vessel.
• Microscopic haematuria,glomerulonephritis and ARF
• Roth spots(boat shaped retinal haemorrhage with pale centre), splinter haemorrhage, Osler nodes, Janeway's lesion.
• Embolic phenomena: abscess in relevant organ- brain, kidney, lung (in R-sided endocarditis)

Diagnosis

• Blood cultures: take 3 sets at different time and from different site at peak fever. 85-90% are diagnosed from the first 2 sets. 10% culture negative.
• Blood test: normochromic, normocytic anaemia, neutrophil leucocytosis, high ESR/CRP. Also check U&E, Mg, LFT
• Urinalysis- microscopic haematuria
• CXR(cardiomegaly)
• ECG (prolonged P-R interval)
• Echo TTE may show vegetation, but only if >2mm, TOE is more sensitive and better for visualizing mitral lesions and possible development of aortic root abscess.

Duke Criteria

Major Criteria	Minor Criteria
Positive blood culture typical organism in 2 separate cultures or persistently +ve blood cultures, eg 3 >12h apart (or majority if > 4) Endocardium involved +ve echocardiogram (vegetation, abscess, dehiscence of prosthetic valve) new valvular regurgitation (change in murmur nor sufficient)	Predisposition (cardiac lesion, IV drug abuse) Fever > 38C Vascular/immunological signs +ve blood culture that do not meet major criteria +ve echocardiogram that does not meet major criteria

Definite IE: 2 major or 1 major and 3 minor or all 5 minor criteria

Management

• Liase early with microbilogist and cardiologist
• Empirical therapy: benzylpenicilin 1.2g/4h IV + gentamicin eg 1mg/kg/8h IV (serum peak 3-5mg/L & a pre-dose trough of <1mg/L) for 4wks. If acute, add flucloxacilin to cover staphylocicci
• Enteroccoci: amoxicilin 1g/6h iv + gentamicin as above
• Streptococci: benzylpenicilin 1.2g/4h IV 2-4wks, then amoxicilin 1g/8h PO for 2wks. Monitor minimum inhibitory concentration (MIC). Add gentamicin
• Staphilococci : flucloxacilin 2g/6h IV + gentamicin as above IV. Treat for 6-8wks, stop gentamicin after 1wk. If prosthetic valve or MRSA suspected, substitute flucloxacilin with vancomicin + rifampicin
• Coxiella: doxycilin 100mg/12h PO indefinitely + co-trimoxazole, rifampicin or ciprofloxacilin
• Fungi: flucytosine 50mg/kg/6h IVI over 30min followed by fluconazole 50mg/24h PO (higher dose may be needed) Amphotericin if flucytosine or Aspergillus. Miconazole if renal fn is poor